Letter: Staphylococcal scalded-skin syndrome in adults

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.

Staphylococcal scalded-skin syndrome in an adult due to methicillin-resistant Staphylococcus aureus

We report a case of a 71-year-old man with staphylococcal scalded-skin syndrome (SSSS). The patient, with a chronic history of diabetes mellitus, was admitted to our hospital with lumbago, and a diagnosis of renal-cell carcinoma with bone metastasis was made. In hospital he had sudden onset of high fever and erythema, followed by the formation of flaccid bullae and exfoliation, with a positive Nikolsky sign. Methicillin-resistant Staphylococcus aureus (MRSA), producing exfoliative toxin B, was isolated from blood and bile cultures, and Aeromonas hydrophila was isolated from bile culture. Skin biopsy specimen showed a cleavage of the epidermis at the level of the granular layer. The patient was diagnosed as having SSSS and cholecystitis, and was treated with intravenous antibiotics and percutaneous transhepatic gallbladder drainage, which led to recovery. SSSS in adults is usually associated with immunosuppression. A. hydrophila is recognized as an opportunistic pathogen. SSSS should be considered in the differential diagnosis of immunocompromised adult patients with sudden onset of high fever and erythema.

Staphylococcal scalded skin syndrome in adults. A clinical review illustrated with a new case

Staphylococcal scalded skin syndrome is rarely observed in adults; only 32 cases have been reported. In contrast to infant cases, the mortality rate is high. Two major risk factors have been identified: kidney failure and immunosuppression. In adults, clinical features are similar to those of the typical pediatric disease, but blood cultures are often positive for Staphylococcus aureus. Detection of the exfoliative toxin is required for diagnosis; the newborn mouse bioassay is, therefore, usually performed. New immunologic methods allow precise characterization of the toxins and oligonucleotide probes can be used for rapid detection of toxigenic strains. We report a case of staphylococcal scalded skin syndrome in an immunocompetent adult in whom blood cultures were positive; this is the first case in which both exfoliative toxins A and B have been identified in an adult.

Studies of the mechanism of epidermal injury by a Staphylococcal epidermolytic toxin

Experimental animal models of the two forms of toxic epidermal necrolysis have been reviewed: a murine model of staphylococcal-induced epidermolysis and a hamster model of graft-versus-host disease. In the former, a protein exotoxin, epidermolysin, has been purified and characterized. The exotoxin has a molecular weight of approximately 30,000 and causes a split beneath the granular layer. It is effective at 3 times 10(-12) moles. Epidermolysin does not require an intact complement system for its action since B10D2 mice deficient in C5 or mice injected with the decomplementing agent in cobra venom factor were susceptible to its epidermolytic effects. Neither are immunocompetent thymocytes required for the action of the toxin since hairless, athymic adult (nu/nu) mice are susceptible. A few reports of epidermolysis due to an exotoxin of group I Staphylococcus aureus have appeared. This toxin is antigenically different from the exotoxin of group II organisms. A model of drug-induced toxic epidermal necrolysis has been described in hamsters, but the toxic principle released from sensitized lymphoid cells has not yet been characterized.