Staphylococcal Scalded Skin Syndrome — MCQs
A child with fever presents with multiple tender erythematous skin lesions, and on microscopic examination, the skin lesions are found to have neutrophilic infiltration in the dermis. What is the diagnosis?
A diabetic patient developed cellulitis due to S. aureus, which was found to be methicillin resistant on the antibiotic sensitivity testing. All of the following antibiotics will be appropriate except ?
A 25-year-old female presented to the hospital on 3rd day of menstruation with complaints of high fever, vomiting and rash on her trunk and extremities. On investigations she had leukocytosis and negative blood culture. She is diagnosed as:
Nikolsky's sign is seen in all of the following, except:
What is the diagnosis of a child with a small abrasion over the face who develops fever with chills, induration, and fiery red swelling over the face extending to the ear?
A patient was diagnosed to have single skin lesion of Leprosy without any AFB positive bacteria from the scrapings. What should be the treatment of this patient according to latest guidelines?
A 35-year-old woman presents with hypopigmented and anesthetic patches on her arms, and a positive skin smear for acid-fast bacilli. What is the most likely diagnosis?
Skin TB which involves skin after involving lymph nodes –
A female patient of 26 years, presents with oral ulcers, photosensitivity and skin malar rash in face sparing the nasolabial folds of both side.
A neonate develops sepsis with organism showing CAMP test positive. Likely organism?
Staphylococcal Scalded Skin Syndrome Indian Medical PG Practice Questions and MCQs
Question 1: A child with fever presents with multiple tender erythematous skin lesions, and on microscopic examination, the skin lesions are found to have neutrophilic infiltration in the dermis. What is the diagnosis?
- A. Sweet syndrome (Correct Answer)
- B. Behcet's syndrome
- C. Pyoderma gangrenosum
- D. Leukemia cutis
Explanation: ***Sweet syndrome*** - **Sweet syndrome**, also known as acute febrile neutrophilic dermatosis, presents with **fever**, **tender erythematous plaques**, and a characteristic histology of **dense neutrophilic infiltrate in the dermis** without vasculitis. - It is often triggered by **infection**, malignancy, or drugs and is more common in women, though it can occur in children. *Behçet's syndrome* - **Behçet's syndrome** is a multisystem vasculitis characterized by **recurrent oral and genital ulcers**, uveitis, and skin lesions such as erythema nodosum or papulopustular lesions, but not typically the specific neutrophilic dermatosis seen here. - The hallmark is **recurrent aphthous ulceration**, which is not mentioned in the patient's presentation. *Pyoderma gangrenosum* - **Pyoderma gangrenosum** presents as rapidly enlarging, **painful necrotic ulcers** with undermined purplish borders, often associated with inflammatory bowel disease or hematological disorders. - While it also involves neutrophilic infiltration, the clinical presentation of **tender erythematous plaques without ulceration** is not typical. *Leukemia cutis* - **Leukemia cutis** refers to infiltration of the skin by leukemic cells, which can present as papules, nodules, or plaques with **neutrophilic (myeloid) infiltration** on histology. - However, it typically occurs in patients with **known or occult hematologic malignancy**, and the lesions are usually **non-tender** and may have a violaceous hue, unlike the tender erythematous plaques of Sweet syndrome. - Sweet syndrome itself can be **paraneoplastic** and associated with myeloid malignancies, making the distinction important.
Question 2: A diabetic patient developed cellulitis due to S. aureus, which was found to be methicillin resistant on the antibiotic sensitivity testing. All of the following antibiotics will be appropriate except ?
- A. Vancomycin
- B. Teicoplanin
- C. Linezolid
- D. Imipenem (Correct Answer)
Explanation: ***Imipenem*** - **Imipenem** is a carbapenem antibiotic that is effective against many Gram-positive and Gram-negative bacteria, but it is **not active against MRSA (methicillin-resistant *Staphylococcus aureus*)**. - MRSA strains are resistant to all beta-lactam antibiotics, including penicillins, cephalosporins, and carbapenems like imipenem, due to the presence of the **mecA gene** which encodes for an altered penicillin-binding protein (PBP2a). *Vancomycin* - **Vancomycin** is a glycopeptide antibiotic that is a primary choice for treating **MRSA infections**, including cellulitis. - It inhibits cell wall synthesis by binding to the D-Ala-D-Ala precursor, preventing cross-linking, and is specifically active against **Gram-positive bacteria**. *Teicoplanin* - **Teicoplanin** is another glycopeptide antibiotic, similar to vancomycin, and is also considered a suitable agent for treating **MRSA infections**. - It works by inhibiting bacterial cell wall synthesis and has a **longer half-life** than vancomycin, allowing for less frequent dosing. *Linezolid* - **Linezolid** is an oxazolidinone antibiotic known for its activity against **Gram-positive bacteria**, including **MRSA** and vancomycin-resistant enterococci (VRE). - It inhibits protein synthesis by binding to the 50S ribosomal subunit, preventing the formation of the initiation complex.
Question 3: A 25-year-old female presented to the hospital on 3rd day of menstruation with complaints of high fever, vomiting and rash on her trunk and extremities. On investigations she had leukocytosis and negative blood culture. She is diagnosed as:
- A. staphylococcal food poisoning
- B. toxic shock syndrome (Correct Answer)
- C. scalded skin syndrome
- D. varicella zoster infection
Explanation: ***Toxic shock syndrome*** - The combination of **high fever, vomiting, rash, leukocytosis, and menstruation** (especially tampon use) is highly suggestive of **Toxic Shock Syndrome (TSS)**, which is often caused by *Staphylococcus aureus* exotoxins. - A **negative blood culture** is common in TSS as it is a toxemia, not primarily a bacteremia, though bacteria are present at the local infection site. *Staphylococcal food poisoning* - While caused by *Staphylococcus aureus* toxins, **food poisoning** is typically characterized by rapid onset **gastrointestinal symptoms** (nausea, vomiting, diarrhea) [1] and usually resolves within 24 hours. - It does not typically present with the widespread **exfoliative rash** and systemic features seen in TSS. *Scalded skin syndrome* - **Staphylococcal scalded skin syndrome (SSSS)** is characterized by **blistering and exfoliation of the skin**, primarily affecting young children. - While both involve staphylococcal toxins, SSSS does not typically present with the prominent **fever, vomiting, and menstrual association** seen in this patient. *Varicella zoster infection* - **Varicella zoster infection** (chickenpox or shingles) presents with characteristic **vesicular lesions** in various stages of healing. - The rash described (trunk and extremities without vesicles) and the association with menstruation do not fit the clinical picture of a varicella zoster infection.
Question 4: Nikolsky's sign is seen in all of the following, except:
- A. Bullous pemphigoid (Correct Answer)
- B. Toxic epidermal necrolysis
- C. Scalded skin syndrome
- D. Mucous membrane pemphigoid
Explanation: ***Bullous pemphigoid*** - **Nikolsky's sign** is typically **negative** in bullous pemphigoid because the blistering occurs in the **subepidermal region**, leading to a strong dermo-epidermal adhesion that resists tangential pressure. - The blisters in bullous pemphigoid are generally **tense** and do not rupture easily, reflecting the deep separation plane. *Mucous membrane pemphigoid* - **Nikolsky's sign** is typically **negative** in mucous membrane pemphigoid (also known as cicatricial pemphigoid) because it is also a **subepidermal blistering disorder**. - Like bullous pemphigoid, the cleavage occurs below the epidermis, preserving the integrity of the epidermal layer and maintaining resistance to lateral shearing forces. - The blisters are typically tense rather than flaccid, reflecting the deeper plane of separation. *Toxic epidermal necrolysis* - **Nikolsky's sign** is **positive** in toxic epidermal necrolysis (TEN) due to the extensive **full-thickness epidermal necrosis** and detachment, which is the hallmark of the condition. - Gentle tangential pressure causes the epidermis to easily shear off, revealing large areas of denuded dermis. *Scalded skin syndrome* - **Nikolsky's sign** is **positive** in scalded skin syndrome (SSSS) because the **exfoliative toxins** produced by *Staphylococcus aureus* cleave **desmoglein 1** in the superficial epidermis. - This cleavage leads to rapid and widespread **intraepidermal detachment** and flaccid blistering, making the skin highly susceptible to shearing.
Question 5: What is the diagnosis of a child with a small abrasion over the face who develops fever with chills, induration, and fiery red swelling over the face extending to the ear?
- A. Anthrax
- B. Carbuncle
- C. Cellulitis
- D. Erysipelas (Correct Answer)
Explanation: ***Erysipelas*** - The presentation of **fiery red swelling** with well-demarcated, raised borders, rapidly extending from a small abrasion, especially on the face and involving the ear, is classic for erysipelas. - It also includes systemic symptoms like **fever and chills** and **induration**, which are characteristic of this superficial skin infection usually caused by **Streptococcus pyogenes**. *Anthrax* - Cutaneous anthrax typically presents with a papule that develops into a **vesicle**, then a painless ulcer with a distinctive **black eschar**, which is not described here. - While it can cause fever, the characteristic skin lesion is distinct from the red, spreading swelling seen in this case. *Carbuncle* - A carbuncle is a deep infection involving multiple hair follicles, presenting as a painful, interconnected lesion with **multiple draining sinuses**. - It is typically more localized, deeper, and pus-filled than the superficial, rapidly spreading, fiery red swelling described. *Cellulitis* - Cellulitis is a deeper infection of the dermis and subcutaneous fat, presenting with redness, warmth, and tenderness, but its borders are typically **less well-demarcated** and not as raised as in erysipelas. - While it can also occur on the face and cause systemic symptoms, the description of "fiery red" and "extending to the ear" with sharp borders makes erysipelas a more precise diagnosis.
Question 6: A patient was diagnosed to have single skin lesion of Leprosy without any AFB positive bacteria from the scrapings. What should be the treatment of this patient according to latest guidelines?
- A. (Rifampicin + Dapsone) for 12 months
- B. (Rifampicin + Dapsone + Clofazamine) for 6 months
- C. (Rifampicin + Dapsone + Clofazamine) for 12 months
- D. (Rifampicin + Dapsone) for 6 months (Correct Answer)
Explanation: ***(Rifampicin + Dapsone) for 6 months*** - This regimen is the standard **Multi-Drug Therapy (MDT)** for **paucibacillary (PB) leprosy**, which is characterized by a **single skin lesion** and **negative acid-fast bacilli (AFB)** on scrapings. - The 6-month duration is effective in eradicating the infection with high cure rates and low relapse rates. * (Rifampicin + Dapsone) for 12 months* - This 12-month regimen is unnecessarily prolonged for paucibacillary leprosy, increasing the risk of side effects and reducing patient adherence without additional clinical benefit compared to the 6-month regimen. - While Rifampicin and Dapsone are correct drugs for PB leprosy, the duration is not aligned with current WHO guidelines for this specific presentation. * (Rifampicin + Dapsone + Clofazamine) for 6 months* - The addition of **Clofazamine** makes this the regimen for **multibacillary (MB) leprosy**, which presents with multiple skin lesions or positive AFB smears. - This patient's presentation of a **single lesion** and **negative AFB** clearly indicates paucibacillary leprosy, for which Clofazamine is not typically included. * (Rifampicin + Dapsone + Clofazamine) for 12 months* - This is the standard regimen for **multibacillary (MB) leprosy**, due to the presence of Clofazamine and the 12-month duration. - It is not appropriate for a patient with a **single, AFB-negative lesion**, as this presentation denotes paucibacillary leprosy requiring a shorter, two-drug treatment.
Question 7: A 35-year-old woman presents with hypopigmented and anesthetic patches on her arms, and a positive skin smear for acid-fast bacilli. What is the most likely diagnosis?
- A. Psoriasis
- B. Leprosy (Correct Answer)
- C. Vitiligo
- D. Pityriasis versicolor
Explanation: ***Leprosy*** - The presence of **hypopigmented and anesthetic patches** is pathognomonic for leprosy, indicating nerve involvement - A **positive skin smear for acid-fast bacilli** directly confirms the presence of *Mycobacterium leprae*, the causative agent - This combination of anesthesia with skin lesions and AFB positivity is diagnostic *Psoriasis* - Psoriasis presents with **red, scaly plaques** with well-demarcated borders, typically on extensor surfaces - Does not cause **anesthesia** and is not associated with acid-fast bacilli - Auspitz sign may be present (pinpoint bleeding on scale removal) *Vitiligo* - Causes **complete depigmentation (white patches)** due to melanocyte destruction, not hypopigmentation - Patches are **not anesthetic** - sensation remains intact - An **autoimmune condition** with no involvement of acid-fast bacilli *Pityriasis versicolor* - A **superficial fungal infection** (Malassezia species) causing hypo- or hyperpigmented patches with fine scaling - Patches are **not anesthetic** and maintain normal sensation - **Skin smear shows yeast and hyphae** ("spaghetti and meatballs" appearance), not acid-fast bacilli
Question 8: Skin TB which involves skin after involving lymph nodes –
- A. Scrofuloderma (Correct Answer)
- B. Lupus erythematosus
- C. Lupus pernio
- D. Lupus vulgaris
Explanation: ***Scrofuloderma*** - This form of **cutaneous tuberculosis** results from the direct extension of underlying **tuberculosis** affecting structures such as **lymph nodes**, bones, or joints to the overlying skin. - The skin lesion often appears as an **ulcer** or **sinus tract** with **purulent discharge**, reflecting the underlying infection communicating with the surface. *Lupus erythematosus* - Lupus erythematosus is a systemic autoimmune disease that can affect the skin, but it is not a form of **tuberculosis**. - Skin manifestations range from acute malar rashes to chronic discoid lesions, which are distinct from **tuberculous ulcers**. *Lupus pernio* - This is a cutaneous manifestation of **sarcoidosis**, characterized by **violaceous plaques** and nodules typically on the face (nose, cheeks), ears, and fingers. - It is not a form of **tuberculosis** and does not result from the direct extension of an underlying local infection. *Lupus vulgaris* - This is a chronic and progressive form of **cutaneous tuberculosis** that directly affects the skin in individuals with high immunity to the **tubercle bacillus**. - It presents as **reddish-brown plaques** with an **apple-jelly** nodule appearance on diascopy, and does not typically arise from an underlying lymph node infection extending to the skin.
Question 9: A female patient of 26 years, presents with oral ulcers, photosensitivity and skin malar rash in face sparing the nasolabial folds of both side.
- A. Sturge weber syndrome
- B. Dermatitis
- C. Psoriasis
- D. SLE (Correct Answer)
Explanation: ***SLE*** - The combination of **oral ulcers**, **photosensitivity**, and a **malar rash** that spares the nasolabial folds is highly characteristic of **Systemic Lupus Erythematosus (SLE)** [1]. - SLE is an autoimmune disease with diverse clinical manifestations involving multiple organ systems. *Sturge weber syndrome* - This is a neurocutaneous disorder characterized by a **port-wine stain** (nevus flammeus) typically on the face, neurological abnormalities like seizures, and ocular involvement. - It does not present with oral ulcers or photosensitivity as primary features. *Dermatitis* - **Dermatitis** is a general term for skin inflammation, often presenting with redness, itching, and sometimes blisters. - It does not typically involve the specific constellation of oral ulcers, photosensitivity, and a malar rash that spares nasolabial folds. *Psoriasis* - **Psoriasis** is a chronic autoimmune disease primarily affecting the skin, characterized by red, scaly patches (plaques) [2]. - While it can cause nail changes and sometimes joint pain, it does not present with photosensitivity, oral ulcers, or the characteristic malar rash described.
Question 10: A neonate develops sepsis with organism showing CAMP test positive. Likely organism?
- A. S. aureus
- B. E. coli
- C. Listeria
- D. Group B Streptococcus (Correct Answer)
Explanation: ***Group B Streptococcus*** - **Group B Streptococcus (GBS)**, or *Streptococcus agalactiae*, is the **most common cause of neonatal sepsis** and is the **classic organism** associated with a **positive CAMP test**. - The **CAMP test** (Christie-Atkins-Munch-Petersen) detects synergistic hemolysis between the CAMP factor produced by GBS and *Staphylococcus aureus* beta-lysin, resulting in an **arrowhead-shaped zone of enhanced hemolysis**. - GBS is strongly associated with **early-onset neonatal sepsis** (within first 7 days), transmitted vertically during delivery. - When the CAMP test is mentioned in the context of neonatal sepsis, **GBS is the intended answer** due to its classical association and epidemiological importance. *S. aureus* - *Staphylococcus aureus* can cause **sepsis** in neonates but is **CAMP test negative**. - It provides the beta-lysin used in the CAMP test to detect other organisms but does not produce the CAMP factor itself. *E. coli* - *Escherichia coli* is a **Gram-negative rod** and a frequent cause of **neonatal sepsis** and meningitis. - As a Gram-negative bacterium, *E. coli* is **CAMP test negative**. The CAMP test is specific for certain Gram-positive bacteria. *Listeria* - *Listeria monocytogenes* is **also CAMP test positive**, which can cause diagnostic confusion. - However, it causes a distinct clinical pattern: **granulomatosis infantiseptica**, meningoencephalitis, and is associated with **maternal ingestion of contaminated food**. - Listeria is **less common** than GBS as a cause of neonatal sepsis and is not the classic teaching association for CAMP positivity. - The CAMP positivity of Listeria is **weaker** and shows a different pattern (reverse CAMP) compared to the strong, characteristic arrowhead pattern of GBS.
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