Case report
Staphylococcal scalded skin syndrome mimicking child abuse by burning

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Abstract

Child abuse by burning comprises 6–20% of all child abuse cases, but misdiagnosis may arise in cases of some medical conditions. We present two cases of suspected inflicted burns, later diagnosed as staphylococcal scalded skin syndrome (SSSS).

In case 1, a 6-month-old girl was referred to hospital for small round ulcerations on the face and abdomen, resembling cigarette burns. Because of the inconsistency of the mother's report (insect bites) with the injury pattern and an unstable family history, hospitalization was decided. The following day, new bullous lesions were visible on the neck and nose, indicating the natural origin of the findings, finally diagnosed as SSSS.

In case 2, a 2-month-old boy was hospitalized for erythema, with bullous lesions on the abdomen. He was transferred to another hospital, with suspected congenital or autoimmune skin disorder but negative searches led to a diagnosis of inflicted scalds: a report was sent to the judicial authorities, and the child was entrusted to his grandparents. In fact, a review of the clinical documentation showed that, in the second hospitalization, new erythematous and bullous lesions had been described, which could not be ascribed to inflicted injuries. Child abuse was finally ruled out, and SSSS was diagnosed.

In cases of suspected inflicted child burns, observation during hospitalization may reveal changes in lesions, ascribed to the evolution of medical conditions. SSSS diagnosis is mainly based on clinical grounds but, if the suspicion of abuse remains, isolation and phage typing of Staphylococcus aureus from nasal, pharyngeal or cutaneous swabs may confirm the diagnosis.

Introduction

Burns and scalds represent 6–20% of all child abuse cases [1] and up to 26% of paediatric burn unit admissions are due to deliberately inflicted injuries [2], [3]. Nevertheless, child abuse by burning is often under-recognized and under-reported, because of the difficulty of identifying non-accidental burns and scalds [4], and up to 50% of children undergo repeated abuse after they return home [1], [5], [6].

However, it must be emphasized that burns and scalds may be mimicked by medical conditions, such as bullous impetigo [7], [8], phytophotodermatitis [9], contact dermatitis [10], and eczema [11], and a mistaken diagnosis and report of child abuse by burning has important consequences for the family and for the child itself.

In this paper, we present two cases of suspected inflicted burns and scalds, which were later diagnosed as staphylococcal scalded skin syndrome (SSSS).

Section snippets

Case 1

A 6-month-old girl was referred to the emergency room of the City Hospital of Padova by her mother, at the request of the nursery-school teacher, who had found suspicious skin lesions on the face of the baby. Her parents were Nigerian immigrants who had been resident in Italy for 3 years. The child had not been brought to the nursery-school in the previous 10 days.

Physical examination revealed an unfebrile child in good clinical condition, with psychomotor development adequate for her age. A

Discussion

SSSS is a blistering skin disease induced by exfoliative toxins of certain strains of S. aureus. An overall incidence of about 0.1 cases per 1 million inhabitants per year has recently been calculated. The age distribution shows two clusters: one in the early age (0–12 years) and another in elderly patients (54–75 years) [12]. Clinical features may vary from a few localized blisters to generalised erythema and exfoliation. In the localized form, the toxin is produced directly in the skin by S.

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