MO109: Staphylococcal Scalded Skin Syndrome in a Young Adult Patient Undergoing Haemodialysis

Abstract

Abstract BACKGROUND AND AIMS Staphylococcal scalded skin syndrome (SSSS) is an infection caused by certain strains of Staphylococcus aureus (usually phage group II), which produce an exfoliative toxin (ET) that causes cleavage of the epidermis at the level of the lower granular layer resulting in epidermolysis that resembles scalding of the skin. It is commonly seen in infants and children and usually has good prognosis. It is rare in adult patients in whom it is frequently combined with bacteraemia and has over 50% mortality rate. Renal failure is one of the major predisposing factors for development of SSSS in adults because of their inability to excrete the ET. Other predisposing factors include underlying malignancies, HIV infection, immunosuppressive therapy, drug abuse, etc. The disease usually begins as a painful, burning skin rash, erythema and edema, development of bullae which later rupture and lead to desquamation, ulcer formation and exfoliative dermatitis. The pathological process develops at the granular layer of the epidermis. Diagnosis is based on clinical features, isolation of S. aureus from skin cultures and biopsy data. S. aureus is also isolated from blood cultures in a large amount of the adult patients with SSSS. Treatment involves application of antibiotics directed against S. aureus; however, the prognosis in adults is generally poor. METHOD We describe a case of a 28-year-old male patient with end-stage renal failure on haemodialysis who developed septicaemia and SSSS. RESULTS The basic disease of our patient is chronic glomerulonephritis. He presented for the first time to nephrologist with end-stage renal failure, and has been treated with peritoneal dialysis for 5 years and has been transferred to haemodialysis, due to dialysis associated peritonitis and subdiaphragmatic abscess. A month after the transfer, he had an episode of catheter-associated infection with Enterobacter cloacae and infectious endocarditis on the aortic valve. He received antibiotic treatment and the tunneled catheter was replaced. Following the treatment, a burning rash appeared on the patient's head, abdomen, elbows, knees and axillae, which later became erythematous, infiltrated with bullae, which desquamated and revealed painful ulcers. S. aureus was isolated from the bullae. A skin biopsy was performed and revealed epidermal parakeratosis, accumulation of white blood cells and colonies of coccal bacteria in the corneal layer of the epidermis. The diagnosis SSSS was confirmed. Blood cultures showed bacteraemia with isolation of S. aureus. A treatment with vancomycin and amikacin was performed. Despite the treatment, the patient's condition continued to deteriorate and lead to a lethal outcome. CONCLUSION Although it is rare, SSSS in adults is a very serious complication that should be thought about and should not be underestimated. Unfortunately, conservative treatment may not always be successful, especially in immunocompromised patients.