Table of contents
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Toxic Epidermal Necrolysis
- Severe life-threatening skin eruption that is most commonly due to an adverse drug reaction. (i.e. classically septra)
- Symptoms:
- Prodrome: Fever, sore throat, burning sensation in eyes (1-3 days before skin lesions)
- Skin findings characterized by flat, atypical, purpuric, targetoid lesions that coalesce into dusky, poorly demarcated, confluent patches (TEN “with spots”)
- or may consist of confluent, tender erythema without identifiable individual lesions (TEN “without spots”).
- Involved skin blisters, sloughs, leaving behind denuded drmis.
- Physical exam:
- Nikolsky sign = Lateral pressure on erythematous skin shears off skin (present but not pathognomonic)
- Mucous membranes involved (not required for dx)
- Diagnosis:
- Skin biopsy --> for frozen section. (confirms dx in hours)
- Treatment:
- Do skin biopsy to confirm
- STOP causative medications (avoid unnecessary medications)
- Admit to Burn or ICU unit.
- Supportive care is mainstay
- wound care
- fluid/electrolyte management, nutrition
- monitor superinfections (do not prophylax)
- Do not use steroids (controversial) (some studies suggest worse morbidity/mortality)
DRESS
- Aka:
- Drug Hypersensitivity Syndrome (DHS)
- Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)
- Aka Drug-Induced Hypersensitivity Syndrome
- Appears 2-8w of starting new drug
- Pathophysiology
- Perhaps drug-triggered viral replication and a pronounced host antiviral response with widespread inflammation
- Triggers:
- Sulfonamide antibiotics
- Allopurinol
- Anticolvulsants
- Many Others!!!
- Symptoms:
- Fevers
- Widespread Morbilliform Eruption (often involving face)
- Facial Edema
- CBC abnormalities (eosinophilia or atypical lymphocytosis)
- Systemic Inflammation
- Lymphadenopathy
- Hepatitis
- Nephritis
- Pneumonitis
- Myocarditis
- Hypotension
- Evaluations:
- CBC+diff (eosinophilia or atypical lymphocytosis?)
- Liver Chemistry, Creatinine, Urinalysis
- Baseline echo (some experts suggest, given severity of myocarditis)
- Management:
- STOP Causative Medication
- Glucocorticoids - Systemic (1-2mg/kg tapered slowly over weeks-to-months)
- HIGH mortality, evaluate for DRESS/DHS any fever/rash after starting a high-risk medication (5% mortality)
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