Theoretically, tampons may contribute to the development of TSS by introducing S. aureus into the vagina during insertion (insertion with fingers instead of the supplied applicator increases the risk) or by traumatizing the vaginal mucosa during insertion, thus leading to infection.

When TSS isn’t related to menstruation, it appears to be linked to S. aureus infections, such as abscesses, osteomyelitis, and postsurgical infections. It’s also associated with prior antibiotic use.

Risk factors include recent use of barrier contraceptives (diaphragms or vaginal sponges), childbirth, and surgery.

TSS can complicate the patient’s use of contraceptives, the puerperium, septic abortion, and gynecologic surgery. Postoperative infections can develop hours to weeks after a surgical procedure. TSS has also been associated with musculoskeletal and respiratory infections caused by S. aureus and with staphylococcal bacteremia.

Complications of organ hypoperfusion related to TSS include renal and myocardial dysfunction, massive edema, acute respiratory distress syndrome, and desquamation of the skin. Late signs include peripheral gangrene, reversible hair and nail loss, muscle weakness, and neuropsychiatric dysfunction. Death may also occur.

TSS symptoms typically are abrupt in onset and produce intense myalgia, fever higher than 104° F (40° C), vomiting, diarrhea, headache, bruising, decreased level of consciousness, rigors, conjunctival hyperemia, and vaginal hyperemia and discharge. Severe hypotension occurs with hypovolemic shock. Within a few hours of onset, a deep red rash develops—especially on the palms of the hands and soles of the feet—that later desquamates.