March 2007

A 21-month-old boy was admitted from the clinic with a febrile illness and a rash. He was in his usual good state of health until the evening before when he began feeling hot and a painful rash appeared.

After a restless night, he awoke with some nausea and a worsening rash that included some blistering. He has been on no medications, and his immunizations are up to date. He has had no recent sick contacts.

Examination revealed a lethargic, moderately dehydrated boy with a temperature of 101°F and a painful rash with diffuse erythema and blister formation as shown in figures 1-2. Except for dry mucous membranes and some erythema of his lips, the rest of his exam was normal.

Specifically, there was no enanthem or conjunctivae inflammation.

What’s Your Treatment?

1. Intravenous steroids
2. Intravenous vancomycin
3. Ceftriaxone
4. Silver sulfadiazine

Answer

With summer just around the corner, I thought this would be a good time to discuss this issue.

By necessity, I had to leave out a critical piece of history; that is that the child had spent the day before at the lake with his family, and he was without a shirt or sunblock for several hours. This, of course, resulted in severe sunburn, with large areas of first and second degree injury to the skin as shown by large areas of blistering, which was treated with topical silver sulfadiazine D (Silvadene, Aventis), to prevent infection. Patients sick enough to require hospitalization for their burns should also be co-managed with surgeons familiar with burn care, usually plastic surgeons. Cases complicated by third degree burn injuries should usually be managed in a burn center. However, one need not be in a burn unit to use Silvadene.

Use of silver

The medicinal use of silver dates to about one and a half centuries BC, but the current product used for burns has its roots in 20th century research. Although Drs. Moyer and Margraf of the Washington University’s department of surgery are credited with much of the work on the use of topical antiseptic compounds on burn patients in the 1970s, it was Dr. Charles Fox of Columbia University who discovered silver sulfadiazine.

However, it was the work of Lieutenant Colonel (LTC) John Moncrief who, in 1963, introduced the use of Sulfamylon at the Brooke Army Medical Center (BAMC) Burn Unit in San Antonio, Texas, and later the work of LTC Janice Mendelson doing animal research with the compound at the Edgewood Arsenal in Maryland, that set the stage for Fox’s work mentioned above.

Burn units

Like many advances in medicine and surgery, including burn management, some of the greatest discoveries occur as a result of war. Certainly, the BAMC Burn Unit saw a lot of casualties in the 1960s and 1970s from the Vietnam War, bringing it to the forefront of burn management. Known today as the Army’s Institute for Surgical Research, the BAMC Burn Unit remains one of the leaders in burn care worldwide.

The choice of vancomycin was to try to trick you into thinking this patient had staphylococcal scalded skin syndrome. Of course, there are some similarities in that they both may cause fever with red, blistering skin; however, patients with staphylococcal scalded skin syndrome will be red all over, including areas normally shaded from the sun, as seen in figure 3 (severe staphylococcal scalded skin syndrome, courtesy of Joan Barenfanger, MD). This results from the production and circulation of a low–molecular-weight protein that can damage the intracellular bonds between cells in the granular layer of the epidermis.

Because the injury is fairly superficial, there is no scarring associated with the blistering. There is also a focus of infection usually found. Treatment includes an anti-staph antibiotic and supportive measures as needed. This may involve the removal of a nidus for infection, such as a foreign body. If there is an abscess, it should be drained.

The choice of systemic steroids is for those who might think this patient had Stevens–Johnson syndrome. Although there are no evidence-based data supporting the use of steroids in Stevens–Johnson syndrome, they are nonetheless often prescribed. Some of us believe they may actually be detrimental, especially if the Stevens–Johnson syndrome is triggered by a viral infection like herpes simplex. The appearance of Stevens–Johnson syndrome is more like erythema multiforme, with discrete lesion as seen in figure 4, rather than the diffuse erythema of sunburn. By definition, Stevens–Johnson syndrome must also have at least two mucous membrane surfaces inflamed, such as the eyes and mouth.

The ceftriaxone choice was a filler to make four choices.

Commentary

I would like to thank Dr. Sylvia Espinoza, a pediatrician at the San Mateo Medical Center for pointing out a mistake I recently made. In the January column, I mistakenly referred to the late Dr. Juan Guido Tatá as Dr. Juan Guido Tatá Cumana. Dr. Tatá was a notable pediatric infectious disease specialist from Cumana, Venezuela. I had received very kind remarks from Dr. Tatá’s family, who were apparently uncomfortable pointing out my obvious error. My apologies go out to Dr. Tatá’s family, and thanks again to Dr. Espinoza.

I would also like to thank again Dr. Joan Barenfanger for the staphylococcal scalded skin syndrome picture above. Dr. Barenfanger sent me several pictures with case histories several years ago, including her own daughter’s Fifth disease. Along these lines, if any of you have an interesting case with pictures that you would like to see in this column, contact me at jhbrien@aol.com.