April 2002

A 12-year-old girl was admitted to the hospital for evaluation and treatment of acute blistering of her left arm and hand. The onset was the day before. There was neither fever nor any other associated complaints noted. Her past medical history was significant for severe static encephalopathy with spastic quadriparesis and a seizure disorder. She has occasional seizures and was seen to have one earlier on the day the blistering was noted.

Her primary physician initially treated her with a first-generation cephalosporin. However, this had no benefit, and she was sent for admission.

Her examination revealed normal vital signs and the static encephalopathy with its associated neurological deficits noted above. She also was noted to have areas of blistering on her left arm and hand as noted in figures 1–3. One of the blisters was aspirated for Gram’s stain and culture. The stain was negative and culture is pending. No other lab tests were done. Nafcillin was empirically started on admission.

What’s Your Diagnosis?

1. Traumatic bullous dermatitis
2. Scalded skin syndrome
3. Bullous pyoderma
4. Linear IgA dermatosis

Answer

This turned out to be #1, traumatic bullous dermatitis. This one is new to me, but even if you have never heard of it, there are hints to rule out the other choices. Our pediatric dermatologist explains this injury as one that occurs during a seizure and is enhanced by a lower oxygen tension in the tissues during the seizure. The area of blistering apparently represents areas of friction injury from rubbing of the arm and hand against another object during the seizure. The culture of course was also negative.

Scalded skin syndrome is caused by the epidermolytic toxin produced by infections with certain types of Staphylococcus aureus (usually phage group 2). It is associated with a site of infection and usually fever. The rash is a diffuse erythroderma with multiple areas of blistering (figure 4). The culture and Gram’s stain of blister fluid in these cases are also negative because the blistering is due to circulating toxin and not the direct effect of the organism.

The treatment is with an antistaph antibiotic and general support, including skin care. There is a bright side to this disease. While the staph infection can be serious, depending on the site and severity of the infection, the skin injury is not as bad as it might appear. The toxin in this disease causes injury to the skin higher in the epidermis, usually no deeper than the granular layer. So while it looks horrible, it is non-scaring, and children usually recover without complications.

Bullous pyoderma is essentially the same thing as bullous impetigo. The term is usually reserved for more severe cases, and historically was more common in young infants and newborns (figure 5). The blistering in this disease is a result of locally produced epidermolytic toxin at the individual sites of infection. Therefore, one would expect to have a positive Gram’s stain and culture for S. aureus. This usually responds well to oral antistaph antibiotics.

Both these staphylococcal skin conditions have become relatively uncommon today. Most of the cases I have seen were during the early part of my career. In fact, figures 4 & 5 are from the Jim Bass collection from the 1960s and 70s. All the bullous staph infections I have seen in recent years have been simple bullous impetigo, or bullous varicella (figure 6).

Linear IgA dermatosis is considered one of the immunobullous diseases, and is characterized by recurrent sterile blisters with erythema often in a linear pattern. It has its onset in early childhood and episodes may persist for more than one month. Dermatologists usually make the diagnosis in patients with the appropriate history and physical features by doing immunoflourescent testing of involved skin adjacent to one of the sausage-shaped lesions and/or detection of circulating autoantibodies. You can read more about this entity in Weston, Lane, and Morelli, Color Textbook of Pediatric Dermatology, second edition, 1996, Mosby.

For Your Information:

• James H. Brien, DO, Pediatric Infectious Disease, Scott and White's Children's Health Center and Texas A&M University, College of Medicine, Temple, Texas. E-mail: jhbriend@aol.com