Staphylococcal scalded skin syndrome imitating Stevens-Johnson syndrome/toxic epidermal necrolysis in adults

Summary: Abstract Body: A 60-year-old woman with type 2 diabetes (T2D), chronic kidney disease (CKD), and history of infected spinal hardware presented with a rapidly worsening diffuse rash featuring denudation and superficial desquamation on the trunk, back, and extremities. Extensive antibiotic exposure initially suggested Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), but frozen-section biopsies revealed psoriasiform, spongiotic dermatitis with subcorneal pustules, indicating staphylococcal scalded skin syndrome (SSSS). This diagnosis was further supported by evidence of Staphylococcus aureus infection and the development of acute kidney injury (AKI). In another case, an 81-year-old man with T2D, stage 4 CKD, and a left below-the-knee amputation presented with a worsening stump wound infected by methicillin-resistant Staphylococcus, refractory to antibiotics and complicated by an AKI. After undergoing a left above-the-knee amputation, he developed pustular plaques on the face and chest, along with sloughing and superficial desquamation of the neck, back, face, groin, and chest. Although extensive antibiotic use initially suggested SJS/TEN, a skin biopsy showing a subcorneal split with neutrophils confirmed SSSS. In both cases, development of an AKI on CKD likely caused exfoliative toxin accumulation and SSSS. Both patient’s symptoms mimicked SJS/TEN, including cutaneous exfoliation, erythema, and superficial desquamation, necessitating histopathological differentiation. SSSS is characterized by superficial epidermal splitting within the granular layer, sparing mucosal surfaces and showing minimal neutrophilic infiltration; SJS/TEN involves full-thickness epidermal necrosis extending to the dermal-epidermal junction with mucosal involvement. These cases underscore the importance of performing skin biopsies in patients with renal dysfunction who present with SJS/TEN-like symptoms to ensure accurate diagnosis and appropriate management. Omar Alani¹, Courtney Chau¹, Dev Patel¹, Raphaella Lambert¹, Nour El-Kashlan¹, Scott Stratman¹, Jónas Adalsteinsson¹ 1. Icahn School of Medicine at Mount Sinai, New York, NY, United States. Innate Immunity, Microbiology, and Microbiome