136
SHORT COMMUNICATION
ActaDV ActaDV
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.