Menstrual toxic shock syndrome: case report and systematic review of the literature

Bleeding beyond binaries: a critical interpretive review of trans, non-binary and gender non-conforming experiences with menstruation

While some barriers for managing menstruation have been mitigated for cisgender women, trans, non-binary, and gender non-conforming people still struggle to navigate menstruation in a gendered society. With an increasing number of young people identifying outside of the gender binary, there is an immediate need to identify and address the barriers to managing menstruation. This review sets out to explore how trans, non-binary, and gender non-conforming people experience and navigate menstruation. Using critical interpretive synthesis methodology, nine pieces of literature including peer-reviewed journal articles, graduate theses, a book chapter, and a conference poster presentation were reviewed using thematic analysis. Four primary themes were identified: (1) menstruation is strongly gendered; (2) there exists inadequate trans, non-binary, and gender non-conforming education and healthcare training; (3) the gendering of public toilets/washrooms poses a barrier to the management of menstruation; and (4) there exists a lack of diverse participants and attention to intersectional menstruation concerns. A set of recommendations, specific to a variety of stakeholders is provided, and implications for future research are discussed.

Menstrual health inequities and "period poverty" in Canada

Period poverty is the lack of access to menstrual products, sexual and reproductive health education, safe waste management, and adequate facilities. Despite its being a public health issue and a significant concern for numerous Canadians, there is a lack of peer-reviewed research on period poverty in Canada. Existing Canadian research has primarily been conducted by non-profit organizations/charities or industry leaders for menstrual products, resulting in incomplete data. More research is needed to explore the menstrual inequities in Canada and their impact on the well-being of Canadians. This is a critical step to ensure the menstrual needs of Canadians are appropriately addressed.

Fever and Rash

Infectious causes of fever and rash pose a diagnostic challenge for the emergency provider. It is often difficult to discern rashes associated with rapidly progressive and life-threatening infections from benign exanthems, which comprise the majority of rashes seen in the emergency department. Physicians must also consider serious noninfectious causes of fever and rash. A correct diagnosis depends on an exhaustive history and head-to-toe skin examination as most emergent causes of fever and rash remain clinical diagnoses. A provisional diagnosis and immediate treatment with antimicrobials and supportive care are usually required prior to the return of confirmatory laboratory testing.

Toxic Shock Syndrome: A Literature Review

Toxic shock syndrome (TSS) is a rare, life-threatening, toxin-mediated infectious process linked, in the vast majority of cases, to toxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes. The pathophysiology, epidemiology, clinical presentation, microbiological features, management and outcome of TSS are described in this review. Bacterial superantigenic exotoxins induces unconventional polyclonal lymphocyte activation, which leads to rapid shock, multiple organ failure syndrome, and death. The main described superantigenic exotoxins are toxic shock syndrome toxin-1 (TSST-1) and enterotoxins for Staphylococcus aureus and Streptococcal pyrogenic exotoxins (SpE) A, B, and C and streptococcal superantigen A (SsA) for Streptococcus pyogenes. Staphylococcal TSS can be menstrual or nonmenstrual. Streptococcal TSS is linked to a severe group A streptococcal infection and, most frequently, to a necrotizing soft tissue infection. Management of TSS is a medical emergency and relies on early detection, immediate resuscitation, source control and eradication of toxin production, bactericidal antibiotic treatment, and protein synthesis inhibiting antibiotic administration. The interest of polyclonal intravenous immunoglobulin G administration as an adjunctive treatment for TSS requires further evaluation. Scientific literature on TSS mainly consists of observational studies, clinical cases, and in vitro data; although more data on TSS are required, additional studies will be difficult to conduct due to the low incidence of the disease.

A randomized, double-blind study on the safety and immunogenicity of rTSST-1 variant vaccine: phase 2 results

Background

Toxic shock syndrome toxin-1 (TSST-1) is a superantigen produced by Staphylococcus aureus that causes the life-threatening toxic shock syndrome. The development of a safe and immunogenic vaccine against TSST-1 remains an unmet medical need. We investigated the safety, tolerability and immunogenicity of a recombinant TSST-1 variant vaccine (rTSST-1v) after 1-3 injections in healthy volunteers.

Methods

In this randomised, double-blind, adjuvant-controlled, parallel-group, phase 2 trial, healthy adults aged 18-64 were randomly allocated to undergo 1-3 injections of either 10 or 100 μg rTSST-1v or Al(OH)3. The primary endpoint was safety and tolerability of rTSST-1v in the intention-to-treat population. The per-protocol population was used for the immunogenicity analysis. The trial is registered with EudraCT#: 2015-003714-24; ClinicalTrials.gov#: NCT02814708.

Findings

Between April and November 2017,140 subjects were enrolled and 126 completed the trial. rTSST-1v showed a good safety and tolerability profile. A total of 855 systemic adverse events occurred, 280 of which were suspected related adverse events, without dose dependency. Two participants were discontinued early because of allergic reactions. Seroconversion occurred in >81% of subjects within 3 months of the first immunisation which was sustained until 18 months after the third immunisation in over 70% of subjects in the pooled low-dose group and in over 85% in the pooled high-dose group.

Interpretation

rTSST-1v in cumulative doses of up to 300 μg was safe, well-tolerated and highly immunogenic. Two immunisations with 100 μg rTSST-1v provided the most persistent immune response and may be evaluated in future trials.

Funding

Biomedizinische Forschung & Bio-Produkte AG funded this study.

Understanding period poverty and stigma: Highlighting the need for improved public health initiatives and provider awareness

Period poverty affects millions of people who menstruate, but there is limited research to fully understand the scope and impact. Societal stigmas and cultural taboos negatively affect menstruation, a natural, biologic process. When unable to afford or find appropriate menstrual products, individuals may resort to alternative, poorer quality items, which increase their risk of infections. In addition, lack of products may cause individuals to miss events and have negative emotions. Implicit sexism and gender inequality are notable through the high cost of essential period products. Uncomfortable environments prevent patients from openly discussing menstruation with health care providers, who may lack training to competently assess needs and address barriers. Period poverty is a public health issue that not only needs to be addressed by our health care providers but also through increased education in schools and changes in local and federal legislation. In this paper, we discuss the financial, physical, and mental health impacts of period poverty and describe our experience creating a period pantry at a free medical clinic.

"For men, by men": Menstrual victimization and the weaponization of period products in carceral settings

BACKGROUND

The literature on menstruation defines period poverty as the inability to access sufficient period products, education, and sanitary facilities needed to manage menstruation healthily and effectively. While research has identified shortcomings of healthcare in the carceral setting, period poverty behind bars has remained largely absent from criminal legal discourse.

OBJECTIVES

The current study examines the interplay of period poverty and carceral control to introduce the novel concept of menstrual victimization, defined as the physical, emotional, and financial victimization that results from period poverty perpetuated through carceral control.

METHODS

The study uses qualitative content analysis to systematically gather and code journalistic accounts pertaining to the menstrual experiences of incarcerated and previously incarcerated females, criminal justice practitioners, and journalists. The analysis uses literary pieces (n = 99), which were coded deductively and guided by concepts related to structural violence and radical feminist criminology.

RESULTS

The findings shed light on the unique structural harms incarcerated menstruators face and reveal the dearth of needed empirical research on period poverty in carceral spaces. The narratives in the sample revealed how manufactured scarcity of period products within carceral spaces is used as a means of oppression by institutional agents. The emergent themes highlight how the intersection of period poverty and carceral control led to menstrual victimization characterized through shame, humiliation, control, and coercion.

CONCLUSION

Potential outcomes associated with understanding menstrual victimization in the carceral setting are discussed, including reducing menstrual stigma, disseminating health education, minimizing health disparities, and ultimately, shifting modes of holding accountability away from oppressive, retributive, and controlling tactics.

Targeted proteomics links virulence factor expression with clinical severity in staphylococcal pneumonia

Introduction

The bacterial pathogen Staphylococcus aureus harbors numerous virulence factors that impact infection severity. Beyond virulence gene presence or absence, the expression level of virulence proteins is known to vary across S. aureus lineages and isolates. However, the impact of expression level on severity is poorly understood due to the lack of high-throughput quantification methods of virulence proteins.

Methods

We present a targeted proteomic approach able to monitor 42 staphylococcal proteins in a single experiment. Using this approach, we compared the quantitative virulomes of 136 S. aureus isolates from a nationwide cohort of French patients with severe community-acquired staphylococcal pneumonia, all requiring intensive care. We used multivariable regression models adjusted for patient baseline health (Charlson comorbidity score) to identify the virulence factors whose in vitro expression level predicted pneumonia severity markers, namely leukopenia and hemoptysis, as well as patient survival.

Results

We found that leukopenia was predicted by higher expression of HlgB, Nuc, and Tsst-1 and lower expression of BlaI and HlgC, while hemoptysis was predicted by higher expression of BlaZ and HlgB and lower expression of HlgC. Strikingly, mortality was independently predicted in a dose-dependent fashion by a single phage-encoded virulence factor, the Panton-Valentine leucocidin (PVL), both in logistic (OR 1.28; 95%CI[1.02;1.60]) and survival (HR 1.15; 95%CI[1.02;1.30]) regression models.

Discussion

These findings demonstrate that the in vitro expression level of virulence factors can be correlated with infection severity using targeted proteomics, a method that may be adapted to other bacterial pathogens.

Servicewomen's experiences of managing pelvic health in occupational settings

BACKGROUND

Despite increasing numbers of women serving in defence forces worldwide, little is currently known about how servicewomen manage their pelvic health in the traditionally male environment of the military.

OBJECTIVES

The aim of this study was to explore the impacts of pelvic health issues on Australian Defence Force servicewomen and their experiences of managing their pelvic health in occupational settings.

DESIGN

A qualitative hermeneutic design.

METHODS

Telephone interviews were conducted on six currently serving female members of the Australian Defence Force located Australia-wide. A semi-structured interview guide, based on the study objectives, was used to guide the audio-recorded interviews. Data were analysed thematically.

RESULTS

Nine themes were identified. The first six themes explored the experiences of servicewomen in maintaining their pelvic health, including suppressing the urge to go, adjusting hydration depending on toilet access, managing menstruation, regaining 'full' fitness postpartum, awareness and prevention of pelvic health conditions, and inhibiting conversations about women's health. The last three themes explored how servicewomen coped with pelvic health conditions, including self-managing symptoms, diagnosing and treating pelvic conditions, and support for servicewomen's pelvic health.

CONCLUSION

This study suggests workplace culture, low levels of insight into pelvic health norms, and limited healthcare strategies within the Australian Defence Force to support female pelvic health have contributed to servicewomen self-managing pelvic health issues using approaches that may have had significant impacts on their health and well-being.

Screening of Toxin Genes in Methicillin-Resistant Staphylococcus aureus Clinical Isolates from a Hospital Setting in a Tertiary Hospital in Northern Cyprus

Methicillin-resistant Staphylococcus aureus (MRSA) is a significant opportunistic pathogen with a wide repertoire of virulence characteristics. Data regarding the molecular profile of MRSA in Northern Cyprus is limited. The current study aimed to examine the virulence profiles of MRSA with a focus on toxin-associated factors. Ninety-one S. aureus isolates collected at a university hospital were included in the study. Identification and antibiotic susceptibility testing were performed with BD Phoenix™ automated system. Methicillin resistance was evaluated by the disc diffusion assay and mecA detection. The presence of nuc was confirmed by conventional PCR. Confirmed MRSA isolates were assessed for the presence of virulence genes hla, eta, etb, etd and tst using molecular methods. Among 91 S. aureus isolates identified as MRSA using the BD Phoenix™ platform, 80.85% (n = 76/91) were confirmed as MRSA using phenotypic and genotypic methods. All confirmed MRSA isolates (n = 76, 100%) were positive for the nuc. MRSA rates were statistically higher in elderly inpatients. The prevalence of toxin-encoding genes was 97.3% (n = 74/76) for hla, 2.63% (n = 2/76) for eta, 1.3% (n = 1/76) for etb, and 2.63% (n = 2/76) for tst. None of the screened isolates harbored the etd gene. These results represent the first report to investigate multiple virulence factors in MRSA isolates in Northern Cyprus.

Acute heart failure associated with toxic shock syndrome due to methicillin-susceptible Staphylococcus aureus during the postpartum period: case report and systematic literature review

BACKGROUND

Toxic shock syndrome (TSS) caused by Staphylococcus aureus in the postpartum period is a rare but life-threatening disease. We present a case of acute heart failure as the initial presentation of TSS due to methicillin-susceptible Staphylococcus aureus (MSSA) and describe its clinical characteristics with a systematic literature review.

CASE PRESENTATION

A 34-year-old woman, 8 days after a normal vaginal delivery presented to our hospital with dyspnea and fever. She had jugular venous distension, bilateral leg edema, and erythema. Laboratory examinations revealed elevated NT-pro-BNP level of 3,233 pg/mL. Transthoracic echocardiography showed elevated tricuspid regurgitation peak gradient, with decreased respiratory variability of the inferior vena cava diameter and bilateral pleural effusions. The patient was hospitalized with suspicion of congestive heart failure. MSSA positive for toxic shock syndrome exotoxin-1 was detected in the culture of the perineal incision wound, and we diagnosed TSS caused by MSSA. Intravenous diuretics were administered, along with eventual cefazolin plus clindamycin. After 2 weeks of antimicrobial therapy, the patient showed improvement and was discharged. No recurrence was observed at the 24-month follow-up.

CONCLUSION

This is a rare case report of acute heart failure being the initial manifestation of TSS due to MSSA in the postpartum period. Clinicians should consider TSS as a possibility in postpartum patients with acute heart failure. This systematic review provides insights into its clinical features, treatment regimens, and prognosis of TSS by S. aureus in the postpartum period. TSS requires an appropriate, prompt diagnosis, because delayed treatment can be fatal.

Identification of a novel fully human anti-toxic shock syndrome toxin (TSST)-1 single-chain variable fragment antibody averting TSST-1-induced mitogenesis and cytokine secretion

Background

Staphylococcal superantigens are virulence factors that help the pathogen escape the immune system and develop an infection. Toxic shock syndrome toxin (TSST)-1 is one of the most studied superantigens whose role in toxic shock syndrome and some particular disorders have been demonstrated. Inhibiting TSST-1 production with antibiotics and targeting TSST-1 with monoclonal antibodies might be one of the best strategies to prevent TSST-1-induced cytokines storm followed by lethality.

Results

A novel single-chain variable fragment (scFv), MS473, against TSST-1 was identified by selecting an scFv phage library on the TSST-1 protein. The MS473 scFv showed high affinity and specificity for TSST-1. Moreover, MS473 could significantly prevent TSST-1-induced mitogenicity (the IC₅₀ value: 1.5 µM) and cytokine production.

Conclusion

Using traditional antibiotics with an anti-TSST-1 scFv as a safe and effective agent leads to deleting the infection source and preventing the detrimental effects of the toxin disseminated into the whole body.

Supplementary information

The online version contains supplementary material available at 10.1186/s12896-022-00760-8.

The Association Between Onset of Staphylococcal Non-menstrual Toxic Shock Syndrome With Inducibility of Toxic Shock Syndrome Toxin-1 Production

Non-menstrual toxic shock syndrome (non-mTSS) is a life-threatening disease caused by Staphylococcus aureus strains producing superantigens, such as staphylococcal enterotoxins A, B, C, and toxic shock syndrome toxin-1 (TSST-1). However, little is known about why the TSS cases are rare, although S. aureus strains frequently carry a tst gene, which encodes TSST-1. To answer this question, the amount of TSST-1 produced by 541 clinical isolates was measured in both the presence and absence of serum supplementation to growth media. Then a set of S. aureus strains with similar genetic backgrounds isolated from patients presenting with non-mTSS and those with clinical manifestations other than non-mTSS was compared for their TSST-1 inducibility by human serum, and their whole-genome sequences were determined. Subsequently, the association of mutations identified in the tst promoter of non-mTSS strains with TSST-1 inducibility by human serum was evaluated by constructing promoter replacement mutants and green fluorescent protein (GFP) reporter recombinants. Results showed that 39 out of 541 clinical isolates (7.2%), including strains isolated from non-mTSS patients, had enhanced production of TSST-1 in the presence of serum. TSST-1 inducibility by human serum was more clearly seen in non-mTSS strains of clonal complex (CC)-5. Moreover, the whole-genome sequence analysis identified a set of sequence variations at a putative SarA-binding site of the tst promoter. This sequence variation was proven to be partially responsible for the induction of TSST-1 production by human serum. We conclude that the onset of staphylococcal toxic shock syndrome caused by TSST-1-producing CC-5 strains seem at least partially initiated by serum induction of TSST-1, which is regulated by the mutation of putative SarA-binding site at the tst promoter.

Water, Sanitation and Hygiene in Schools in Low- and Middle-Income Countries: A Systematic Review and Implications for the COVID-19 Pandemic

The global COVID-19 pandemic has revealed the extent to which schools are struggling with the provision of safe drinking water, sanitation and hygiene (WASH). To describe the WASH conditions in schools and discuss the implications for the safe reopening of schools during the ongoing COVID-19 pandemic, a systematic review of peer-reviewed literature on WASH in schools in low- and middle-income countries was performed. In April 2021, five databases, including MEDLINE (via PubMed), Web of Science, Scopus, AJOL, and LILACS, were used to identify studies. Sixty-five papers met the inclusion criteria. We extracted and analyzed data considering the Joint Monitoring Programme (JMP) definitions and the normative contents of Human Rights to safe drinking water and sanitation. Publications included in this systematic review considered 18,465 schools, across 30 different countries. Results indicate a lack of adequate WASH conditions and menstrual hygiene management requirements in all countries. The largely insufficient and inadequate school infrastructure hampers students to practice healthy hygiene habits and handwashing in particular. In the context of the COVID-19 pandemic, being hindered to implement such a key strategy to contain the spread of SARS-CoV-2 in the school environment is of major concern.

Thrombus formation and ischemic necrosis of the uterus and adnexa due to purpura fulminans: A case report

Purpura fulminans (PF) is a syndrome characterized by the sudden onset of progressive skin hemorrhage, necrosis of the extremities, and thrombotic occlusion. Although the cause is believed to be protein C deficiency, many aspects of this syndrome have yet to be clarified. A 45-year-old Japanese woman, G2P2 (vaginal delivery), developed fever and lower abdominal pain. It was her 5th day of menstruation, and a tampon had been in the vagina for a few days. Septic shock and disseminated intravascular coagulation were diagnosed, and multidisciplinary treatment was started. Also, toxic shock syndrome due to tampon use was suspected. The purpura on the limbs turned into blisters and then blackish-purple spots, leading to hemorrhagic necrosis within a few days. Moreover, imaging showed that the uterus and both adnexa had enlarged significantly, and raised suspicion of abscess formation. Total hysterectomy and bilateral adnexectomy were performed, and the histopathological diagnosis was hemorrhagic necrosis due to extensive thrombus formation. In men, PF affects the scrotum and penis, leading to autoamputation of the male genitalia, while there are no reports of PF involving the female genitalia. Regarding the PF, in this case, we considered the possibility of pathologic conditions progressing to the female genitalia.

Toxic shock syndrome associated with menstrual cup use

Staphylococcal toxic shock syndrome is a rare but life-threatening condition. It occurs when Staphylococcus aureus bacteria colonizing the vagina of a healthy woman, produce toxic shock syndrome toxin 1 activating the immune system and leading to multiorgan failure. Menstrual cups also known as vaginal cups are usually used as alternatives to other intravaginal products for menstrual blood collection. In rare cases, they can also lead to toxic shock syndrome. We report a case of toxic shock syndrome associated with vaginal cup use in a healthy menstruating woman. The diagnosis was made based on the United States Centers for Disease Control and Prevention criteria of the syndrome and confirmed with a vaginal cultural growth of Staphylococcus aureus.

Menstrual toxic shock syndrome: a French nationwide multicenter retrospective study

BACKGROUND

Studies describing the clinical features and short-term prognosis of patients admitted to the intensive care unit (ICU) for menstrual toxic shock syndrome (m-TSS) are lacking.

METHODS

This was a multicenter retrospective cohort study of patients with a clinical diagnosis of m-TSS admitted between January 1, 2005 and December 31, 2020 in 43 French pediatric (n=7) or adult (n=36) ICUs. The aim of the study was to describe the clinical features and short-term prognosis, as well as assess the 2011 Centers for Disease and Control (CDC) diagnostic criteria, of critically ill patients with m-TSS.

RESULTS

In total, 102 patients with m-TSS (median age: 18 [16-24] years) were admitted to one of the participating ICUs. All blood cultures (n=102) were sterile. Methicillin-sensitive Staphylococcus aureus grew from 92 of 96 vaginal samples. Screening for super-antigenic toxin gene sequences was performed for 76 of the 92 (83%) vaginal samples positive for Staphylococcus aureus and TSST-1 isolated from 66 (87%) strains. At ICU admission, no patient met the 2011 CDC criteria for confirmed m-TSS and only 53 (52%) fulfilled the criteria for probable m-TSS. Eighty-one patients (79%) were treated with anti-toxin antibiotic therapy and eight (8%) received intravenous immunoglobulins. Eighty-six (84%) patients required vasopressors and 21 (21%) tracheal intubation. No patient required limb amputation or died in the ICU.

CONCLUSIONS

In this large multicenter series of patients included in ICUs for m-TSS, none died or required limb amputation. The CDC criteria should not be used for the clinical diagnosis of m-TSS at ICU admission.

Vaginal Tampon Colonization by Staphylococcus aureus in Healthy Women

Tampons recovered from a cohort of 737 healthy women (median age, 32 years) were analyzed for the presence of Staphylococcus aureus A total of 198 tampons (27%) were colonized by S. aureus, 28 (4%) by a strain producing toxic shock syndrome toxin 1 (TSST-1). S. aureus was detected more frequently in tampons that did not require an applicator for their insertion (74/233 [32%] versus 90/381 [24%]; odds ratio [OR] = 1.51 [95% confidence interval, 1.04 to 2.17]) and in women who used an intrauterine device for contraception (53/155 [34%] versus 145/572 [27%]; OR = 1.53 [95% confidence interval, 1.05 to 2.24]). The S. aureus strains isolated from tampons belonged to 22 different clonal complexes (CCs). The most prevalent CC was CC398 agr1 (n = 57 [27%]), a clone that does not produce superantigenic toxins, followed by CC30 agr3 (n = 27, 13%), producing TSST-1 (24/27 [89%]), the principal clone of S. aureus involved in menstrual toxic shock syndrome (MTSS).IMPORTANCE Menstrual toxic shock syndrome (MTSS) is an uncommon severe acute disease that occurs in healthy menstruating women colonized by TSST-1-producing S. aureus who use intravaginal protection, such as tampons and menstrual cups. The catamenial product collected by the protection serves as a growth medium for S. aureus and allows TSST-1 production. Previous studies evaluated the prevalence of genital colonization by S. aureus by vaginal swabbing, but they did not examine tampon colonization. This study demonstrated a high prevalence of tampon colonization by S. aureus and the presence of the CC30 TSST-1 S. aureus clone responsible for MTSS in tampons from healthy women. The results support the vaginal carriage of this lineage in healthy women. In addition, the higher prevalence of S. aureus within tampons that do not require an applicator indicates a crucial role for handwashing before tampon handling to decrease the risk of tampon contamination.

Disparate effects of methicillin-resistant Staphylococcus aureus infection on renal function in IgA-dominant infection-associated glomerulonephritis and menstrual toxic shock syndrome: a case report and literature review

The sudden outbreak of severe acute respiratory syndrome coronavirus 2 pneumonia posed a significant challenge to medical professionals because treatment of critically ill patients requires the efforts of a multidisciplinary team. To highlight this principle, we examined acute kidney injury (AKI) in IgA-dominant infection-associated glomerulonephritis (GN) and menstrual toxic shock syndrome (mTSS). Both GN and mTSS are rare diseases caused by staphylococcal infection, and renal function is frequently impaired. The resulting AKIs are disparate pathological entities driven by distinct immune mechanisms. We begin by describing the case of a diabetic man with pyopneumothorax following methicillin-resistant Staphylococcus aureus (MRSA). He had endocapillary proliferative GN with in situ IgA-dominant immune-complex formation in the mesangium accompanied by complement C3 deposition in the glomerular capillary wall. By contrast, acute tubular necrosis was observed in a case of mTSS; the patient’s immune response was stimulated differently by MRSA enterotoxin and exotoxin resulting in aberrant IgA deposition, complement activation, and insufficient antibody production. As a multidisciplinary communication covering the fields of nephrology, immunology, and pathology, this report may help clinicians to understand these distinct renal lesions and make optimal therapeutic decisions expeditiously.

Association of characteristics of tampon use with menstrual toxic shock syndrome in France

BACKGROUND

Menstrual tampons are widely used in western countries. Indirect evidence suggests that tampon misuse could be associated with an increased risk of menstrual toxic shock syndrome (MTSS). The aim of this study was to determine what characteristics of tampon use are associated with increased risk of menstrual toxic shock syndrome (MTSS).

METHODS

A nationwide, case-control study in France, was conducted with women that use tampons with MTSS diagnoses according to the CDC diagnostic criteria (n = 55, from January 2011, to December 2017) and a control group of women with no MTSS history (n = 126, from February to December 2017). Information regarding tampon use during a 6-month period was collected. Associations between tampon use and MTSS were assessed using logistic regression models stratified by residential area.

FINDINGS

Compared to controls, women diagnosed with MTSS more frequently reported maximum tampon wear of >6 h (62% vs. 41%; P = 0.02), overnight tampon use (77% vs. 54%; P = 0.006), and neither read nor followed tampon instructions in case of reading (65% vs. 42%; P = 0.006). In univariate analysis, MTSS risk was two-fold higher with tampon use for >6 consecutive hours (odds ratio, 2.3 [95% CI, 1.2-4.5]), and three-fold higher with tampon use during sleep for >8 h (odds ratio, 3.2 [95% CI, 1.4-7.7]). In multivariate logistic regression analysis, only maximum tampon use for >6 h (odds ratio, 2.03 [95% CI, 1.04-3.98]), and neither read nor followed the tampon instructions in case of reading (odds ratio, 2.25 [95% CI, 1.15-4.39]) were independently associated with MTSS.

INTERPRETATION

Our study suggests that the risk of MTSS was associated with using tampons for more than 6 h, overnight tampon use during sleep, and neither read nor followed tampon insertion instructions in case of reading.

FUNDING

LABEX ECOFECT (ANR-11-LABX-0048) of Université de Lyon within the programme "Investissements d'Avenir" (ANR-11-IDEX-0007) operated by the French National Research Agency (ANR).

IL-35 is critical in suppressing superantigenic Staphylococcus aureus-driven inflammatory Th17 responses in human nasopharynx-associated lymphoid tissue

The human nasopharynx is frequently exposed to microbial pathogens, including superantigen-producing Staphylococcus aureus (SAg-Sau), which activates potent pro-inflammatory T cell responses. However, cellular mechanisms that control SAg-Sau-driven T cell activation are poorly understood. Using human nasopharynx-associated lymphoid tissue (NALT), we show that SAg-Sau drove a strong Th17 activation, which was associated with an impaired CD4⁺ T cell-mediated immune regulation. This impairment of immune control correlated with a significant downregulation of interleukin-35 (IL-35) expression in tonsillar CD4⁺ T cells by SAg-Sau. Supplementing recombinant IL-35 suppressed SAg-Sau-activated Th17 responses, and this IL-35-mediated suppression positively correlated with the level of Th17 activation. Interestingly, SAg-Sau stimulation induced Foxp3⁺ Treg expansion and interleukin-10 (IL-10) production, which effectively suppressed the Th1 response, but failed to control the activation of Th17 cells. Overall, our results reveal an aberrant T cell regulation on SAg-Sau-driven Th17 activation and identify IL-35 as a critical cytokine to control superantigenic S.aureus-activated Th17 responses.