Thursday, April 1, 2010

Straight from the nose

"S., I'm referring to you a case of a 3-week old baby who is having skin desquamation...", so went another doctor from the town's local health center. She was sending over one of her patients because this one was from one of the mountain towns and would have a hard time following up is she was only put on oral meds, and would need to be admitted.

(She calls me by my first name because I'm a younger doctor and since we shared a bus conversation a few weeks earlier, it was a pretty comfortable working relationship.)

After getting the necessary information, and finding out that the patient was stable, I waited. I had some differentials in mind prior to seeing the patient, but the moment I saw the patient, I couldn't help but smile...a big Cheshire cat grin was slowly spreading across my face and I had to quickly stifle and hide it, otherwise, somebody who could see it would think I was going crazy. I whispered to myself, "Gotcha..."

It was a case of Staphylococcal Scalded Skin Syndrome (brief info here, medical journal here :-)), and my patient had clear-cut symptomatology straight from the book. Now, I wasn't happy that the patient had it, no, but it was kind of a triumphant "Yess!!" moment for me back there.

The story is that one time, when I was doing my internship rotation in Pediatrics, I happened to admit an 8 month-old patient who had sudden onset of skin redness and cough. The patient was said to have been placed under a mango tree (in bloom) before developing the redness, which prompted his parents to bring him to the hospital. Now, this kid had a history of atopy, and was prone allergies in the recent past. On physical examination, he was essentially well, only that he had the generalized redness.

In internship, it is customary to "endorse" newly-admitted patients in morning rounds; to state their history and physical examination (as complete as possible) from the interview you had done previously and to let the receiving team know of the patients they were receiving for the day. So anyway, when my turn came, one of the residents asked  me to endorse a patient, my "red" patient.

And so, I stated all the facts required, and in the end, presented my working diagnosis as that of a hypersensitivity reaction, which would resolve shortly after meds were given. One of the residents asked me how I came up with my diagnosis and if I was considering something else, like, maybe Staphylococcal Scalded Skin Syndrome. And I paused before speaking, because I wanted to measure out my words carefully, because one thing could lead to another and thus a neverending line of questioning would be started.

I quietly (most interns would, haha) answered, "It is possible, Doctor, but an allergic reaction would the more likely situation..." and then the chief resident's eyes go huge and his voice rises a couple of decibels higher and he goes, "Isn't that clear enough for you???"

"But..." I started to say, because I did a physical exam of this patient, and instinct told me anyway, that the symptoms didn't match up. "Why do you still insist???" he went again..

I think I got a nudge from my seatmate B., as a sort of a sign for me to back down. It was a better idea than to risk the ire of that resident by plodding on, perhaps. B., pulled me aside afterward and said, "You know, it never is a good idea to insist, just try to do your job, and try not to get in trouble next time. This is not the time yet to assert yourself, you know."

And so, with a bruised ego, and a partial annoyance, i let the matter be, but I did read up more on Staphylococcal scalded skin syndrome just in case I would need to have to defend myself again.

I never did get to, no other similar cases came up...


The patient's mother was kind enough to allow me to take pictures of her baby so I could do more research. She gave me her [explicit] permission, which I'm thankful for. :-) This works both ways, you see...I'll get to know more about SSSS educate other people better, and correspondingly, she'll also get better treatment, and will also learn about and understand her child's condition better.

From Drop Box

It is characteristic to have tissue-paper thin peeling and bullae, with superficial desquamation, which heals within 5-7 days.

From Drop Box

This condition is caused by a toxin-producing Staphylococcus (a common agent of skin infections) which causes skin layers to separate, resulting in easy tears of skin layers, as noted in the picture above.

From Drop Box

Funnily enough, epidemics of these, are caused by being naturally affectionate. :-p  The patient's mother revealed that they had house contacts who had the sniffles and would repeatedly kiss and hug the baby.Research revealed that 20-40% of normal persons are frequently asymptomatic (meaning, they may have bacteria present in their nasopharyngeal secretions, but these don't cause any visible disease), or the skin, or the axillae or the buttocks.

The prognosis is quite good in young children, as long as meds are taken and there is constant follow-up, the condition should resolve in 5-7 days without complications (adults are a different story). Fingers crossed, hopefully we'll all do well in the next few days.


By the way, here's something I'd like to leave you with...

The attending physician of the "red baby" signed out the final diagnosis in the chart. Guess what she wrote?

"Hypersensitivity Reaction...(and etc etc)"




  1. Wow, that's interesting. I never heard of SSSS before. I hope it is rare.

    It sounds like that resident did not remember what it was like to be an intern. He should have encouraged discussion--plus it might have helped him understand he was wrong. I hope he/she read the final diagnosis! =)

    Have you ever heard of a regular human having the ability to sting another person? I think it happened to me once. The link to the story is below. The only thing I know for sure it that it hurt! LOL

  2. gotcha doc!Often the best best learning tool in medicine is a "bad" experience. Not even a book has such pinpoint accuracy! keep on!

  3. hehe.. you are such a sweet doctor.. i know a lot of my friends who become doctors . but then non of em stay their sweet nice selves after they join work.. you have to really enjoy what you are doing with you heart to smile an open smile from time to time. and you do that . :).. hope that kids getting better :)



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