P3C339: Shocking Source of Toxic Shock Syndrome in an Adolescent Female: A Case Report

Introduction: Toxic Shock Syndrome (TSS) is an acute-onset illness characterized by fever, hypotension, sunburn-like rash, and end-organ damage. It is caused by toxin-producing Staphylococcus aureus or Group A Strep. TSS has classically presented in the setting of menses and the use of high-absorbency tampons until these were eventually taken off the market. The current incidence of TSS is estimated to be around 0.8 to 3.4 per 100,000 in the United States. Reusable silicone menstrual cups have increased in popularity, marketed as a cheaper, safer, and eco-friendly alternative to tampons. We present a rare case of a previously healthy 17-year-old female diagnosed with Staphylococcus aureus TSS in the setting of recent menstrual cup use.

Case Description: We present a 17-year-old previously healthy female with a 5-day history of fever and fatigue.

The patient noted an episode of vaginal spotting two days prior to admission, for which she inserted a menstrual cup and did not remove it. She developed a sore throat, body aches, non-bloody diarrhea, severe fatigue, and extremity swelling one day prior to presentation.
In the Emergency Room, the patient had hypotension and tachycardia. Her initial labs indicated significant systemic inflammation, with marked leukocytosis and elevated acute phase reactants. Despite multiple fluid boluses, her vitals did not improve, requiring an epinephrine infusion and admission to the Pediatric Intensive Care Unit.

With supportive care and empiric antibiotics, she began to improve clinically. Blood cultures were negative. Urine and genital cultures grew pan-sensitive Staphylococcus aureus. The patient completed a 10-day total course of Clindamycin upon discharge.

Discussion: TSS is a known risk associated with using high-absorbency tampons during menses. It is thought that increased pH, oxygen, and carbon dioxide levels in the vagina during menses create an optimal environment for bacterial growth and production of TSST-1, the superantigen responsible for mediating TSS.

Recently, silicone menstrual cups have become a popular alternative to tampons as they are reusable and more cost-effective. A recent study evaluated the impact of currently marketed tampons and menstrual cups on S. aureus and TSST-1 production in vitro. This experiment found that higher levels of S. aureus growth and toxin production were seen in menstrual cups, likely due to the additional air being introduced into the vaginal canal.

Conclusion: Menstrual cup-associated TSS has been described in the literature. However, to our knowledge, this is the first reported pediatric case. As these products become more affordable and commercialized for their reusable and eco-friendly nature, their use in the pediatric population will likely increase. Therefore, pediatricians must educate their patients on the associated risks and strategies to mitigate them.