A 61-year-old man presented with fever, malaise, and a blistering red rash 5 days after undergoing a laparoscopic cholecystectomy. Per report, the rash started at his port insertion sites but has progressed and now involves his face, trunk, and extremities. His medical history includes end-stage renal disease on intermittent hemodialysis, hypertension, and diabetes mellitus. Vital signs are T 38.7°C, HR 76 beats/min, BP 150/80 mm Hg, RR 26 breaths/min, and oxygen saturation of 97% on room air. Examination reveals red, blistering, tender skin, warm-to-touch and peels with gentle stroking. The rash is accentuated in the flexor creases. Perioral crusting is present but mucous membranes are spared.
What is the MOST likely etiology of this condition?
A. Systemic infection with circulating endotoxinsCorrect Answer: C
The patient’s presentation is consistent with staphylococcal scalded skin syndrome (SSSS). SSSS is a localized S. aureus infection that produces exfoliative exotoxins (exfoliatin). These cause the breakdown of desmosomes and detachment of the epidermal layer. Skin biopsy shows separation within the superficial layer of the epidermis—in contrast to toxic epidermal necrolysis (TEN) which has skin separation at the dermoepidermal junction. SSSS is a disease usually seen in infancy but may appear in older, immunosuppressed patients with renal failure (as the toxins are cleared renally). The skin typically appears burnt, with fluid-filled bullae that easily rupture, with exfoliation of the epidermis under gentle pressure (positive Nikolsky sign). The rash often begins centrally, is sandpaper-like, progressing into a wrinkled appearance, and accentuated in flexor creases. Accompanying signs and symptoms include fever, tenderness and warmth to palpation, facial edema, conjunctivitis, and perioral crusting, but mucous membranes are spared. Dehydration may be present and significant.
Antibiotic treatment depends on whether the isolated pathogen is methicillin-resistant. Supportive treatment includes IV hydration to replace fluid losses, and aggressive skin care with petroleum jelly or similar agent to maintain moisture. A systemic infection with circulating endotoxins is characteristic of bacteremia and sepsis. Drug-induced keratinocyte necrosis is typical of toxic epidermal necrolysis and is noninfectious. Fascial bacterial infection alone would not cause the characteristic skin blistering described here.
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