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4-year-old male presents with discrete, annular lesions around both ankles
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A 4-year-old male with a past history of moderately severe eczema and asthma, presents with the onset of some discrete, mildly painful lesions about both ankles. The next morning, a few more individual lesions were seen scattered about his body, many with a blistering component. After 7 days of an increasing number of lesions, the discomfort associated with the lesions became significant, and the child was admitted from the ED for evaluation and management.
Figure 1. Lesions had an ulcerative appearance along with some crusting.
Source: Brien JH
Figure 2. Lesions had an ulcerative appearance along with some crusting.
Source: Brien JH
Figure 3. Lesions had an ulcerative appearance along with some crusting.
Source: Brien JH
His vital signs were normal. Specifically, he had no fever throughout this period, and the only abnormal findings were his eczematous skin and numerous discrete, annular skin lesions from his head to his ankles, with variable degrees of blistering. Some lesions had an ulcerative appearance along with some crusting in areas of older lesions, with some coalescence where numerous lesions appeared to “grow together,” particularly about the ankles where the problem was first seen 7 days earlier (Figures 1-3). As seen in the figures, there is no erythema of the skin surrounding the lesions.
The patient’s immunizations were documented to be up-to-date, including varicella vaccine. His family history revealed that no one else at home or day care has been sick, but his grandmother, whom he visits frequently, is being treated for a “Staph skin infection.” There has been no travel in over a year, and the only animal exposure is a healthy family dog. His pre-illness medications included topical steroid cream periodically and inhaled albuterol as needed.
Admitting lab tests include a normal C-reactive protein level, erythrocyte sedimentation rate, metabolic profile and UA. However, the CBC had 15,800 WBCs, and a Gram stain of the fluid from one of the lesions has some Gram-positive cocci, and the culture is growing an organism the next day, not yet identified.
Case Discussion
This is an unusual case of disseminated bullous impetigo (B), apparently brought on by heavy colonization with an epidermolytic toxin-producing Staphylococcus aureus on skin damaged by chronic eczema. The lesion culture grew methicillin-sensitive S. aureus, and the condition rapidly started clearing with a few days of IV anti-staph antimicrobial therapy (Figure 4).
Figure 4. Epidermolytic toxin-producing Staphylococcus aureus on skin damaged by chronic eczema.
Source: Brien JH
Figure 5. Diff use erythema and large, flaccid bullae.
Source: Brien JH
We don’t know if the grandmother was infected with the same organism, but there is often close contact with someone with Staphylococcal pyoderma. A disseminated pattern of bullous impetigo has to be fairly unusual, because in 39 years of pediatric practice, I have never seen this before, although I have read of a similar presentation in an adult.
The admitting diagnosis of this patient was staphylococcal scalded skin syndrome (SSSS). While the causative organism of SSSS and bullous impetigo is the same staphylococcal phage group 2 strain, the clinical manifestations are clearly different, with SSSS being the consequence of circulating epidermolytic toxin, resulting is diffuse erythema and large, flaccid bullae (Figure 5). Conversely, bullous impetigo is a localized infection with locally contained epidermolytic toxin.
As noted above, the most likely explanation for this unusual manifestation in this patient would be the gradual spread of infection over damaged skin for several days. The typical manifestations of SSSS would likely occur in a fairly short period of time, and would be accompanied by some generalized erythema of nonblistering skin. However, as shown in Figure 4, this may be difficult to appreciate in children with dark skin. Also, the organism would not be expected to be recovered from the blister fluid of SSSS lesions, whereas it is routinely found in the lesions of bullous impetigo, as in this case. For reference, SSSS was featured in my August 2015 column.
Figure 6. Erythema multiforme.
Source: Brien JH
Figure 7. Blistering varicella.
Source: Brien JH
Erythema multiforme is usually brought on by a reaction to a drug or infection, resulting in fixed, target-like lesions (Figure 6), often with mucous membrane involvement. It would also develop faster than this patient, and would not have bacteria found within the blister. Erythema multiforme was featured in the March 2015 column for reference.
Bullous varicella has become very uncommon as the incidence of varicella has been vaccinated down to only an occasional case. This occurs when varicella lesions become secondarily infected with this same toxin-producing S. aureus, resulting in a lesion that has the appearance of blistering varicella (Figure 7, from the James W. Bass, MD, collection). It always looks worse than it really is, provoking a high level of fear in the parent and concern in the provider, but the child is usually not very sick, and the condition responds well to appropriate anti-Staph therapy. For those of you who keep these old columns, bullous varicella was featured in the April 2006 issue.
I hope your summer has been without having any of these conditions featured over the last few months. Get ready for the next onslaught that comes with the colder months, and get your flu shot. – James H. Brien, DO
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- 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.