Introduction: Staphylococcal scalded skin syndrome is blistering condition characterized by extensive desquamation and cleavage of the superficial layers of the epidermis which has been well characterized in neonates and children below the age of 6 years. It is a rare syndrome in adults Case Report: A 55 year old female with HIV (CD4 1342), chronic hepatitis C, type 2 diabetes mellitus, chronic kidney disease stage III presented with 7 days of rash. It began on the soles and spread proximally involving her legs, torso and arms. It appeared dry with areas of desquamation and erythema. She felt constitutionally weak and fatigued. She had a recent admission for Clostridium difficile colitis and was discharged on parenteral metronidazole via peripherally inserted central catheter (PICC). Her diarrhea resolved. On examination, she was hypothermic to 94.8°F, hypotensive to 92/61 mmHg, and had extensive sloughing rash over bilateral legs and arms with areas of edema, erythema, and hyperkeratosis that was moderately tender. There were no bullae, crepitus, or mucosal membrane involvement. Along bilateral posterior heels, there was complete loss of epidermis with exposed underlying tissue with a hemorrhagic base. There was leukocytosis to 14.3 x 10^9/dL with 81% neutrophils. Creatinine was 1.8 mg/dL and albumin was 2 mg/dL. She received broad spectrum antibiotics and PICC line was removed. Dermatology obtained punch biopsies which showed cleavage of the superficial layer of the epidermis without inflammatory infiltration or apoptotic keratinocytes and diagnosis of Staphylococcal scalded skin syndrome was made. She improved on vancomycin. Discussion: Staphylococcus aureus is a facultative anaerobic gram positive coccus which can produce exfoliatin, an exotoxin, which cleaves the stratum granulosum from the underlying epidermal layers giving rise to the characteristic rash with Nikolsky sign. Adults with certain risk factors including chronic kidney disease, immune compromise and NSAID use have higher propensity given the inability to clear the toxin. This syndrome is defined by certain clinical and histopathological criteria. Given the extensive desquamation of the skin, insensible skin losses of fluids and toxin mediated immunological reaction - patients usually present in shock, with hypothermia, hypotension and multisystem dysfunction. It is important to distinguish SSSS from toxic epidermal necrolysis (TEN) which is done via skin biopsy. In TEN, sub-epidermal split and full thickness epidermal necrosis can be seen. Conclusion: Staphylococcal scalded skin syndrome is a rare but well characterized syndrome in adults with certain risk factors. Clinicians should have a high suspicion based on comorbidities and clinical presentation as it is a significant source of morbidity, highly contagious but easily treatable.
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