Dr.Takeuchi,

Thank you for the interesting question.

At first, Staphylococcus epidermidis (lat.) is one of the app.20 species of the so-called coagulase-negative staphylococci considered as saprophytes of the skin. However, I cannot recollect who he was, but one of the prominent microbiologist of the 20th century entitled his paper "Chaos, or introduction into Staphylococci". They have very fluctuating phenotype, he said, and confusing, intertangled genomics. So, my answer is: why not?

At second, the sizes of the scratched wounds do the matter. How large was their total square in percent of the patient's body surface approximately?

At last, there are many diseases, other than diabetes mellitus, that may cause a state of immunodeficiancy: various chronic gepatitis, NAFLD, intrahepatic holelithiasis, etc., with a dot immunodeficiency to a single species, as the case of the spontaneous bacterial peritonitis in cirrhotic patients. So, the immunogramm should be taken to evaluate the patient's status.

Hi Nobuhiro,

Interesting case indeed.  How and when did the patient develop skin eruptions.  Was the patient on any drugs, be it may any over the counter drugs.  It seems that the patient developed skin eruptions due to some drugs and the skin eruptions got infected.  The patient scratched the eruptions and developed septicemia.  As Dr. Borodach has suggested that it is quite possible, given the size of the eruptions and other predisposing immunodeficiency due to other diseases, that the patient could develop sepsis.

If the skin eruptions is due to any culprit drugs, it may be a case of Stevens Johnson Syndrome which can result in skin eruptions and sepsis.  We need to get more information on this case before we can definitively make a diagnosis.

Omer

I appreciate your help, Dr Easow, Dr Iqbal, and Dr Borodach.  

Here is the more detailed information regarding the patient.

On day 4, trans-esophageal echocardiography was performed. There was no evidence of IE.  

Sputum culture revealed staphylococcus aureus (GPC) and streptococcus sp (GPC).  Cerebrospinal fluid culture revealed no presence of bacteria. Urine culture revealed no presence of bacteria (except a small colony of gram negative bacilli). Unfortunately, no sample of skin culture was taken.

With respect to her skin legions, we consulted with a dermatologist. She has a history of childhood atopic dermatitis. Skin lesions were seen only in her hands and lower legs; dry and scratched skin like xerotic eczema. Her skin lesions did not seem like Stevens-Johnson syndrome. She did not take medicine including over-the-counter drugs.

No evidence of immunosuppressive state was found (HbA1c was within normal limit and, serum anti-HBV-Ag, anti-HCV-Ab, and TRHA were negative).

Our treatment included the administration of antibiotic drugs (CLDM, PIPC, and ABPC/SBT) and IVIg, dialysis, and respiratory management. 

If more information is needed, I am willing to give. Thank you!  

Nobuhiro

Dr.Takeuchi,

Thank you for the answer above. Unfortunately, you did not provide the square of the skin lesions.

A dermatitis and/or eczema, taken in mind their chronicity, seem to be sufficient ground for the coagulase-negative Staph. to overgrow on the skin lesions and to become the reason for sepsis to develop. It is just a speculation, of course. However, the count exceeded 10 5 CFU/mm2 is considered to be sufficient for expansion.

Dr. Borodach,

Thanks for valuable comments as usual!

I am sorry that I did not take the picture. Her skin lesions are limited to her back of the hands, between the fingers, and a part of her lower legs. 

It is hard to understand that coagulase-negative Staph. may cause bacteremia in this healthy female. I have to delve into this case. 

Thanks for your kind help!

Nobuhiro

Dr.Takeuchi,

The point is seemingly that that the lady is not, or at least was not, a healthy person. May I ask, what kinds of medicins did/does she use to treat her hands' and legs' lesions?

Thanks for your answers,

Andrey

Dr. Borodach,

I appreciate your concern for this medical case.

As far as I know,  she denied having used skin ointments and taking drugs (She left the skin lesions untreated without seeing a doctor). 

I have to delve into this case furthermore. Thanks again for your kind help!

Nobuhiro

Dr.Takeuchi,

What is about Cat Scratch Disease (CSD)?

I know about investigations of prof. Soichi Maruyama about wide spread of Bartonellosis among domestic cats in Japan.

Bartonella quintana is agent of infection disease with similar symptoms: “high fever and conscious disturbance”.  Staphylococcus epidermidis in your case can be of agent limphoadenoiditis (superinection). It is not so rare in CSD cases.

Alexander

Dear Alexander,

Thank you for a kind reply!

I totally missed that infectious disease.  Now her condition is developed and there is no chance to examine her blood sample. 

Next time I see the same kind of a patient with high fever, conscious disturbance, and scratched wounds, I keep in my mind that CSD can be the differential diagnosis.

Nobuhiro