CORRESPON DENCE

History, science and the community

Staphylococcal scalded skin syndrome

To the editor: Reflection on Professor Mazumdar's short treatise regarding the freedom of science (Can Med Assoc J 117: 313, 1977) stimulates some observations and comment. It is somewhat difficult to follow Mazumdar's line of thought. She seems to oppose the standard-bearers of absolute freedom for science such as Polanyi and J.R. Baker and favours external influences on science and scientists, an idea much in vogue in the past several decades. Her arguments, however, seem to relate much more to the practical application of, rather than to pure, science. No one will dispute the interaction between society as a force and science in the abstract or in its practical manifestations, but should we not strongly oppose regulations and limitations imposed upon scientists in pursuit of their ideals? Yes, society does interfere. Remember the experiments on inmates of German concentration camps during World War II and the political referrals of dissenters to insane asylums in the Soviet Union. Remember, too, the theories of racial superiority and those of Soviet geneticists on the environmental effects on the genes. The historian can record these occurrences and speculate on their significance in their effect on science, but we can never recognize the necessity for curtailing freedom of thought or of developing new ideas. Society is like a blind giant to be led by outstanding personalities of integrity relying on a body of unwavering factual knowledge and ideas that are influenced only by the brilliance of genius and scientific truth, and are never altered by external influences even if their eventual application and effect are modified by the necessities and limitations of society of the day.

To the editor: In the 8 years since the publication of an editorial on toxic epidermal necrolysis (TEN) (Can Med Assoc J 101: 126, 1969) much information on the subject has accumulated. It is now clear that TEN can be divided into two conditions distinguishable by the clinical, histologic and bacteriologic findings. One of these conditions is the staphylococcal scalded skin syndrome (SSSS).1 SSSS usually occurs in children under 5 years of age. It starts as purulent conjunctivitis or an upper respiratory tract infection. A widespread tender scarlatiniform erythema rapidly develops and is worse in the central portion of the face, neck, axillae and groins. Rubbing causes wrinkling and peeling of the upper epidermis of normal-appearing skin (Nikolsky sign). Within 24 to 48 hours there is spontaneous wrinkling and large flaccid bullae appear. The upper portion of the epidermis separates into sheets and a moist erythematous base is left. Minor friction at this stage (as from finger pressure or adhesive tape) will cause the outer epi-

I.S. SIMOR, MD, FRcP[c] Department of radiological sciences Mount Sinai Hospital Toronto, Ont. Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten doubled spaced and, except for case reports, should not exceed i½ pages in length.

854

dermis to peel. At this time juicy impetiginous crusts are frequently present on the central portion of the face, particularly around the orifices. Recovery is usually within 5 to 7 days, with or without the administration of antibiotics. The fluid in the bullae is sterile. Occasionally one can see bullous impetigo on the breasts of a mother who is nursing a newborn infant who has

ssss.

The rash is due to elaboration of an exotoxin from phage group 2 staphylococci at a distant site (where they are causing purulent conjunctivitis, pharyngitis or otitis media). Occasional positive cultures from the rash are due to secondary seeding of the denuded skin. This epidermolytic exotoxin is called exfolatin or epidermolysin. It is a heatstable protein with a molecular weight of about 30 000 daltons. In 1970 Melish and Glasgow2 found an animal model for SSSS. Injections into neonatal mice of organisms isolated from patients with SSSS produced exfoliation resembling clinically and histologically that found in human disease. Important factors were dose (less than 10. organisms had no effect) and age (after 5 to 7 days exfoliation could

I-(haracterist1csofsta.%ococcat scalded skin syndrome (SSSS) as compared with those SSSS

Cat.s. .ClinIcot features 1)Istrlbtition of lesions Skin tondrnss NIksisk$. sign Nucosee histologic features General With Giemsa stain Psarstionfwk) Ubrtallty

CMA JOURNAL/OCTOBER 22, 1977/VOL. 11'.

BfiiIrns impotigo in siblings ylococoal infection at a staht site

TEN >40 None Drug ingestion, reaction to smallpox vaccine, lymphoma, leukemia, graft v.*host reaction

typiCal pattrn and succession Generalized 0t.pv.piiiOflt (appearing tedS, neck, axullae and Absent Positive for lesions only Pwitlv.all.ver Involved tMluvulim4 Mid tpaappvepidermal cleavage Necrosis of epidermal cells; subepidermal split wltfracawtholysis; Intra. .p*nspht Kormaf.app.ring acantholytic Necrotic epidermal cells poly. morph; aniceliular debris celIa and electrolyte Cortlcostorol4s, P.nlcIJllj.awresistant and biopd volume Inaistenance penicillin ItoS I High tow

0

incleraF (PROPRANOLOL)

A beta-adrenergic receptor blocking agent for the treatment of angina pectoris. INDERAL, given daily, prophylactically, reduces the incidence of anginal pains and the requirements for nitroglycerin tablets. Exercise tolerance and physical activity are increased. In many cases, pulse rate may be reduced. Dosage should be adjusted to patient's requirements for maximal benefit with minimal adverse effects (see PRECAUTIONS). Dosag. and administratIon: First day 20 mg; then increase by 20 mg per day for one week. Then 40 mg tour times daily before meals and at bedtime. Occasionally, in resistant cases, doses as high as 320-400 mg per day have been administered safely with beneficial results. If treatment is to be discontinued, reduce dosage .RECAUTiO a period of about two weeks (see NS). CautIon: Abrupt CessatIon of INDERAL Therapy In Angina Pectorla There have been reports of severe exacerbation of angina and myocardial infarction occurring in patients with angina pectoris following abrupt discontinuation of INDERAL. Therefore, when discontinuation of INDERAL is planned in patients with angina pectoris, the dosage should be gradually reduced over a period of about two weeks and the patient should be carefully observed. The same frequency of administration should be maintamed. In situtations of greater urgency, INDERAL therapy should be discontinued stepwise and under close observation. If angins markedly worsens or acute coronary insufficiency develops, it is recommended that treatment with INDERAL be reinstituted promptly, at least temporarily. In addition, patients with angina pectoris should be warned against abrupt discontinuation of INDERAL Note: The CAUTION concerning the abrupt cessation of INDERAL therapy referred to under ANGINA PECTORIS (see above) need not apply to patients with hypertension provided they have no angina pectoris. Contraindlcations: Bronchial asthma. Allergic rhinitis during the pollen season. Sinus bradycardia and g reaterthan second degree or total heart block. Cardi.enic shock Right ventricular failure secondary to pulmonary hypertension. Congestive heart failure unless the failure is secondary to a tachyarrhythmia treatable with INDERAL. In chloroform and in ether anesthesia. PrecautIons: Occasionally, INDERAL has caused sinus bradycardia due to unopposed vagal activity which has been corrected by atropine. A resting pulse of 55-60 is frequently associated with INDERAL therapy. Patients without a previous history of cardiac failure have occasionally developed failure, or patients in incipient failure have developed overt congestive failure after treatment with INDERAL. In such cases, if the response is unsatisfactory, INDERAL should be stopped immediately. If a good response is obtained, patients should be fully digitalized and observed closely. If failure persists, INDERAL should be withdrawn completely. The number of patients with such difficulties is small compared with the total number treated. The safety of INDERAL in pregnancy has not been established. INDERALahouId be administered cautiously to children, patients subject to hypoglycemia, patients on hypoglycemic agents, patients with impaired renal or hepatic function, uncontrolled diabetes, shock, metabolic acidosis, and to patients undergoing elective surgery. Patients receiving catecholamine-depleting drugs, such as reserpine, should be closely watched when INDERAL is given concomitently. Adverse reactIons: Epigastric distress; dry mouth; mild diarrhea; constipation; lightheadedness; dizziness. Hypotension, congestive heart failure and marked bradycardia, including sinus arrest, have been reported. Bronchospasm and, rarely, respiratory distress and laryngospasm have occurred, particularly in patients with bronchial asthma. During anesthesia, INDERAL may produce bradycardia due to unopposed vagal activity, reversible with atropine. A few cases of marked bradycardia have resulted while on INDERAL in the presence of hypovolemia and a vasoconstrictor. For other, rarely observed adverse reactions see Product Monograph. Supplied: Tablets of 10 mg and 40 mg in bottles of 100 and 1000; tablets of 80 m. in bottles of 100. Also INDERAL Starter P8k-incremental dosage for first weekof therapy in push-through blister pack.

Ayersl .. AYERST LABORATORIES Division of Averst McKenna & Harrison Limited Montreal Canada Made in Canada by arrangement with IMPERIAL CHEMICAL INDUSTRIES LIMITED Product Monograoh available on request Reg d

not be produced). The incubation period was between 9 and 12 hours. Massive doses of corticosteroids given to adult mice could result in the development of a mild form of generalized 5555. 5555 can be expected in immunologically compromised adults and in adults with metabolic abnormalities; healthy adults can better metabolize the epidermolytic toxin. Intradermal injection of purified staphylococcal epidermolytic toxin in healthy adult volunteers produced locally the same clinical and histologic changes that are seen when the disease occurs naturally. The characteristics of SSSS, especially those that differentiate it from TEN,3 are outlined in Table I. ROBERT JACKSON, MD, FRCP[c] 1081 Caning Ave. Ottawa, Ont.

References 1. ELIAS PM, FRITSCK P, EPsmIN EH: Staphylococcal scalded akin syndrome. Arch Dermatol 113: 207, 1977 2. MELISH ME, GLASGOW LA: The staphylococcal scalded-skin syndrome. Development of an experimental model. N Engi J Med 282: 1114, 1970

3. LYELL A, DICK TIM, ALEXANDER JO: Outbreak of toxic epidermal necrolysis associated with staphylococci. Lancet 1: 787, 1969

Patient relations

not so hopeful that the "delinquents" will pay much attention to it. ELAINE WADDINGTON Women's Pavilion Library Royal Victoria Hospital Montreal, PQ

Student selection for medical school To the editor: It was with great interest and profound sympathy that I read the letter by Richard J. Meadows concerning the difficulties in obtaining admission to medical school (Can Med AsSoc 1 117: 430, 1977). Mr. Meadows, after an unusually frank avowal of his personal experiences, wishes to know by what criteria future doctors are chosen. Evidently this has always been a mystery and, despite repeated assurances of fairness and honesty, for the rejectee there is always a lingering Kafkaesque atmosphere about the procedure. The rejected applicant inculpates many factors for his unsuccessful attempt, at times even blaming his lack of a long line of medical forbears. But whatever the reason he can never really know why he was refused admission. The form letter, no matter how sweetly phrased, affords no explanation. Would it not be kinder and more just to tell the would-be doctor bluntly and unequivocally the actual reason rather than allow him to go through life perpetually haunted by the unexplained rejection? At times remedial treatment might even be possible.

To the editor: Mr. Landry's article on patient relations (Can Med Assoc I 117: 380, 1977) made interesting reading. As a medical librarian who deals with physicians every day, but even more so as an occasional patient, I have a few comments that to me are PHILIP EIBEL, MD, ERC5[C] 5845 Cote des Neiges just as important as those listed. Montreal, PQ What annoys me most, other than a long delay, is that when you finally get into the physician's office and start To the editor: Although I sympathize explaining your problem, the phone with the frustration felt by Mr. Mearings. The physician then has a long dows in his unsuccessful attempts to conversation with another patient, who gain admission to medical school, I has not taken the troLlble to make an disagree with some of the conclusions appointment, while you sit and stew. he has drawn regarding the functions I know some physicians have messages of medical school admissions comtaken by their nurses and phone the mittees. caller later, but not all of them. SituaSpeaking only for the faculty of tions such as this are much more im- medicine at Queen's University, Kingportant than wall-to-wall carpets. ston, I can assure Mr. Meadows that I get very annoyed when I am at- academic achievement, as represented tended by a young, inefficient, lacka- by a student's university transcript, is daisical, discourteous receptionist when only one of the factors considered. I suspect the physician is too stingy Character evaluation can be judged to pay a trained person and has prob- from the candidate's account of himably given his niece an easy summer self, from the reports of referees and, job. I realize that I'm being unfair to at times, from personal interviews, and young people and that some of them is accorded equal weighting with acado a great job, bLIt I have encountered demic achievement. this type of girl more than once in a The offspring of physicians are not waiting room. An efficient receptionist accorded priority status at this medical makes or breaks a physician's relations school and, contrary to what Mr. with his patients. Meadows believes, a rejection does not Apart from these few things. I found prejudice an applicant's later applicaLandry's qLlestiOnnaire excellent. I am tion for admission. In fact, many canCMA JOURNAL/OCTOBER 22, 1977/VOL. 117 857