# Staphylococcal Scalded Skin Syndrome (SSSS) in a Preterm Infant: Clinical Presentation and Role of Next-Generation Sequencing in Toxin Gene Identification—A Case Report

## TL;DR

A preterm infant developed a severe skin condition caused by a toxin-producing Staphylococcus aureus strain, and next-generation sequencing helped identify the specific toxins and guide treatment.

## Contribution

The study highlights the role of next-generation sequencing in identifying dual exfoliative toxin genes in a neonatal SSSS case.

## Key findings

- Whole-genome sequencing identified an ST121 S. aureus strain carrying both eta and etb genes.
- The infant responded well to targeted antibiotic therapy after catheter removal.
- A subsequent nasal swab revealed an asymptomatic MRSA strain lacking exfoliative toxins.

## Abstract

Staphylococcal scalded skin syndrome (SSSS) is a rare, toxin-mediated dermatosis caused by exfoliative toxin–producing Staphylococcus aureus strains, with neonates and preterm infants being particularly vulnerable due to immature immunity and reduced toxin clearance. We report the case of a male preterm infant, born at 24 weeks of gestation, who presented at the age of one month with fever and later developed widespread erythema, flaccid bullae, and periorificial desquamation. Methicillin-sensitive S. aureus (MSSA) was isolated from blood, catheter, and auricular swabs. Whole-genome sequencing revealed sequence type ST121 carrying both eta and etb genes, confirming the dual-toxin profile associated with severe disease. The infant improved with targeted intravenous oxacillin following catheter removal. A subsequent nasal swab identified a methicillin-resistant S. aureus (MRSA) ST30 strain lacking exfoliative toxins, consistent with asymptomatic colonization. This case underscores the importance of integrating advanced molecular diagnostics such as next-generation sequencing into the management of neonatal SSSS, enabling precise identification of virulence factors and resistance genes. Literature also highlights the global epidemiology of SSSS, diversity of S. aureus toxin genes, and value of genomic surveillance in neonatal care; our case aligns with reports of ST121 strains carrying both ETA and ETB, where the dual-toxin profile drives rapid onset, extensive skin disease, and good outcomes with prompt therapy.