To the Editor.—
We thank Dr. Elias for his timely comments. We agree that in our case it is difficult to define whether deficient cell-mediated immunity or the metabolic disturbances of uremia were responsible for the development of the staphylococcal scalded skin syndrome (SSSS). However, the suggestion that normal adults may develop SSSS is open to question. In the case reported by Rothenberg et al1 and quoted by Dr. Elias, the evidence for normal immunity is scant. Their 64-year-old patient had staphylococcal septicemia, was a chronic alcoholic, had hypoalbuminemia, had treated advanced syphilis, and an atonic bladder, with chronic urinary tract infections. Furthermore, Rothenberg et al did not investigate cell-mediated immunity beyond performing a single skin test. It is difficult to classify their patient as a "normal" adult.Although uremia had been present in both our patient and the first adult in the case reported by Levine and Norden,