Years after Air Force Capt. Rebecca Lauters worked in an emergency room, the memory of a young woman who came in gravely ill still stands out. The patient was in her 20s, Lauters thought, with symptoms so severe that she was barely responsive. The diagnosis: toxic shock syndrome.

The National Institutes of Health defines toxic shock syndrome as a condition caused by a toxin that is produced by some types of staphylococcus bacteria. When the toxins are released into the blood stream, they spread to the organs, which can lead to shock, illness, and potentially death.

“Toxic shock syndrome is not common, but we can possibly decrease the prevalence even more by making women aware of the signs and how they can prevent it,” said Lauters, a physician specializing in Family medicine at Eglin Air Force Base, Florida.

Lauters said in 2016, the Centers for Disease Control and Prevention received reports of 323 cases of TSS in the United States among men and women. Of those cases, 26 were fatal, she said.

“Early symptoms are similar to other infections, but they can progress quickly to become life-threatening,” Lauters said.

In such cases, she recommends seeking medical attention immediately. Symptoms include a sudden onset of fever greater than 102 degrees, a widespread red rash, nausea and vomiting, headache, muscle aches, abdominal pain, diarrhea and disorientation.

She said women need to be aware of a particular warning sign: “If you’re at the onset of your period and you start feeling like this and have this rash, you need to be seen by a provider. The biggest reason for fatality is that toxic shock is not recognized soon enough.”

In women, TSS has been linked with tampon use during menstruation, with nearly half of current cases linked to tampon use, NIH said. Lauters said women ages 15-24 are at greater risk, most likely because of the lack of knowledge about proper tampon usage. Diagnoses of TSS spiked during the 1970s and 80s as a result of a substance in the tampons at the time, but the number has since declined and remained steady since the late 1980s, she said.

Army Lt. Col. Caela Miller, an obstetrician-gynecologist at Tripler Army Medical Center, Hawaii, and deputy consultant for obstetrics and gynecology to the Office of the Surgeon General, said the spike in infections caused companies producing feminine products to change how they made tampons.

“After that happened, the rate of TSS became very rare,” said Miller, adding it is unclear why some women develop it and others do not. She recommends women use the lowest absorbency tampon possible and change them frequently, with no more than six to eight hours in between.

“You want to change it as frequently as possible, even on light flow days,” said Miller, who advises against wearing a tampon overnight.

For women working in a field environment, symptoms of TSS are similar to those of heatstroke, she warns.

“If you’re in an environment where it’s not possible to change tampons frequently, you may want to consider other options, such as pads or birth control that helps delay the menstrual cycle,” Miller said

Women can develop TSS from diaphragm and sponge usage as well, she said. According to the National Institutes of Health, TSS also can be associated with skin infections, burns, recent childbirth, recent surgery and wound infection after surgery.

Once a person goes into shock, the likelihood of survival depends on how early antibiotics, fluids and blood pressure supporting medications are received, Miller said.

“It’s a very difficult diagnosis to make, and I think it’s something that’s hard because tampons are sort of just a fact of life in developed countries,” Miller said.

She recommends going to a facility that has intensive care unit capabilities. Recovery can range from a couple of days to a couple of weeks, depending on the severity and stage of illness.

Miller warns women who have developed TSS are more likely to have recurrent infections. After the initial infection, the vagina can become colonized with the staphylococcus bacteria that produces the toxin, so if a woman has survived TSS, she should no longer use tampons, she said.

While the possibility of TSS should not prevent women from wearing tampons, it is important to be aware of the symptoms and seek medical attention if they arise, especially during the first few days of the menstrual cycle, Miller said.

“Most women who wear tampons are just fine, but it’s important to realize that occasionally, complications like toxic shock syndrome can happen,” she said.