Fatal toxic shock syndrome following tattooing.

Background: Toxic shock syndrome (TSS) is a rare but potentially fatal condition caused by toxin-producing strains of Staphylococcus aureus. While typically associated with menstruation or postoperative complications, non-menstrual forms related to skin trauma, including tattooing, are increasingly recognized.

Case presentation: We report the sudden death of a woman in her early thirties who had experienced dizziness and circulatory instability in the days preceding death. She had recently undergone multiple tattoo sessions for a full-arm ("sleeve") tattoo. At medicolegal external examination, no traumatic injuries were found apart from a recent tattoo-associated skin lesion but the postmortem rectal temperature was elevated at 41.1 °C. Autopsy revealed white mucous content in the airways and widespread coagulated blood in major vessels, but no morphological cause of death. Postmortem blood cultures grew Staphylococcus aureus, and PCR confirmed the presence of the toxic shock syndrome toxin-1 (TSST-1) gene. Histological examination of the tattooed skin demonstrated granulocytic infiltration consistent with acute local inflammation. Findings were interpreted as consistent with fulminant TSS, with the tattooed skin as a plausible bacterial entry site.

Conclusion: This case emphasizes the need to consider TSS as a differential diagnosis in sudden deaths with systemic inflammatory features, particularly when recent skin trauma is present. Postmortem microbiological and molecular diagnostics are crucial in establishing this rare diagnosis.