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1/46. staphylococcal scalded skin syndrome in an adult associated with methicillin-resistant staphylococcus aureus.

    We report the first adult case of staphylococcal scalded skin syndrome (SSSS) due to methicillin-resistant staphylococcus aureus (MRSA). This case is particularly unusual as the MRSA produced toxic shock syndrome toxin 1 and enterotoxin, but not exfoliatoxin. SSSS was originally described in neonates and is thought to result from exfoliatins which produce subcorneal splitting of the epidermis and are only produced by certain strains of S. aureus. This case reflects the range of toxins that can be associated with SSSS and the clinical manifestations of MRSA infection in adult patients. ( info)

2/46. Cutaneous (non-hiv) infections.

    Cutaneous infections continue to represent a large proportion of inpatient dermatology. Though most infectious skin diseases do not warrant hospitalization, some do and can rapidly become fatal if not treated promptly. A selected group of infections are reviewed--primary cutaneous infections, exotoxin-mediated syndromes, and systemic infections--that warrant hospitalization. Dermatologists play a critical role in the synthesis of patient history and appreciation of morphologic skin disease, which, when coupled with appropriate lab tests, may help to establish a diagnosis allowing for the timely implementation of effective and targeted therapy. ( info)

3/46. staphylococcal scalded skin syndrome with prosthetic valve endocarditis.

    We report staphylococcal scalded skin syndrome (SSSS) in a 67-year-old man. He showed diffuse erythema with erosion on his face and erythema with giant desquamation on his neck, axilla, genitalia, chest and abdomen 39 days after a coronary artery bypass graft and aortic valve replacement. He died of cardiac rupture caused by myocardial necrosis, and autopsy findings demonstrated prosthetic valve endocarditis due to a strain of exfoliative toxin-B producing methicillin-resistant staphylococcus aureus. To the best of our knowledge, this is the first case of SSSS caused by prosthetic valve endocarditis. ( info)

4/46. Non-thermic skin affections.

    The Centre for burns can help by its means (material, technical and personal) in the treatment of burns with extensive and deep losses of the skin cover and other tissue structures and in some affections with a different etiology (non-thermic affections). Indicated for admission are, in particular, extensive exfoliative affections--Stevens-Johnson's syndrome (SJS), Lyell's syndrome--toxic epidermal necrolysis (TEN) and staphylococcal scalded skin syndrome (SSSS), deep skin and tissue affections associated with fulminant purpura (PF), possibly other affections (epidermolysis bullosa, posttraumatic avulsions etc.). The similarity with burn injuries with loss of the skin cover grade II is typical, in particular in exfoliative affections with a need for adequate fluid replacement in the acute stage and aseptic surgical treatment of the affected area from the onset of the disease. In conditions leading to full thickness skin loss, in addition to general treatment rapid plastic surgical interventions dominate. ( info)

5/46. staphylococcal scalded skin syndrome in a healthy adult.

    We report a case of staphylococcal scalded skin syndrome (SSSS) in a 65-year-old healthy woman. Fever, purulent conjunctivitis, and exfoliation of the skin in the gluteal region were noted. A scarlatiniform rash was observed on the body, and this erythema was followed by generalized desquamation. Staphylococcus aureus was isolated from her eye discharge, posterior nasopharynx, and the erosive surface of the skin. All the investigated strains produced exfoliative toxin B, but none produced toxic shock toxin-1 (TSST-1) or enterotoxin. The patient was treated with antibiotics and fluid supplementation, resulting in subsidence. This case is thought to have been caused by an abortive form of SSSS or a scarlatiniform variant, which is very rare in healthy adults. ( info)

6/46. Staphylococcal scalded-skin syndrome in a very low birth weight premature infant.

    Exfoliative skin diseases are rare in neonates. When caused by coagulase-positive Staphylococcus aureus, scalded-skin diseases such as staphylococcal scalded-skin syndrome (SSSS), bullous impetigo, and staphylococcal scarlet fever may develop. These diseases might cause significant complications and mortality. SSSS is caused by staphylococcal exfoliative toxins A or B, which split the granular layer of the skin, induce proteolysis, and might exhibit superantigen activities, such as epidermolysis and lymphocyte mitogenicity. We describe a 1378-g premature male infant who was born at 29 weeks' gestation and developed SSSS on day 3 of life, with no clinical signs of neonatal sepsis. After cultures from the lesion and bloodstream were obtained, intravenous cloxacillin therapy was started. infection control measures were implemented instantly and included isolation of the infected infant, personnel handwashing with hexachlorophene, and placement of exposed neonates into a cohort. The initial lesion expanded and additional lesions appeared, but 12 hours after initiation of antibacterial therapy, the lesions ceased to proliferate. Cultures from scalded-skin lesions grew coagulase-positive Staphylococcus aureus, whereas the bloodstream culture was sterile. The lesions resolved completely within 6 days, and the infant's subsequent course was uneventful. No similar skin lesions were noticed in other infants in the neonatal intensive care unit. We discuss recent advances in understanding the pathogenesis of neonatal SSSS, highlight the importance of early diagnosis and treatment, and stress the need for new adjunctive therapies for this disease. ( info)

7/46. staphylococcal scalded skin syndrome developing during burn treatment.

    We report a case of staphylococcal scalded skin syndrome (SSSS) in a 5-year-old girl who had been hospitalized for burn treatment. When she developed an upper respiratory tract infection, she manifested extensive erythema and exfoliation. There was a purulent discharge from the ulcer caused by the burn, and exfoliation was observed in the surrounding area. Based on clinical symptoms and laboratory data, SSSS was diagnosed and treated with antibiotics, resulting in subsidence. Staphylococcus aureus was isolated from the posterior nasopharynx and the skin erosion and was proved to produce exfoliative toxin A (ETA). Infection from an asymptomatic carrier of an ET-producing strain was suspected, but we failed to identify the origin, in spite of a thorough inspection of the mother, nurses, and physician. SSSS is occasionally reported as a hospital-acquired infection. We should study the frequency of asymptomatic carriers of ET-producing strains so that we can formulate strategies to prevent such infections. ( info)

8/46. Recurring staphylococcal scalded skin syndrome-like bullous mastocytosis: the utility of cytodiagnosis and the rapid regression with steroids.

    We report a male infant with onset of an extensive bullous eruption at the age of 45 days. staphylococcal scalded skin syndrome (SSSS) was suspected. Bullous mastocytosis was diagnosed by cytodiagnosis and confirmed by histologic examination. Three serious relapses were noted in a 2-year follow-up, and SSSS was again suspected because of high fever and leukocytosis with neutrophilia in an infectious context. cytodiagnosis revealed the presence of mast cells and permitted rapid diagnosis of recurrences of bullous mastocytosis. Systemic corticotherapy dramatically improved the cutaneous lesions and general symptoms. This case report emphasizes the utility of cytodiagnosis in extensive blistering diseases in infancy and the possibility of obtaining rapid healing by using steroids. ( info)

9/46. staphylococcal scalded skin syndrome complicating acute generalized pustular psoriasis.

    A 60-year-old woman with psoriasis vulgaris treated with oral cyclosporin and acitretin developed an acute generalized pustular eruption with erythema and associated fever consistent with acute generalized pustular psoriasis. She was admitted to hospital and, despite intravenous fluid replacement, developed acute renal failure. In addition, she developed staphylococcal septicaemia. After transfer to the intensive care unit because of deteriorating renal function, a sudden onset of widespread flaccid blistering (Nikolsky sign positive) and superficial erosions was noted. histology of a biopsied blister revealed subcorneal splitting of the epidermis consistent with staphylococcal scalded skin syndrome. The patient was treated with intravenous dicloxacillin and the blistering gradually improved over 10 days. ( info)

10/46. 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. ( info)
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