LA TIMES: Nearly forgotten, toxic shock may be on the rise

[Guest guest]

Toxic shock is but another good reason NOT to get breast

implants ... one study below.

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http://www.latimes.com/features/health/medicine/la-he-

toxic21feb21,1,7521929.story?coll=la-health-

medicine & ctrack=1 & cset=true

Nearly forgotten, toxic shock may be on the rise

Cases of tampon-related illness worry health officials. At least

five have been reported recently in Southern California.

By Shari Roan

Times Staff Writer

February 21, 2005

Toxic shock syndrome linked to tampon use, which made headlines 25

years ago when the dangerous illness sickened thousands of U.S.

women and killed dozens, may be reemerging as a public health

threat, according to physicians and other experts.

Two leading researchers say the number of cases reported to them by

doctors nationwide has increased during the last three years, though

the levels are not thought to be nearly as high as they were in

1980, the peak year for toxic shock cases. And a U.S. Food and Drug

Administration official said recently that the agency had received

an increasing number of reports of toxic shock syndrome linked to

tampon use.

The suspected increase is still largely anecdotal, and government

statistics are unavailable because federal researchers stopped

actively monitoring TSS cases in 1987.

In Los Angeles County, five cases of TSS have been discovered in

teenage girls using tampons in the last year — four since September,

according to physicians who treated the girls.

Some health officials are concerned about the possible reappearance

of the illness, thought to have largely disappeared when a brand of

tampon linked to TSS was withdrawn from the market in 1980. The

illness can strike swiftly, and cases could easily be missed if

people assume that tampon-related TSS is no longer a threat, experts

said.

The apparent rise in TSS cases is " really surprising, " said Dr. Jay

M. Lieberman, chief of pediatric infectious diseases at

Children's Hospital in Long Beach, where four of the cases were

treated. " It can quickly be fatal. I think it's important that

teenage girls and their parents be aware of the potential for TSS if

the girl wears tampons. I don't want to scare people, but the

disease is still around. "

At UCLA Medical Center, doctors who treated a teenager last fall

with toxic shock syndrome thought the diagnosis was so unusual they

submitted a report to a medical journal. " People don't think of this

as a diagnosis today, " said Dr. Cherry, a professor of

pediatric infectious diseases at the Geffen School of Medicine

at UCLA.

All of the teenagers at UCLA and Children's Hospital were

critically ill but survived. However, a 16-year-old girl in Santa

Clara County died in November from probable TSS, according to the

county's medical examiner.

" I've gotten calls from doctors from a variety of places around the

country, " says Schlievert, a professor of microbiology and

immunology at the University of Minnesota who has studied TSS. " They

say, 'Gee, all of a sudden I'm seeing cases again,' and they ask me

what's going on. Basically, what we're seeing is a steady rise in

incidence such that [the rate of TSS] is one-third to one-half of

what it was when the incidence peaked around 1980. "

Even as rates may be increasing, TSS remains a rare illness. At its

peak in the early '80s, about 10 cases were reported for every

100,000 menstruating women. In 1980, 772 U.S. women developed the

illness and 38 died, a development that generated headlines and

caused many women to question the safety of tampons. The cause of

the illness was eventually attributed to highly absorbent tampons

made with synthetic materials.

After the Rely tampon was removed from the market, rates fell to

about one case per 100,000. Schlievert now estimates the rate is 3

to 4 cases per 100,000 menstruating women.

Schlievert, who has studied TSS for decades, reported last year that

cases of the illness, both in menstruating women and others, in the

Minneapolis-St. area climbed from 15 cases in 2000 to 50 in

cases in 2003. The study was published in the Journal of Clinical

Microbiology.

The U.S. Centers for Disease Control and Prevention, which keeps

statistics on infectious diseases, said it had no evidence that

tampon-related TSS was increasing. Dr. Rosenstein, of the

CDC's National Center for Infectious Diseases, acknowledged that the

agency's methods for tracking TSS rates — national mandatory

reporting of cases by states was dropped in 1987 — were insufficient

to detect an increase in a relatively rare disease.

Last May, in remarks to the North American Society for Pediatric and

Adolescent Gynecology, Dr. Judith U. Cope of the FDA's Center for

Devices and Radiological Health, told an audience of physicians that

tampon-related TSS reports to the FDA were increasing, though the

overall rates were still small. The remarks were published in the

June issue of the society's medical journal.

Asked about Cope's assessment recently, an FDA official in the

Center for Devices and Radiological Health, said TSS rates were not

going up. The official, who asked not to be identified, offered no

explanation for the apparent discrepancy. Cope was not available for

comment, according to an FDA spokeswoman.

Toxic shock syndrome is caused by the Staphylococcus aureus bacteria

that is commonly found on the skin and mucous membranes. Certain

strains of S. aureus, however, can cause infection, and tampons —

highly absorbent tampons, in particular — increase that risk. Toxic

shock syndrome occurs when certain strains of S. aureus that produce

toxins pass into the bloodstream. Another type of TSS, called

nonmenstrual TSS, can occur in people who have undergone surgeries

or who have postoperative wound infections. Those types of TSS cases

are also thought to be rising, according to Schlievert.

Women with tampon-associated TSS usually become sick during

menstruation or in the two days before or after their periods. It

begins with flu-like symptoms: high fever, chills, vomiting,

diarrhea and dizziness. Within as few as two days, however, the

toxins can attack the body's organs. The illness is fatal in 5% of

cases, according to the CDC.

Meghan Duron, 14, was about to start her freshman year at Mira Costa

High School in Manhattan Beach last September when she began having

flu-like symptoms and a rash, and then two days later, became

violently ill.

When doctors admitted Meghan to Children's Hospital, she was

experiencing septic shock, a condition in which not enough blood is

flowing through the body. " I was in high school when toxic shock

syndrome first happened. I didn't even think it was around anymore, "

said Meghan's mother, Kathy Duron.

In the years since the 1980s scare, TSS has slipped from the radar

screen of many doctors, especially younger physicians who may never

have seen a case, said Lieberman.

Lieberman said that in two of the recent cases treated at

Children's Hospital, doctors who saw the girls before their

hospitalization did not immediately recognize the signs of TSS, even

though the girls had been wearing tampons. " They were critically

ill,'' he said, adding that any further delays could have been fatal.

While no one is certain why cases of tampon-related TSS appear to be

occurring again, several factors are suspected, doctors said. One

explanation is that the bacteria that causes TSS may, over time,

have become more virulent. Schlievert's research shows that one type

of S. aureus that is resistant to methicillin and similar

antibiotics may cause up to 30% of new tampon-related TSS cases.

Methicillin-resistant S. aureus may also be behind an upswing in

nonmenstrual TSS cases too, Schlievert said.

Other experts worry that changes in tampons may be contributing to

more cases of toxic shock syndrome. In 2000, the FDA allowed a more-

absorbent tampon, labeled " ultra, " on the market. " In the past,

increases in absorbency were shown to directly relate to the

incidence of TSS, " says Dr. Philip M. Tierno, a microbiologist at

New York University Medical Center.

Girls today often start their periods at younger ages than in the

past. By adulthood, most people have developed antibodies to S.

aureus, but only about half of 13-year-olds have such antibodies,

Schlievert says. Most of the TSS cases reported to him have been

among 12- to 15-year-olds

The FDA advises women to change tampons every four to eight hours

and to use only the most absorbent tampon appropriate for their

menstrual flow. While tampons are often marketed as safe for

overnight use, some health experts think that's a bad idea. " That

the FDA would allow [labeling] of an eight-hour, overnight usage of

tampons is outrageous, " said Tierno, noting that teens often sleep

for 10 to 12 hours.

According to an FDA official, current manufacturing and marketing

practices related to tampons are safe. The FDA requires tampon

manufacturers to provide information about toxic shock syndrome with

their products, usually found on a pamphlet inside the box.

Meghan Duron, however, said she had never heard of TSS. And, says

her mother, " With something this serious and this dangerous, there

should be a more-prominent warning on the outside of the box. "

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http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?

cmd=Retrieve & db=pubmed & dopt=Abstract & list_uids=9618183

Toxic shock syndrome in plastic surgery patients: case report and

review of the literature.

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www.BreastImplantAwareness.org