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PRESENTER : Kobinathan (090100452)Elveena Muthiriar (090100380)
SUPERVISOR : Dr. Hj.Bugis Mardina Lubis, Sp A (K)
DEPARTEMENT OF PEDIATRICSMEDICAL FACULTY OF
UNIVERSITY OF NORTH SUMATERAM E D A N
2 0 13
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Staphylococcal scalded skin syndrome (SSSS) is theclinical term used for a spectrum of blistering skin
diseases
induced by the exfoliative (epidermolytic) toxins (ET)
usually group II Staphylococci (phage type 3A, 3B, 3C,55 or 71)
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Overall incidence is higher in developing countries
Exfoliative skin disease is rare in neonates.
The incidence rate is estimated to be 1 to 1.4 cases per millioninhabitants per year.
The male to female ratio of SSSS disease was 5:1
Whereas 2 cases of staphylococcal scalded-skin syndrome(SSSS) in five years later in neonates at Dr Soetomo Hospital,Surabaya, Indonesia from January 2001-January 2006.
Case studyin
Indonesia
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Etiology
S aureus(severaltypes) leads to release
of exotoxin
TypeA
TypeB
separation ofthe epidermisbeneath thegranular cell
layer
Spread-person to person via towels-droplets from either coughing or sneezing
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fever
erythema initially with formation of large superficiallocalized blisters to generalized exfoliation of the
whole body. They form large superficial thin formed bullae which
rupture and leave denuded skin behind after oozingfluid which varies from thin, serous liquid to purulent
pus.
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initial infection occurs
Epidermolytic toxins are produced
red rash and separation of the epidermis beneath thegranular cell layer
Bullae form, and diffuse sheetlike desquamation occurs
localized form
only patchyinvolvement of theepidermis
generalized form,in whichsignificant areas ofare involved,remote from theinitial site ofinfection
Pathophysiology
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The diagnosis may be clear from the appearance of the
skin. Surface fluid or pus may be sampled (via a skin swab)
to confirm the presence of the bacteria and in somecases blood will also be tested for infection.
A small piece of skin may be sent for microscopicexamination
(The British Association Of Dermatologists, 2009).
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Neonates should be isolated and the skin lesion mustbe treated with care like burn wounds.
It responds very well to antibiotic therapy
Oral antibiotics effective against penicillin-resistantstaphylococcus can be used as well.
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CASE REPORT
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Name : DL
Age : 16 years 8 months
Sex : Female
Date of Admission : September, 26th 2013
Main Complaint :Blisters surrounding lips.History :Baby A was admitted in Perinatology, 2 bours later red colored rashes was formed on upperlips of patient. Then this patch develops fluid blister and white membrane formed on lower lips. The following day bulla was
formed on the hand, leg and abdomen. The lesion spread to the hand, leg and abdomen. Within 2 days almost of his body
was affected. Some of the blisters had ruptured, there was desquamation of the skin, and large, fragile, the blisters easily
ruptured on the slightest pressure.
Baby A born on 23rdOctober 2013 at 16.42 pm with cesarian operation with indication of severe preeclampsia
with Impending Eclampsia + AG + KDR + PK + AH + B Inpartus. Birth weight: 3100 gram, Birth length: 50cm, AS : 8/9. Babywas born and cried spontaneously. Baby was cleaned with 3 clothes, baby was dried and warmed and positioned, airway
clearance was done, tactile stimuli was done and the baby cried loud immediately, clamping, cutting and wrapping the
umbilical cord was done with the aid of steril gauze.
Immunization : incomplete
History of previous illness: -
History of previous medications:-
History of feeding : from birth to 11thday : breast milk only
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Physical Examination
Body weight : 3.1kgHeight : 50cm
Presens statusSens:Compos Mentis, Body temperature: 37.6 oC, Pulse: 140 bpm, Respiratory Rate: 48 bpm.
Localized status
Head :Fontanel is wide open. Head circumference: 35 cmEye :Light reflexes(+/+), isochoric pupil, conjunctiva palpebra inferior anemia
(+/+), icteric (-/-) , Ear : Normal appereance ,Mouth :Bula found 1cm containing
water on lips,white membrane formed on lower lips , Nose: Normal appereance.Thorax: Symmetrical fusiformis. Epigastria retraction (-). HR: 140 bpm, reguler,
RR: 48 bpm, reguler. Crackles (-/-).Abdomen: Soepel, Peristaltic(+)N. Liver/Spleen/Renal :not palpable,
Extremities: Pulse 140 bpm, regular, adequate pressure and volume, warm acral,
CRT
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Complete blood count(CBC)Hemoglobin (HGB) g% 13.9 13.4-19.8Eritrosit (RBC) 106/ mm3 4.13 5.33-5.47Leukosit (WBC) 103/ mm3 8.73 6.02- 17.5Hematokrit % 38.4 51 65Trombosit (PLT) 103/ mm3 88 217-497MCV fL 93 104-116MCH Pg 33.70 35-39MCHC g%
36.20 32-34RDW % 19.10 14.9 18.7WBC CountNeutrofil % 50.80 37 80Limfosit % 27.40 20 40Monosit % 15.90 2 8Eosinofil
%
5.20 1 6
Basofil % 0.70 0 1Neutrofil Absolut 103/L 4.44 5.5 - 18.3Limfosit Absolut 103/L 2.39 2.8 - 9.3Monosit Absolut 103/L 1.39 0.5 - 1.7Eosinofil Absolut 103/L 0.45 0.02 - 0.70Basofil Absolut 103/L 0.06 0.1 - 0.2
Laboratory Result:September,26th 2013
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Liver
Billirubin total Mg/dl 8.41
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Differential DiagnosisDD/ Staphylococcus skin scalded syndrome
-Impetigo
-Pemfigus bulosa
Working DiagnosisDD/ Staphylococcus skin scalded syndrome
Treatment
Total fluid required 60 ml/kg BW/dayParenteral None
Enteral Breast Milk Diet / breast milk substitute :16 ml/2 hours/oralInj Neo K 1mg/IM (single dose)Gentamicin Eyedrop 1x1 gtt ODSChange pampersUmbilical cord treatment with steril gauze
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Th
eory
the case mainly ininfants andchildren
Pa
tient
Patient categorizedas infant
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Theoryerythema initially withformation of large superficial
localized blisters togeneralized exfoliation of thewhole body.
They form large superficial
thin formed bullae whichrupture and leave denudedskin behind after oozing fluidwhich varies from thin, serousliquid to purulent pus.
They are more common
around the extremities in theolder children and in theperiumbilical area in theneonates.
Patientskin lesion initially appearedas redness patches and tender
on his upper lips.
Then this patch develops fluidblister and white membraneformed on lower lips. The
lesion spread to the hand, legand abdomen.
Within 2 days almost of hisbody was affected.
Some of the blisters had
ruptured, there wasdesquamation of the skin, andlarge, fragile, the blisters easilyruptured on the slightestpressure.
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Theory
A biopsy of the blister is one ofthe most definitive diagnostictests in SSSS.
However, this is not alwayspossible due to limited availability
of the tests and the timeconsuming factor.
So, the diagnosis is often clinicaland confirmation is made afterfavorable response to anti-staphylococcal medicationss
Patient
Supportive examinations revealedleucocytosis.
The culture result from the fluidblister pending.
Based on the physical
examination the diagnosis ofStaphylococcal Scalded SkinSyndrome (SSSS) was established
Treated initially with Ceftazidime155mg two times daily injectionsand Gentamicin injections 16mgper 36hours.
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TheoryThe differential diagnosisof the described
exfoliative skin lesions inneonates includes
staphylococcal scalded-
skin syndrome (SSSS)
bullous impetigo (BI)
drug-induced toxicepidermal necrolysis
epidermolysis bullosabullous mastocytosis
neonatal pemphigus
Patientdd/
-Staphylococcus SkinScalded
-Impetigo
-Pemfigus bulosa
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TheoryThe differential diagnosisof the described
exfoliative skin lesions inneonates includes
staphylococcal scalded-
skin syndrome (SSSS)
bullous impetigo (BI)
drug-induced toxicepidermal necrolysis
epidermolysis bullosabullous mastocytosis
neonatal pemphigus
Patientdd/
-Staphylococcus SkinScalded
-Impetigo
-Pemfigus bulosa
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Theory
Management of SSSS isprimarily supportive
with careful monitoringof electrolyte levelsbecause of the potentialfluid shifts across thedenuded skin.
Intravenous antibiotics
are administered todecrease thestaphylococcal burden.
Patient
Ceftazidime 155mg twotimes daily injections
and Gentamicininjections 16mg per36hours.
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