Annals of Clinical Cytology and Pathology

An Adult Male Presented with Bullous Impetigo with Leukocytoclastic Vasculitis (LAC) in Pathology Secondary to MRSA Bacteremia

Case Report | Open Access

  • 1. Department of Infectious Diseases, Louisiana State University Health Sciences Center, USA
  • 2. Department of Internal Medicine, Louisiana State University Health Sciences Center, USA
  • 3. Department of Infectious Diseases, Louisiana State University Health Sciences Center, USA
  • 4. Department of Infectious Diseases, Louisiana State University Health Sciences Center, USA
  • 5. Department of Infectious Diseases, Shreveport VA Medical Center, USA
  • 6. Department of Pathology, Shreveport VA Medical Center, USA
  • 8. Department of Infectious Diseases, Shreveport VA Medical Center, USA
+ Show More - Show Less
Corresponding Authors
Pradeep Kumar Mada, Department of Infectious Diseases, Louisiana State University Health Sciences Center, USA

We present an adult male with MRSA bacteremia presented as Bullous impetigo with leukocytoclastic vasculitis (LAC) in pathology.


Mada PK, Malus ME, Castano G, Saldaña Koppel DA, Washburn R, et al. (2018) An Adult Male Presented with Bullous Impetigo with Leuko-cytoclastic Vasculitis (LAC) in Pathology Secondary to MRSA Bacteremia. Ann Clin Cytol Pathol 4(1): 1095.


•    MRSA
•    Bullous impetigo
•    Leukocytoclastic vasculitis


Impetigo incidence is highest in children under five years, followed by ages 5-14, and the elderly are the least affected group [1]. It is important to remember that impetigo has two variants; non-bullous, representing 70% of all cases, and bullous form representing 30%. Bullous impetigo is common in children of 1-5 years of age and in immunocompromised patients.

Staphylococcus aureus is still the most common pathogen responsible for a diversity of infections; however only a few diseases have been associated with their toxins: Toxic shock syndrome, furuncles, staphylococcal scalded skin syndrome (SSSS) and bullous impetigo. SSSS and bullous impetigo are most common in newborns. Epidermolysins are the primary causative toxins of bullous impetigo and SSSS, and it is still not clear if this disease results from their protease activity or by a super-antigen property [2].


A 59-year-old male with a history of chronic systolic heart failure, mitral valve repair, hypertension, chronic kidney disease stage III, atrial flutter, gout, and alcohol abuse who had presented to our hospital with new bullous lesions on both of his hands and both of his feet for two days before admission. He said that blisters on his feet appeared first which then ruptured (Figure 1,2) and then he noticed the blisters on his hands appearing later in the disease progression (Figure 3). The blisters were not painful, but he did have some itching. He denied fever, chills, sore throat, cough, diarrhea or night sweats. He also denied recent ingestion of new medications, sick contacts, similar rashes in family members, dietary change, exposure to chemicals, or tick or mosquito bites. On presentation, he was afebrile and hemodynamically stable. Vitals were: Blood Pressure 106/76 mm of Hg, Heart rate 90 beats per minute, Respiratory rate 20 per minute, and Temperature was 97.2F. Notable labs included WBC 6.5k, Hgb 10.1, Hct 31.3, Plt 165k, Na 139, K 4.3, BUN 13.1, and Cr 1.56 (baseline 1.4-1.5), CRP 18.88, and ESR 29. HIV, RPR and Hepatitis serology were nonreactive. Procalcitonin was 0.07. Autoimmune screen including ANA screen, Rheumatoid factor, and Anti-CCP IgG antibody was all negative. Immunoglobulin levels except IgG subclass 4 were all within normal limits. IgG subclass 4 was elevated at 338. Herpes simplex virus type 1 and 2 DNA was not detectable. Dermatology team performed a biopsy of the bulla. Pathology reported as leukocytoclastic vasculitis and features suggestive of bullous pemphigoid or bullous drug eruption (Figure 4-6) and the patient was started on dexamethasone. Unfortunately, cultures were not done at this time. All non-essential medications were withheld due to the concern of Erythema Multiforme. Blood cultures on admission grew methicillin-resistant Staphylococcus aureus (MRSA). Organism was resistant to Clindamycin, Erythromycin, Levofloxacin, Oxacillin, Tetracycline, and Trimethoprim + Sulfamethoxazole and sensitive to Vancomycin, Daptomycin and Linezolid. Infectious Diseases was consulted at this point. The patient was started on Intravenous vancomycin one gram every 12 hours. The patient had developed Acute Kidney Injury with creatinine elevation (Baseline creatinine was 0.98 mg/ dl, trended up to 1.6 mg/dl) and vancomycin was switched to intravenous daptomycin 6mg/kg every 24 hours with base line check of Creatinine phosphokinase (His CPK level was with in normal limits). We performed aspirate from one of the blisters which yielded five ml of serous fluid, and bacterial cultures were negative. Blood cultures were repeated three days after were negative. Rheumatology was consulted, and they believed leukocytoclastic vasculitis was not from a systemic vasculitis or connective tissue disease but it was from MRSA bacteremia and there was no need for steroid therapy. A 2-D transthoracic echocardiogram was negative for valvular vegetation. A PICC line was inserted, and the patient was sent home on daptomycin for two weeks. He was scheduled for follow up by primary team clinic after one month; however patient was lost to follow up.


Bullous lesions have a broad differential; bullous erythema multiforme, bullous fixed drug eruption, bullous lupus, bullous pemphigoid, bullous scabies, contact dermatitis, dermatitis herpetiformis, insect bites, linear immunoglobulin A bullous dermatosis, necrotizing fasciitis, pemphigus vulgaris, steven johnson syndrome, thermal burns, transient neonatal pustular melanosis. However, the diagnosis is nearly always clinical. Clinical swabs cannot differentiate between bacterial infection and colonization; and in patients whom first-line therapy fails, a culture of the pus or bullous fluid may be helpful for pathogen identification and antimicrobial susceptibility [3].

Staphylococcal scalded skin syndrome (SSSS) is a toxin-mediated disease, usually in children, in which the skin easily detaches by rubbing, which is known as Nikolsky’s sign. The toxin acts on the stratum granulosum of the epidermis. SSS differs from toxic epidermonecrolysis since SSS almost never involves the mucosa while TEN typically usually involves the mucous membranes. The severity of SSS varies from a few blisters that are localized at the site of infection to a severe exfoliation affecting the entire body.

Linear IgA bullous disease (LABD) is an idiopathic autoimmune subepidermal blistering disorder characterized by a vesiculobullous eruption of the skin and mucous membranes. Pathology shows linear IgA deposition alongthe basement membrane. IV vancomycin can precipitate Drug-induced LABD which resolves withdiscontinuation of vancomycin.

Dermatitis herpetiformis is characterized by extremely pruritic grouped excoriations, erythematous plaques, and papuleswith vesicles usually located on the extensor surfaces of the back, elbows, knees, and buttocks. It is an autoimmune blistering disorder that is frequentlyassociated with coeliac disease. The usual location for bullous pemphigoid is a chronic subepidermal blistering disease.

Kouskoukis did a study to try to establish firm criteria to differentiate between pemphigus and bullous impetigo concluded that bullous impetigo would present bacteria within intact blisters and pemphigus presents with no bacteria in blisters [4]. In our case, the patient had been taking antibiotics before aspirate resulting in no growth of bacteria.


Skin infections are caused due to a breach in the epithelium which serves as a barrier through abrasions, trauma, insect bites, eczema and even other diseases like scabies. All this are probable causes for impetigo, either bullous or non-bullous [5]. The blister formation of the skin is mediated by exfoliative toxins, A and B (ETA and ETB), both causing exfoliation of the epidermis without necrolysis or inflammatory response of the skin. These toxins act as proteases that cleave desmosomes (desmoglein 1-Dsg1) in the granular layer [6]. Bullous impetigo and SSSS are a result of skin separation, from the stratum granulosa and spinosum, and Nicholsky sign is positive.

ETA and ETB share a very similar amino acid structure, and they are “atypical” glutamate-specific serine proteases. The “atypical” term is used because the catalytic site is not appropriately configured to be active, perhaps requiring activation by binding to Dsg1, which is also the relevant substrate in the autoimmune disease pemphigus foliaceus, leaving identical blisters to those of bullous impetigo and SSSS. Recently ETD was also identified, along with ETA and ETB, these toxins act as some glutamic acid-specific serine proteases with unusually focused specificity that breaks down Dsg1. This mechanism could be attributed to hydrolysis of a single peptide bond in Dsg1 [7].

The epidermolytic toxin of staphylococcal is not able to bind to any cells in the skin, and it may not be found in the fluid from the blisters. Leaving as an unknown mechanism of action of the toxins when it comes to bullae formation [8].

Diagnosis of impetigo is almost exclusively clinical. Identifying risk factors such as atopic eczema, scabies, chickenpox, insect bite, abrasion, thermal burn, surgical wound [9], is very helpful for the diagnosis. The lesions of bullous impetigo are vesicles that rapidly progress to superficial, thin-roofed, flaccid, and transparent bullae that initially have clear fluid that turns into cloudy and dark yellow. The bullae break easily, and this usually happens in the first three days. This disease is very contagious, and contact isolation is needed [10]. It can be seen in older patients with the renal deficiency or with immunosuppression [11]. It is rare to have an adult with impetigo, even when the bullous variant is more common in adults and immunocompromised it is still a rare disease for this age group. Da shi et al. conducted a study in children on 134 bullous impetigo cases, of which 19.4% were positive for MRSA, in those, the ET gene carriage was 61.5% for MRSA [12].


In our case, despite having the leukocytoclastic vasculitis, there was no need for immune suppressive treatment because it was secondary to the staphylococcal infection.Bullous impetigo is a milder form of SSSS, and it can be treated with topical therapy such as fusidic acid or mupirocin. First-line systemic treatment for MSSA bullous impetigo is oral or intravenous flucloxacillin and for MRSA bullous impetigo is intravenous vancomycin.


1. Bernard P. Management of common bacterial infections of the skin. Curr Opin Infect Dis. 2008; 21: 122-128.

2. Prévost G, Couppié P, Monteil H. Staphylococcal epidermolysins. Curr Opin Infect Dis. 2003; 16: 71-76.

3. Hartman Adams Holly, Christine Banvard, Gregory Juckett. Impetigo: Diagnosis and Treatment. Am Fam Physician. 2014; 90: 229-235.

4. Kouskoukis CE, Ackerman AB. What histologic findings distinguish superficial pemphigus and bullous impetigo? Am J Dermatopathol. 1984; 6: 179-181.

5. Ibrahim F, Khan T, Pujalte GG. Bacterial Skin Infections. Prim Care. 2015; 42: 485-499.

6. Yamaguchi T, Yokota Y, Terajima J, Hayashi T, Aepfelbacher M, Ohara M, et al. Clonal association ofstaphylococcus aureus causing bullous impetigo and the emergence of new methicillin resistant clonal groups in kansai district in japan. J Infect Dis. 2002; 185: 1511-1516.

7. Hanakawa Y, Schechter NM, Lin C, Garza L, Li H, Yamaguchi T, et al. Molecular mechanisms of blister formation in bullous impetigo and staphylococcal scalded skin syndrome. J Clin Invest. 2002; 110: 53-60.

8. Baker DH, Dimond RL, Wuepper KD. The epidermolytic toxin of staphylococcus aureus: its failure to bind to cells and its detection in blister fluids of patients with bullous impetigo. J Invest Dermatol. 1978; 71: 274-275.

9. Hon A. Impetigo. DermNet NZ. 1999.

10. Schiazza Luciano. Bullous Impetigo. 2015.

11. Junkins Hopkins, Jacqueline M, Klaus J, Busam. Blistering Skin Diseases. Dermatopathol. 2010; 210-249.

12. Shi D, Higuchi W, Takano T, Saito K, Ozaki K, Takano M, et al. Bullous impetigo in children infected with methicillin-resistant staphylococcus aureus alone or in combination with methicillin-susceptible s. aureus: analysis of genetic characteristics, including assessment of exfoliative toxin gene carriage. J Clin Microbiol. 2011; 49: 1972-1974.

Received : 23 Feb 2018
Accepted : 16 Mar 2018
Published : 19 Mar 2018
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X