Z Geburtshilfe Neonatol 2016; 220(01): 35-38
DOI: 10.1055/s-0035-1559653
Kasuistik
© Georg Thieme Verlag KG Stuttgart · New York

Staphylococcal Scalded Skin Syndrome bei einem sehr unreifen Frühgeborenen

Staphylococcal Scalded Skin Syndrome in a Very Low Birth Weight Premature Infant
K. Wiedemann
1   Neonatologie, Kinderklinik und Poliklinik, Würzburg
,
C. Schmid
2   Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg
,
H. Hamm
2   Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg
,
J. Wirbelauer
1   Neonatologie, Kinderklinik und Poliklinik, Würzburg
› Author Affiliations
Further Information

Publication History

eingereicht 31 March 2015

angenommen nach Überarbeitung 11 July 2015

Publication Date:
11 February 2016 (online)

Zusammenfassung

Einleitung: Das früher häufig endemisch beobachtete Staphylococcal Scalded Skin Syndrome (SSSS) tritt heute nur noch selten auf. Durch eine hämatogene Aussaat von Staphylokokkentoxin Exfoliatin A (ETA) oder B (ETB) nach lokaler Staphylokokkeninfektion wird ein „Syndrom der verbrühten Haut“ mit disseminierter Blasenbildung verursacht.

Fallbericht: Am 14. Lebenstag erkrankte ein männliches Frühgeborenes (30+5 Schwangerschaftswochen, 1065 g Geburtsgewicht) an einer perioralen Staphylodermie und wurde empirisch über 6 Tage antibiotisch behandelt. Die Läsion heilte ab, allerdings zeigte sich nach einem symptomfreien Intervall am 26. Lebenstag ein Rezidiv. Trotz sofortiger intravenöser antibiotischer Therapie entwickelte sich binnen weniger Stunden ein Erythem mit schlaffer Blasenbildung, welche histologisch eine subkorneale Epidermisablösung zeigte. Durch Änderung und Erweiterung des Antibiotika-Regimes auf eine Kombinationstherapie aus Cefotaxim, Flucloxacillin und Clindamycin konnte das Fortschreiten der Exfoliation verhindert werden. Supportiv kamen eine Analgesie, parenterale Flüssigkeitssubstitution und lokal antiseptische Maßnahmen zum Einsatz. Die Erkrankung heilte folgenlos aus. Aus dem Primärherd konnte ein ETA-produzierender S.-aureus-Stamm isoliert werden. Als Ursache des fulminanten Krankheitsbildes wurde ein Mikrotrauma im Bereich des Naseneingangs durch eine nasogastrale Sonde vermutet.

Diskussion: Das SSSS zeigt bei Früh- und Neugeborenen eine höhere Inzidenz als bei älteren Kindern. Ursächlich hierfür könnten niedrigere Antikörper-Titer gegen Exfoliatine in Kombination mit einer verminderten Elimination der Toxine durch renale Unreife sein. Eine rasche Diagnosestellung sowie der rasche Beginn einer adäquaten antibiotischen Therapie sind unerlässlich, um Sekundärinfektion, Flüssigkeitsverlust mit Elektrolytstörung, Tod oder eine endemische Ausbreitung zu verhindern.

Abstract

Introduction: Staphylococcal scalded skin syndrome (SSSS) was often endemic in the past but is nowadays rare. The hematogeneous spread of exfoliative toxins A (ETA) or B (ETB) produced by specific Staphylococcus aureus strains causes a scald-like eruption with disseminated bullous lesions.

Case Report: A perioral impetigo lesion occurred on day 14 of life in a preterm male infant (1 065 g, 30 weeks of gestational age). Empiric antibiotic therapy with cefotaxime and vancomycin was given for 6 days and led to complete resolution. A Staphylococcus aureus strain was isolated. After a symptom-free interval a relapse was noted on day 26 of life. Despite restarting the antibiotic therapy immediately the initial lesion expanded, and disseminated flaccid blisters on an erythematous base appeared within a few hours. On histological examination the cleavage was in the level of the granular layer. There was no mucosal involvement, and the Nikolsky I sign was positive. The antibiotic therapy was changed to a combination of cefotaxime, flucloxacillin and clindamycin which rapidly stopped progression of the exfoliation. Supportive therapy included adequate analgesia, parenteral rehydration, and application of local antiseptics. The preterm infant completely recovered. In the primary lesion an ETA-producing Staphylococcus aureus strain was isolated. Nasal microtrauma by a nasogastric tube was assumed to have caused the fulminant disease. At the same time, no other Staphylococcus aureus infections were seen in our Department of Neonatology.

Discussion: According to the literature, the incidence of SSSS is higher in premature infants and newborns than in older children. Possible causes include lower antibody levels against exfoliative toxins and renal immaturity. Rapid diagnosis and immediate appropriate antibiotic therapy are essential to prevent secondary infection, dehydration with electrolyte disturbance, death, and endemic spread.

 
  • Literatur

  • 1 Handler MZ, Schwartz RA. Staphylococcal scalded skin syndrome: diagnosis and management in children and adults. Journal of the European Academy of Dermatology and Venereology: JEADV 2014; 28: 1418-1423
  • 2 Li MY, Hua Y, Wei GH et al. Staphylococcal scalded skin syndrome in neonates: an 8-year retrospective study in a single institution. Pediatric dermatology 2014; 31: 43-47
  • 3 Makhoul IR, Kassis I, Hashman N et al. Staphylococcal scalded-skin syndrome in a very low birth weight premature infant. Pediatrics 2001; 108: E16
  • 4 Saida K, Kawasaki K, Hirabayashi K et al. Exfoliative toxin A staphylococcal scalded skin syndrome in preterm infants. European journal of pediatrics 2015; 174: 551-555
  • 5 Cribier B, Piemont Y, Grosshans E. Staphylococcal scalded skin syndrome in adults. A clinical review illustrated with a new case. Journal of the American Academy of Dermatology 1994; 30: 319-324
  • 6 Duijsters CE, Halbertsma FJ, Kornelisse RF et al. Recurring staphylococcal scalded skin syndrome in a very low birth weight infant: a case report. Journal of medical case reports 2009; 3: 7313
  • 7 Coleman JC, Dobson NR. Diagnostic dilemma: extremely low birth weight baby with staphylococcal scalded-skin syndrome or toxic epidermal necrolysis. Journal of perinatology: official journal of the California Perinatal Association 2006; 26: 714-716
  • 8 Curran JP, Al-Salihi FL. Neonatal staphylococcal scalded skin syndrome: massive outbreak due to an unusual phage type. Pediatrics 1980; 66: 285-290
  • 9 Leaute-Labreze C, Sarlangue J, Pedespan L et al. Neonatal staphylococcal epidermolysis due to maternal-fetal transmission. Annales de dermatologie et de venereologie 1999; 126: 713-715
  • 10 Peters B, Hentschel J, Mau H et al. Staphylococcal scalded-skin syndrome complicating wound infection in a preterm infant with postoperative chylothorax. Journal of clinical microbiology 1998; 36: 3057-3059
  • 11 Saiman L, Jakob K, Holmes KW et al. Molecular epidemiology of staphylococcal scalded skin syndrome in premature infants. The Pediatric infectious disease journal 1998; 17: 329-334
  • 12 Hoffmann R, Lohner M, Bohm N et al. Staphylococcal scalded skin syndrome (SSSS) and consecutive septicaemia in a preterm infant. Pathology, research and practice 1994; 190: 77-81 discussion 81-73
  • 13 Itani O, Crump R, Mimouni F et al. Picture of the month. Ritter’s disease (neonatal staphylococcal scalded skin syndrome). American journal of diseases of children 1992; 146: 425-426
  • 14 Florman AL, Holzman RS. Nosocomial scalded skin syndrome. Ritter’s disease caused by phage group 3 Staphylococcus aureus. American journal of diseases of children 1980; 134: 1043-1045
  • 15 Shi D, Ishii S, Sato T et al. Staphylococcal scalded skin syndrome in an extremely low-birth-weight neonate: molecular characterization and rapid detection by multiplex and real-time PCR of methicillin-resistant Staphylococcus aureus. Pediatrics international: official journal of the Japan Pediatric Society 2011; 53: 211-217
  • 16 Horner A, Horner R, Salla A et al. Staphylococcal scalded skin syndrome in a premature newborn caused by methicillin-resistant Staphylococcus aureus: case report. Sao Paulo medical journal=Revista paulista de medicina 2015; DOI: 10.1590/1516-3180.2013.79400715. 0
  • 17 Berk DR, Bayliss SJ. MRSA, staphylococcal scalded skin syndrome, and other cutaneous bacterial emergencies. Pediatric annals 2010; 39: 627-633
  • 18 Mockenhaupt M, Idzko M, Grosber M et al. Epidemiology of staphylococcal scalded skin syndrome in Germany. The Journal of investigative dermatology 2005; 124: 700-703
  • 19 Braunstein I, Wanat KA, Abuabara K et al. Antibiotic sensitivity and resistance patterns in pediatric staphylococcal scalded skin syndrome. Pediatric dermatology 2014; 31: 305-308
  • 20 Kato T, Fujimoto N, Nakanishi G et al. Adult Staphylococcal Scalded Skin Syndrome Successfully Treated with Plasma Exchange. Acta dermato-venereologica 2014; DOI: 10.2340/00015555-2033.
  • 21 Neylon O, O’Connell NH, Slevin B et al. Neonatal staphylococcal scalded skin syndrome: clinical and outbreak containment review. European journal of pediatrics 2010; 169: 1503-1509
  • 22 Paranthaman K, Bentley A, Milne LM et al. Nosocomial outbreak of staphyloccocal scalded skin syndrome in neonates in England, December 2012 to March 2013. Euro surveillance: bulletin Europeen sur les maladies transmissibles=European communicable disease bulletin 2014; 19
  • 23 Hawk RJ, Storer JS, Daum RS. Toxic epidermal necrolysis in a 6-week-old infant. Pediatric dermatology 1985; 2: 197-200
  • 24 de Groot R, Oranje AP, Vuzevski VD et al. Toxic epidermal necrolysis probably due to Klebsiella pneumoniae sepsis. Dermatologica 1984; 169: 88-90
  • 25 Scully MC, Frieden IJ. Toxic epidermal necrolysis in early infancy. Journal of the American Academy of Dermatology 1992; 27: 340-344
  • 26 Lohmeier K, Megahed M, Schulte KW et al. Toxic epidermal necrolysis in a premature infant of 27 weeks’ gestational age. The British journal of dermatology 2005; 152: 150-151
  • 27 Spies M, Vogt RM Herndon Toxisch epidermale Nekrolyse. Ein Fall für das Schwerverbranntenzentrum. Der Chirurg 2003; 74: 452
  • 28 Bukowski M, Wladyka B, Dubin G. Exfoliative toxins of Staphylococcus aureus. Toxins 2010; 2: 1148-1165