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Staphylococcal scalded skin syndrome, toxic shock syndrome, and Kawasaki disease.

Three dramatic clinical syndromes have been compared and contrasted. Of these, staphylococcal scalded syndrome is most readily recognized and least likely to have a morbid or fatal outcome. It is easy to confuse toxic shock syndrome and Kawasaki disease. Since the case fatality rate is significant in both of these diseases, and the management so different, proper recognition of the disease by its external features is critical.

Adolescent↗

Hyperemia of the intraperitoneal organs associated with scald burn.

A 65-year-old man with a history of cerebral infarction sustained scald burns over 54% of the body surface. In spite of adequate fluid therapy, respiratory management with an artificial ventilator, and continuous hemodiafiltration, the patient died on day 5 post-admission. Autopsy revealed necrotic change on the surface of the liver, and necrosis and perforation of the ileum. Histologic examination showed necrosis of the hepatocytes lining the surface and necrosis of the hepatocytes and congestion in the central area of the liver. We speculated that systemic responses to the extensive burn resulted in hyperemia of the intraperitoneal organs, thereby inducing acute liver failure and the subsequent development of multiple organ failure.

Aged↗

Toxic shock syndrome following cessation of prophylactic antibiotics in a child with a 2% scald.

Toxic shock syndrome (TSS) is a rare but serious complication of burns in children. Symptoms usually start within 3 days of the burn injury and even children with minor burns can be susceptible. Prompt diagnosis and rapid treatment is crucial in limiting the morbidity associated with this condition. We report here a 19-month-old child with a 2% scald who developed TSS following cessation of a 5-day course of flucloxacillin. This case highlights a number of issues regarding the use of prophylactic antibiotics and TSS as well as illustrating the continuing need to educate parents concerning the importance of seeking a prompt medical opinion if the child becomes ill following even a minor burn injury.

Bacterial Toxins↗

The influence of apoptosis of mucosal epithelial cells on intestinal barrier integrity after scald in rats.

OBJECTIVE: To study the influence of apoptosis of intestinal epithelial cells occurring as a result of reperfusion after burn shock on the intestinal barrier. METHODS: Fifty Wistar rats were subjected to a 30% TBSA full thickness burn, and normal saline (40 ml/kg) was given intraperitoneally immediately after the injury (group A). Ten rats served as a sham control group. The experimental group B consisted of 50 rats with identical injuries, but the normal saline was not given until 6h after the injury. Apoptosis of intestinal epithelial cells was verified by DNA fragmentation, DNA agarose gel electrophoresis, TUNEL and electron microscope (EM), and DNA fragmentation rate was expressed as ap%. The D-lactic acid in portal vein blood and intestinal diamine oxidase (DAO) were determined to evaluate the permeability and integrity of intestinal mucosal epithelium. RESULTS: The ap% of intestinal epithelium group B was higher than in that of group A (P<0.05 or 0.01), and its amplitude peaked at 12h for both groups. Typical DNA ladder pattern was seen in electrophoresis in both groups. Apoptotic cells were discerned on the tips of the ileal villi at 3h postscald by TUNEL and EM in the group B, and they appeared earlier than in the group A. There was a significant positive correlation between the ap% and the level of D-lactic acid (group A: r=0.817, P<0.05; group B: r=0.727, P<0.05). On the other hand, a significant negative correlation was found between the ap% and the DAO values (group A: r=-0.937, P<0.01; group B: r=-0.836, P<0.05). CONCLUSION: Apoptosis occurred in enterocytes after scald injury this pathological change might contribute to a breach of integrity of intestinal epithelium, leading to a compromise in its barrier function. Delayed fluid resuscitation might lead to an earlier and higher degree of apoptosis of the intestinal epithelial cells.

Amine Oxidase (Copper-Containing)↗

Scald burns in children caused by hot drinks--the importance of the type of cup.

A prospective study of 36 consecutive scald injuries in children caused by hot beverages is reported. Almost a third of these were deep dermal or full skin thickness and the highest percentage resulted in injury to the upper chest region. The study further investigates the cooling characteristics in four different types of cup. These studies clearly show the potential for significant disfigurement from this type of injury for up to 11 min from the time the drink is poured. The need for greater public awareness in relation to hot drinks is highlighted.

Accidents, Home↗

An extraordinary cause of scalding injury in childhood.

In an attempt to statistically evaluate burn injuries in childhood in terms of incidence, aetiology, mortality and morbidity, a surprising aetiological cause was noticed, not only as having a high mortality rate, but also as being preventable in most cases if simple precautions are taken. Fifteen preschool children had been severely scalded in kitchens by hot milk which was heated in a cauldron to produce cheese, a traditional custom. The clinical data relating to this aetiology and the probable underlying factors pertaining to the social characteristics are given and discussed.

Accidents, Home↗

The continuing risk of domestic hot water scalds to the elderly.

Elderly people are particularly at risk of accidents in the home and with an ageing population, they constitute a large proportion of scald victims. We have seen several elderly patients every year in our own unit who had sustained domestic hot water burns. We decided to ascertain the temperature of water in the private homes of elderly people and in residential care homes in our community. Twenty-five private homes and 14 residential care homes were visited and peak water temperatures were measured in the kitchens and bathrooms. Only one private home and one residential home had water below 45 degrees C. It is recommended that water should be delivered at less than 43 degrees C. We conclude that water is dangerously hot. However, if water is stored at a temperature of less than 60 degrees C there is a risk of infection with Legionella pneumophila. Existing regulations governing the use of 'fail safe' thermostatic mixing devices must be enforced and extended to cover domestic hot water systems.

Accidents, Home↗

Effects of dietary arginine supplementation on protein turnover and tissue protein synthesis in scald-burn rats.

We assessed the effects of dietary arginine supplementation on protein turnover and organ protein synthesis in burned rats. Male Wistar rats weighing about 200 g underwent catheter jejunostomy and received scald burns covering 30% of the whole-body surface area. Animals were divided into a control group (n = 9) and an arginine group (n = 9) and continuously received total enteral nutrition for 7 d (250 kcal.kg-1.d-1, 1.72 gN.kg-1.d-1). Changes in body weight, plasma total protein, plasma albumin, urinary excretion of polyamines, nitrogen balance, whole-body protein kinetics, and tissue protein synthesis rates were determined. Whole-body protein kinetics and tissue fractional protein synthetic rates (Ks, percent/d) were estimated using a 24-h constant enteral infusion of 15N glycine on the last day. The changes in body weight were not different between the control and arginine groups. The urinary excretion of polyamines was higher in the arginine group than in the control group (P < 0.01). Burned rats enterally fed arginine-supplemented diet yielded significantly greater cumulative and daily nitrogen balance on days 3 and 5 than those fed a control diet (cumulative, P < 0.05; day 3, P < 0.01; day 5, P < 0.01). Whole-body protein turnover rate was significantly elevated in the arginine group as compared to that in the control group (P < 0.05). The Ks of rectus abdominis muscles were significantly increased in the arginine group in comparison to the control group (P < 0.01). We have shown that dietary arginine supplementation improved protein anabolism and attenuated muscle protein catabolism after thermal injury.

Animals↗

Scalds among children in Kuwait.

In a prospective study of 560 children treated for burns as in-patients over a period of four-and-a-half years in specialized hospitals responsible for the majority of burn cases in Kuwait, 388 patients (69%) had sustained scalds. The mean age of these 388 children, between 0 to 12 years, was 3.02 +/- 2.08, and male to female ratio 1.5 to 1. They were categorized into three age groups, first, up to 1 year comprised 17.5% cases, who were solely dependent on parents or childminder; second 2 to 5 years of age, who were inquisitive, independent, pre-school children, and constituted the majority of cases (73%), and third 6 to 12 years who were 9.5% school children. The pre-school children (2-5 years) thus formed a highly vulnerable group in the country. Accidents (99.4%) occurred at home and the kitchen being the commonest place. The hot water from pan and pots in the kitchen was the most common etiologic factor in 229 cases (59%), followed by tea/coffee 20.7%, soup 9.0%, hot oil 6.7%, and milk 4.6% patients. The most common circumstance was the child upsetting the pan of hot fluid in the kitchen. The mean total body surface areas of second and third degree burns were 14.21 +/- 9.66 (range 1 to 60%). The average length of stay in the hospital was 16.90 +/- 15.74 days, varying from one to 109 days. Thirty-nine children were ill prior to burn, and the commonest disease was respiratory tract infection. Three patients (0.8%) with 3rd degree burns were treated with primary excision and grafting, and 137 (35.3%) needed secondary skin grafting for residual burn wounds. Four patients (1%) died, one due to burn shock, two due to septicemia and one due to multiorgan failure. There is need for general awareness through public education, which may lead to the prevention of significant number of such accidents.

Accidents, Home↗

Regulation of protein metabolism by a physiological concentration of insulin in mouse soleus and extensor digitorum longus muscles. Effects of starvation and scald injury.

1. Although high concentrations of insulin affect both synthesis and degradation of skeletal-muscle protein, it is not known to what extent these effects occur with physiological concentrations. The effects of a physiological concentration of insulin (100 mu units/ml) on muscle protein synthesis, measured with [3H]tyrosine, and on muscle protein degradation, measured by tyrosine release in the presence of cycloheximide, were studied in mouse soleus and extensor digitorum longus muscles in vitro. 2. Insulin significantly stimualated protein synthesis in both muscles, but an inhibition of degradation was seen only in the extensor digitorum longus. 3. Starvation for 24 h decreased the rate of protein synthesis and increased the rate of breakdown in the extensor digitorum longus. Sensitivity to insulin-stimulation of proteins synthesis in the soleus was increased by starvation. 4. ;a 20%-surface-area full-skin-thickness dorsal scald injury produced a fall in total protein content in soleus and extensor digitorum muscles, maximal on the third day after injury. Soleus muscles 2 days after injury showed an impairment of protein synthesis; degradation was unaffected and neither synthesis nor degradation in vitro was significantly affected in the extensor digitorum longus. 5. The advantages and limitations of studies of protein metabolism in vitro are discussed.

Amino Acids↗

Regulation of plasma acute-phase protein and albumin levels in the liver of scalded rats.

At 12 h after scalding of rats a doubling of the hepatocyte nuclear DNA content, which arose from the presence of additional complete genomes and not from amplification of genes coding for the major acute-phase proteins or albumin, was observed. Examination of relative transcription rates per control DNA mass revealed that alpha 1-acid-glycoprotein and cysteine-proteinase-inhibitor genes remained constitutive, alpha- and gamma-fibrinogen and haptoglobin genes underwent transcriptional activation for 290 and 339% respectively, whereas the relative transcription rate of albumin decreased to 65% of the control level. Along with these changes, the alpha 1-acid glycoprotein, cysteine-proteinase inhibitor and the fibrinogen mRNA concentrations increased about 500%, haptoglobin mRNA 250%, whereas the albumin mRNA concentration fell to 86% of the control. The regulation of the mRNA levels was assessed by comparing the relative change in transcription rates expressed per control DNA content with the relative changes of mRNA concentrations. We arrived at the conclusion that the concentrations of alpha 1-acid-glycoprotein and cysteine-proteinase-inhibitor mRNAs were predominantly regulated by a post-transcriptional mechanism, albumin mRNA by a transcriptional mechanism, and the fibrinogen and haptoglobin mRNAs by a combination of both. The degree of change of the serum levels of the examined proteins was similar to that of their mRNA concentrations and was the result of the complete use of the available RNA templates in protein synthesis.

Acute-Phase Proteins↗

Rhynchosporoside, a host-selective toxin produced by Rhynchosporium secalis, the causal agent of scald disease of barley.

Rhynchosporoside, a phytotoxic compound, has been isolated from cultures of Rhynchosporium secalis, the causal agent of scald disease of barley. The toxin is a cello-bioside of 1,2-propanediol. The compound may play some role in symptom expression because it was isolated from diseased plants in concentrations similar to those that could cause symptoms in toxin-treated plants. The toxin causes leaf tip and marginal necrosis and subsequent chlorosis of the entire leaf. The toxin affects only certain cultivars and lines of barley and rye; however, it also affects certain nonhosts of R. secalis. The genetic factor controlling host resistance to the fungus is not identical to that controlling insensitivity to the toxin.

Journal Article↗

Identification of RFLPs flanking a scald resistance gene on barley chromosome 6.

We report the map location of the scald resistance gene, Rrs13, from wild barley (Hordeum vulgare ssp. spontaneum) with respect to RFLP loci on barley chromosome 6 (= 6H). The identification of two RFLP loci (Cxp3 and ABG458) flanking the Rrs13 locus will assist selection for the resistant allele in barley breeding programs.

Base Sequence↗

Fatal hot coffee scald of the larynx. Case report.

We present a case of fatal upper aerodigestive tract scald sustained by a schizophrenic man who drank hot coffee. After describing the clinical and pathologic findings, we discuss the risks for incurring such injuries.

Accidents↗

Case report. Staphylococcal scalded skin syndrome in adults: case report and review of the literature.

An adult drug abuser with endocarditis due to a group II Staphylococcus aureus developed the staphylococcal scalded skin syndrome (SSSS). Studies of the patient's immune function found cell-mediated immunity (CMI) to be essentially normal; thus, previous suggestions that deficient CMI is required in adults who develop SSSS seem unfounded. Pathogenesis, diagnosis, and therapy of SSSS and its differentiation from drug-induced hypersensitivity reaction are discussed in detail.

Adult↗

The relationship between experimental fluid therapy and wound edema in scald wounds.

It is evident clinically that fluid loads administered acutely after thermal injury increase wound edema, but this relationship has not been well defined. Scalded rats were given intravenous water loads of up to 40% body weight. Concomitantly, sodium and albumin loads were also varied around clinically recommended norms for resuscitation (0-48 mEq sodium/kg, albumin in concentration of 1-10%). Attendant edema and sodium content were measured in the wound and in uninjured skeletal muscle. Wound edema was found to be linearly related to the net volume of the fluid administered, irrespective, within wide limits, of its sodium or albumin content. The positivity of the slope of the regression of wound edema on administered volume varied depending on extent of the injury. The changes in uninjured muscle were comparatively small. Wound sodium content always closely paralleled water content. Since all of the treatments studied had an equivalent propensity to enter the wound, other criteria must be used to judge their efficacy in the resuscitation of acutely burned patients.

Albumins↗

Tap-water scald burns. Awareness is not the problem.

Review of admissions to a regional burn center showed that tap-water burns were an injury of pediatric, elderly, and neurologically impaired patients. A study was designed to measure general knowledge of tap-water injury and awareness of tap-water temperatures in homes. All those surveyed realized the potential for tap-water scald burns in their homes, and few believed that they could tolerate hot-only tap water at home for as long as 30 seconds. Respondents who had previous experience with tap-water burns had not lowered the settings of their water-heater thermostats. Economical but effective programs must be developed to encourage burn-reduction behaviors in high-risk groups.

Adolescent↗

In vivo microcirculation of a scald burn and the progression of postburn dermal ischemia.

The homozygous hairless mouse ear provides a reproducible model for the study of the microcirculatory changes of the burn wound during and following a scald burn injury. This model has allowed us to correlate the dynamic changes of the microcirculation to progressive zones of injury, which show an approximate tenfold increase in the area of complete capillary occlusion during the first 48 hours after injury. Platelet thromboembolism appears to be the major factor causing this progression of postburn dermal ischemia. Edema (increased skin water content) was greatest in the burned ear at 6 hours after the burn (20 percent greater than control values); edema of the unburned, contralateral ear was significant at 2 hours after the burn (9 percent greater than control values).

Animals↗