TSS is caused by penicillin-resistant Staphylococcus aureus, which produces exoproteins that are toxic in nature. TSST-1 is the toxin most commonly detected; staphylococcal enterotoxin B is second most frequent. For illness to develop, the patient must be infected with a toxigenic strain of S. aureus and lack antibodies to that strain. More than 90% of people develop antibodies by adulthood.

Menstruation is the most common setting for TSS occurrence, but half of all cases occur in settings other than menstruation and individuals of both sexes and all ages can be affected. Although tampons are clearly implicated in this infection, their exact role is uncertain. They may contribute to the infection by:

Postoperative infections can develop hours to weeks after a surgical procedure. TSS has been associated with musculoskeletal and respiratory infections caused by S. aureus and with staphylococcal bacteremia.

Complications of organ hypoperfusion from TSS include renal and myocardial dysfunction, massive edema, adult respiratory distress syndrome, and desquamation of the skin. Late signs include peripheral gangrene, reversible nail and hair loss, muscle weakness, and neuropsychiatric syndrome.

The condition begins with a high fever (102° F [38.9 C]), intense myalgia, nausea, vomiting, diarrhea, sore throat, and headache. Hypotension that develops can cause dizziness. The patient’s mental status is often abnormal.

Macular erythroderma occurs over the first 2 days. The rash is usually generalized but is sometimes locally confined and may or may not be persistent.

Strawberry tongue develops in half of the cases, and the patient may develop conjunctival suppression, pharyngeal infection, and peripheral edema. Inspection may reveal vaginal hyperemia and purulent vaginal discharge.

Palpation may disclose signs of shock —a rapid, thready pulse and hypotension.