Recent developments in staphylococcal scalded skin syndrome

Unusual Presentation of Staphylococcal Scalded Skin Syndrome in an Elderly Patient With Acute Kidney Injury: A Case Report

Staphylococcal Scalded Skin Syndrome (SSSS) is characterized by denudation of the skin caused by Staphylococcus species. SSSS is common in infants, children, and rarely immunosuppressed adults or those with severe renal disease. We report a case of a 70-year-old female patient with an acute kidney injury who developed peeling of the skin over the axilla and back, which gradually spread to involve the upper and lower limbs, chest, and abdomen. A skin biopsy was performed, and a histopathological examination revealed a sub-corneal split consistent with SSSS. The patient was diagnosed with adult SSSS and was started on treatment with intravenous antibiotics, following which the skin lesions resolved.

Molecular Characteristics and Pathogenicity of Staphylococcus aureus Exotoxins

Staphylococcus aureus stands as one of the most pervasive pathogens given its morbidity and mortality worldwide due to its roles as an infectious agent that causes a wide variety of diseases ranging from moderately severe skin infections to fatal pneumonia and sepsis. S. aureus produces a variety of exotoxins that serve as important virulence factors in S. aureus-related infectious diseases and food poisoning in both humans and animals. For example, staphylococcal enterotoxins (SEs) produced by S. aureus induce staphylococcal foodborne poisoning; toxic shock syndrome toxin-1 (TSST-1), as a typical superantigen, induces toxic shock syndrome; hemolysins induce cell damage in erythrocytes and leukocytes; and exfoliative toxin induces staphylococcal skin scalded syndrome. Recently, Panton-Valentine leucocidin, a cytotoxin produced by community-associated methicillin-resistant S. aureus (CA-MRSA), has been reported, and new types of SEs and staphylococcal enterotoxin-like toxins (SEls) were discovered and reported successively. This review addresses the progress of and novel insights into the molecular structure, biological activities, and pathogenicity of both the classic and the newly identified exotoxins produced by S. aureus.

Antibiotic-resistant profile and the factors affecting the intravenous antibiotic treatment course of generalized Staphylococcal Scalded Skin Syndrome: a retrospective study

Background

Staphylococcal Scalded Skin Syndrome (SSSS) is caused by a special type of Staphylococcus aureus (S.aureus) which can produce exfoliative toxins. The generalized SSSS is recommended to be admitted and treated with intravenous antibiotics. However, there were limited reports on whether personal and clinical factors can have impacts on the duration of intravenous antibiotic application for pediatric patients with generalized SSSS.

We performed a study to assess the factors affecting intravenous antibiotic treatment course of SSSS patients. Additionally, the positive culture rates of S.aureus in different samples and the antibiotic-resistant profile were investigated.

Methods

Two hundred nineteen patients with generalized SSSS were included. Gender, age, area, season, maximum axillary temperature, white blood cell (WBC) count, C-reactive protein (CRP) level, types of intravenous antibiotics, and types of external antibiotics were recorded as the baseline. Simple linear regression was applied in the univariate analysis to determine the variables with statistical significance and then these variables were further examined in multivariate linear regression model. The positive culture rates of S.aureus in different sample sources were calculated and the drug sensitivity results were statistically compared by pairwise Chi square test.

Results

According to the multiple linear regression, older ages (β = − 0.01, p < 0.05) and external application of fusidic acid (β = − 1.57, p < 0.05) were associated with shorter treatment course, elevated leukocytes (β = 0.11, p < 0.001) and CRP level (β = 1.64, p < 0.01) were associated with longer treatment course. The positive culture rates of periorificial swabs, throat swabs, and blood samples were 54.55, 30.77, and 5.97% respectively. The resistant rates of levofloxacin (8.33%), gentamycin (8.33%), tetracycline (25%), oxacillin (8.33%), vancomycin (0%) were significantly lower than the ones of erythromycin (100%), trimethoprim-sulfamethoxazole (TMP/SMX) (83.33%), clindamycin (91.67%), penicillin G(100%) (p < 0.001).

Conclusion

Elevated leukocytes and CRP level indicated prolonged intravenous antibiotic treatment course. Older ages and external application of fusidic acid helped to reduce the treatment course. Compared with blood samples, the culture positive rates of S.aureus in periorificial and throat swabs were higher. Oxacillin and vancomycin resistance was rare and clindamycin resistance was common. Clindamycin monotherapy for SSSS should be avoided.

Genome-wide comparison of four MRSA clinical isolates from Germany and Hungary

Staphylococcus aureus is a drug-resistant pathogen, capable of colonizing diverse ecological niches and causing a broad spectrum of infections related to a community and healthcare. In this study, we choose four methicillin-resistant S. aureus (MRSA) clinical isolates from Germany and Hungary based on our previous polyphasic characterization finding. We assumed that the selected strains have a different genetic background in terms of the presence of resistance and virulence genes, prophages, plasmids, and secondary metabolite biosynthesis genes that may play a crucial role in niche adaptation and pathogenesis. To clarify these assumptions, we performed a comparative genome analysis of these strains and observed many differences in their genomic compositions. The Hungarian isolates (SA H27 and SA H32) with ST22-SCCmec type IVa have fewer genes for multiple-drug resistance, virulence, and prophages reported in Germany isolates. Germany isolate, SA G6 acquires aminoglycoside (ant(6)-Ia and aph(3’)-III) and nucleoside (sat-4) resistance genes via phage transduction and may determine its pathogenic potential. The comparative genome study allowed the segregation of isolates of geographical origin and differentiation of the clinical isolates from the commensal isolates. This study suggested that Germany and Hungarian isolates are genetically diverse and showing variation among them due to the gain or loss of mobile genetic elements (MGEs). An interesting finding is the addition of SA G6 genome responsible for the drastic decline of the core/pan-genome ratio curve and causing the pan-genome to open wider. Functional characterizations revealed that S. aureus isolates survival are maintained by the amino acids catabolism and favor adaptation to growing in a protein-rich medium. The dispersible and singleton genes content of S. aureus genomes allows us to understand the genetic variation among the CC5 and CC22 groups. The strains with the same genetic background were clustered together, which suggests that these strains are highly alike; however, comparative genome analysis exposed that the acquisition of phage elements, and plasmids through the events of MGEs transfer contribute to differences in their phenotypic characters. This comparative genome analysis would improve the knowledge about the pathogenic S. aureus strain’s characterization, and responsible for clinically important phenotypic differences among the S. aureus strains.

Variation in Diagnostic Test Use and Associated Outcomes in Staphylococcal Scalded Skin Syndrome at Children's Hospitals

OBJECTIVES

The incidence of staphylococcal scalded skin syndrome (SSSS) is rising, but current practice variation in diagnostic test use is not well described. Our aim was to describe the variation in diagnostic test use in children hospitalized with SSSS and to determine associations with patient outcomes.

METHODS

We performed a retrospective (2011-2016) cohort study of children aged 0 to 18 years from 35 children's hospitals in the Pediatric Health Information System database. Tests included blood culture, complete blood count, erythrocyte sedimentation rate, C-reactive protein level, serum chemistries, and group A streptococcal testing. K-means clustering was used to stratify hospitals into groups of high (cluster 1) and low (cluster 2) test use. Associations between clusters and patient outcomes (length of stay, cost, readmissions, and emergency department revisits) were assessed with generalized linear mixed-effects modeling.

RESULTS

We included 1259 hospitalized children with SSSS; 84% were ≤4 years old. Substantial interhospital variation was seen in diagnostic testing. Blood culture was the most commonly obtained test (range 62%-100%), with the most variation seen in inflammatory markers (14%-100%). Between hospital clusters 1 and 2, respectively, there was no significant difference in adjusted length of stay (2.6 vs 2.5 days; P = .235), cost ($4752 vs $4453; P = .591), same-cause 7-day readmission rate (0.8% vs 0.4%; P = .349), or emergency department revisit rates (0.1% vs 0.6%; P = .148).

CONCLUSIONS

For children hospitalized with SSSS, lower use of diagnostic tests was not associated with changes in outcomes. Hospitals with high diagnostic test use may be able to reduce testing without adversely affecting patient outcomes.

Staphylococcus aureus Toxins and Their Molecular Activity in Infectious Diseases

Staphylococcus aureus is a microorganism resident in the skin and nasal membranes with a dreadful pathogenic potential to cause a variety of community and hospital-acquired infections. The frequency of these infections is increasing and their treatment is becoming more difficult. The ability of S. aureus to form biofilms and the emergence of multidrug-resistant strains are the main reasons determining the challenge in dealing with these infections. S. aureus' infectious capacity and its success as a pathogen is related to the expression of virulence factors, among which the production of a wide variety of toxins is highlighted. For this reason, a better understanding of S. aureus toxins is needed to enable the development of new strategies to reduce their production and consequently improve therapeutic approaches. This review focuses on understanding the toxin-based pathogenesis of S. aureus and their role on infectious diseases.

Staphylococcal scalded skin syndrome: A pediatric dermatology case report

Staphylococcal scalded skin syndrome is a condition which predominantly affects children and causes a spectrum of skin lesions. We present a case of a 2-month-old infant with complaints of fever and fragile blisters over the body. The mucosal areas were spared. The diagnosis of staphylococcal scalded skin syndrome was reached on clinical grounds and culture report. The patient responded well to the treatment, which included an antibiotic (cloxacillin), an analgesic (paracetamol), and hydration with intravenous fluids. He was discharged after 8 days, with almost complete resolution of his skin lesions. Having a high clinical suspicion for staphylococcal scalded skin syndrome, early diagnosis/treatment, and following robust hygiene measures are imperative for the effective management of staphylococcal scalded skin syndrome. More efforts are needed to develop novel therapies for staphylococcal scalded skin syndrome.

An outbreak of skin infections in neonates due to a Staphylococcus aureus strain producing the exfoliative toxin A

PURPOSE

Staphylococcus aureus is an important cause of infections in hospitalized neonates. Preterm or low birthweight infants are especially at risk to develop a S. aureus infection due to the immaturity of the immune system, length of hospital stay and invasive procedures. Exfoliative toxin (ET)-producing S. aureus is often responsible for neonatal infections, causing clinical manifestations such as staphylococcal scalded skin syndrome, characterized by both localized blisters or generalized exfoliation of the skin.

METHODS

We describe an outbreak due to an S. aureus strain producing ETA occurring in a local hospital in Northern Italy. Molecular typing of the isolates included spa typing and multilocus sequence typing. DNA microarray hybridization was also performed on one representative strain.

RESULTS

In the period from July 2013 to February 2014, 12 neonates presented with skin infections, mainly bullae or pustules. Cultures of skin swabs yielded methicillin-susceptible S. aureus (MSSA). By molecular typing, an epidemic strain (t1393/ST5) was identified in nine neonates; microarray analysis and PCR revealed that it contained the ETA encoding gene. Screening of staff, mothers and healthy neonates and environmental cultures did not reveal the presence of the epidemic strain. However, the father of an infected neonate was found to be a carrier of MSSA t1393 five months after the outbreak started.

CONCLUSION

Implementation of hygiene procedures and sanitization of the ward twice terminated the outbreak. Timely surveillance of infections, supported by molecular typing, is fundamental to prevent similar episodes among neonates.

Recurrent Staphylococcal Scalded Skin Syndrome in an Extremely Low-Birth-Weight Neonate

Staphylococcal scalded skin syndrome (SSSS) in premature infants is a rare condition. We present SSSS in an extremely low-birth-weight (ELBW) infant with recurrent and confirmed bacterial sepsis. We present it to emphasize the importance for clinicians to not only recognize the clinical manifestations of SSSS, but also the need to closely monitor infants, especially very low-birth-weight (VLBW) and ELBW infants with SSSS for recurrence and bacterial sepsis. SSSS in preterm infants is a potentially lethal condition and early recognition and appropriate supportive care could be life-saving.

Rapid containment of nosocomial transmission of a rare community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) clone, responsible for the Staphylococcal Scalded Skin Syndrome (SSSS)

Background

The aims of this study were to identify the source and the transmission pathway for a Staphylococcal Scalded Skin Syndrome (SSSS) outbreak in a maternity setting in Italy over 2 months, during 2014; to implement appropriate control measures in order to prevent the epidemic spread within the maternity ward; and to identify the Methicillin-Resistant Staphylococcus aureus (MRSA) epidemic clone.

Methods

Epidemiological and microbiological investigations, based on phenotyping and genotyping methods, were performed. All neonates involved in the outbreak underwent clinical and microbiological investigations to detect the cause of illness. Parents and healthcare workers were screened for Staphylococcus aureus to identify asymptomatic carriers.

Results

The SSSS outbreak was due to the cross-transmission of a rare clone of ST5-CA-MRSA-SCCmecV-spa type t311, exfoliative toxin A-producer, isolated from three neonates, one mother (from her nose and from dermatological lesions due to pre-existing hand eczema) and from a nurse (colonized in her nose by this microorganism). The epidemiological and microbiological investigation confirmed these as two potential carriers.

Conclusions

A rapid containment of these infections was obtained only after implementation of robust swabbing of mothers and healthcare workers. The use of molecular methodologies for typing was able to identify all carriers and to trace the transmission.

A Systemic Review on Staphylococcal Scalded Skin Syndrome (SSSS): A Rare and Critical Disease of Neonates

The symptoms of Staphylococcal scalded skin syndrome (SSSS) include blistering of skin on superficial layers due to the exfoliative toxins released from Staphylococcus aureus. After the acute exfoliation of skin surface, erythematous cellulitis occurs. The SSSS may be confined to few blisters localized to the infection site and spread to severe exfoliation affecting complete body. The specific antibodies to exotoxins and increased clearence of exotoxins decrease the frequency of SSSS in adults. Immediate medication with parenteral anti-staphylococcal antibiotics is mandatory. Mostly, SSSS are resistant to penicillin. Penicillinase resistant synthetic penicillins such as Nafcillin or Oxacillin are prescribed as emergency treatment medicine. If Methicillin-resistant Staphylococcus aureus (MRSA) is suspected), antibiotics with MRSA coverage (e.g., Vancomycin or Linezolid) are indicated. Clindamycin is considered as drug of choice to stop the production of exotoxin from bacteria ribosome. The use of Ringer solution to to balance the fluid loss, followed by maintainence therapy with an objective to maintain the fluid loss from exfoliation of skin, application of Cotrimoxazole on topical surface are greatlly considered to treat the SSSS. The drugs that reduce renal function are avoided. Through this article, an attempt has been made to focus the source, etiology, mechanism, outbreaks, mechanism, clinical manisfestation, treatment and other detail of SSSS.

Epidermal exfoliation of over 95% after a burn in an 18-month-old boy: Case report and review of the literature

This report concerns an 18-month-old boy who presented with a 6% total body surface area scald. The subject of this report is unique in that he developed the largest exfoliation described in literature. After 3 days an epidermal exfoliation with the appearance of a deliberately inflicted scald developed. As the exfoliation progressed to over 95% total body surface area the suspicion of child abuse or neglect could be abandoned. The diagnosis Staphylococcal scalded skin syndrome was set, due to the finding of Staphylococcus aureus on swabs, the lack of mucosal engagement, and the patient's age. The boy's skin healed within 3 weeks. The few reports published are all case reports and most frequently described visually infected burns with smaller epidermal exfoliations, and clinically based exfoliation diagnosis. S. aureus often cause burn wound infections that can lead to complications caused by cross-infection. It is important for burn surgeons and intensive care specialists to be aware of the increased possibility of Staphylococcal scalded skin syndrome occurring in patients who have a reduced barrier to infection such as burn patients and also, that the diagnosis can be difficult to make.

Staphylococcal scalded skin syndrome: diagnosis and management in children and adults

Staphylococcal scalded skin syndrome is a potentially life-threatening disorder caused most often by a phage group II Staphylococcus aureus infection. Staphylococcal scalded skin syndrome is more common in newborns than in adults. Staphylococcal scalded skin syndrome tends to appear abruptly with diffuse erythema and fever. The diagnosis can be confirmed by a skin biopsy specimen, which can be expedited by frozen section processing, as staphylococcal scalded skin syndrome should be distinguished from life threatening toxic epidermal necrolysis. Histologically, the superficial epidermis is detached, the separation level being at the granular layer. The diffuse skin loss is due to a circulating bacterial exotoxin. The aetiological exfoliating toxin is a serine protease that splits only desmoglein 1. The exfoliative toxins are spread haematogenously from a localized source of infection, causing widespread epidermal damage at distant sites. Sepsis and pneumonia are the most feared complications. The purpose of this review is to summarize advances in understanding of this serious disorder and provide therapeutic options for both paediatric and adult patients. Recent epidemiological studies have demonstrated that paediatric patients have an increased incidence of Staphylococcal scalded skin syndrome during the summer and autumn. Mortality is less than 10% in children, but is between 40% and 63% in adults, despite antibacterial therapy. Previously, intravenous immunoglobulin had been recommended to combat Staphylococcal scalded skin syndrome, but a recent study associates its use with prolonged hospitalization.

Differences in virulence genes and genome patterns of mastitis-associated Staphylococcus aureus among goat, cow, and human isolates in Taiwan

A total of 117 mastitis-associated Staphylococcus aureus isolates from cow, goat, and human patients were analyzed for differences in antibiotic susceptibility, virulence genes, and genotypes using accessory gene regulator (agr) typing, pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Multidrug-resistant (MDR) S. aureus were commonly found in all sources, though they were predominantly found in human and goat isolates. Almost 70% of the isolates were resistant to ampicillin and penicillin. Host-associated virulence genes were identified as follows: tst, a gene encoding toxic shock syndrome toxin, was found in goat isolates; lukED and lukM, genes encoding leukocidin, found in cow isolates; lukPV, a gene encoding leukocidin, found in human isolates; and eta, a gene encoding for exfoliative toxin, found in both human and cow isolates. All four types of hemolysin, α, β, γ, and δ, were identified in human isolates, three types (α, γ, and δ), were identified in cow isolates, and two types (α and δ) were identified in goat isolates. Agr-typing determined agr1 to be the main subtype in human and cow isolates. PFGE and MLST analysis revealed the presence of diverse genotypes among the three sources. In conclusion, mastitis-associated, genetically diverse strains of MDR S. aureus differed in virulence genes among human, cow, and goat isolates.

Epidemiological data of staphylococcal scalded skin syndrome in France from 1997 to 2007 and microbiological characteristics of Staphylococcus aureus associated strains

Epidemiological data on staphylococcal scalded skin syndromes (SSSS), including bullous impetigo (BI) and generalized exfoliative syndrome (GES), are scarce. To better characterize SSSS and associated Staphylococcus aureus strains, we conducted a retrospective study of 349 cases collected in France between 1997 and 2007 by the National Reference Centre of Staphylococci. Our results showed a stationary evolution of SSSS cases, with a heterogeneous distribution of cases in France. Although notification was not exhaustive, we estimated an incidence of 0.56 cases/year/million inhabitants, in accordance with previous studies conducted in France and Europe, with a median age of 2 years old and sex ratios of 1. A seasonal effect was observed, with a higher GES/BI ratio in autumn compared with other seasons, which could be explained by the impact of viral co-infection. Genetic analysis of S. aureus strains showed that accessory gene regulator (agr) 4, exfoliative toxin A (eta) and B (etb) genes, staphylococcal and enterotoxin-like O (selo) gene and agr4 etb selo profiles were predominantly associated with GES, whereas agr2 eta and agr4 eta selo were more frequently observed with BI. Only one methicillin-resistant strain was found. Protein A (spa) typing identified two main genotypes: spa clonal complex (CC) 159/sequence-type (ST) 121 (75%) and spaCC346/ST15 (18%). spaCC159 was mainly associated with agr4 eta etb selo, agr4 eta selo and agr4 etb selo, and spaCC346 was mainly associated with agr2 eta, suggesting that French SSSS cases are caused by these two main lineages. However, in a multivariate analysis, only etb was independently associated with GES.

Pediatric dermatology emergencies

PURPOSE OF REVIEW

The purpose of this review is to summarize recent advances in the diagnosis and treatment of several severe skin diseases seen in children.

RECENT FINDINGS

Several articles published recently added significantly to our understanding of drug reaction with eosinophilia and systemic symptoms (DRESS), eczema herpeticum, staphylococcal scalded skin syndrome and inherited ichthyosis. A review of 60 patients with DRESS showed 80% with hepatic involvement, 40% with renal involvement, 33% with pulmonary involvement and 50% with hematologic abnormalities. A review on eczema herpeticum describes several clinical scenarios in which it is vital to keep that diagnosis in mind. Another review on severe staphylococcal skin infections reminds us of the importance of covering for methicillin-resistant Staphylococcus aureus in all such cases until cultures and sensitivities show otherwise. The results of an international consensus conference on ichthyosis published this year will help all of us to better characterize these complicated patients. Additionally, the first case of hypothyroidism associated with a collodion baby was reported, as was the finding of an increased incidence of atypical nevi in patients with inherited ichthyosis.

SUMMARY

Although all of the conditions discussed in this article are relatively rare, it is important that they be kept on the differential diagnosis for sick infants and children with cutaneous findings, as early diagnosis and treatment of some of these conditions can be life saving.

Staphylococcus sciuri exfoliative toxin C (ExhC) is a necrosis-inducer for mammalian cells

Staphylococcus sciuri (S. sciuri) is a rare pathogen in humans, but it can cause a wide array of human infections. Recently a S. sciuri isolate (HBXX06) was reported to cause fatal exudative epidermitis (EE) in piglets and thus considered as a potential zoonotic agent. To investigate the pathogenicity of this bacterium, we cloned exfoliative toxin C (ExhC), a major toxin of the S. sciuri isolate and performed functional analysis of the recombinant ExhC-his (rExhC) protein using in vitro cell cultures and newborn mice as models. We found that rExhC could induce necrosis in multiple cell lines and peritoneal macrophages as well as skin lesions in newborn mice, and that the rExhC-induced necrosis in cells or skin lesions in newborn mice could be completely abolished if amino acids 79-128 of rExhC were deleted or blocked with a monoclonal antibody (3E4), indicating aa 79-128 portion as an essential necrosis-inducing domain. This information contributes to further understandings of the mechanisms underlying S. sciuri infection.

Staphylococcal scalded skin syndrome in a newborn

A six-day-old newborn was admitted with exfoliating erythematous lesions over the face, of two days duration. The lesions spread to the rest of the body during the next two days. A diagnosis of Staphylococcal Scalded Skin Syndrome (SSSS) was made clinically and confirmed by isolation of Staphylococcus aureus from a blood sample. The child responded to Injection vancomycin and no fresh lesions were seen after the next 48 hours. However the child developed severe pneumonia and left against medical advice.

Plakoglobin rescues adhesive defects induced by ectodomain truncation of the desmosomal cadherin desmoglein 1: implications for exfoliative toxin-mediated skin blistering

Desmoglein 1 (Dsg1) is a desmosomal cadherin that is essential to epidermal integrity. In the blistering diseases bullous impetigo and staphylococcal scalded-skin syndrome, pathogenesis depends on cleavage of Dsg1 by a bacterial protease, exfoliative toxin A, which removes residues 1 to 381 of the Dsg1 ectodomain. However, the cellular responses to Dsg1 cleavage that precipitate keratinocyte separation to induce blister formation are unknown. Here, we show that ectodomain-deleted Dsg1 (Δ381-Dsg1) mimics the toxin-cleaved cadherin, disrupts desmosomes, and reduces the mechanical integrity of keratinocyte sheets. In addition, we demonstrate that truncated Dsg1 remains associated with its catenin partner, plakoglobin, and causes a reduction in the levels of endogenous desmosomal cadherins in a dose-dependent manner, leading us to hypothesize that plakoglobin sequestration by truncated Dsg1 destabilizes other cadherins. Accordingly, a triple-point mutant of the ectodomain-deleted cadherin, which is uncoupled from plakoglobin, does not impair adhesion, indicating that this interaction is essential to the pathogenic potential of truncated Dsg1. Moreover, we demonstrate that increasing plakoglobin levels rescues cadherin expression, desmosome organization, and functional adhesion in cells expressing Δ381-Dsg1 or treated with exfoliative toxin A. Finally, we report that histone deacetylase inhibition up-regulates desmosomal cadherins and prevents the loss of adhesion induced by Dsg1 truncation. These findings further our understanding of the mechanism of exfoliative toxin-induced pathology and suggest novel strategies to suppress blistering in bulbous impetigo and staphylococcal scalded-skin syndrome.

Levels of antibody against 11 Staphylococcus aureus antigens in a healthy population

Serum samples from 151 healthy individuals aged from 15 to 89 years were investigated by enzyme-linked immunosorbent assay (ELISA) for IgG levels against 11 different purified antigens from Staphylococcus aureus. Surface antigens, such as teichoic acid, clumping factors A and B, and bone sialoprotein binding protein, and extracellular proteins, such as alpha-toxin, lipase, enterotoxin A, toxic shock syndrome toxin, scalded-skin syndrome toxin, fibrinogen binding protein, and extracellular adherence protein, were used. The IgG values were analyzed in relation to the state of nasal carriage at the time of sampling. There was great individual variation in antibody levels in both young and elderly healthy subjects. Occurrence of S. aureus in the nares at the time of sampling was correlated with higher antibody levels, while elderly individuals over 65 years of age showed slightly lower levels than younger adults. More individuals than was expected from random probability calculations showed high antibody levels against several antigens, and more individuals than would be expected showed low levels against several antigens. Certain extracellular proteins had more often induced IgG levels of the same magnitude in the same individuals, indicating that among these individuals, there was a tendency to respond to certain antigens in the same way. Most individuals had circulating IgG antibodies to the 11 tested antigens, and some individuals had the tendency to be "good responders" to several antigens, while others were "poor responders." These findings constitute basic knowledge for the development of improved serological diagnostics, immune prophylaxis, individual prognosis tools, and therapy against invasive Staphylococcus aureus infections.

Secreted virulence factor comparison between methicillin-resistant and methicillin-sensitive Staphylococcus aureus, and its relevance to atopic dermatitis

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strains have emerged as serious health threats in the last 15 years. They are associated with large numbers of atopic dermatitis skin and soft tissue infections, but when they originate from skin and mucous membranes, have the capacity to produce sepsis and highly fatal pulmonary infections characterized as necrotizing pneumonia, purpura fulminans, and postviral toxic shock syndrome. This review is a discussion of the emergence of 3 major CA-MRSA organisms, designated CA-MRSA USA400, followed by USA300, and most recently USA200. CA-MRSA USA300 and USA400 isolates and their methicillin-sensitive counterparts (community-associated methicillin-sensitive S aureus) typically produce highly inflammatory cytolysins alpha-toxin, gamma-toxin, delta-toxin (as representative of the phenol soluble modulin family of cytolysins), and Panton Valentine leukocidin. USA300 isolates produce the superantigens enterotoxin-like Q and a highly pyrogenic deletion variant of toxic shock syndrome toxin 1 (TSST-1), whereas USA400 isolates produce the superantigens staphylococcal enterotoxin B or staphylococcal enterotoxin C. USA200 CA-MRSA isolates produce small amounts of cytolysins but produce high levels of TSST-1. In contrast, their methicillin-sensitive S aureus counterparts produce various cytolysins, apparently in part dependent on the niche occupied in the host and levels of TSST-1 expressed. Significant differences seen in production of secreted virulence factors by CA-MRSA versus hospital-associated methicillin-resistant S aureus and community-associated methicillin-sensitive S aureus strains appear to be a result of the need to specialize as the result of energy drains from both virulence factor production and methicillin resistance.

Superantigen profile of Staphylococcus aureus isolates from patients with steroid-resistant atopic dermatitis

BACKGROUND

Superantigens induce skin inflammatory responses in atopic dermatitis, which is commonly associated with Staphylococcus aureus infection. T cells activated in vitro by superantigens become steroid resistant. The objective was to assess the superantigen profiles of S. aureus isolates from patients with steroid-resistant atopic dermatitis.

METHODS

We compared the superantigen-production capability of S. aureus isolates from 78 patients with steroid-resistant atopic dermatitis (group 1) with that of 30 vaginal isolates from healthy women (group 2) and 22 isolates from a general population of patients with atopic dermatitis (group 3). Polymerase chain reaction with primers for superantigens, combined with selected antibody testing, was used to analyze the presence of toxic shock syndrome toxin 1, staphylococcal enterotoxins, and enterotoxin-like superantigens.

RESULTS

S. aureus isolates from group 1 had a statistically significant difference in superantigen profile, compared with the profiles of group 2 and group 3 isolates. Group 2 isolates were similar in profile to group 3 isolates, with 4 and 5 superantigens per isolate, respectively. In contrast, group 1 isolates produced a mean of 8 superantigens each (P<<.001, for comparison with group 2 or group 3). These group 1 isolates were more likely to produce the 3 major toxic shock syndrome-associated superantigens (toxic shock syndrome toxin 1, staphylococcal enterotoxin B, and staphylococcal enterotoxin C) and to produce unusual combinations of superantigens (e.g., toxic shock syndrome toxin 1 and staphylococcal enterotoxin B).

CONCLUSIONS

S. aureus isolates from patients with steroid-resistant atopic dermatitis appear to be selected on the basis of greater production of superantigens, compared with that of isolates from control groups. Superantigens may offer selective advantages for colonization of patients.

Approach to the acute, generalized, blistering patient

This article discusses the approach to the acute, generalized, blistering patient from the perspective of the dermatologic consultant. Initially, a case is presented, followed by a discussion of the relevant evaluation, differential diagnosis, and treatment options.

Alpha and beta chains of hemoglobin inhibit production of Staphylococcus aureus exotoxins

Prior studies suggest Staphylococcus aureus exotoxins are not produced when the organism is cultured in human blood. Human blood was fractionated into plasma and water-lysed red blood cells, and it was demonstrated that mixtures of alpha and beta globins of hemoglobin (as low as 1 mug/mL) inhibited S. aureus exotoxin production while increasing production of protein A and not affecting bacterial growth. Pepsin but not trypsin digestion destroyed the ability of alpha and beta globin to inhibit exotoxin production. Exotoxin production by both methicillin-resistant and methicillin-susceptible organisms was inhibited. Production of streptococcal pyrogenic exotoxin A by Streptococcus pyogenes was unaffected by alpha and beta globin chains but was inhibited when produced in S. aureus. Use of isogenic S. aureus strains suggested the targets of alpha and beta globin chains, leading to inhibition of staphylococcal exotoxins, included the two-component system SrrA-SrrB. delta hemolysin production was also inhibited, suggesting the two-component (and quorum sensing) system AgrA-AgrC was targeted. The alpha and beta globin chains represent promising molecules to interfere with the pathogenesis of serious staphylococcal diseases.

Thematic review series: skin lipids. Antimicrobial lipids at the skin surface

The skin surface represents our interface with the external environment, and as such, is our first line of defense against microbial colonization and infection. Lipids at the skin surface are thought to underlie at least part of an antimicrobial barrier. Some of these lipids are synthesized in the epidermis and are carried to the surface as cells differentiate, whereas others are secreted onto the surface from the sebaceous glands. One such group, free sphingoid bases, are known to have broad antimicrobial activity, and our previous studies demonstrate their presence at the skin surface. Free sphingoid bases may be generated by enzymatic hydrolysis of epidermal ceramides. In addition, our preliminary results demonstrate potent antibacterial activity associated with two specific fatty acids derived from sebaceous triglycerides. Most remarkably, one of these fatty acids (sapienic acid, C16:1Delta6), in combination with a low concentration of ethanol, is very effective against methicillin-resistant Staphylococcus aureus (MRSA). In fact, this combination was far more effective than mupirocin with or without ethanol. Mupirocin is a "gold standard" for activity against MRSA.

Staphylococcal scalded skin syndrome mimicking child abuse by burning

Child abuse by burning comprises 6-20% of all child abuse cases, but misdiagnosis may arise in cases of some medical conditions. We present two cases of suspected inflicted burns, later diagnosed as staphylococcal scalded skin syndrome (SSSS). In case 1, a 6-month-old girl was referred to hospital for small round ulcerations on the face and abdomen, resembling cigarette burns. Because of the inconsistency of the mother's report (insect bites) with the injury pattern and an unstable family history, hospitalization was decided. The following day, new bullous lesions were visible on the neck and nose, indicating the natural origin of the findings, finally diagnosed as SSSS. In case 2, a 2-month-old boy was hospitalized for erythema, with bullous lesions on the abdomen. He was transferred to another hospital, with suspected congenital or autoimmune skin disorder but negative searches led to a diagnosis of inflicted scalds: a report was sent to the judicial authorities, and the child was entrusted to his grandparents. In fact, a review of the clinical documentation showed that, in the second hospitalization, new erythematous and bullous lesions had been described, which could not be ascribed to inflicted injuries. Child abuse was finally ruled out, and SSSS was diagnosed. In cases of suspected inflicted child burns, observation during hospitalization may reveal changes in lesions, ascribed to the evolution of medical conditions. SSSS diagnosis is mainly based on clinical grounds but, if the suspicion of abuse remains, isolation and phage typing of Staphylococcus aureus from nasal, pharyngeal or cutaneous swabs may confirm the diagnosis.

Toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is an unpredictable, life-threatening drug reaction associated with a 30% mortality. Massive keratinocyte apoptosis is the hallmark of TEN. Cytotoxic T lymphocytes appear to be the main effector cells and there is experimental evidence for involvement of both the Fas-Fas ligand and perforin/granzyme pathways. Optimal treatment for these patients remains to be clarified. Discontinuation of the offending drug and prompt referral to a burn unit are generally agreed upon steps. Beyond that, however, considerable controversy exists. Evidence both pro and con exists for the use of IVIG, systemic corticosteroid, and other measures. There is also evidence suggesting that combination therapies may be of value. All the clinical data, however, is anecdotal or based on observational or retrospective studies. Definitive answers are not yet available. Given the rarity of TEN and the large number of patients required for a study to be statistically meaningful, placebo controlled trials are logistically difficult to accomplish. The absence of an animal model further hampers research into this condition. This article reviews recent data concerning clinical presentation, pathogenesis and treatment of TEN.

LEARNING OBJECTIVES

At the conclusion of this learning activity, participants should have acquired a more comprehensive knowledge of our current understanding of the classification, clinical presentation, etiology, pathophysiology, prognosis, and treatment of TEN.

Dermatologic emergencies

Primary care physicians are the gatekeepers of the medical community. They are the physicians to whom patients first present, and they are often the physicians with whom patients have the longest lasting relationships. Primary care physicians, as a result of these long-term relationships, have been endowed with a unique responsibility to the health of their patients. By the very nature of their practice, primary care physicians do not have the resources to treat emergent life-threatening conditions. They must, however, be able to diagnose these potentially life-threatening conditions and be able to stabilize and appropriately refer a patient for urgent evaluation by specialists or emergency physicians. There are many types of emergencies encountered in the outpatient setting, ranging from cardiac to toxicologic. As important as recognizing signs and symptoms of cardiac ischemia is the ability to recognize potentially life-threatening dermatologic disorders or dermatologic manifestations of life-threatening systemic diseases.

Staphylococcal skin infections in children: rational drug therapy recommendations

Staphylococcus aureus remains one of the most common and troublesome of bacteria causing disease in humans, despite the development of effective antibacterials and improvement in hygiene. The organism is responsible for over 70% of all skin and soft tissue infections in children and accounts for up to one-fifth of all visits to pediatric clinics. Skin and soft tissue infections that are predominantly caused by S. aureus include bullous and non-bullous impetigo, folliculitis, furunculosis, carbunculosis, cellulitis, surgical and traumatic wound infections, mastitis, and neonatal omphalitis. Other skin and soft tissue infections may also be caused by S. aureus but are often polymicrobial in origin and require special consideration. These include burns, decubitus ulcers (particularly in the perianal region), puncture wounds of the foot, as well as human and mammalian bites. Treatment of staphylococcal skin infections varies from topical antiseptics to prolonged intravenous antibacterials, depending on severity of the lesions and the health of the child. The treatment of choice for oral antibacterials remains the penicillinase-resistant penicillins such as flucloxacillin. Cefalexin and erythromycin are suitable cost-effective alternatives with broader cover, although care must be taken with the use of macrolides because of development of resistance to multiple families of antibacterials, particularly the lincosamides. Other cephalosporins such as cefadroxil and cefprozil are also effective, can be given once daily and have a better tolerability profile -- while azithromycin has a further advantage of a 3-day course. However, all of these agents are more expensive. Although the antibacterials have been given for 10 days in most clinical trials, there is no evidence that this duration is more effective than a 7-day course. In children requiring intravenous therapy, ceftriaxone has a major advantage over other antibacterials such as sulbactam/ampicillin and cefuroxime in that it can be given once daily and may, therefore, be suitable for outpatient treatment of moderate-to-severe skin infections. Newer-generation cephalosporins and loracarbef are also effective and have a broader spectrum of activity, but do not offer any added benefit and are significantly more expensive. Skin and soft tissue infections due to methicillin-resistant S. aureus (MRSA) are still relatively uncommon in children. Well children with community-acquired MRSA infections can be treated with clindamycin or trimethoprim-sulfamethoxazole (cotrimoxazole), but must be observed closely for potentially severe adverse effects. In severe infections, vancomycin remains the treatment of choice, while intravenous teicoplanin and clindamycin are suitable alternatives. Linezolid and quinupristin/dalfopristin are currently showing great promise for the treatment of multi-resistant Gram-positive infections. While the choice of antibacterial is important, supportive management, including removal of any infected foreign bodies, surgical drainage of walled-off lesions, and regular wound cleaning, play a vital role in ensuring cure.

Cloning of swine desmoglein 1 and its direct proteolysis by Staphylococcus hyicus exfoliative toxins isolated from pigs with exudative epidermitis

Exudative epidermitis (EE) is an acute, often fatal skin disease of piglets caused by Staphylococcus hyicus. Clinical and histopathological manifestations of EE are similar to those of staphylococcal scalded skin syndrome (SSSS), a human blistering skin disease, in which exfoliative toxins produced by Staphylococcus aureus digest the extracellular domains of desmoglein (Dsg) 1 and cause loss of epidermal cell-cell adhesion. The aims of this study were to isolate and characterize cDNA for full length of swine Dsg1, and to determine whether the extracellular domains of swine Dsg1 produced by baculovirus (sDsg1-His) could be digested by four isoforms of exfoliative toxin produced by S. hyicus (ExhA, ExhB, ExhC and ExhD). Nucleotide sequencing revealed that swine Dsg1 cDNA consisted of an open reading frame of 3138 bp, encoding a precursor protein of 1045 amino acids. Deduced amino acid sequence of the swine Dsg1 precursor were highly homologous to corresponding bovine, canine, human and murine sequences. Immunoadsorption assay with a secreted form of sDsg1-His revealed that sDsg1-His specifically absorbs the immunoreactivity of 10 human pemphigus foliaceus sera against swine keratinocyte cell surfaces, suggesting its proper conformation. When sDsg1-His was incubated in vitro with Exhs, all four isoforms of Exh directly digested sDsg1-His into smaller peptides, whereas removal of calcium from sDsg1-His completely inhibited its proteolysis by these four Exhs. Recognition and digestion of calcium-stabilized structure on the extracellular domains of swine Dsg1 by Exhs indicated that EE shares similar molecular pathophysiological mechanisms of intra-epidermal splitting with SSSS in humans.

Impact of community-associated, methicillin-resistant Staphylococcus aureus on management of the skin and soft tissue infections in children

Skin and soft tissue infections (SSTIs) are common illnesses that have a significant impact on health care management. Community-associated, methicillin-resistant Staphylococcus aureus (CA-MRSA) infections have been documented among healthy individuals without predisposing risk factors. The appearance and spread of CA-MRSA represent a new challenge in pediatric medicine and have important clinical implications for therapy of infections caused by S. aureus. This article provides a review of recent changes in the epidemiology of CA-MRSA, pathogenic potential, and therapeutic considerations in the management of SSTIs in children.

Life-threatening eruptions due to infectious agents

Some infectious diseases may cause rapidly fatal eruptions that need to be diagnosed and treated in an early phase for patient survival. The main life-threatening eruptions of infectious etiology include Rocky Mountain spotted fever, meningococcemia, toxic shock syndrome, streptococcal toxic shock syndrome, and staphylococcal scalded skin syndrome.

Staphyloccocal scalded skin syndrome in an adult

We report a case of staphyloccocal scalded skin syndrome due to an oxacillin-susceptible Staphylococcus aureus in an 81-year-old woman. The patient was admitted to the emergency room with arthritis of the left shoulder, ten days after an intra-articular injection of corticosteroids. The shoulder's puncture showed a purulent liquid and gram positive cocci in cluster suggesting the presence of Staphylococcus sp. on the Gram-stain. The culture confirmed the identification of an oxacillin-susceptible Staphylococcus aureus. Before administration of any dose of oxacillin, blisters appeared on the skin, that quickly ruptured, particulary in areas of friction. The exfoliated areas were extensive and resolution of all the lesions was reached after 3 weeks. The skin biopsy showed superficial epidermolysis confirming the diagnosis. Staphyloccocal scalded skin syndrome is usually described in neonates and young children, often in outbreaks. Few cases have been reported in adults, most often associated with severe underlying diseases. The mortality rate is low in children but can reach almost 60% in adults. The most important diagnosis to exclude is Lyell's syndrome which can be done by the skin biopsy.

The intraepidermal blistering conditions

The intraepidermal vesiculobullous disorders constitute a wide variety of pathogenically unrelated disorders that share in common the formation of cleft or bullae formation within the epithelium. The etiologic, pathogenic, clinical and, in particular, the histopathologic attributes of the most important intraepidermal blistering conditions are described.

Crystal and Solution Structures of a Superantigen from Yersinia pseudotuberculosis Reveal a Jelly-Roll Fold

Superantigens are a class of microbial proteins with the ability to excessively activate T cells by binding to the T cell receptor. The staphylococcal and streptococcal superantigens are closely related in structure and possess an N-terminal domain that resembles an OB fold and a C-terminal domain similar to a beta-grasp fold. Yersinia pseudotuberculosis produces superantigens, YPMa, YPMb, and YPMc, which have no significant amino acid similarity to other proteins. We have determined the crystal and solution structures of YPMa, which show that the protein has a jelly-roll fold. The closest structural neighbors to YPMa are viral capsid proteins and members of the tumor necrosis factor superfamily. In the crystal structure, YPMa packs as a trimer, another feature shared with viral capsid proteins and TNF superfamily proteins. However, in solution YPMa behaves as a monomer, and any functional relevance of the trimer observed in the crystals is yet to be established.

Enzymatic and Molecular Characteristics of the Efficiency and Specificity of Exfoliative Toxin Cleavage of Desmoglein 1

Exfoliative toxins (ETs) from Staphylococcus aureus blister the superficial epidermis by hydrolyzing a single peptide bond, Glu381-Gly382, located between extracellular domains 3 and 4 of desmoglein 1 (Dsg1). Enzyme activity is dependent on the calcium-stabilized structure of Dsg1. Here we further define the characteristics of this cleavage. Kinetic studies monitoring the cleavage of Dsg1 by ETA, ETB, and ETD demonstrated kcat/Km values of 2-6 x 10(4) m(-1) s(-1), suggesting very efficient proteolysis. Proteolysis by ETA was not efficiently inhibited by broad spectrum serine protease inhibitors, suggesting that the enzyme cleavage site may be inactive or inaccessible before specific binding to its substrate. Using truncated mutants of human Dsg1 and chimeric molecules between human Dsg1 and either human Dsg3 or canine Dsg1, we show that for cleavage, human-specific amino acids from Dsg1 are necessary in extracellular domain 3 upstream of the scissile bond. If these residues are canine rather than human, ETA binds, but does not cleave, canine Dsg1. These data suggest that the exquisite specificity and efficiency of ETA may depend on the enzyme's binding upstream of the cleavage site with a very specific fit, like a key in a lock.

Understanding the mechanism of action of the exfoliative toxins of Staphylococcus aureus

The exfoliative toxins of Staphylococcus aureus are responsible for the staphylococcal scalded skin syndrome, a blistering skin disorder that particularly affects infants and young children, as well as adults with underlying disease. Their three-dimensional structure is similar to other glutamate-specific trypsin-like serine proteases with two substrate-binding domains and a serine-histidine-aspartate catalytic triad that forms the active site. However, unlike other serine proteases, the exfoliative toxins possess a highly charged N-terminal alpha-helix and a unique orientation of a critical peptide bond, which blocks the active site of the toxins so that, in their native state, they do not possess any significant enzymatic activity. The target for the toxins has recently been identified as desmoglein-1, a desmosomal glycoprotein which plays an important role in maintaining cell-to-cell adhesion in the superficial epidermis. It is speculated that binding of the N-terminal alpha-helix to desmoglein-1 results in a conformation change that opens the active site of the toxin to cleave the extracellular domain of desmoglein-1 between the third and fourth domains, resulting in disruption of intercellular adhesion and formation of superficial blisters. Elucidating the mechanism of action of the toxins and identifying desmoglein-1 as their specific epidermal substrate has not only given us an insight into the pathogenesis of the staphylococcal scalded skin syndrome, but also provided us with useful information on normal skin physiology and the pathogenesis of other toxin-mediated diseases. It is hoped that this knowledge will lead to development of rapid screening and diagnostic tests, and new antitoxin strategies for the treatment and prevention of the staphylococcal scalded skin syndrome in the near future.

Molecular mechanisms of blister formation in bullous impetigo and staphylococcal scalded skin syndrome

Bullous impetigo due to Staphylococcus aureus is one of the most common bacterial infections of man, and its generalized form, staphylococcal scalded skin syndrome (SSSS), is a frequent manifestation of staphylococcal epidemics in neonatal nurseries. Both diseases are mediated by exfoliative toxins (ETs), which show exquisite pathologic specificity in blistering only the superficial epidermis. We show that these toxins act as serine proteases with extremely focused molecular specificity to cleave mouse and human desmoglein 1 (Dsg1) once after glutamic acid residue 381 between extracellular domains 3 and 4. Mutation of the predicted catalytically active serine to alanine completely inhibits cleavage. The mutated ETs bind specifically to Dsg1 by immunofluorescence colocalization and by coimmunoprecipitation. Thus, ETs, through specific recognition and proteolytic cleavage of one structurally critical peptide bond in an adhesion molecule, cause its dysfunction and allow S. aureus to spread under the stratum corneum, the main barrier of the skin, explaining how, although they circulate through the entire body in SSSS, they cause pathology only in the superficial epidermis.