A Report of Staphylococcus Scalded Skin Syndrome in Adult

Summary@#Staphylococcal scalded skin syndrome (SSSS) is typically a clinical diagnosis,1 affecting primarily neonates and children. It is characterised by a diffuse skin disorder with tenderness, erythema, large wrinkled superficial blistering, and desquamation caused by the hematogenous dissemination of exotoxin-producing strains of staphylococcus aureus to the skin.4,10 Hospital admission is required for intravenous anti-staphylococcal antibiotic therapy and supportive care. The rarity of SSSS in adults is best explained by the presence of exotoxins neutralizing antibodies and renal elimination of the toxins.2 Two major risk factors are kidney failure and immunosuppression. Therefore, SSSS in adults warrants thorough evaluation.3 Mortality is also greater than 60% in adults, attributed to predisposing comorbid conditions.1,4 One of the mimickers of SSSS is toxic epidermal necrolysis (TEN). Here, we report a successful treatment of SSSS in an adult with recreational drug abuse and incidental liver cirrhosis possibly secondary to hepatitis C viral infection, after careful exclusion of TEN.

No Epidermis: Is it the drug, COVID-19 or Something Else?

Summary@#Staphylococcal toxic shock syndrome (TSS) is a clinical disease with acute onset of fever, rash, hypotension and multi-organ system involvement. Staphylococcal scalded skin syndrome (SSSS), mostly described in neonate and children, is a superficial blistering disease caused by the exfoliative toxin of specific strains of Staphylococcus aureus. TSS and SSSS rarely occur concurrently in adults. We here describe a 35-year-old woman who was initially referred to dermatology team as toxic epidermal necrolysis. She presented with a rapid epidermal detachment without mucosal involvement, fever and shock, associated with acute kidney injury and transaminitis, severe metabolic acidosis, complicated by COVID-19 infection, and finally succumbed within 36 hours of hospitalization. Early recognition and prompt treatment are the key factors in the management as TSS itself can lead to mortality. Staphylococcal TSS and SSSS are important differential diagnosis to consider in acute epidermal detachment, as not all cases are drug-induced.

Descripcion Fisiopatológica de la Descamacion Cutanea por Toxinas Exfoliativas Estafilococicas, Nuevo Enfoque de Diagnostico Diferencial

Resumen El síndrome de piel escaldada estafilocócica, la escarlatina estafilocócica y el impétigo ampollar son patologías que tienen en común el mecanismo de lesión de la piel por toxinas exfoliativas producidas por estafilococos, su presentación y manifestaciones clínicas son difíciles de diferenciar de otras patologías sistémicas como la enfermedad de Kawasaki, el síndrome de Steven Johnson y diferentes farmacodermias. En los últimos años se ha podido explicar el mecanismo molecular de lesión cutánea, lo que ayudo de manera importante a interpretar y poder realizar un adecuado diagnóstico diferencial entre estas patologías. Los pediatras necesitan múltiples herramientas para llegar a un diagnóstico certero de las noxas que producen lesiones en piel y manifestaciones sistémicas. Una buena anamnesis y el conocimiento de un abanico de diagnósticos diferenciales son importantes para el tratamiento médico.

Abstract Staphylococcal scalded skin syndrome, staphylococcal scarlet fever and bullous impetigo are pathologies that have in common the mechanism of skin injury by exfoliative toxins produced by staphylococci, their presentation and clinical manifestations are difficult to differentiate from other systemic pathologies such as Kawasaki disease, the syndrome of Steven Johnson and drug induced skin diseases. In recent years, it has been possible to explain the molecular mechanism of skin injury, which has helped in an important way to interpret and be able to make an adequate differential diagnosis between these pathologies. Pediatricians need multiple tools to reach an accurate diagnosis of the disease that produce skin lesions and systemic manifestations. A good history and knowledge of a range of differential diagnoses are important for medical management.

Síndrome de la piel escaldada estafilocócica en un paciente pediátrico con dermatitis atópica / Staphylococcal scalded skin syndrome in a pediatric patient with atopic dermatitis

El síndrome de la escaldadura estafilocócica es una entidad dermatológica poco frecuente que, en fases iniciales, puede ser confundida con una reagudización de un brote de dermatitis atópica. Se presenta el caso de un niño de 8 años, con antecedentes de dermatitis atópica y alergia al huevo, que acudió al Servicio de Urgencias por lesiones eritematoampollosas en la piel. La sintomatología comenzó como un eritema en áreas de flexuras, que asociaba conjuntivitis y eritema palpebral bilateral. A las 24 horas, apareció un eritema generalizado con ampollas flácidas de predominio en áreas flexurales, acompañado de hiperqueratosis y xerosis perioral. Ante la sospecha clínica de síndrome de escaldadura estafilocócica, se inició el tratamiento empírico con cloxacilina, con respuesta favorable. Con este caso, se destaca la importancia de realizar un correcto diagnóstico diferencial de las lesiones cutáneas de los pacientes con dermatitis atópica, con el objetivo de aplicar el tratamiento más adecuado.

The staphylococcal scalded skin syndrome is a rare dermatological entity that in early stages may be confused with a flare-up of a rush of atopic dermatitis. We present the case of an 8-year-old boy with a history of atopic dermatitis and egg allergy that went to the Emergency Department for erythematous-bullous lesions on the skin. Symptoms began as an erythema in areas of flexures, which associated conjunctivitis and bilateral eyelid erythema. After 24 hours, a generalized erythema appeared with flaccid blisters predominating in flexural areas, accompanied by hyperkeratosis and perioral xerosis. Due to the clinical suspicion of staphylococcal scalded skin syndrome, empirical treatment with cloxacillin with favorable response was initiated. This case highlights the importance of making a correct differential diagnosis of skin lesions of patients with atopic dermatitis in order to apply the most appropriate treatment.

Infection related severe skin damage / 中国小儿急救医学

Infection plays an important role in the pediatric intensive care unit. Severe skin damage caused by bacterial infection often causes acute onset and high mortality,which should be paid attention to by clinicians. In this paper,the diagnosis,differential diagnosis and treatment of Staphylococcus aureus scalding syndrome and ecthyma gangrenosum caused by Pseudomonas aeruginosa infection were reviewed.

The Characteristics of Staphylococcal Scalded Skin Syndrome in Atopic Dermatitis / 고신대학교의과대학학술지

OBJECTIVES: Staphylococcal scalded skin syndrome (4S), a blistering dermatosis caused by exfoliative toxins from Staphylococcus aureus, occurs frequently in patients with atopic dermatitis (AD). However, association between 4S and AD has not rarely been reported. We investigated the characteristics of 4S according to AD status.METHODS: The study included 146 children with 4S who visited Busan St. Mary's Hospital from 2007–2018. Clinical features were analyzed from medical records and pictures, and 4S was classified as localized or generalized. We also retrospectively investigated the preceding conditions and test results related to AD.RESULTS: Among 146 patients with 4S, median age was 2.0 years, and 35 (24.0%) had AD. Since 2007, the incidence of both 4S and AD have increased, without obvious seasonal patterns. Generalized and localized disease occurred in 90 and 56 patients, respectively. Twenty-four of 35 patients with AD (68.6%) and 32 of 111 (28.8%) without AD had localized disease. Significant differences were observed between the groups (P = 0.000). Among those with AD, the most common preceding condition was skin infection or unknown (45.2%); however, respiratory disease was the most common (47.9%) among patients without AD. Eosinophil levels were higher in the AD group (P = 0.002), and there were no statistically significant differences in total immunoglobulin E (IgE), Dermatophagoides farinae (Df IgE), egg-white IgE, and culture results between the groups.CONCLUSIONS: Localized 4S frequently occurred without preceding conditions in children with AD and usually arose from skin infection compared to generalized 4S.

Antibiotic resistance of Staphylococcus aureus colonized in children with staphylococcal scalded skin syndrome / 고신대학교의과대학학술지

OBJECTIVES: Systemic antibiotic therapy with semisynthetic penicillinase-resistant penicillin or vancomycin and clindamycin are recommended for the treatment of staphylococcal scalded skin syndrome (SSSS). This study assessed the rate of antibiotic resistance of Staphylococcus aureus isolated from the anterior nares or skin of children diagnosed with SSSS. METHODS: A retrospective review of the medical records of 25 patients with SSSS between July 2010 and October 2014 was conducted. The clinical characteristics of patients were collected and the antibiotic susceptibility of S. aureus were analyzed using automated systems. RESULTS: The median age of the patients was 22 months (range: 2–95). Ninety-two percent of patients were less than 5 years of age. Nasal swab samples of all patients and skin swab samples of 17 patients were cultured to isolate S. aureus. Twenty-one (84%) of 25 patients were colonized with methicillin-resistant S. aureus (MRSA). The results of swab samples of the other four patients were no growth or isolation of bacteria other than S. aureus. Among 20 strains isolated from the anterior nares, 1 strain (5%) was methicillin-susceptible S. aureus. All 15 strains isolated from the skin were MRSA. All 21 strains isolated from anterior nares or skin were found to be resistant to clindamycin upon evaluation using automated systems. CONCLUSIONS: The rates of methicillin and clindamycin resistance in S. aureus colonized in children with SSSS were very high. Further studies evaluating proper antibiotic regimens and the effectiveness of systemic antibiotic therapy are needed.

Síndrome da pele escaldada estafilocócica no adulto. Relato de caso / Staphylococcal Scalded Skin Syndrome in adults: case report

A síndrome da pele escaldada estafilocócica é uma dermatose esfoliativa rara no adulto, que acomete cerca de 0,09 a 0,56 por milhão de habitantes. É causada por exotoxinas produzidas por Staphylococcus aureus e manifesta-se com a formação de lesões bolhosas difusas pelo corpo. O diagnóstico é feito por meio de exame físico, hemocultura, cultura de sítio infectado e análise histopatológica. As medidas de suporte e a antibioticoterapia são a base do tratamento. Este relato descreve o raro acometimento de paciente idoso e evidencia a associação da doença com a imunossupressão. A presença de lesões em mucosa oral é um achado atípico e similar a um dos principais diagnósticos diferenciais da síndrome da pele escaldada estafilocócica: a necrólise epidérmica tóxica. É de suma importância diferenciá-las por meio de análise histopatológica das lesões de pele devido às formas inerentes de tratamento e à gravidade. O relato alerta para a importância do rápido reconhecimento do diagnóstico, a fim de introduzir tratamento adequado precoce, evitando os riscos da terapia inadequada e das complicações naturais da doença. Desta forma, é possível alcançar um desfecho positivo em uma doença de baixa prevalência e alta mortalidade no adulto.(AU)

The Staphylococcal Scalded Skin Syndrome is a rare exfoliative dermatitis in adults, affecting about 0.09 to 0.56 per million inhabitants. It is caused by exotoxins produced by Staphylococcus aureus and is manifested by the formation of diffuse bullous body lesions. The diagnosis is made through physical examination, blood culture, infected site culture, and histopathology. Supportive measures and antibiotics are the mainstay of the treatment. This report describes the rare involvement of an elderly patient, and highlights the association of the disease with immunosuppression. The presence of lesions in the oral mucosa is an atypical finding, being similar to one of the main differential diagnosis of the Staphylococcal Scalded Skin Syndrome: the Toxic Epidermal Necrolysis. It is very important to differentiate them through histopathology of the skin lesions due to the peculiar forms of treatment and the severity of the diseases. The report highlights the importance of rapid recognition of diagnosis in order to introduce early appropriate treatment, avoiding the risks of inappropriate therapy, and natural complications of the disease. This way, it is possible to achieve a positive outcome in a disease of low prevalence and high mortality in adults.(AU)

Recent Trends in Methicillin-resistant Staphylococcus aureus Infection and Antibiotic Treatment in Staphylococcal Scalded Skin Syndrome in Patients in Childhood: A Single-center Study / 대한피부과학회지

BACKGROUND: Staphylococcal scalded skin syndrome (SSSS) is a blistering disease of superficial skin mediated by Staphylococcus aureus (S. aureus) exfoliative toxin. Generally, SSSS affects mainly infants and children younger than 5 years and has a good prognosis. However, an increasing number of cases of methicillin-resistant S. aureus (MRSA) have been reported recently. OBJECTIVE: The purposes of this study were to evaluate the clinical features and course, to investigate the microbiological manifestations, and to perform antimicrobial susceptibility testing of SSSS among Korean children. METHODS: From March 2003 to July 2016, a total of 141 children were included in this study. The patients were divided into two different groups according to time of onset of their disease: before or after September 2011. We retrospectively reviewed medical records, microbiological results, bacterial detection sites, and antimicrobial susceptibility tests of all participating children. The results of comparison between the two groups were evaluated using the chi-square test. RESULTS: S. aureus infections were identified in all patients. Among all cultured S. aureus specimens, 63.1% (89/141) showed methicillin resistance. Beginning in September 2011, MRSA infection showed a significantly higher prevalence than that previously demonstrated (71.7% vs. 38.8%; p=0.0010). Moreover, MRSA infections were detected on the skin and neck and in the nose (each detected on 61, 41, and 18 occasions, respectively) with overlap observed in many cases. CONCLUSION: In conclusion, since the prevalence of MRSA infection has been gradually increasing in recent years, careful consideration is needed in the selection of antibiotics covering MRSA.

Pathogenic Bacteria and Drug Sensitivity of 374 Cases of Children with Staphylococcal Scalded Skin Syn-drome / 中国药师

Objective:To understand the pathogen bacteria detection and drug sensitivity results in the children with staphylococ -cal scalded skin syndrome to provide data for the clinical treatment .Methods: Totally 374 children with staphylococcal scalded skin syndrome treated from January 2010 to June 2015 were selected .The children's wound secretion and blood samples were collected , and bacterial culture and drug sensitivity test were carried out .Results:Totally 223 pathogenic bacteria were detected out in the wound se-cretion samples;17 cases of blood culture were positive with the positive rate of 4.55%;187 strains of staphylococcus aureus were de-tected out;64 strains of MRSA were found out with the MRSA detection rate of 34.22% (64/187).The sensitivities of MSSA and MRSA to common antibacterial drugs were different .The susceptibility rates of MSSA and MRSA to vancomycin , teicoplanin , teicopla-nin and linezolid were all 100.00%.The sensitivity rates of MRSA to penicillin , oxacillin, piperacillin, piperacillin, cefoperazone so-dium, cefazolin, cefuroxime, cefoxitin, azithromycin and clindamycin were all zero .Conclusion: The pathogenic examination of staphylococcal scalded skin syndrome is very important , and antibiotics should be used reasonably according to the results of drug sensi-tivity.

Staphylococcal scalded skin syndrome in a premature newborn caused by methicillin-resistant Staphylococcus aureus: case report / Síndrome da pele escaldada estafilocócica em um recém-nascido prematuro causada por Staphylococcus aureus meticilina-resistente: relato de caso

CONTEXT: Staphylococcal scalded skin syndrome is an exfoliative skin disease. Reports of this syndrome in newborns caused by methicillin-resistant Staphylococcus aureus are rare but, when present, rapid diagnosis and treatment is required in order to decrease morbidity and mortality. CASE REPORT: A premature newly born girl weighing 1,520 g, born with a gestational age of 29 weeks and 4 days, developed staphylococcal scalded skin syndrome on the fifth day of life. Cultures on blood samples collected on the first and fourth days were negative, but Pseudomonas aeruginosa and Enterococcus sp. (vancomycin-sensitive) developed in blood cultures performed on the day of death (seventh day), and Pseudomonas aeruginosa and Serratia marcescens were identified in cultures on nasopharyngeal, buttock and abdominal secretions. In addition to these two Gram-negative bacilli, methicillin-resistant Staphylococcus aureus was isolated in a culture on the umbilical stump (seventh day). The diagnosis of staphylococcal scalded skin syndrome was based on clinical criteria.

CONTEXTO: A síndrome da pele escaldada estafilocócica é uma doença esfoliativa de pele. São raros os relatos desta síndrome causada por Staphylococcus aureusresistente à meticilina em neonatos, mas, quando presentes, exigem diagnóstico e tratamento rápidos para diminuir a morbidade e mortalidade. RELATO DE CASO: Uma menina recém-nascida prematura, pesando 1.520 g ao nascimento, com idade gestacional de 29 semanas e 4 dias, desenvolveu síndrome da pele escaldada estafilocócica no quinto dia de vida. As culturas de sangue coletadas no primeiro e quarto dias foram negativas, mas houve desenvolvimento de Pseudomonas aeruginosa e Enterococcus sp. (vancomicina sensível) na hemocultura realizada no dia do óbito (sétimo dia) e Pseudomonas aeruginosa e Serratia marcescens foram identificadas nas culturas de secreção da nasofaringe, nádega e da secreção abdominal. Na cultura do coto umbilical (sétimo dia), além desses dois bacilos Gram-negativos, foi isolado o Staphylococcus aureus resistente à meticilina. O diagnóstico da síndrome da pele escaldada estafilocócica foi baseado em critério clínico.

Staphylococcal scalded skin syndrome – A case series with review of literature.

Staphylococcal scalded skin syndrome (SSSS) is an acute dermatological illness which requires prompt treatment. It is a condition associated with widespread exfoliation of skin caused by Staphylococcus aureus (SA). The toxins elaborated by these gram positive microorganisms especially the exfoliative toxins A and B causes the SSSS. Literature review mentions that only 5% of SA produces these exfoliative toxins. The main route of spread of the toxins is by the hematogenous spread and the process results in extensive damage to the epidermis. This case series reports the SSSS in two children and highlights the significance of promptly diagnosing this serious pediatric dermatological illness.

Staphylococcal Scalded Skin Syndrome, A Descriptive Review of 17 Korean Patients / 대한피부과학회지

BACKGROUND: Staphylococcal scalded skin syndrome is a superficial blistering skin disease caused by exfoliative toxins of Staphylococcus aureus. Adult cases are rare but accompanied by high mortality rates and poor prognoses. A rapid diagnosis, including distinguishing this disease from toxic epidermal necrolysis, and immediate treatment are essential. An increasing number of methicillin-resistant Staphylococcus aureus cases has been reported recently, which further complicates the treatment options. OBJECTIVE: We performed this study to evaluate clinical features and courses, and to investigate microbiological and histological manifestations of staphylococcal scalded skin syndrome in Korean children and adults. METHODS: We retrospectively reviewed, among 14 children (including 2 neonates) and 3 adults, medical records, clinical photographs, microbiological results and histological findings, including frozen section on the blister roof and Tzanck smear in some patients. RESULTS: The adult patients had longer disease durations than children (mean 24.7 versus 9.9 days). One adult patient died of pneumonia and sepsis. The children recovered without complications. All of cultured Staphylococcus aureus in 11 of the 17 patients were methicillin-resistant. On the frozen sections, the roof of the blister consisted of the uppermost epidermis. Taking specimens from fresh blisters was important for clear diagnosis. CONCLUSION: Adult patients had longer disease durations and poorer prognoses than children. The frozen section on the roof of fresh blister and the Tzanck smear were convenient methods for early and dependable diagnosis. Given the prevalence of methicillin-resistant strains of Staphylococcus aureus, treating the condition with antibiotics covering this strain should be considered.

A Clinical Review of Staphylococcal Scalded Skin Syndrome for the Last 10 Years

OBJECTIVE: Staphylococcal scalded skin syndrome (4S) is not common, but has been increasingly recognized. We investigated the clinical features of 4S for the last 10 years. METHODS: This retrospective study was performed on 68 children who were admitted with 4S during 2001 to 2011. The patients were divided into 3 age groups: or =48 months. We evaluated the clinical findings and the differences among the 3 age groups. RESULTS: The mean age was 32 months with a peak incidence at age 12 to 47 months. The peak incidence was observed in 2007 with a seasonal occurrence, mainly from July to October. Except 2007, there was no obvious seasonal pattern in incidence. Atopic dermatitis was combined in 10 patients (14.7%). By clinical types, 4 patients (5.9%) were in generalized type, 17 patients (25%) in intermediate type, and 47 patients (69.1%) in abortive type. The patients with generalized type were all neonates, and intermediate type was more frequent in children younger than 12 months. In contrast, abortive type was a most frequent form after 12 months of age. Of 44 patients performed skin culture, methicillin-resistant Staphylococcus aureus was isolated in 25 cases. All affected patients recovered completely with semi-synthetic penicillin or 3rd generation cephalosporins. Four neonates were treated with vancomycin or teicoplanin. CONCLUSION: The peak incidence of 4S was at age 12 to 47 months. The severity of 4S was most severe in children younger than 12 months, showing a difference in clinical types according to the age groups.

Síndrome estafilocócico de la piel escaldada. Nuestra experiencia en 10 años / Staphylococcal scalded skin syndrome (SSSS). Our 10-year experience

El síndrome estafilocócico de la piel escaldada (SEPE) es una enfermedad cutánea aguda infrecuente, causada por toxinas exfoliativas del Staphylococcus aureus. El objetivo de este estudio es describir las características epidemiológicas, clínicas y terapéuticas de los pacientes con diagnóstico de SEPE en nuestro medio.Material y métodos.Se realizó un estudio retrospectivo, descriptivo y observacional, en el que se revisaron las historias clínicas de los pacientes con diagnóstico de SEPE vistos entre mayo de 2000 y mayo de 2010, atendidos en la Sección de Dermatología Pediátrica del Hospital Ramos Mejía, y entre mayo de 2005 y mayo de 2010 en el Servicio de Dermatología del Hospital Alemán.Resultados.Se incluyó un total de 62 pacientes, cuya edad media al momento del diagnóstico fue de 22 meses. No se observó predilección por sexo ni estación del año. El 13% de los pacientes recibió corticoides sistémicos previo al diagnóstico de SEPE. Todos los pacientes excepto uno, realizaron tratamiento antibiótico luego del diagnóstico de esta entidad. El 92% recibió cefalosporinas de primera generación. El 23% de los pacientes requirió internación y el 100% evolucionó satisfactoriamente.Conclusiones.El SEPE es una entidad poco frecuente. Si bien en nuestro medio no hallamos datos epidemiológicos sobre esta entidad, los datos demográficos encontrados en este estudio difieren de los publicados en la literatura mundial. Debe sospecharse en recién nacidos y niños pequeños con eritrodermia aguda y afectación peribucal o conjuntival.

Staphylococcal scalded skin syndrome (SSSS) is a rare cutaneous disease caused by exfoliativetoxins of Staphylococcus aureus. The aim of this study is to describe the epidemiology, clinicalmanifestations and treatment of patients with the diagnosis of SSSS in our community.Methods. We conducted a retrospective, descriptive and observational study, reviewing the clinicalrecords of patients with a diagnosis of SSSS, as seen between May 2000 and May 2010 atthe Pediatric Dermatology Section of the Hospital Ramos Mejía, and between May 2005 and May2010 at the Dermatology Unit of the Hospital Alemán.Results. A total of 62 patients were included, whose average age at the time of diagnosis was22 months. No predilection for sex or season of the year was observed. Thirteen percent of thepatients received systemic steroids prior to SSSS diagnosis. All but one of the patients received antibiotictreatment after the diagnosis of this entity. First generation cephaloporins were given to92% of patients; 23% of them required hospitalization and all of them had a satisfactory outcome.Discussion. SSSS is an infrequent entity. Even though there are no epidemiological studies inour country concerning SSSS, the data we gathered differs with world-wide published literature.SSSS must be suspected in new-borns and in young children with an acute onset of erythroderma,perioral affectation and conjunctivitis.

Síndrome de la piel escaldada estafilocóccica / Staphylococcal scalded skin syndrome

Lactante de 10 meses de edad, de sexo femenino, procedente del área periurbana de Encarnación, ingresa con lesiones cutáneas de 7 días de evolución tipo ampollosas al inicio, que luego se rompieron dejando un exudado seroso y con costras, simulando una quemadura, rápidamente extensivas a todo el cuerpo. Examen físico: Paciente grave, hipoactiva e irritable, con lesiones descamativas en todo el cuerpo, con pocas lesiones ampollosas, signo de Nikolsky (+), áreas de piel agrietada, otras denudadas, con costras melicéricas. Signos de deshidratación severa y edema de extremidades. Tª 38ºC, Peso 8650 grs., Talla: 69,5 cm, FR 40, FC 150. Se instala vía central, se realizan expansiones con solución fisiológica y se inicia cefotaxima más oxacilina. Estudios auxiliares: Hemograma; GB 22400 por mm3, N 59%, L 41%, Hg 10,7 gr/dl, Hcto. 33 %, Glucosa: 103 mg/dl, Urea: 65mg/dl, Calcio: 5,4 mg/dl, PCR positivo, VDRL no reactivo, HIV negativo. Plaquetas 360000 por mm3, TP 35% de actividad, Albúmina: 2,1g/dl. Orina simple normal. Electrolitos; Sodio146, Potasio: 5,59. Rx de tórax normal. Al 3º día de internación presenta Hg7 gr/dl, Hcto 22 %, requirió transfusión de GRC, albúmina, vitamina K, corrección de Calcio por hipocalcemia y convulsiones. Recibió leche Kass1000 por SNG y se le realizó lavados de piel con solución fisiológica. Paciente muy grave y edematizada los 3 primeros días y luego con mejoría progresiva, fue dada de alta a los 14 días con nivel de albúmina de 3,6 g/dl, sin edemas y con la piel cicatrizada con indicación de emolientes cutáneos y orientación nutricional. El síndrome de la Piel Escaldada es una entidad grave cuando se presenta en la forma generalizada; en este caso la consulta tardía agravó la presentación clínica, ingresando la paciente en estado séptico y con complicaciones severas. El manejo de estos pacientes requiere de una UCIP, nuestra niña fue atendida en una sala de terapia intermedia con los recursos básicos para su tratamiento exitoso.

Introduction: Staphylococcal Scalded Skin Syndrome, or Ritter’s disease, is a severe skin condition caused by the systemic impact of the exfoliative toxin produced by Staphylococcus aureus phage-group II, which causes intradermal separation in the granular layer. The diagnosis is clinical and supported by corroborative skin biopsy that excludes the differential diagnoses of epidermolysis bullosa or Stevens-Johnson syndrome. Case Presentation: Infant, 10 months old, female, from the peri-urban area of Encarnacion, was admitted with skin lesions of 7 days duration, initially of bullous type, which then broke, leaving a serous exudate and crusting, similar to the results of a burn, which quickly extended all over her body. Physical exam: Severely ill patient, underactive and irritable, with scaly lesions all over her body and a few bullous lesions, Nikolsky sign positive, areas of cracked skin, other areas bare with melicerous crusts, signs of severe dehydration, and swelling of limbs. Temp 38º C, weight 8650 grams, height: 69.5 cm, respiratory rate 40, heart rate 150. Installed central venous catheter; skin expansions done with saline, and initiated cefotaxime plus oxacillin. Ancillary studies: CBC: WBC 22400 mm3, neutrophils 59%, lymphocytes 41%, Hgb 10.7 g/dL, HCT 33%, glucose 103 mg/dL, urea 65 mg/dL, calcium 5.4 mg/dL, positive PCR, negative VDRL negative, HIV negative. Platelets 360 000 mm3, prothrombin time (PT) 35% of activity, albumin: 2.1 g/dL. Urinalysis: Electrolytes, Sodium 146, Potassium: 5.59, CXR normal. On the 3rd day of hospitalization HG 7 g/dL, HCT 22%, required transfusion of packed red blood cells PRBC, albumin, vitamin K, Calcium correction due to hypocalcemia and convulsions. Administered “Leche Kas 1000" (hydrolyzed sodium casein formula) administered by NGT and skin washed with saline. Patient was critically ill and edematous for the first 3 days then gradually improved...

Staphylococcal scalded skin syndrome in patients with hematologic malignancy: a report of 4 cases / 中华全科医师杂志

Objective To investigate the development of Staphylococcal scalded skin syndrome (SSSS) in patients with hematologic malignancy. Methods The clinical data of 4 cases of SSSS admitted from November 2006 to June 2008 were analyzed, and the related literatures were reviewed. Results Four patients developed SSSS all under severe immunosuppression. Two of them were in neutropenia, and the others had been intensively treated for severe graft versus host disease. They presented high fever and erythema, followed by the formation of flaccid bullae and exfoliation. Three patients recovered successfully with the treatment of vancomycin and intravenous administration of immunoglobulin. Withdraw of mmunosuppressive agents in patients following hematopoietie stem cell transplantation was helpful. Conclusions SSSS should be considered when high fever and erythema suddenly occur in patients with hematologic malignancy.

Staphylococcal Scalded Skin Syndrome in an Immunocompetent Adult / 대한피부과학회지

Staphylococcal scalded skin syndrome (SSSS) is an exfoliative infectious disorder caused by the exfoliative toxins of Staphylococcus aureus. The condition usually affects infants and children younger than 5 years of age. However, SSSS is rarely observed in adults. Adult SSSS is usually associated with renal failure, immunosuppression, malignancy, alcohol abuse, or HIV infection. In contrast to infant cases, adult SSSS is often accompanied with a high mortality rate, sepsis and poor prognosis. We report a rare case of SSSS in an immunocompetent 34-year-old man without renal failure.

Exfoliative toxin serotype genes and antibiotic resistance of staphylococcus aureus isolated from children with staphylococcal scalded skin syndrome / 中华皮肤科杂志

Objective To investigate the exfoliative toxin serotype genes and antibiotic resistance of Staphylococcus aureus (SA) isolated from children with staphylococcal scalded skin syndrome (SSSS). Methods In total, 108 strains of SA were isolated from 36 patients with SSSS, 36 patients with impetigo and 36 patients with abscess. Multiplex PCR was used to detect the staphylococcal exfoliative toxin A, B and D genes, Kirby-Baner method to test the susceptibilities of SA strains to 20 antibiotics. Results All the 36 SA isolates from SSSS patients were ET-positive, and 2 (6%) produced ETA, 7 (19%) ETB, 27 (75%) both ETA and ETB; of the 36 isolates from patients with impetigo, 78% produced ET, and 14% produced ETA, 64% produced both ETA and ETB, while no single ETB-producing strain was found; ET was detected in only one (2.8%) SA isolate from abscess patients, which produced both ETA and ETB. ETD was detected in none of the SA isolates. There was a statistical difference in the distribution of ET serotype among the three diseases (χ2=89.4, P < 0.01) and the proportion of ET-producing strains in SSSS group was signifi-cantly higher than that in impetigo group (χ2=9.0, P < 0.01) and abscess group (χ2= 68.1, P < 0.01). All the SA isolates were highly resistant to penicilin, ampicillin, macrolides and clindamycin, but sensitive to other 15 common antibiotics such as cephalosporin. Two strains of MRSA were found in patients with abscess. Conclusion In Chongqing, ET-producing SA is the common pathogenic bacteria of SSSS and impetigo, and most of SA strains produce both ETA and ETB.

Four Cases of Staphylococcal Scalded Skin Syndrome / 소아과

Staphylococcal scalded skin syndrome is a systemic disease with a clinical spectrum ranging from subcorneal pustules, patterned exfoliation to extensive erosion and peeling of skin by the exfoliative toxin of group II Staphylococcus aureus. This disease occurs mainly in infancy and children below five years and it isn't easy to differentiate from other vesicular diseases clinically, but skin biopsy shows an epidermal split at the granular layer. The form and severity of staphylococcal scalded skin syndrome will vary according to defense system and toxic factors. Treatment is effective antibiotics, and the mortality rate increases to 5% in children. In our four cases, symptoms were erythema and fever, followed by formation of large bullae and denuded skin. On laboratory findings, leukocytosis was noted in three cases, and S. aureus was confirmed by culture of eye discharge in all cases. Our cases improved with antibiotic therapy. We experienced four cases of staphylococcal scalded skin syndrome which were presented with vesicle and exfoliative skin lesion and treated successfully.