Staphylococcal scalded-skin syndrome in an adult

The Candidate Antigens to Achieving an Effective Vaccine against Staphylococcus aureus

Staphylococcus aureus (S. aureus) is an opportunistic pathogen that causes various inflammatory local infections, from those of the skin to postinfectious glomerulonephritis. These infections could result in serious threats, putting the life of the patient in danger. Antibiotic-resistant S. aureus could lead to dramatic increases in human mortality. Antibiotic resistance would explicate the failure of current antibiotic therapies. So, it is obvious that an effective vaccine against S. aureus infections would significantly reduce costs related to care in hospitals. Bacterial vaccines have important impacts on morbidity and mortality caused by several common pathogens, however, a prophylactic vaccine against staphylococci has not yet been produced. During the last decades, the efforts to develop an S. aureus vaccine have faced two major failures in clinical trials. New strategies for vaccine development against S. aureus has supported the use of multiple antigens, the inclusion of adjuvants, and the focus on various virulence mechanisms. We aimed to present a compressive review of different antigens of S. aureus and also to introduce vaccine candidates undergoing clinical trials, from which can help us to choose a suitable and effective candidate for vaccine development against S. aureus.

Staphylococcal scalded skin syndrome: diagnosis and management in children and adults

Staphylococcal scalded skin syndrome is a potentially life-threatening disorder caused most often by a phage group II Staphylococcus aureus infection. Staphylococcal scalded skin syndrome is more common in newborns than in adults. Staphylococcal scalded skin syndrome tends to appear abruptly with diffuse erythema and fever. The diagnosis can be confirmed by a skin biopsy specimen, which can be expedited by frozen section processing, as staphylococcal scalded skin syndrome should be distinguished from life threatening toxic epidermal necrolysis. Histologically, the superficial epidermis is detached, the separation level being at the granular layer. The diffuse skin loss is due to a circulating bacterial exotoxin. The aetiological exfoliating toxin is a serine protease that splits only desmoglein 1. The exfoliative toxins are spread haematogenously from a localized source of infection, causing widespread epidermal damage at distant sites. Sepsis and pneumonia are the most feared complications. The purpose of this review is to summarize advances in understanding of this serious disorder and provide therapeutic options for both paediatric and adult patients. Recent epidemiological studies have demonstrated that paediatric patients have an increased incidence of Staphylococcal scalded skin syndrome during the summer and autumn. Mortality is less than 10% in children, but is between 40% and 63% in adults, despite antibacterial therapy. Previously, intravenous immunoglobulin had been recommended to combat Staphylococcal scalded skin syndrome, but a recent study associates its use with prolonged hospitalization.

Dermatologic emergencies

Primary care physicians are the gatekeepers of the medical community. They are the physicians to whom patients first present, and they are often the physicians with whom patients have the longest lasting relationships. Primary care physicians, as a result of these long-term relationships, have been endowed with a unique responsibility to the health of their patients. By the very nature of their practice, primary care physicians do not have the resources to treat emergent life-threatening conditions. They must, however, be able to diagnose these potentially life-threatening conditions and be able to stabilize and appropriately refer a patient for urgent evaluation by specialists or emergency physicians. There are many types of emergencies encountered in the outpatient setting, ranging from cardiac to toxicologic. As important as recognizing signs and symptoms of cardiac ischemia is the ability to recognize potentially life-threatening dermatologic disorders or dermatologic manifestations of life-threatening systemic diseases.

Severe bacterial infections of the skin: uncommon presentations

Although most bacterial infections of the skin prove to be minor in nature, a few such dermatologic entities are significant, to the point of even being fatal. Their course can be extremely rapid and can lead to dreadful complications. The mortality rate is usually up to 30% to 50% and depends upon the type of infection, underlying disease, and immune status. Patients suffering them usually need to be hospitalized, sometimes in intensive care or burn units. They should be treated systemically with appropriate antimicrobial therapy plus aggressive supportive care. The two life-threatening skin infections which are most commonly experienced are toxin-mediated staphylococcal and streptococcal disorders; one could overlap the other. Several other related entities will also be discussed.

Treatment of staphylococcal scalded skin syndrome

Humans are a natural reservoir for Staphylococcal aureus. Colonization begins soon after birth and predisposes to infection. S. aureus is one of the most common causes of skin infection, giving rise to folliculitis, furunculosis, carbuncles, ecthyma, impetigo, cellulitis and abscesses. In addition, S. aureus may cause a number of toxin-mediated life-threatening diseases, including staphylococcal scalded skin syndrome (SSSS). Epidermolytic toxins released by certain S. aureus strains cause SSSS by cleaving the epidermal cell adhesion molecule, desmogelin-1, resulting in superficial skin erosion. Recent experiments have revealed similarities in the pathophysiology of SSSS and pemphigus foliaceus, an autoimmune disorder that is characterized by antibodies targeting the same epidermal attachment protein. SSSS typically affects neonates and infants but may also occur in predisposed adults. It is painful and distressing for the patient and parents, although most cases respond to antibiotic treatment. Mortality is low in infants but can be as high as 67% in adults, and is dependent on the extent of skin involvement and the comorbid state. Thus, the management of adults who develop SSSS remains a major therapeutic challenge. The antibody response against the toxins neutralizes their effect and prevents recurrence or limits the effects to the area of infection, which is known as bullous impetigo.

Staphylococcal scalded skin syndrome. II. Serum level of anti exfoliatin and anti alpha-toxin in patients with staphylococcal scalded skin syndrome or bullous impetigo

In order to study the differences between staphylococcal scalded skin syndrome (SSSS) and bullous impetigo, the anti exfoliatin level was assessed in the sera from both groups of patients, and no significant difference in the level was found. However a significant difference was noted in the anti alpha-toxin levels in sera from both group of patients; that of SSSS patients was much lower than that of impetigo patients and of children in a control group. Five out of 6 patients with SSSS showed an unchaged level of anti alpha-toxin at the second examination, while an increased anti exfoliatin level was noted in 4 out of 6 SSSS patients.

Staphylococcal scalded skin syndrome: diagnosis and management

Staphylococcal scalded skin syndrome (SSSS) is a common disorder that is usually seen in infants and children and rarely seen in adults. SSSS usually presents with a prodrome of sore throat or conjunctivitis. Extremely tender flaccid bullae, which are Nikolsky sign-positive, develop within 48 hours and commonly affect the flexures; occasionally, large areas of the skin may be involved. The bullae enlarge and rupture easily to reveal a moist erythematous base, which gives rise to the scalded appearance. SSSS in adults is a rare disorder, though there are now over 50 documented cases. Usually SSSS occurs in predisposed individuals, but not all adults have an underlying illness. Whereas mortality in childhood SSSS is approximately 4%, the mortality rate in adults is reported to be greater than 60%. SSSS is caused by an infection with a particular strain of Staphylococcus aureus, which leads to blistering of the upper layer of the skin, by the release of a circulating exotoxin. It has recently been demonstrated that the exfoliative exotoxin responsible for SSSS leads to the cleavage of desmoglein 1 complex, an important desmosomal protein. The same toxins that are responsible for causing SSSS also cause bullous impetigo. There appears to be a relationship between the disease extent, the amount of toxin produced and whether the toxin is released locally or systemically. As a result there is likely to be a spectrum of disease and there are likely to be a number of milder cases of adult SSSS that go undiagnosed. Social improvements and hygiene have led to a dramatic fall in the number of cases of SSSS. Treatment is usually straightforward, when there is no coexistent morbidity and the presentation is mild, but can be demanding if the patient is particularly ill. SSSS is still associated with mortality, particularly when it occurs in adults.

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.

Chronic staphylococcal scalded skin syndrome

Staphylococcal scalded skin syndrome (SSSS), not previously recorded as a chronic disease, persisted for 2 years in a 50-year-old woman with epilepsy and cerebellar ataxia. Lesions initially suggestive of erythema multiforme and toxic epidermal necrolysis evolved over 2 years into those typical for SSSS, with extensive erosions and subcorneal blisters, showing an epidermal split at the granular cell layer. Exfoliatin A-producing phage I-III Staphylococcus aureus, previously linked only to acute mild adult cases of SSSS, was cultured from purulent discharge in the patient's eyes, ears and open skin lesions. The roles of epilepsy and antiepileptic medications are discussed as possible predisposing factors.

Staphylococcal scalded skin syndrome in an immunocompromised adult

Staphylococcal scalded skin syndrome, a generalized exfoliative dermatitis complicating infections by exfoliative toxin-producing strains of Staphylococcus aureus, is rarely observed in adults. In contrast to mortality in infants, mortality in adults is usually high. A case of generalized staphylococcal scalded skin syndrome in an immunocompromised woman is reported. Culture of skin biopsy and pleural fluid yielded identical strains of staphylococcus aureus belonging to phage group II. Exfoliative toxins A and B were detected in both isolates. As far as can be determined, this is the first reported case of generalized staphylococcal scalded skin syndrome in an adult with detection of exfoliate toxins A and B in which the patient was treated successfully.

Staphylococcal scalded skin syndrome in adults. A clinical review illustrated with a new case

Staphylococcal scalded skin syndrome is rarely observed in adults; only 32 cases have been reported. In contrast to infant cases, the mortality rate is high. Two major risk factors have been identified: kidney failure and immunosuppression. In adults, clinical features are similar to those of the typical pediatric disease, but blood cultures are often positive for Staphylococcus aureus. Detection of the exfoliative toxin is required for diagnosis; the newborn mouse bioassay is, therefore, usually performed. New immunologic methods allow precise characterization of the toxins and oligonucleotide probes can be used for rapid detection of toxigenic strains. We report a case of staphylococcal scalded skin syndrome in an immunocompetent adult in whom blood cultures were positive; this is the first case in which both exfoliative toxins A and B have been identified in an adult.

Acute epidermal necrolysis or Lyell syndrome

Acute epidermal necrolysis may be caused by staphylococcal toxins (staphylococcal scalded skin syndrome and toxic shock syndrome) or may be related to usually drug-induced hyper-sensitivity mechanisms (toxic epidermal necrolysis). Diagnostic certainty can only be obtained by histologic localisation of a cleavage plane which is intraepidermal in staphylococcal scalded skin syndrome but situated at the dermo-epidermal junction in toxic epidermal necrolysis. Steroid therapy is indicated in toxic epidermal syndrome. This report of two cases of acute epidermal necrolysis emphasizes the importance of an early skin biopsy for accurate diagnosis and appropriate treatment.

Staphylococcal scalded skin syndrome in a homosexual adult

A homosexual man developed staphylococcal scalded skin syndrome associated with a Staphylococcus aureus septicemia. We discuss the role of prednisone, renal insufficiency, and immunosuppression as predisposing factors to staphylococcal scalded skin syndrome in adults. In particular, our study of the patient's immune function revealed anergy and lymphopenia, with a reduced response to phytohemagglutinin. Studies of T cell subpopulations revealed an elevated percentage of T suppressor cells and a diminished percentage of T helper cells with a depressed T helper/T suppressor ratio. Because of those abnormalities, we suspected acquired immunodeficiency syndrome. A few months after recuperation from the acute disease, the patient has had a normalization of the T helper/T suppressor ratio, but because of persistent polyadenopathy, hypergammaglobulinemia, and a negative sensitization to keyhole-limpet hemocyanin (KLH), we now consider the patient to have an acquired immunodeficiency syndrome-related complex.

Dermatologic Problems in the Intensive Care Unit: Part I

Skin disorders are present in many patients hospitalized in the intensive care unit. They range in severity from being the reason for admission to being a nuisance acquired during care These cutaneous problems have been categorized into four groups: (1) serious skin diseases that may incur life-threatening complications; (2) subtle skin findings associated with systemic disorders that may be characterized by critical events; (3) prominent cutaneous manifestations that accompany life-threatening systemic diseases: and (4) skin disorders that develop as complications during intensive care. Diseases in the first category are discussed in this article. Diseases in the second category will be discussed in Part II. The remaining disorders will be covered in Parts III and IV.

Drug-induced toxic epidermal necrolysis (Lyell's syndrome) in a 4-year-old girl

Toxic epidermal necrolysis (Lyell's syndrome) with erythematous skin lesions and bulla formation developed in a 4-year-old girl. An accurate diagnosis using the cryostat technique on the top of a bulla was available within 1 h of hospital admission. The course was unusually mild, probably because of early treatment with corticosteroids. Skin prick tests revealed salicylamide as the agent responsible for inducing the disease. The patient was advised to avoid this substance for the rest of her life.

Abnormal neutrophil chemotaxis and T-lymphocyte function in staphylococcal scalded skin syndrome in an adult patient

Staphylococcal scalded skin syndrome, a disease rarely reported in adults, developed in a 38-year-old male while on steroid therapy for chronic active hepatitis. Studies of immunologic parameters important in staphylococcal host defense revealed normal opsonic activity and phagocytic function but marked defects in neutrophil chemotaxis and T-lymphocyte function. Compromised host defense appears to play a significant role in the pathogenesis of the syndrome in adults.

Toxic epidermal necrolysis in two patients with pustular psoriasis

Two cases of toxic epidermal necrolysis are described in patients suffering from pustular psoriasis. In one of these cases there were no recognized predisposing causes. In the other, although there were alternative possibilities, we consider that the most likely cause of the toxic epidermal necrolysis was pustular psoriasis.

The fate of Staphylococcal exfoliatin in newborn and adult mice

The distribution and excretion of the staphylococcal exfoliatin was investigated following in vivo administration of highly purified 125I-labelled exfoliatin fractions to adult and newborn mice. Adult mice excrete approximately one-third of a test dose by 3 hours as compared to a fifteenth of a test dose excreted by newborn mice. Accordingly, blood tracer radioactivity reaches a relatively higher peak and shows a slower decline in newborns than in adults. The urine of adult mice contains considerable biologically active exfoliating material. Both nephrectomized and carbon tetrachloride-poisoned adult mice injected with exfoliatin develop generalized exfoliation whereas comparable doses in untreated controls have no effect. On the other hand, subtotal hepatectomy, followed by injection of exfoliatin, does not lead to exfoliation. We conclude that renal immaturity is a critical factor responsible for the susceptibility of neonates to generalized staphylococcal scalded skin syndrome.

Acute (toxic) epidermal necrolysis. Report of a case

A case of acute (toxic) epidermal necrolysis is reported in the dental literature for the first time. This severe, life-threatening mucocutaneous syndrome resembles severely scalded skin. Sloughing vesiculobullous oral lesions are a frequent component. Staphylococcus aureus and drug reactions may cause separate entities presenting clinically as acute epidermal necrolysis. This case of drug-induced epidermal necrolysis ina child was successfully treated with methicillin and hydrocortisone.

Staphylococcal scalded skin syndrome. An ultrastructural study

The authors investigated the ultrastructure of the epidermis of two children who suffered from the staphylococcal scalded skin syndrome (or the Ritter's type of toxic epidermal necrolysis). This syndrome is attributed to the action of an exfoliative toxin produced by Staphylococcus aureus phage group II. A characteristic bullous cleavage was selectively observed at the level of the granular layer, without any damage in other epidermal layers. This cleavage was the result of disruption of of desmosomes between granular cells in two halves, each half desmosome conserving the tonofilaments which were attached to its attachment plaque. No remarkable cytoplasmic alteration occurred in the granular layer, with the exception of the development of thickened tonofilaments among dilated endoplasmic reticulum. Odland bodies were particularly numerous in the areas of desmosomal disruption. This syndrome must be considered as an entity clinically, histologically and ultrastructurally separate from the drug form of toxic epidermal necrolysis.

Studies of the mechanism of epidermal injury by a Staphylococcal epidermolytic toxin

Experimental animal models of the two forms of toxic epidermal necrolysis have been reviewed: a murine model of staphylococcal-induced epidermolysis and a hamster model of graft-versus-host disease. In the former, a protein exotoxin, epidermolysin, has been purified and characterized. The exotoxin has a molecular weight of approximately 30,000 and causes a split beneath the granular layer. It is effective at 3 times 10(-12) moles. Epidermolysin does not require an intact complement system for its action since B10D2 mice deficient in C5 or mice injected with the decomplementing agent in cobra venom factor were susceptible to its epidermolytic effects. Neither are immunocompetent thymocytes required for the action of the toxin since hairless, athymic adult (nu/nu) mice are susceptible. A few reports of epidermolysis due to an exotoxin of group I Staphylococcus aureus have appeared. This toxin is antigenically different from the exotoxin of group II organisms. A model of drug-induced toxic epidermal necrolysis has been described in hamsters, but the toxic principle released from sensitized lymphoid cells has not yet been characterized.

Staphylococcal scalded skin syndrome: potentiation by immunosuppression in mice; toxin-mediated exfoliation in a healthy adult

Staphylococcal scalded skin syndrome, associated with exfoliative toxin produced by phage group II Staphylococcus aureus, has recently been reported in an adult receiving immunosuppressive therapy. To determine the effect of immunosuppression on the development of the staphylococcal scalded skin syndrome, experimental animals were treated with prednisolone, azathioprine, or a combination of both drugs utilizing the clinical isolate from the adult with scalded skin syndrome. The mean lethal dose and mean exfoliating dose were identical and were 6,000-fold lower in animals receiving both drugs or azathioprine alone. The isolate was not more virulent and did not produce more toxin than other group II phage-type strains. Furthermore, immunosuppressive therapy failed to enhance the susceptibility of experimental animals to a purified preparation of toxin. Finally, purified exfoliative toxin was demonstrated to produce erythema, Nikolsky's sign, bullous formation, and flaking desquamation in a normal human adult. The results demonstrated the enhanced susceptibility of experimental animals receiving immunosuppressive therapy to the development of the staphylococcal scalded skin syndrome. They further showed that human adults are susceptible to the action of exfoliative toxin and suggested that, in the host with compromised defense mechanisms, toxin-producing strains may invade and initiate infection resulting in toxin production and exfoliation.