Curling’s Ulcer in Association with Staphylococcal Scalded Skin Syndrome in the Neonate

Abstract

Case ReportThis 24-day-old infant boy was the second born of a 36-week twin gestation delivered at an outlying hospital by spontaneous vaginal delivery after a pregnancy complicated only by mild maternal preeclampsia. His nursery course was unremarkable. Physical examination at 2 weeks of life was within normal limits, and an elective circumcision was then performed without difficulty at his community hospital. Over the 2 days following the circumcision, his mother noted increased redness in the groin area; on day 3, peeling of the skin of the scrotum and penis were evident. On day 4 after circumcision, the patient was febrile and was seen by his primary physician. Rectal temperature at this time measured 38.3°C. Blood and urine cultures were performed. Lumbar puncture was unsuccessful. The infant received intravenous (i.v.) antibiotics and was transferred to the neonatal intensive care unit for further management of suspected staphylococcal scalded skin syndrome (SSSS). His vital signs on admission revealed a rectal temperature of 37°C, a heart rate of 200 beats/min, a respiratory rate of 50 breaths/minute, and blood pressure of 104/69 mm Hg. Physical examination at this time was notable for erythematous and tender skin with sloughing over the entire body but was otherwise unremarkable (Figure 1, A and B). Skin cultures and a skin biopsy of the affected area were performed on admission. Topical therapy with Vaseline and Aquaphor was initiated. Systemic antibiotic therapy included i.v. vancomycin (15 mg/kg i.v. every 12 hours) and gentamicin (2.5 mg/kg i.v. every 12 hours). Blood and urine cultures obtained at the referring hospital showed no growth at 3 days, and many colonies of Staphylococcus aureus were identified on the admission skin culture. Antibiotic therapy was then changed to i.v. nafcillin (50 mg/kg i.v. every 8 hours). Skin biopsy revealed a plane of separation in the region of the granular cell layer of the epidermis consistent with SSSS. Pain was controlled with morphine (0.05 mg/kg i.v.) and subsequently with acetaminophen (20 mg/kg orally every 4 hours). The patient's cardiorespiratory status remained stable, and oral feedings of human milk and/or standard infant formula were continued from admission. By day 3 of hospitalization, the patient was feeding well; however, a 10% weight loss from admission was noted, and supplemental i.v. fluids at 100 ml/kg per day were started to supplement oral feedings. On day 5, the patient became edematous and had several episodes of emesis; blood cultures were redrawn, and the abdominal x-ray was interpreted as normal. On day 7 of hospitalization, the patient developed acute onset of pallor, abdominal distention, and irritability. Hemoglobin measured at 5.3 gm/dl, and the abdominal radiograph revealed evidence of free intraperitoneal air. He was stabilized with red blood cell transfusions and oxygen and emergently taken to the operation room, where a clean, round, 7-to 8-mm isolated perforation of the first part of the duodenum was identified and closed with an...