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Impetigo + Body Rash + Fever?

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Today I want to talk about a patient that came into my office a couple weeks back.  She was a 4 year old female who came into the clinic complaining of a rash and a swollen thumb for 3 days. The onset was rapid and the patient was complaining that her thumb was very painful. The mother states the child started with a fever the day before. The rash was first noted on the upper lip 3 days prior and over the last couple of days, solitary lesions were noted on the abdomen and upper back.

Upon examining the patient, it was evident she was scared and lethargic. I noticed a perioral yellow crusted lesion and very minor yellow crusted lesions over the abdomen and back.

A large bullae was also noted over her right thumb which limited her range of motion.

It was obvious this was a staph infection. The question in my head was: is this bullous impetigo or something more?

It was a Saturday afternoon and I just didn’t feel comfortable sending the patient home with oral antibiotics. Bullous impetigo can be treated with oral antibiotics, but there was just something about this patient that made me uncomfortable.

So, I decided to send her to the emergency room. I wrote a SOAP note (yes there are times when you still need to write them – sorry) and sent her on her way.

Upon arriving to the hospital, the clinician at the ED sees the patient, and then tells the mother to follow up with her PCP on Monday. He told her it was a little staph infection that would clear up on it’s own – she would be fine.

Sure enough, Sunday morning, the rash had spread further across her body. So, back she went to the ED. Again, they turned her away and back home she went.

Over the course of the day, the rash had spread to the entire body, the patient’s body had began “peeling”, the fever was worsening, and the patient had stopped eating/drinking. So, the mom went to another ED, where they finally admitted the poor child.

Dehydrated and in pain, they started her on IV antibiotics and fluid rehydration.

She was diagnosed with Staphylococcal Scalded Skin Syndrome (SSSS).

SSSS is a superficial skin disorder caused by toxins produced from Staphylococcus aureus. This is a disease that typically occurs in children (98% of cases are under 6 years of age). The mortality rate is low (~1%), but the patients are very uncomfortable.

When seeing these patients, it is important to distinguish SSSS from toxic epidermal necrolysis (TEN). SSSS will spare the mucous membranes while TEN will not. Also, the infection in SSSS is intradermal while the necrosis in TEN is at the basement membrane.

You may even be able to appreciate Nikolsky sign during the exam (gentle pressure to the skin results in separation of the epidermis). The bullae that the patient had is part of the normal presentation – the bullae usually affect the hands, feet, and buttocks.

Staphylococcal scalded skin syndrome and bullous impetigo can also be easily confused. The difference is that in bullous impetigo, the toxins are restricted to areas of infection while the toxins in SSSS are generalized. This means that the the bullae in SSSS are sterile while the bullae in bullous impetigo carry bacteria.

Intravenous penicillinase-resistant penicillin, such as nafcillin or oxacillin or a first generation cephalosporin is the treatment of choice for staphylococcal scalded skin syndrome. Those with severe allergies are given a macrolide or aminoglycoside. If MRSA is suspected, then coverage with vancomycin is warranted.

The important take away here is to trust your gut. Gestalt is something that you should never ignore. Although the clinical presentation wasn’t all too impressive, I still felt like she needed more care than I could provide. You do not simply want to place these patients on oral antibiotics with mupirocin. They need IV antibiotics and in her case IV rehydration as she was not eating or drinking.