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Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 138-140

A rare early presentation of staphylococcal scalded skin syndrome in a Neonate

1 Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, Telengana, India
2 Department of Pediatrics, Ankura Hospital for Women and Children, Hyderabad, Telengana, India

Date of Web Publication29-Mar-2019

Correspondence Address:
Dr. Srinivas Abhishek Gaddam
17 Gruhalaxmi Colony, Karkhana, Secunderabad - 500 015, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpd.IJPD_81_18

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Staphylococcal Scalded Skin Syndrome (SSSS) is caused by the exfoliative toxins (ETs) of Staphylococcus aureus. We present a case of a 3 days old infant with complaints of fever and diffuse erythematous exfoliation all over the body with bilateral conjunctivitis. The diagnosis of SSSS was reached based on clinical features and positive blood culture report. He responded well to the antibiotics paracetamol, and intravenous fluids for rehydration. He was discharged after 14 days, with complete resolution of symptoms. Having a high clinical suspicion for SSSS, early diagnosis/treatment, and following strict aseptic measures in neonatal intensive care unit are important.

Keywords: Exotoxin, methicillin-resistant Staphylococcus aureus, Nikolsky's sign

How to cite this article:
Gaddam SA, Thirunagari S. A rare early presentation of staphylococcal scalded skin syndrome in a Neonate. Indian J Paediatr Dermatol 2019;20:138-40

How to cite this URL:
Gaddam SA, Thirunagari S. A rare early presentation of staphylococcal scalded skin syndrome in a Neonate. Indian J Paediatr Dermatol [serial online] 2019 [cited 2020 Oct 20];20:138-40. Available from: https://www.ijpd.in/text.asp?2019/20/2/138/255216

  Introduction Top

Mortality in children with SSSS is approximately 4%. Staphylococcus aureus is a bacterium commonly found harmlessly colonizing human skin and mucosa without causing any morbidity.[1] Colonization begins soon after birth. Sometimes, it breaks through the skin causing infection. In neonates, the risk of SSSS is much higher due to inadequate immunity and immature renal clearance of exotoxin in them.[2] The severity of SSSS varies from a few blisters to severe exfoliation affecting the entire body.[3] The epidermolytic toxins (ETs) released by S. aureus, particularly ETA and ETB, lyse desmoglein-1, present on desmosomes located in the strata granulosum of the epidermis, causing a loss of cell-to-cell adhesion between the keratinocytes, leading to intraepidermal splitting.

  Case Report Top

A 3-day-old infant was brought to the neonatal intensive care unit (NICU) with diffuse erythematous exfoliation all over the body with conjunctivitis in both his eyes [Figure 1]. He was irritable and had fever. The baby was born through normal vaginal delivery in a government hospital elsewhere, cried immediately after birth. The mother was a G2P1 L1A0 and had no history of consumption of any drug, except for iron and folic acid tablets. There was no history in the family of any skin diseases. The baby was apparently well till 2 days of life and developed the above symptoms on 3rd day of life probable the origin of which was nosocomial infection. On examination, the baby was toxic looking and irritable and had a high fever of 103°F with signs of dehydration and tachycardia. His weight was 3.0 kg. Nikolsky's sign was positive. SSSS was suspected based on clinical features. Central lines in the form of umbilical vein catheter were placed. On admission, blood culture was sent. Cultures from conjunctiva/nasopharynx were not sent. Immunofluorescence and genetic studies, to detect exfoliative toxins (ETs) and ET genes, were not performed due to the lack of material in our hospital setting. The infant was started on cefotaxime on admission. Blood culture showed growth of methicillin-resistant S. aureus (MRSA). Antibiotics were upgraded according to the sensitivity pattern. Parental linezolid was started. He was started on analgesic for fever and pain. Lumbar puncture was done, and the cerebrospinal fluid was sterile. Antibiotics were given for 14 days for which he responded well.
Figure 1: Diffuse erythematous exfoliation all over the body with conjunctivitis of both the eyes

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  Discussion Top

SSSS in neonate is a serious and occasionally fatal condition. The ETs produced by S. aureus are considered to be the pathogenetic agent in SSSS. There are two exfoliative toxins that are identified, exotoxin A and exotoxin B. Most strains of S.aureus isolated from patient suffering from SSSS belong to phage Group II (about 80%). These toxins have exquisite specificity in causing loss of desmosome-mediated cell adhesion within the superficial epidermis only. When the toxins are released into the bloodstream, the lack of protective antitoxin antibody in neonates allows the toxins to reach the epidermis where they act locally to produce the characteristic skin lesions.[4] These human exfoliative toxin antibodies which have neutralizing properties decrease from 0 to 3 months.

SSSS clinical presentation includes fever, facial edema, conjunctivitis, perioral crusting with mucous membranes being spared, dehydration, Nikolsky's sign being positive. The diagnosis is usually made on clinical grounds (characteristic appearance of the rash with fever) and the presence of S. aureus in the nasal, conjunctival, pharyngeal, wound swabs, or positive blood culture. Antibiotics are the mainstay of SSSS treatment. Consideration needs to be given to pain management, temperature regulation, fluid management (rehydration), nutrition, and skin care. Corticosteroids are contraindicated. We added important rehydration, antipain, and skin care. The treatment was effective, and the neonate was completely healed after 2 weeks.[5]

The percentage of carriers of antibody to ET-A decreases from 88% immediately after birth to a minimum of 30% from 4 months to 2 years and then rises again. Thus, lack of transplacental ET-A antibodies due to no immunity of the mother as well as decreasing antibody titers may contribute to SSSS. The differential diagnosis of SSSS includes drug-induced toxic epidermal necrolysis, epidermolysis bullosa, bullous mastocytosis, herpetic lesions, and neonatal pemphigus. Staphylococcal Scalded Skin Syndrome (SSSS) can occasionally lead to serious complications such as pneumonia, septic arthritis, hypothermia, dehydration, and secondary infections. SSSS has an incidence between 0.09 and 0.56 cases/million.[6] Phage typing the S. aureus is found to be useful, as almost 80% of the strains of S. aureus causing SSSS belong to phage Group II. Other sparingly used diagnostic tools are techniques measuring the titers of the ETs and isolating their gene sequences.

As most strains of S. aureus causing SSSS are methicillin-sensitive, penicillinase-resistant beta-lactam agents such as cloxacillin, dicloxacillin, oxacillin, flucloxacillin, and nafcillin are the first-line antibiotics. If the patient is not responding to these agents, MRSA should be suspected, for which vancomycin and linezolid are the drugs of choice. Topical therapy should constitute either fusidic acid and/or mupirocin. Exposed, damaged areas can be treated with emollients which soothe and moisturize the skin. With the rise of MRSA strains and increase in the mortality rate of SSSS, some newer therapies have been investigated by researchers. Infusion of fresh frozen plasma obtained from adults into children with SSSS has been found to be successful in a pediatric age group.

There are reports suggesting better patient outcomes following the use of artificial skin substitutes over conventional sterile gauze dressings. However, there have been no clinical trials conducted to authenticate these. Although theoretically developing desmoglein-1 antitoxins/analogs to antagonize the ETs causing SSSS should show superior results, no clinical or experimental studies exploring this therapy are available. Vaccines targeting S. aureus have failed in the Phase III of clinical trials and are still in developmental phase. Cases, such as this, emphasize the importance of dermatological conditions in NICU. The significance of skin failure as a distinct entity comparable to any other organ system failures leading to high mortality in a NICU setting.

  Conclusion Top

SSSS responds well to specific antibiotic therapy, it remains an emergency and a potential fatal condition in neonates. Hence, early diagnosis, prompt treatment, and following aseptic measures in NICU are the mainstay for its successful management. Isolating neonates is mandatory to prevent the outbreak of SSSS in the unit. Future policies to prevent similar situations may include continuous monitoring and surveillance of infection rates, effective nursery design and staffing, emphasis on hand washing to prevent cross infection, educational programs, and feedback to nursing staff to improve infection control.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Jalaludeen A, Thomas N, Mohammad S. Case report on the efficacy of linezolid in staphylococcal scalded skin syndrome (ssss) in pediatrics ejpmr, 2018;5:287-8.  Back to cited text no. 1
Kadam S, Tagare A, Deodhar J, Tawade Y, Pandit A. Staphylococcal scalded skin syndrome in a neonate. Indian J Pediatr 2009;76:1074.  Back to cited text no. 2
Jeyakumari D, Gopal R, Eswaran M, Maheshkumar C. Staphylococcal scalded skin syndrome in a newborn. J Glob Infect Dis 2009;1:45-7.  Back to cited text no. 3
Hubiche T, Bes M, Roudiere L, Langlaude F, Etienne J, Del Giudice P, et al. Mild staphylococcal scalded skin syndrome: An underdiagnosed clinical disorder. Br J Dermatol 2012;166:213-5.  Back to cited text no. 4
Gemmell CG. Staphylococcal scalded skin syndrome. J Med Microbiol 1995;43:318-27.  Back to cited text no. 5
Handler MZ, Schwartz RA. Staphylococcal scalded skin syndrome: Diagnosis and management in children and adults. J Eur Acad Dermatol Venereol 2014;28:1418-23.  Back to cited text no. 6


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