Introduction Staphylococcal scalded skin syndrome (SSSS) is caused by an exfoliative toxin-producing strain of Staphylococcus aureus (SA). It is a disorder that is commonly seen in children but rarely found in adults. In recent years, there appears to be an increasing awareness of the diagnostic criteria, and as a result, there are now over 50 documented adult cases reported in the literature. However, only two adult cases have been documented from methicillin-resistant SA (MRSA). This is the first reported case involving communtiy-acquired MRSA meningitis in association with SSSS.
Case Report A 45-year-old female with type 2 diabetes mellitus presented to an outside hospital with subjective fevers and progressive lower back pain radiating down her legs, inhibiting ambulation. Lumbar puncture studies were initially consistent with viral meningitis. Multiple blood and CSF cultures returned with MRSA. She received a 21-day course of vancomycin, rifampin, and claforan for MRSA meningitis. One week after discharge, the patient presented to our emergency department with a severe desquamating rash with underlying normal skin from the occiput to knees bilaterally, body aches, and dehydration. The rash began on her right upper extremity and spread globally, only sparing the mucous membranes, soles of the feet, and palms of the hands. Nikolsky's sign was present. Laboratory upon admission revealed an elevated leukocyte count and BUN/Cr of 136/2.3. Skin biopsy revealed subcorneal splitting along the granular layer without dermal infiltration or organisms. MRSA was found in multiple blood cultures. She was treated with a 21-day course of vancomycin, maxipime, and rifampin; in addition, she was treated with aggressive wound care and intravenous hydration. During her hospital course, the patient's skin rash resolved without scarring. Antibodies to TSST-1 and staphylococcal enterotoxin B were positive. Exfoliative toxins A and B were negative. MRSA was positive for Panton-Valentine leukocidin.
Discussion SSSS occurs secondary to a systemic SA infection that produces bullous lesions that spare the mucous membranes. Nikolsky's sign is typically positive. Exfoliative toxin A or B frequently causes the syndrome, but in the three reported cases involving MRSA, TSST-1 and circulating enterotoxin likely contribute to SSSS. Diagnostic criteria include SA-positive blood cultures, presence of SA toxins, skin biopsy, and clinical findings. Skin biopsy typically reveals subcorneal splitting along the granular layer without dermal infiltration. Treatment for SSSS includes anti-SA antibiotics, meticulous wound care, and aggressive fluid resuscitation. Despite aggressive therapy, the prognosis in adult cases is poor.
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