This article is more than 5 years old. Information may no longer be current.
Blistering rash in a 22-month-old male
Click Here to Manage Email Alerts
A 22-month-old male is referred from a community hospital ER for admission with a blistering rash. The problem was first noticed when the mother observed that the child was trembling and limping when she got home from work.
When she looked him over, the mother noted some large blisters in various places, and took him to the local ER. The child had been well earlier that day, with no history of fever, nausea, vomiting, diarrhea, or injury, but he did have a mild cough. In the local ER, his vital signs were normal, but because of the blistering of the skin, he was diagnosed with an infection and given IV fluids and a dose of ceftriaxone before transfer.
James H. Brien
The child’s past medical history was unremarkable, and his immunizations are up to date. His review of systems was positive only for a mild cough and the skin complaint.
Family and social history: Mother works, while her friend keeps her children, including the patient and three health siblings. The mother denies any smoke or other toxin exposure, and the child was on no medication before the onset of the blistering.
Examination revealed an alert child in no significant distress, with normal vital signs, and several areas of blistering from the left ear, down the left side of his body to his left foot (Figures 1-2).
Source: Brien JH
Examination revealed an alert child in no significant distress, with normal vital signs, and several areas of blistering from the left ear, down the left side of his body to his left foot (Figures 1-4). His right side was essentially normal. Additionally, he had two abrasion-like lesions, on his back and chin, as well as an ulcerative lesion in the anterior sulcus of his mouth (Figure 5). The rest of his exam was normal.
Examination revealed an alert child in no significant distress, with normal vital signs, and several areas of blistering from the left ear, down the left side of his body to his left foot (Figures 3-4).
He had two abrasion-like lesions, on his back and chin, as well as an ulcerative lesion in the anterior sulcus of his mouth (Figure 5).
Case Discussion
The findings are most consistent with a thermal injury (A), probably with a liquid. However, some staff argued that it was consistent with atypical staphylococcal scalded skin syndrome (SSSS), which led to a skin biopsy. However, the biopsy was consistent with a “thermal burn,” not SSSS. Also, the two abrasion-like lesions, and ulcer in the anterior sulcus are not consistent with a toxin-mediated illness. When the lesions were placed on a body diagram, it appears to support unilateral injury, predominately on the right side; not likely to be the case with SSSS. This, along with the abrasions and injury to the mouth, makes nonaccidental trauma high on the list of causes.
SSSS will typically result in a generalized erythroderma with scattered areas of blistering as a result of the effects of one of the circulating epidermolytic toxins being released into the bloodstream from a primary site of infection. Often this also is associated with fever. Lastly, the depth of injury to the skin caused by the toxin is so superficial, the blisters of SSSS have overlying skin so thin that the blisters rupture with the slightest disturbance (Figure 6). The patient described in this case has persistent, intact blisters, implying a deeper level of injury than that seen with SSSS.
The blisters of SSSS have overlying skin so thin that the blisters rupture with the slightest disturbance (Figure 6). There is also usually more erythema of nonblistering skin (Figure 7).
Sunburn is easy to eliminate by history and seeing blistering in nonsun-exposed areas. There is also usually more erythema of nonblistering skin (Figure 7). As we are in the middle of summer, this would be a good time to reinforce our efforts to encourage our parents to protect children from too much unprotected sun exposure. They do not have to sustain second degree burns to have damage that may increase their risk for skin cancer later in life.
Toxic epidermal necrolysis also is easy to rule out, as it is a severe, generalized drug reaction, resulting in a deeper level of injury to the skin, similar to a third degree burn in some places. This condition also will present with intact blisters for the same reason; thicker overlying skin (Figure 8). These patients are always fairly sick with fever and toxicity, and should be managed in a burn unit or similar facility.
This condition also will present with intact blisters for the same reason; thicker overlying skin (Figure 8).
No one wants to think that children get injured at the hands of their parents or friends of their families, but sometimes they do, and it is important to recognize it when we see it, and not be misled from the obvious. A skin biopsy is usually not needed to make this distinction, just a good history and physical examination and common sense.
For more information:
James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.