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Advances in dermatology and venereology Acta Dermato-Venereologica
Adult Staphylococcal Scalded Skin Syndrome Successfully Treated with Multimodal Therapy Including Intravenous Immunoglobulin
Toru URATA 1 , Michihiro KONO 1 *, Yuka ISHIHARA 2 and Masashi AKIYAMA 1
1
Department of Dermatology , Nagoya University Graduate School of Medicine , 65 Tsurumai-cho , Showa-ku , Nagoya 466-8550 , and 2 Department of Nursing , Sugiyama Jogakuen University School of Nursing , Nagoya , Japan . * E-mail : miro @ med . nagoya-u . ac . jp Accepted Aug 16 , 2017 ; Epub ahead of print Aug 17 , 2017
Staphylococcal scalded skin syndrome ( SSSS ) is a systemic toxic disease whose symptoms include diffuse erythema and blister formation over the whole body ( 1 ). SSSS develops when exfoliative toxin ( ET ) produced by Staphylococcus aureus reaches the skin via blood flow . SSSS is ordinarily seen in children ; in adults it is rare but serious ( 1 ). We report here a severe case of adult SSSS caused by an ET A-producing strain of Staphylococcus . The patient had had immunosuppressive therapy for rheumatoid arthritis ( RA ) and was complicated with kidney failure associated with septic shock . She was treated successfully with intravenous immunoglobulin ( IVIG ) therapy .
CASE REPORT
The patient was a 71-year-old woman with a history of RA . She had been taking methotrexate , 8 mg per week , as well as non-steroidal anti-inflammatory drugs . She had regularly received intra-articular injections of hyaluronic acid to treat osteoarthritis of the right knee joint . Four days before her first visit to our hospital , she developed general malaise and rashes on the limbs and trunk . As those symptoms did not resolve , she visited a neighbourhood clinic . The general physician suspected drug eruption and prescribed oral prednisolone , 15 mg / day . However , the rash spread and the malaise intensified . The patient was referred to our hospital and arrived by ambulance . On arrival , she was in septic shock and had generalized rash with erosions and bullae . The emergency physician suspected toxic epidermal necrolysis ( TEN ) and consulted us .
At initial examination , membranous blister roofs , shallow erosions and flaccid bullae were observed over most of the patient ’ s body , but predominantly on intertriginous areas of the limbs and the trunk ( Fig . 1A – D ). Purpura was observed on the right calf and the left thigh ( Fig . 1E , F ). Enanthema was not observed in the oral cavity , the eyes , or the vulva . Mild , but painful , swelling was noted in the right knee joint .
On histopathological examination , blister formation was observed under the stratum corneum in the lesions with flaccid bullae , consistent with SSSS ( Fig . S1A 1 ). The purpuric lesions on the right calf ( Fig . 1E ) and left thigh ( Fig . 1F ) revealed bacterial colonies in the upper epidermis , necrosis of the epidermis and the dermis , and neutrophilic infiltration from the epidermis to the adipose tissue , consistent with an abscess with necrotic tissue ( Fig . S1B 1 ).
Blood examinations showed total leukocytes of 2,400 /µ l , serum blood urea nitrogen of 3 mg / dl , serum creatinine of 2.13 mg / dl , serum aspartate aminotransferase of 96 IU / l , serum alanine aminotransferase of 41 IU / l , serum creatinine kinase of 5,155 IU / l , C-reactive protein of 28.41 mg / dl , procalcitonin at 96.6 mg / dl , international normalized ratio of prothrombin time of 2.08 , fibrinogen of 786 mg / dl , D-dimer of 60.4 µ g / ml , and fibrin degradation products of 143 µ g / ml . Peripheral blood , synovial fluid samples from the right knee and necrotic tissues from the thigh were subjected to bacterial culture . From all of these samples , methicillinsensitive S . aureus ( MSSA ) was cultured and was characterized as positive for ET A and negative for toxic shock syndrome toxin-1 , staphylococcal enterotoxins A through D , and endotoxin . Panton – Valentine leukocidin was not detected in the strain of MSSA isolated from the patient ’ s blood by previously reported PCR methods ( 2 ). In addition , magnetic resonance imaging ( MRI ) scan revealed discitis and an epidural abscess at L3 / L4 ( Fig . S1C , D 1 ). Based on these results , the patient was diagnosed with SSSS resulting from MSSA septic arthritis of the right knee .
The patient was transferred to the emergency room ( ER )
Fig . 1 . Clinical features of the adult patient with staphylococcal scalded skin syndrome ( SSSS ). ( A ) Erosive plaques and shallow flaccid bullae are observed on the face . The erosive plaques with crusts around the eyes and mouth that are often seen in paediatric SSSS are not observed in the present patient . ( B – D ) Membranous blister roofs , erosive plaques and shallow flaccid bullae are seen on the whole body . Even skin that appears normal in colour shows diffuse superficial blister formation ( B : an upper limb ; C : a lower limb ; D : the back ). ( E , F ) Flaccid bullae and purpuric plaques are observed on the right lower leg ( arrow indicates the biopsy site ) ( E ) and the left thigh ( F ), indicating necrotic lesions of the skin . of our hospital early in the morning . Shortly after her arrival , meropenem ( 1 g every 8 h ) was started , and then daptomycin ( 500 mg every 24 h ) was additionally administered . Continuous haemofiltration was started from the early afternoon . However , the patient ’ s general condition was serious , and it worsened despite the treatments . Thus , we started doi : 10.2340 / 00015555-2770 Acta Derm Venereol 2018 ; 98 : 136 – 137
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2018 Acta Dermato-Venereologica .