Staphylococcal Scalded Skin Syndrome bei einem sehr unreifen Frühgeborenen

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.

Schlüsselwörter

Frühgeborene - interdisziplinäres Vorgehen - Therapie

Key words

preterm birth - interdisciplinary process - therapy

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