2013.3-22.Staphylococcal

                                                                                                                            article in PDF  
Our Dermatol Online. 2013; 4(3): 347-348
DOI: 10.7241/ourd.20133.86
Date of submission: 22.03.2012/acceptance: 27.04.2013
Conflicts of interest: None
 

STAPHYLOCOCCAL SCALDED SKIN SYNDROME MIMICKING TOXIC EPIDERMAL NECROLYSIS IN A HEALTHY ADULT

Tomoko Oishi, Yuka Hanami, Yasunobu Kato, Mikio Otsuka, Toshiyuki Yamamoto

Department of Dermatology, Fukushima Medical University, Hikarigaoka 1, Fukushi­ma 960-1295, Japan
 

Corresponding author:  Prof. Toshiyuki Yamamoto    e-mail: toyamade@fmu.ac.jp


 

Abstract
Introduction: Staphylococcal scaled skin syndrome (SSSS) presents generalized form bullous impetigo caused by Staphylococcus aureus (S. aureus) infection, typically seen in infants and children. SSSS may occur also in adults; however, the majority of adult cases are those with immunosuppression. Atypical clinical features of impetigo in adults sometimes make it difficult to diagnose correctly.
Case Report: A 74-year-old healthy woman was hospitalized, complaining of extensive desquamative erythema and a number of erosions. She was administered oral antiviral drugs under suspicion of herpes zoster prior to 10 days. Initial diagnosis on the admission was toxic epidermal necrolysis (TEN) due to antiviral tablets; however, steroid pulse therapy resulted in no effect. Bacterial culture yielded coagulase-positive methicillin-resistent S. aureus, producing exfoliative toxin B. A biopsy specimen showed subcorneal splitting of the epidermis. The diffuse erosions gradually improved over 10 days by the treatment with intravenous antibiotics.
Conclusions: The differentiation between streptococcal scaled skin syndrome (SSSS) and TEN is sometimes difficult. It is important to remind SSSS when we suspect TEN, even in healthy adults..
 
Key words:  SSSS; TEN; MRSA; adult

 

Introduction
Streptococcal scaled skin syndrome (SSSS) presents generalized form bullous impetigo caused by Staphylococcus aureus (S. aureus) infection, typically seen in infants and children. SSSS may occur also in adults; however, the majority of adult cases are those with immunosuppression, overwhelming sepsis, kidney failure, or under immunosuppressive conditions. We herein report a case of SSSS due to methicillin-resistant Staphylococcus aureus (MRSA) in a healthy adult, which mimicked the clinical feature of toxic epidermal necrolysis (TEN).
 
Case Report
A 74-year-old woman initially visited a practical clinic, complaining of several bullae on the left hip. She was administered oral antiviral drugs under a suspicion of herpes zoster. However, erythema and erosions appeared and spread rapidly all over the body. She visited an emergency room of another hospital 10 days later. Then, she was prescribed oral prednisolone (30mg daily) under a diagnosis of drug eruption, and referred to our hospital on the next day. On physical examination, there were broad erosions around her left hip and lower abdomen with a background of systematic erythema including her face (Fig. 1).
 
Figure 1. Extensive desquamative erythema, erosions, and scales on the trunk
 
Bulbar conjunctival hyperemia was seen. Nikolsky sign was positive on her back skin. She had no special past health histories and there were no significant laboratory findings expect for a slight degree of hypoproteinemia (TP 6.2g/dl, Alb 3.2g/dl) and inflammatory reaction (CRP 2.51mg/dl). Under suspicion of TEN due to antivirus tablets, we started a steroid pulse therapy with gamma globulin, which however resulted in no effects. Histological examination revealed splitting at the level of the granular cell layer (Fig. 2), without inflammation in the dermis.
 
Figure 2. Histopathology showing cleavage in the upper epidermis. (H&E stain, X200)
 
Bacterial cultures from skin erosion yielded coagulase-positive MRSA, producing exfoliative toxin B. Neither toxic shock syndrome toxin-1 (TSST-1) nor enterotoxin was detected. The diagnosis of SSSS was made, and antibiotics (teicoplanin (TargocidR); 200 mg/day for 5 days followed 400mg/day for 4 days) were administered. Because she developed drug eruption, antibiotics were changes to vancomycin (1g/day for 2 days). All eroded surface epithelized in 2 weeks.
 
Discussion
SSSS is an extensive exfoliative dermatitis caused by S. aureus infection. The blisters in SSSS is caused by exfoliative toxin (ET) released by S. aureus, occasionally by MRSA [1,2]. S. aureus infection results in a loss of keratinocyte cell-cell adhesion through desmoglein-1, leading to blister formation [3]. SSSS usually occurs in children, and is rarely seen in healthy adults [4-6]. SSSS in adults frequently occur in association with kidney failure, malignancy, and immunosuppression [7]. Although our case was an elderly female, she did not either present a prior condition for SSSS such as burn, wounds, or had diabetes, renal failure, or other immunosuppressive conditions. Our case presented diffuse erosive erythema with Nikolsky sign, following intake of antiviral drugs under a misdiagnosis of herpes zoster. Therefore we initially suspected TEN because the patient was healthy adult and had no significant past health history. However, a steroid therapy resulted in no effect and histology examination also denied TEN. Differentiation between TEN and SSSS is sometimes difficult. Nikolsky sign is not specific for TEN. Examination by histological examination by immediate cryosections, Tzank test, and blister roof histology may be useful as rapid tools. In SSSS, blister roof histology shows that the epidermal cleavage is within the stratum granulosum [8].
 
Conclusion
It is important to remind SSSS in cases suspecting TEN even in healthy adults, because the treatment for both diseases is different and SSSS is still associated with mortality.
 
REFERENCES
1. Acland KM, Darvay A, Griffin C, Aali SA, Russell-Jones R: Staphylococcal scalded skin syndrome in an adult associated with methicillin-resistant Staphylococcus aureus. Br J Dermatol. 1999;140:518-20.
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3. Hanakawa Y, Schechter NM, Lin C, Garza L, Li H, Yamaguchi T, et al: Molecular mechanisms of blister formation in bullous impetigo and staphylococcal scalded skin syndrome. J Clin Invest. 2002;110:53-60.
4. Patel GK, Varma S, Finlay AY: Staphylococcal scalded skin syndrome in healthy adults. Br J Dermatol. 2000;142:1253-5.
5. Oyake S, Oh-i T, Koga M: Staphylococcal scalded skin syndrome in a healthy adult. J Dermatol. 2001;28:145-8.
6. Opal SM, Johnson-Winegar AD, Cross AS: Staphylococcal scalded skin syndrome in two immunocompetent adults caused by exfoliating B-producing Staphylococcus aureus. J Clin Microbiol. 1988;26:1283-6.
7. Cribier B, Piemont Y, Grosshans E: Staphylococcal scalded skin syndrome in adults: a clinical review illustrated with a new case. J Am Acad Dermatol. 1994;30:319-24.
8. Dobson CM, King CM: Adult staphylococcal scalded skin syndrome: histological pitfalls and new diagnostic perspectives. Br J Dermatol. 2003;148:1068-9.


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