Dr.Shobika,Dr.C.Jayakumar,Dr.Praveena
AIMS KOCHI
Kerala
One year old male child presented with high grade intermittent fever of 2 days duration,associated with cough and rhinitis
On day 2 of illness,the child developed small red lesions on the back which gradually spreads to whole body.H/o irritability and itching was present.
In the past the child was admitted for bronchopneumonia at 4 months and 8 months of age treated with iv antibiotics and aerosol therapy
At examination child was febrile,irritable,sicklooking.
Vitals were stable
Anthropometry reveals normal growth parameters.
Head to foot examination showed erythematous maculopapular rashes mainly over the periorbital and peri oral region.
Rashes were present over the medial aspect of both arms,neck,chest also
After 2 days erythematous rash start desquamating with tenderness.
Systemic examination was unremarkable.
There was no mucosal involvement
Differential diagnosis:
Steven johnson syndrome
Kawasaki disease
Measles
Staphylococcal scalded syndrome
Drug rash
Investigations:
CRP- 6.67mg/l
TC- 16.97
N-22.9,L-67.6
Plt- 4.19L
Hb- 14.2gm%
Peripheral smear: Leucocytosis with absolute lymphocytes
LFT/RFT/SE/URE were within normal limits
Blood Culture showed no growth.
Impression: Staphylococcal scalded skin syndrome
The child was started on iv Flucloxacillin and Gentamicin and with that fever and rashes starts regressing At this point parental drug was changed to cap.Dicloxacillin.
Antibiotics was given for period of 10 days.
Discussion:
SSSS(Ritter disease)
Is a bacterial toxin mediated skin disorder that results from Infection with exotoxin producing strains of S.aureus.Common – below 5 years of age.
Clinical manifestations: onset of rash followed malaise,fever,irritability and tenderness of the skin.Scarlatiniform erythema develops diffusely in flexural and periorficial areas. Erythematous skin may rapidly acquire a wrinkled appearance, in severe cases,sterile, flaccid blisters and erosions develop diffusely.
Circumoral erythema is characteristically prominent,as crusting and fissuring around eyes,mouth and nose.As sheets of epidermis peel away,moist,glistening,deluded areas become apparent, initially in the flexure and subsequently over much of the body surface.
This development leads to secondary cutaneous Infection, sepsis, fluid and Electrolyte Disturbances.This desquamative phase begins after 2 to 5 days of cutaneous erythema and healing occurs without scarring in 10 to 14 days.
Diagnosis:
History and physical examination, bacterial culture,Histology and Nikolsky sign.
Management:
Antibiotic therapy:IV oxacillin -100 to 150mg/kg per day in divided doses every 6hrs;maximum daily dose of 12g per day.
IV cefazolin – 50 to 100 mg/kg per day in divided doses every 8 hrly;maximum daily dose of 6g.
Iv vancomycin – 45mg/kg per day in divided doses every 8 hrly;maximum daily dose of 2g.
Prognosis: With appropriate treatment,signs and symptoms of SSSS usually resolve completely within two to three weeks.
Complications:
Secondary Infection,hypovolemia and Electrolyte disturbances
Recurrence: Rare