Clinical Scorecard: MSSA Bacteremia–Associated Staphylococcal Scalded Skin Syndrome in an Older Adult Resembling Toxic Epidermal Necrolysis

At a Glance

Key Highlights

• SSSS can occur in adults, especially in the presence of immunocompromising conditions such as hematologic malignancy.
• Mucosal sparing and superficial desquamation supported SSSS over SJS/TEN in the reported patient.
• MSSA-positive blood cultures and biopsy showing intraepidermal cleavage with subcorneal splitting supported the diagnosis.
• Treatment included targeted intravenous antibiotics, wound care, pain control, and nutritional support.
• The patient improved with progressive re-epithelialization and completed intravenous antibiotic treatment in a skilled nursing facility.

Guideline-Based Recommendations

Diagnosis

• In the reported case, the differential included SSSS, SJS/TEN, and bullous pemphigoid.
• Mucosal sparing and superficial desquamation supported SSSS in this patient; advanced age heightened concern for TEN.
• Blood cultures identified MSSA, and biopsy showed intraepidermal cleavage and subcorneal splitting, supporting SSSS.

Management

• Empirical intravenous vancomycin and ceftriaxone were started while the cause of the eruption was being determined.
• After MSSA identification, treatment was narrowed to intravenous oxacillin and then changed to cefazolin for a planned 4-week regimen after bacteremia cleared.
• Care included daily wound care, pain management, nutritional supplementation, and input from dermatology, burn surgery, and hand surgery.

Monitoring & Follow-up

• Serial assessments showed progressive re-epithelialization and decreased erythema.
• Subsequent blood cultures were negative, and transthoracic echocardiography showed no infective endocarditis.

Risks

• The source describes adult SSSS as uncommon and associated with high morbidity.
• The source identifies renal dysfunction and immunosuppression, including hematologic malignancy, as adult predisposing conditions; it also lists prolonged corticosteroid or immunosuppressive treatment, transplantation, and alcohol use disorder.
• The source notes that TEN occurs more frequently in older adults and is associated with high mortality.

Patient & Prescribing Data

The reported patient was an 88-year-old woman with untreated diffuse large B-cell lymphoma, MSSA bacteremia, and preserved renal function.

She received empirical intravenous vancomycin and ceftriaxone, followed by targeted intravenous oxacillin and then cefazolin for a planned 4-week regimen after bacteremia cleared. Supportive care included daily wound care, acetaminophen and intermittent oxycodone for pain, protein supplementation, multivitamins, and zinc.

Clinical Best Practices

• In this case, clinical examination, microbiology, and histopathology were used to distinguish SSSS from SJS/TEN and bullous pemphigoid.
• Mucosal sparing and superficial desquamation supported SSSS in the reported patient; biopsy showed the level and pattern of epidermal injury.
• The reported patient had untreated diffuse large B-cell lymphoma and preserved renal function.
• The case included wound and nutritional support alongside targeted antimicrobial treatment.

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