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

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.

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.

A young girl with a painful rash.

The speed with which this rash spread and the fact that the patient's skin sloughed off when pressure was applied made the diagnosis clear.

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.

Quemaduras graves relacionadas con la terapia inhalatoria con vahos / Severe burns related to steam inhalation therapy

INTRODUCCIÓN: Todavía se emplean vahos con agua caliente como tratamiento de procesos respiratorios banales, a pesar del riesgo de ocasionar quemaduras y de no haberse demostrado su efectividad. OBJETIVOS: Caracterizar los casos de quemaduras relacionadas con vahos (QRV) en una población de niños quemados con el objeto de formular criterios para su prevención. PACIENTES Y MÉTODOS: Revisión de pacientes ingresados por QRV en una unidad de quemados durante el periodo 2006-2012. Se analizó: epidemiología, clínica, gravedad y evolución. RESULTADOS: Ingresaron 530 pacientes quemados; 375 (70%) con escaldaduras y 15 con QRV (2,8% del total; 4% de las escaldaduras). Los vahos fueron indicados mayoritariamente para tratar episodios catarrales banales. La edad mediana fue 7 años (2,5 meses-14 anos). La superficie corporal quemada (SCQ) fue ≥ 10% en el 60% de los casos (SCQ máxima 22%). Las quemaduras afectaron al tronco, a los genitales y a las extremidades y solo en un caso afectó a la cara. La estancia media hospitalaria fue de 14 días (3-30 d). Cinco niños (33%) ingresaron en la UCIP, la mayoría (60%) menores de 3 años. Ocho casos (53%) requirieron intervención quirúrgica (injerto de piel). Un paciente de 12 años fue diagnosticado de tos ferina y otro de 2,5 años presentó un shock tóxico estafilocócico. No hubo fallecimientos. Todos los pacientes evolucionaron satisfactoriamente. CONCLUSIONES: Las QRV pueden ser graves y consumir importantes recursos. Los profesionales de la atención al niño, particularmente los pediatras, deben velar por su prevención, absteniéndose de indicar los vahos como tratamiento y educando a los padres para que no los utilicen por sí mismos

INTRODUCTION: Despite lack of proven effectiveness and its potential to cause severe burns, steam inhalation therapy (SIT) is still used as a treatment for benign respiratory conditions. OBJECTIVE: To characterize cases of burns related to steam inhalation therapy (BRSIT) in order to formulate appropriate preventive criteria. PATIENTS AND METHODS: A review was conducted on cases of BRSIT admitted to a Burns Unit between 2006 and 2012, analysing epidemiological data, clinical aspects, severity and course. RESULTS: A total of 530 patients were admitted; 375 (70%) with scalds, and 15 with BRSIT (2.8% of burns; 4% of scalds). SIT was indicated in most cases for mild upper airway infections. The median age of patients was 7 years (2.5 m-14 y). The burned area (BA) was ≥ 10% in 60% of cases (max. BA 22%). Injuries involved trunk, genital area, and extremities; only in one case was the face affected. The mean hospital length-of-stay was 14 days (3-30d). Five patients (33%) were admitted to the PICU, most of them (60%) younger than 3 years. Eight patients (53%) underwent surgical treatment (skin grafting). In a 12-year-old patient whooping cough was diagnosed in the Burns Unit, and a 2.5-year-old patient developed staphylococcal toxic shock syndrome. No patient died. The final course was satisfactory in all patients. CONCLUSIONS: BRSIT can be severe and cause significant use of health resources. Professionals caring for children, particularly paediatricians, should seriously consider their prevention, avoiding treatments with SIT, and educating parents in order not to use it on their own

Escarlatina estafilocócica como manifestación atenuada del síndrome de escaldadura estafilocócica / Staphylococcal scarlet fever as a mild manifestation of Staphylococcal Scalded Skin Syndrome

Se presenta el caso de un niño de cuatro años con fiebre, adenopatías y faringoamigdalitis con exantema escarlatiniforme. Se trató con amoxicilina/ácido clavulánico y evolucionó favorablemente. Se aisló Staphylococcus aureus en la faringe y dos semanas después presentó descamación en dedo de guante. Parece tratarse de una forma abortada del síndrome de escaldadura estafilocócica (AU)

We report the case of a four years old child with fever, adenopathies, pharyngitis and scarlet micropapular exanthema. He was treated with amoxicillin/clavulanic acid and he had a favourable outcome. Staphylococcus aureus was isolated from his throat. Two weeks later he presented exfoliation. It seems to be an abortive form of Staphylococcal Scalded Skin Syndrome (AU)

Varicella infection in a neonate with subsequent staphylococcal scalded skin syndrome and fatal shock.

A male term neonate, at day 23 of life, presented with vesicular lesions over the trunk, which spread to allover the body on the next day. Five days later, he started developing blistering of the skin over the trunk and extremities, which subsequently ruptured, leaving erythematous, tender raw areas with peeling of the skin. The mother had vesicular eruptions, which started on the second day of delivery and progressed over the next 3 days. Subsequently, similar eruptions were noticed in two of the siblings before affecting the neonate. On the basis of the exposure history and clinical picture, a diagnosis was made of varicella infection with staphylococcal scalded skin syndrome (SSSS). The blood culture and the wound surface culture grew Staphylococcus aureus. Treatment included intravenous fluid, antibiotics, acyclovir and wound care. However, after 72 h of hospitalisation, the neonate first developed shock, refractory to fluid boluses, vasopressors and catecholamine along with other supports; and he then succumbed. In all neonates, staphylococcal infection with varicella can be fatal due to SSSS, the toxic shock syndrome or septicaemia.

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...

Cleavage isn't everything: potential novel mechanisms of exfoliative toxin-mediated blistering.

This Commentary describes breakthroughs in understanding the interactions between desmoglein 1 and plakogloben in staphylococcal-mediated blistering skin diseases.

Bullous congenital ichthyosiform erythroderma: a sporadic case produced by a new KRT10 gene mutation.

Bullous congenital ichthyosiform erythroderma is an unusual type of inherited ichthyosis by mutations in the genes that encode K1 and K10. We report the case of a girl with typical clinical and histopathologic findings of bullous congenital ichthyosiform erythroderma, who was found to have a new mutation in KRT10 gene, Glu445Lys at position 445, affecting the 2B region of the KRT10 protein, the end of the rod domain, where many other keratin mutations associated with hereditary skin disease have been reported. This new mutation contributes to add to the catalog of bullous congenital ichthyosiform erythroderma mutations known.

Staphylococcal scalded skin syndrome and toxic shock syndrome after tooth extraction.

Staphylococcus aureus may cause cutaneous and systemic infections such as staphylococcal scalded skin syndrome (SSSS) and toxic shock syndrome (TSS). Although exfoliative toxins A and B, which cause SSSS, and TSS toxin-1 may be produced by different strains of S aureus, the two syndromes rarely occur simultaneously. We describe a patient admitted to the intensive care department with an exfoliative generalized erythroderma, signs of shock, and biopsy specimen findings consistent with SSSS. This patient presented after a tooth extraction. Symptoms recurred after dismissal, and he was readmitted. Subsequent test results were positive for exfoliative toxin B and TSS toxin-1, suggesting concurrent SSSS and TSS. For patients with acute, exfoliative, generalized erythroderma, TSS and SSSS should be considered. Although rare, it is possible to see both syndromes present concurrently.

Molluscum contagiosum prevents progression of staphylococcal scalded skin syndrome.

Prevention of progression of staphylococcal scalded skin syndrome by molluscum contagiosum indicated a possible interference by viral anti-cytokine molecule such as interleukin-18 binding protein.

Treatment of bullous impetigo and the staphylococcal scalded skin syndrome in infants.

Impetigo is a common, superficial, bacterial infection of the skin characterized by an inflamed and infected epidermis. The rarer variant, bullous impetigo, is characterized by fragile fluid-filled vesicles and flaccid blisters and is invariably caused by pathogenic strains of Staphylococcus aureus. Bullous impetigo is at the mild end of a spectrum of blistering skin diseases caused by a staphylococcal exfoliative toxin that, at the other extreme, is represented by widespread painful blistering and superficial denudation (the staphylococcal scalded skin syndrome). In bullous impetigo, the exfoliative toxins are restricted to the area of infection, and bacteria can be cultured from the blister contents. In staphylococcal scalded skin syndrome the exfoliative toxins are spread hematogenously from a localized source causing widespread epidermal damage at distant sites. Both occur more commonly in children under 5 years of age and particularly in neonates. It is important to swab the skin for bacteriological confirmation and antibiotic sensitivities and, in the case of staphylococcal scalded skin syndrome, to identify the primary focus of infection. Topical therapy should constitute either fusidic acid (Fucidin, Leo Pharma Ltd) as a first-line treatment, or mupirocin (Bactroban, GlaxoSmithKline) in proven cases of bacterial resistance. First-line systemic therapy is oral or intravenous flucloxacillin (Floxapen, GlaxoSmithKline). Nasal swabs from the patient and immediate relatives should be performed to identify asymptomatic nasal carriers of Staphylococcus aureus. In the case of outbreaks on wards and in nurseries, healthcare professionals should also be swabbed.

Neonatal Staphylococcal scalded skin syndrome complicating ileal atresia.

Staphylococcal scalded skin syndrome is a toxin mediated Staphylococcal infection, the toxin produced by staphylococcus aureus type 2 phage types (55,71,3A,3B,3C). There is a generalized tender erythema which commences on the head and neck, accompanied by fever, irritability, continuous cry and miserable look. The erythema is followed by cleavage of the upper epidermis in a large sheets mainly in the head, neck and the flexures, with formation of bullae (Nikolsky sign). It is most common in infants and children under 5 years. Most cases respond to antibiotics with other supportive measures. The prognosis is good, and the skin lesions disappear without a residual scar.