Staphylococcal scalded skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions syndrome (SSSS), also known as Ritter disease and staphylococcal epidermal necrolysis, is a toxin-mediated condition caused by StaphylococcusStaphylococcusStaphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora.Staphylococcus aureus. The exfoliative toxin produced disseminates and cleaves desmogleinDesmogleinA group of desmosomal cadherins with cytoplasmic tails that resemble those of classical cadherins.The Cell: Cell Junctions 1 in the epidermisEpidermisThe external, nonvascular layer of the skin. It is made up, from within outward, of five layers of epithelium: (1) basal layer (stratum basale epidermidis); (2) spinous layer (stratum spinosum epidermidis); (3) granular layer (stratum granulosum epidermidis); (4) clear layer (stratum lucidum epidermidis); and (5) horny layer (stratum corneum epidermidis).Skin: Structure and Functions, causing separation and detachment of the skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions. SSSS most commonly affects young children. Prodromal symptoms precede diffuse cutaneous erythemaErythemaRedness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes.Chalazion, tenderness, bullaeBullaeErythema Multiforme formation, and superficial desquamation. The mucous membranes are spared. The diagnosis is made clinically and can be confirmed with culture data (targeting possible primary infectionPrimary infectionHerpes Simplex Virus 1 and 2 sites) and biopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma. However, cultures of bullaeBullaeErythema Multiforme are not useful. Antibiotics and supportive care should be initiated as soon as the diagnosis is suspected.
IncidenceIncidenceThe number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time.Measures of Disease Frequency (in the United States):
8 cases per 1 million children
1 case per 1 million adults
Demographics:
Most patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship are < 2 years of age.
Causative organism: exfoliative toxin-producing strains of StaphylococcusStaphylococcusStaphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora.Staphylococcus aureus:
Exfoliative toxin is produced in approximately 5% of S. aureusS. aureusPotentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications.Staphylococcusstrains.
Most common strains: types 55 and 71
Transmission: contact with an asymptomatic or colonized carrierCarrierVaccination
Common sites of outbreaksOutbreaksSudden increase in the incidence of a disease. The concept includes epidemics and pandemics.Influenza Viruses/Influenza:
ICUs
Nurseries
Risk factors:
Children are more vulnerable because of:
Lack of immunity
Immature renal clearanceRenal ClearancePharmacokinetics and Pharmacodynamics (exotoxin cleared through the kidneysKidneysThe kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine.Kidneys: Anatomy)
Renal failureRenal failureConditions in which the kidneys perform below the normal level in the ability to remove wastes, concentrate urine, and maintain electrolyte balance; blood pressure; and calcium metabolism. Renal insufficiency can be classified by the degree of kidney damage (as measured by the level of proteinuria) and reduction in glomerular filtration rate.Crush Syndrome
DiabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus
Microscopic image of Staphylococcus aureus
Image: “Staphylococcus aureus Gram” by Y Tambe. License: CC BY-SA 3.0
Pathophysiology
Starts as a localized, staphylococcal infection:
SkinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions wounds
ConjunctivitisConjunctivitisConjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis
PharyngitisPharyngitisPharyngitis is an inflammation of the back of the throat (pharynx). Pharyngitis is usually caused by an upper respiratory tract infection, which is viral in most cases. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, and hoarseness. Pharyngitis
PneumoniaPneumoniaPneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy.Pneumonia
The primary site of infection is notalways evident.
StaphylococcusStaphylococcusStaphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora.Staphylococcusproduces exotoxin → spread hematogenously
Two types of exotoxinsExotoxinsToxins produced, especially by bacterial or fungal cells, and released into the culture medium or environment.Bacteriology:
Disrupts keratinocyte-to-keratinocyte adhesionAdhesionThe process whereby platelets adhere to something other than platelets, e.g., collagen; basement membrane; microfibrils; or other ‘foreign’ surfaces.Coagulation Studies
Causes separation and detachment of the superficial epidermisEpidermisThe external, nonvascular layer of the skin. It is made up, from within outward, of five layers of epithelium: (1) basal layer (stratum basale epidermidis); (2) spinous layer (stratum spinosum epidermidis); (3) granular layer (stratum granulosum epidermidis); (4) clear layer (stratum lucidum epidermidis); and (5) horny layer (stratum corneum epidermidis).Skin: Structure and Functions
Pathophysiology of staphylococcal scalded skin syndrome:
Exfoliative toxin cleaves desmoglein (Dsg) 1, disrupting the cell-to-cell adhesion of the stratum granulosum. This detachment of the superficial epidermis causes bullae formation and desquamation.
IncubationIncubationThe amount time between exposure to an infectious agent and becoming symptomatic.Rabies Virus period: 1–10 days
Prodromal symptoms:
FeverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
Erythematous macules on the face and flexural surfaces (e.g., axillaAxillaThe axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus: Anatomy, inguinal folds, gluteal cleft)
SkinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and FunctionspainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
ErythemaErythemaRedness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes.Chalazion spreads diffusely within 24–48 hours.
Resembles an acute burn
Flaccid blisters develop, creating a wrinkled appearance.
SkinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions peeling and erosionsErosionsCorneal Abrasions, Erosion, and Ulcers in areas of friction with red, moist skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions underneath
Positive Nikolsky’s sign: extensionExtensionExamination of the Upper Limbs of skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions blistering or sloughing by applying pressure
Fissures and crusting around the mouth, eyes, and noseNoseThe nose is the human body’s primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Nose and Nasal Cavity: Anatomy (called “SSSS sad face”)
Spares the mucosa
Widespread desquamation may take place within 36–72 hours.
Healing occurs within 2 weeks.
The loss of the skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions barrier predisposes patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship to:
SepsisSepsisSystemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock.Sepsis and Septic Shock
HypothermiaHypothermiaHypothermia can be defined as a drop in the core body temperature below 35°C (95°F) and is classified into mild, moderate, severe, and profound forms based on the degree of temperature decrease. Hypothermia
Staphylococcal scalded skin syndrome in a newborn:
This image shows diffuse erythema, bullae formation, and skin peeling.
Image: “Staphylococcal Scalded Skin Syndrome in Neonate” by Kouakou K, Dainguy ME, Kassi K. License: CC BY 3.0
Cutaneous manifestations of SSSS:
Skin peeling and erythema is noted over the thigh.
Image: “Staphylococcal scalded skin syndrome in a newborn” by Jeyakumari D, Gopal R, Eswaran M, Maheshkumar C. License: CC BY 2.0
Cutaneous manifestations of SSSS:
Erythema, skin peeling, and crusting on the face
Image: “Staphylococcal scalded skin syndrome in a newborn” by Jeyakumari D, Gopal R, Eswaran M, Maheshkumar C. License: CC BY 2.0
Diagnosis and Management
Diagnosis
Usually diagnosed clinically
Cultures:
Used for confirmation and antibiotic susceptibility data
ConjunctivaConjunctivaThe mucous membrane that covers the posterior surface of the eyelids and the anterior pericorneal surface of the eyeball.Eye: Anatomy
Nares
NasopharynxNasopharynxThe top portion of the pharynx situated posterior to the nose and superior to the soft palate. The nasopharynx is the posterior extension of the nasal cavities and has a respiratory function.Pharynx: Anatomy
Blood
BiopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma:
Can be used for confirmation if the diagnosis is unclear.
Chest radiography → rule out staphylococcal pneumoniaPneumoniaPneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy.Pneumonia as the originating source
Monitor and replace electrolytesElectrolytesElectrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions.Electrolytes
Gentle skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions and wound care
IV antibiotics should be initiated upon suspicion of the diagnosis:
For coverage of methicillin-sensitive S. aureusS. aureusPotentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications.Staphylococcus (MSSA):
Oxacillin
Nafcillin
CefazolinCefazolinA semisynthetic cephalosporin analog with broad-spectrum antibiotic action due to inhibition of bacterial cell wall synthesis. It attains high serum levels and is excreted quickly via the urine.Cephalosporins
For coverage of methicillin-resistant S. aureusS. aureusPotentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications.Staphylococcus (MRSAMRSAA strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins.Staphylococcus):
VancomycinVancomycinAntibacterial obtained from streptomyces orientalis. It is a glycopeptide related to ristocetin that inhibits bacterial cell wall assembly and is toxic to kidneys and the inner ear.Glycopeptides
LinezolidLinezolidAn oxazolidinone and acetamide derived anti-bacterial agent and protein synthesis inhibitor that is used in the treatment of gram-positive bacterial infections of the skin and respiratory tract.Oxazolidinones
ClindamycinClindamycinAn antibacterial agent that is a semisynthetic analog of lincomycin.Lincosamides may be added in severe cases:
Stevens–Johnson syndrome: a cutaneous, immune-mediated hypersensitivity reaction that is commonly triggered by medications: Stevens–Johnson syndrome runs on a spectrum with toxic epidermal necrolysisToxic Epidermal NecrolysisStevens-Johnson Syndrome and is characterized by keratinocyte necrosisKeratinocyte NecrosisStevens-Johnson Syndrome and separation of the epidermisEpidermisThe external, nonvascular layer of the skin. It is made up, from within outward, of five layers of epithelium: (1) basal layer (stratum basale epidermidis); (2) spinous layer (stratum spinosum epidermidis); (3) granular layer (stratum granulosum epidermidis); (4) clear layer (stratum lucidum epidermidis); and (5) horny layer (stratum corneum epidermidis).Skin: Structure and Functions from the dermisDermisA layer of vascularized connective tissue underneath the epidermis. The surface of the dermis contains innervated papillae. Embedded in or beneath the dermis are sweat glands; hair follicles; and sebaceous glands.Skin: Structure and Functions. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship will present with a flu-like prodromeProdromeSymptoms that appear 24–48 hours prior to migraine onset.Migraine Headache, followed by cutaneous bullaeBullaeErythema Multiforme and sloughing. Unlike SSSS, the mucous membranes are involved. Management is largely supportive, and withdrawal of the causative agent is required.
Bullous impetigoImpetigoImpetigo is a highly contagious superficial bacterial infection typically caused by Staphylococcus aureus (most common) and Streptococcus pyogenes. Impetigo most commonly presents in children aged 2 to 5 years with lesions that evolve from papules to vesicles to pustules, which eventually break down to form characteristic “honey-colored” crusts. Impetigo: a superficial skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions infection caused by StreptococcusStreptococcusStreptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci.Streptococcus or StaphylococcusStaphylococcusStaphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora.Staphylococcus: Unlike SSSS, the exotoxin remains localized and does not spread. Bullous impetigoImpetigoImpetigo is a highly contagious superficial bacterial infection typically caused by Staphylococcus aureus (most common) and Streptococcus pyogenes. Impetigo most commonly presents in children aged 2 to 5 years with lesions that evolve from papules to vesicles to pustules, which eventually break down to form characteristic “honey-colored” crusts. Impetigo is commonly seen in children and manifests as clusters of vesiclesVesiclesFemale Genitourinary Examination that quickly enlarge and form bullaeBullaeErythema Multiforme. After the bullaeBullaeErythema Multiforme burst, the exposed basesBasesUsually a hydroxide of lithium, sodium, potassium, rubidium or cesium, but also the carbonates of these metals, ammonia, and the amines.Acid-Base Balance become covered with a honey-colored crustCrustDried exudate of body fluids (blood, pus, or sebum) on an area of damaged skinSecondary Skin Lesions. The diagnosis is clinical, but cultures may be obtained from the lesions if the patient does not respond to antibiotic therapy.
Bullous pemphigoidBullous pemphigoidBullous pemphigoid and pemphigus vulgaris are two different blistering autoimmune diseases. In bullous pemphigoid, autoantibodies attack the hemidesmosomes, which connect epidermal keratinocytes to the basement membrane. This attack results in large, tense subepidermal blisters. Bullous Pemphigoid and Pemphigus Vulgaris: an autoimmune blistering disease caused by antibodiesAntibodiesImmunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution.Immunoglobulins: Types and Functions against hemidesmosomes: PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship are usually elderly and present with pruritic, tense, bullous lesions and spared mucosal surfaces. TriggersTriggersHereditary Angioedema (C1 Esterase Inhibitor Deficiency) include medications, trauma, skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions conditions, and systemic disease. BiopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma with immunofluorescent staining is used for the diagnosis. Management includes steroidsSteroidsA group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus.Benign Liver Tumors, immunosuppressantsImmunosuppressantsImmunosuppressants are a class of drugs widely used in the management of autoimmune conditions and organ transplant rejection. The general effect is dampening of the immune response.Immunosuppressants, and antiinflammatory medications.
Pemphigus vulgarisPemphigus vulgarisBullous pemphigoid and pemphigus vulgaris are two different blistering autoimmune diseases. In pemphigus vulgaris, autoantibodies attack the desmosomal proteins, which connect the keratinocytes to one another. This attack results in a more severe, potentially fatal condition with fragile, flaccid blisters, usually with significant mucosal involvement. Bullous Pemphigoid and Pemphigus Vulgaris: an autoimmune disorderAutoimmune DisorderSeptic Arthritis due to antibodiesAntibodiesImmunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution.Immunoglobulins: Types and Functions against desmogleinDesmogleinA group of desmosomal cadherins with cytoplasmic tails that resemble those of classical cadherins.The Cell: Cell Junctions 1 and 3, causing intraepidermal blistering and erosionsErosionsCorneal Abrasions, Erosion, and Ulcers of the skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions and mucous membranes: PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship will have cutaneous bullaeBullaeErythema Multiforme appearing on normal-appearing skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions and painful mucocutaneous erosionsErosionsCorneal Abrasions, Erosion, and Ulcers. Diagnosis is by biopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma with immunofluorescent staining. Blistering occurs lower in the epidermisEpidermisThe external, nonvascular layer of the skin. It is made up, from within outward, of five layers of epithelium: (1) basal layer (stratum basale epidermidis); (2) spinous layer (stratum spinosum epidermidis); (3) granular layer (stratum granulosum epidermidis); (4) clear layer (stratum lucidum epidermidis); and (5) horny layer (stratum corneum epidermidis).Skin: Structure and Functions than occurs with SSSS. Management includes corticosteroidsCorticosteroidsChorioretinitis, immunosuppressantsImmunosuppressantsImmunosuppressants are a class of drugs widely used in the management of autoimmune conditions and organ transplant rejection. The general effect is dampening of the immune response.Immunosuppressants, and IV immunoglobulinIv ImmunoglobulinDermatomyositis.
Exfoliative dermatitisDermatitisAny inflammation of the skin.Atopic Dermatitis (Eczema): a generalized, symmetric, erythematous, scaling rashRashRocky Mountain Spotted Fever caused by an underlying cutaneous diseases (psoriasisPsoriasisPsoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis, atopic dermatitisDermatitisAny inflammation of the skin.Atopic Dermatitis (Eczema)), medications, and malignancyMalignancyHemothorax (lymphomaLymphomaA general term for various neoplastic diseases of the lymphoid tissue.Imaging of the Mediastinum): Unlike SSSS, bullaeBullaeErythema Multiforme are not typically seen and the Nikolsky signNikolsky SignDermatologic Examination is negative. Diagnosis is made clinically, and management focuses on treating the underlying cause, withdrawal of implicated medications, and supportive care.
Toxic shock syndromeToxic Shock SyndromeToxic shock syndrome (TSS) is an acute, multi-systemic disease caused by the toxin-producing bacteria, Staphylococcus aureus and Streptococcus pyogenes. Staphylococcal TSS is more common and associated with tampons and nasal packing. Toxic Shock Syndrome: a systemic syndrome caused by StaphylococcusStaphylococcusStaphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora.Staphylococcus or StreptococcusStreptococcusStreptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci.StreptococcusendotoxinsEndotoxinsToxins closely associated with the living cytoplasm or cell wall of certain microorganisms, which do not readily diffuse into the culture medium, but are released upon lysis of the cells.Bacteriology: PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship present with feverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, shockShockShock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock, and multisystem organ dysfunction, which are not seen in SSSS. Cutaneous manifestations include a diffuse, erythematous rashRashRocky Mountain Spotted Fever and desquamation. Diagnosis is based on blood culture results, the clinical history, and the exam. Management includes hemodynamic support, fluid resuscitationResuscitationThe restoration to life or consciousness of one apparently dead. .Neonatal Respiratory Distress Syndrome, and antibiotics.
Comparison of common childhood rashesRashesRashes are a group of diseases that cause abnormal coloration and texture to the skin. The etiologies are numerous but can include irritation, allergens, infections, or inflammatory conditions. Rashes that present in only 1 area of the body are called localized rashes. Generalized rashes occur diffusely throughout the body. Generalized and Localized Rashes
Number
Other names for the disease
Etiology
Description
1st disease1st diseaseMeasles (also known as rubeola) is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. It is highly contagious and spreads by respiratory droplets or direct-contact transmission from an infected person. Typically a disease of childhood, measles classically starts with cough, coryza, and conjunctivitis, followed by a maculopapular rash. Measles Virus
MeaslesMeaslesMeasles (also known as rubeola) is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. It is highly contagious and spreads by respiratory droplets or direct-contact transmission from an infected person. Typically a disease of childhood, measles classically starts with cough, coryza, and conjunctivitis, followed by a maculopapular rash. Measles Virus
RubeolaRubeolaMeasles (also known as rubeola) is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. It is highly contagious and spreads by respiratory droplets or direct-contact transmission from an infected person. Typically a disease of childhood, measles classically starts with cough, coryza, and conjunctivitis, followed by a maculopapular rash. Measles Virus
14-day measlesMeaslesMeasles (also known as rubeola) is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. It is highly contagious and spreads by respiratory droplets or direct-contact transmission from an infected person. Typically a disease of childhood, measles classically starts with cough, coryza, and conjunctivitis, followed by a maculopapular rash. Measles Virus
MorbilliMorbilliMeasles (also known as rubeola) is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. It is highly contagious and spreads by respiratory droplets or direct-contact transmission from an infected person. Typically a disease of childhood, measles classically starts with cough, coryza, and conjunctivitis, followed by a maculopapular rash. Measles Virus
MeaslesMeaslesMeasles (also known as rubeola) is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. It is highly contagious and spreads by respiratory droplets or direct-contact transmission from an infected person. Typically a disease of childhood, measles classically starts with cough, coryza, and conjunctivitis, followed by a maculopapular rash. Measles VirusmorbillivirusMorbillivirusA genus of the family paramyxoviridae (subfamily paramyxovirinae) where the virions of most members have hemagglutinin but not neuraminidase activity. All members produce both cytoplasmic and intranuclear inclusion bodies. Measles virus is the type species.Measles Virus
Cough, coryzaCoryzaInflammation of the nasal mucosa, the mucous membrane lining the nasal cavities.Rhinitis, conjunctivitisConjunctivitisConjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis
Koplik’s spots (blue-white spots with a red halo) on the buccal membrane
Scarlet feverScarlet feverInfection with group a Streptococci that is characterized by tonsillitis and pharyngitis. An erythematous rash is commonly present.Scarlet Fever
ScarlatinaScarlatinaInfection with group a Streptococci that is characterized by tonsillitis and pharyngitis. An erythematous rash is commonly present.Scarlet Fever
StreptococcusStreptococcusStreptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci.Streptococcus pyogenes
Dark, hyperpigmented areas, especially in skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions creases, called Pastia’s lines
Strawberry tongueTongueThe tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves.Lips and Tongue: Anatomy: coated white membrane through which swollen, red papillaePapillaeLips and Tongue: Anatomy protrude
3rd disease3rd diseaseAn acute infectious disease caused by the rubella virus. The virus enters the respiratory tract via airborne droplet and spreads to the lymphatic system.Rubella Virus
RubellaRubellaAn acute infectious disease caused by the rubella virus. The virus enters the respiratory tract via airborne droplet and spreads to the lymphatic system.Rubella Virus
German measlesMeaslesMeasles (also known as rubeola) is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. It is highly contagious and spreads by respiratory droplets or direct-contact transmission from an infected person. Typically a disease of childhood, measles classically starts with cough, coryza, and conjunctivitis, followed by a maculopapular rash. Measles Virus
3-day measlesMeaslesMeasles (also known as rubeola) is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. It is highly contagious and spreads by respiratory droplets or direct-contact transmission from an infected person. Typically a disease of childhood, measles classically starts with cough, coryza, and conjunctivitis, followed by a maculopapular rash. Measles Virus
RubellaRubellaAn acute infectious disease caused by the rubella virus. The virus enters the respiratory tract via airborne droplet and spreads to the lymphatic system.Rubella VirusvirusVirusViruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology
Asymptomatic in 50% of cases
Fine macular rashRashRocky Mountain Spotted Fever on the face (behind the ears) → spreads to the neckNeckThe part of a human or animal body connecting the head to the rest of the body.Peritonsillar Abscess, trunk, and extremities (spares palms/soles)
Forscheimer spots: pinpoint red macules and petechiaePetechiaePrimary Skin Lesions over the soft palateSoft palateA movable fold suspended from the posterior border of the hard palate. The uvula hangs from the middle of the lower border.Palate: Anatomy/uvulaUvulaA fleshy extension at the back of the soft palate that hangs above the opening of the throat.Peritonsillar Abscess
Generalized tender lymphadenopathyLymphadenopathyLymphadenopathy is lymph node enlargement (> 1 cm) and is benign and self-limited in most patients. Etiologies include malignancy, infection, and autoimmune disorders, as well as iatrogenic causes such as the use of certain medications. Generalized lymphadenopathy often indicates underlying systemic disease. Lymphadenopathy
4th disease
Staphylococcal scalded skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions syndrome
Filatow–Dukes’ disease
Ritter’s disease
Due to StaphylococcusStaphylococcusStaphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora.Staphylococcus aureus strains that make epidermolytic (exfoliative) toxin
Some believe that 4th disease is a misdiagnosis and is, thus, nonexistent.
The term was dropped in the 1960s and today is used only as medical trivia.
Nikolsky’s sign: Applying pressure on the skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions with a finger (stroking) results in sloughing of upper layers.
5th disease
Erythema infectiosumErythema infectiosumErythema infectiosum is a rash illness caused by parvovirus B19. Erythema infectiosum is also known as fifth disease, being 5th in the historical list of rash-causing childhood infectious diseases: measles (1st), scarlet fever (2nd), rubella (3rd), Dukes’ disease (4th), and roseola (6th). Erythema Infectiosum
Erythrovirus or parvovirus B19Parvovirus B19Primate erythroparvovirus 1 (generally referred to as parvovirus B19, B19 virus, or sometimes erythrovirus B19) ranks among the smallest DNA viruses. Parvovirus B19 is of the family Parvoviridae and genus Erythrovirus. In immunocompetent humans, parvovirus B19 classically results in erythema infectiosum (5th disease) or “slapped cheek syndrome.”Parvovirus B19 (primate erythroparvovirusErythroparvovirusParvovirus B19 1)
Facial erythema (“slapped-cheek rash”) that consist of red papules on the cheeksCheeksThe part of the face that is below the eye and to the side of the nose and mouth.Melasma
Begins on the face → spreads to the extremities → extends to trunk/buttocks
Initially confluent, then becomes net-like or reticular as it clears
6th disease
ExanthemExanthemDiseases in which skin eruptions or rashes are a prominent manifestation. Classically, six such diseases were described with similar rashes; they were numbered in the order in which they were reported. Only the fourth (Duke’s disease), fifth (erythema infectiosum), and sixth (exanthema subitum) numeric designations survive as occasional synonyms in current terminology.Varicella-Zoster Virus/Chickenpox subitum
Roseola infantumRoseola infantumAn acute, short-lived, viral disease of infants and young children characterized by a high fever at onset that drops to normal after 3-4 days and the concomitant appearance of a macular or maculopapular rash that appears first on the trunk and then spreads to other areas. It is the sixth of the classical exanthematous diseases and is caused by HHV-6.Human Herpesvirus 6 and 7
3-day feverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
HHV-6B or HHV-7HHV-7Human herpesvirus (HHV)-6 and HHV-7 are similar double-stranded DNA viruses belonging to the Herpesviridae family. Human herpesviruses are ubiquitous and infections are commonly contracted during childhood.Human Herpesvirus 6 and 7
Sudden onset of high feverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
Nagayama’s spots: papular spots on the soft palateSoft palateA movable fold suspended from the posterior border of the hard palate. The uvula hangs from the middle of the lower border.Palate: Anatomy/uvulaUvulaA fleshy extension at the back of the soft palate that hangs above the opening of the throat.Peritonsillar Abscess
RashRashRocky Mountain Spotted Fever begins as feverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever resolves (the term “exanthemExanthemDiseases in which skin eruptions or rashes are a prominent manifestation. Classically, six such diseases were described with similar rashes; they were numbered in the order in which they were reported. Only the fourth (Duke’s disease), fifth (erythema infectiosum), and sixth (exanthema subitum) numeric designations survive as occasional synonyms in current terminology.Varicella-Zoster Virus/Chickenpox subitum” describes “surprise” of rashRashRocky Mountain Spotted Fever after the feverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever subsides)
Numerous rose-pink, almond-shaped macules on the trunk and neckNeckThe part of a human or animal body connecting the head to the rest of the body.Peritonsillar Abscess → sometimes spreads to face/extremities
Arora P, et al. (2011). Staphylococcal scalded skin syndrome in a preterm newborn presenting within first 24 h of life. BMJ Case Rep. https://pubmed.ncbi.nlm.nih.gov/22670002/
Neubauer HC, et al. (2018). Variation in diagnostic test use and associated outcomes in staphylococcal scalded skin syndrome at children’s hospitals. Hosp Pediatr 8(9), 530–537. https://pubmed.ncbi.nlm.nih.gov/30139766/
Staiman A, Hsu DY, Silverberg JI. (2018). Epidemiology of staphylococcal scalded skin syndrome in U.S. children. Br J Dermatol 178(3):704–708. https://pubmed.ncbi.nlm.nih.gov/29077993/