CASE REPORT Journal of the College of Physicians and Surgeons Pakistan 2022, Vol. 32(03): 380-382 380 Scabies Surrepticius (Bullous Scabies) Presenting as Bullous Impetigo in a Child Rao Muhammad Abid Khan 1 , Asma Muzammil 2 , Sualleha Siddiqi 1 , Shazia Muhammad Qasim 3 and Ali Nadeem 1 1 Department of Microbiology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan 2 Department of Dermatology, Dr. Ruth K.M. Pfau Civil Hospital, Karachi, Pakistan 3 Department of Molecular Biology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan ABSTRACT Bullous scabies (BS) is a rare and atypical presentation of scabies, usually affecting elderly males during the seventh decade of life. BS is characterised by intense pruritic eruptions, nocturnal itch, and characteristic blisters with or without burrows in scabies-prone areas. The scabies lesions might predispose patients to bacterial super-infections, resulting in bullae formation similar to bullous impetigo. The diagnosis of BS is often puzzling and delayed. Few cases of BS have been reported among chil- dren globally. We, herein, report a case of BS in an eight-year boy from Pakistan, treated successfully with 5% topical perme- thrin and 2% mupirocin. Complete healing was noted within four weeks with no recurrence at two months follow-up. Key Words: Scabies, Bullous, Child, Diagnosis, Treatment. How to cite this article: Khan RMA, Muzammil A, Siddiqi S, Qasim SM, Nadeem A. Scabies Surrepticius (Bullous Scabies) Presenting as Bullous Impetigo in a Child. J Coll Physicians Surg Pak 2022; 32(03):380-382. INTRODUCTION Sarcoptes scabiei var. hominis, the causative agent of scabies, affects all races and social classes of mankind and is endemic among individuals living in overcrowded, unhygienic conditions, immigrants, immunocompromised and elderly population. 1 Several atypical variants of scabies such as bullous, crusted (Nor- wegian scabies), hidden, incognito, and nodular, have been described;andrecentlytheterm“scabiessurrepticius”wasintro- ducedforthesenon-classicpresentations . 2 Bullousscabies(BS)is a rare presentation characterised by blister formation with or without nocturnal itch, burrows, pruritic papules, and nodules. BS was first reported in 1974; and to date, less than 60 cases have been reported worldwide. 3 The first case of BS from Pakistan was reportedinayoungadultmalein2015. 4 Herein,wereportthefirst such case in a child under the age of ten years. CASEREPORT An 8 -year boy presented with numerous skin-colored, non-erythe- matous, mildly itchy, fluid-filled vesicles on palms, web-spaces, flexor surfaces of the wrists, fingers, and toes. He had one-month history of intense itching with nocturnal exacerbation, primarily affecting inter-digital spaces with a gradual decrease in itching and formation of bullae. Correspondence to: Dr. Rao Muhammad Abid Khan, Department of Microbiology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan E-mail: raoabid101@hotmail.com ..................................................... Received: January 02, 2020; Revised: February 12, 2020; Accepted: March 02, 2020 DOI: https://doi.org/10.29271/jcpsp.2022.03.380 There was no associated fever, history of allergies, drug-abuse, or involvement of other family members. He had poorly responded to the treatment with topical anti-bacterial and anti-- fungal agents. Cutaneous examination revealed two clear fluid- filled,non-tenderbullae,oneontherightpalmmeasuring20×18 mm (Figure 1A) and a smaller one on the left index finger measuring 22×10 mm (Figure 1B) along with numerous small to large bullae on other areas (Figures 2A and B). Figure 1: Large tense bullae (A) On right palm (B) On left index finger. The differential diagnosis included pompholyx, bullous impetigo, chronic bullous dermatosis of childhood, and BS. The skin scrapings from margins of the lesions on inter-digital spaces of hands were obtained. The fluid from bulla on the right palm was also collected for culture and wet mount preparation. Wet mount preparation was unrevealing; whereas, culture was positiveforstaphylococcusaureus.Thedirectmicroscopyofskin