BAL HARBOUR, FLA. — Infections are a major cause of emergencies in pediatric dermatology, Howard Pride, M.D., said at the annual Masters of Pediatrics Conference sponsored by the University of Miami.
Though rare, such conditions must be kept in mind to ensure prompt diagnosis and appropriate treatment. Staphylococcal scalded skin syndrome, for example, is often thought to be a nondeadly disease, but it is associated with a mortality of up to 7%, particularly in the very young and should be identified early, said Dr. Pride, a pediatric dermatologist at Geisinger Medical Center, Danville, Pa.
The disease presents with a scarlet fever-like rash, usually beginning around the lips and nose and then becoming more generalized with flexural accentuation in the groin area; it may involve superficial bullae that rapidly denude and leave large areas of raw, red, moist skin that appears scalded. It typically occurs in children younger than 5 years.
Onset is abrupt and includes irritability, malaise, fever, and extreme pain. In fact, pain is often the dominant symptom, Dr. Pride noted.
Staphylococcus aureus is the associated pathogen, but exfoliative toxins A and B, either of which is released at the infection site and spreads hematogenously, are the cause of the lesions. Therefore, cultures of the blisters are not useful.
The diagnosis is typically made clinically; there is little in the way of diagnostic testing for scalded skin syndrome. Biopsies or cultures of the eyes, nose, or pharynx can be performed, but Dr. Pride said he biopsies only on rare occasions.
For the most part, diagnosis is based on clinical intuition. However, for a rapid diagnosis and to differentiate this from toxic epidermal necrolysis, a snap frozen section can be performed.
Care for staphylococcal scalded skin syndrome is mostly supportive; skin care includes application of emollients, such as a petrolatum ointment. Mupirocin is not necessary since staphylococcus is not the direct cause of the skin lesions.
Strict attention to fluids and electrolytes is important, as is maintenance of body temperature. Antibiotic treatment against staphylococcus is useful, but a few articles have shown that some cases in adults have been associated with methicillin-resistant Staphylococcus aureus, so keep this in mind when considering antibiotic coverage, Dr. Pride advised.
“But the best thing we can do for these patients is control pain, because they are absolutely miserable,” he said.
Other pediatric emergencies that Dr. Pride discussed include:
▸ Ecthyma gangrenosum. Lesions associated with this condition, which almost always occurs in the setting of immunocompromise, have a central hemorrhage with a purplish halo. They may have a punched-out ulcer appearance with a necrotic base and black eschar. They commonly occur in patients undergoing chemotherapy, and Pseudomonas aeruginosa is usually the culprit, Dr. Pride said. But other organisms, such as herpes simplex, S. aureus, and species of Klebsiella, Neisseria, and Candida may be involved.
“But when you think about empirical coverage [P. aeruginosa] is the organism you really want to be covering,” he said.
The diagnosis is usually made clinically, and supportive measures along with a broad-spectrum antibiotic should be initiated to ensure coverage while awaiting culture or biopsy results. Aspiration or drainage of lesions should be performed as necessary.
▸ Meningococcemia. This is a scary and sometimes rapidly progressing disease that also requires quick action. Presentation includes high fever, headache, nausea, diarrhea, and a petechial rash of the skin and mucous membranes. The fulminant form presents with massive skin and mucosal hemorrhage, shock, and rapid death. Peripheral gangrene can occur.
Rapid antigen tests exist, but specificity is not very high, so the diagnosis should be made clinically, and treatment should be initiated quickly in an intensive care unit. Penicillin remains the treatment of choice for this condition, and supportive care and skin care with mupirocin are useful. Prophylaxis of patient contacts is imperative, he said.
▸ Rocky mountain spotted fever. The peak incidence of this often tick-borne illness, which generally occurs in the southeastern and south central United States in early summer, is in children 5–9 years old. They present with sudden severe headache, malaise, myalgia, arthralgia, anorexia, photophobia, chills, and fever. Hypotension also can occur.
A rash, which progresses centrally and mostly affects the extremities, occurs on the fourth day of illness in about 90% of patients. Early in the course of illness, the rash appears with small discrete red blanching macules, which later become papules with a dark hue. The extremities have a nonpitted edematous characteristic, and in young children the rash may occur periorbitally.
About 80% of patients report a recent tick bite.