Episode 162.0 – Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
Core EM - Emergency Medicine Podcast
English - May 06, 2019 13:07 - 9 minutes - 13.6 MB - ★★★★★ - 128 ratingsMedicine Health & Fitness Homepage Download Apple Podcasts Google Podcasts Overcast Castro Pocket Casts RSS feed
A look at this deadly mucocutaneous reaction and how to best manage these patients in the ED
https://media.blubrry.com/coreem/content.blubrry.com/coreem/SJS.mp3
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Tags: Critical Care, Dermatology
Show Notes
Episode Produced by Audrey Bree Tse, MD
Rash with dysuria should raise concern for SJS with associated urethritis
Dysuria present in a majority of cases
SJS is a mucocutaneous reaction caused by Type IV hypersensitivity
Cytotoxic t-lymphocytes apoptose keratinocytes → blistering, bullae formation, and sloughing of the detached skin
Disease spectrum
SJS = <10% TBSA
TEN = >30% TBSA
SJS/ TEN Overlap = 10-30% TBSA
Incidence is estimated at around 9 per 1 million people in the US
Mortality is 10% for SJS and 30-50% for TEN
Mainly 2/2 sepsis and end organ dysfunction.
SJS can occur even without a precipitating medication
Infection can set it off especially in patients with risk factors including HIV, lupus, underlying malignancy, and genetic factors
SATAN for the most common drugs
Sulfa, Allopurinol, Tetracyclines, Anticonvulsants, and NSAIDS
Anti-epileptics include carbamazepine, lamictal, phenobarb, and phenytoin
Can have a curious course
Hypersensitivity reaction can develop while taking medication, or even one to four weeks after exposure
In pediatric population, mycoplasma pneumonia and herpes simplex have been identified as precipitating infections
Patients often have a prodrome 1-3 days prior to the skin lesions appearing
A look at this deadly mucocutaneous reaction and how to best manage these patients in the ED
https://media.blubrry.com/coreem/content.blubrry.com/coreem/SJS.mp3
Download
Leave a Comment
Tags: Critical Care, Dermatology
Show Notes
Episode Produced by Audrey Bree Tse, MD
Rash with dysuria should raise concern for SJS with associated urethritis
Dysuria present in a majority of cases
SJS is a mucocutaneous reaction caused by Type IV hypersensitivity
Cytotoxic t-lymphocytes apoptose keratinocytes → blistering, bullae formation, and sloughing of the detached skin
Disease spectrum
SJS = <10% TBSA
TEN = >30% TBSA
SJS/ TEN Overlap = 10-30% TBSA
Incidence is estimated at around 9 per 1 million people in the US
Mortality is 10% for SJS and 30-50% for TEN
Mainly 2/2 sepsis and end organ dysfunction.
SJS can occur even without a precipitating medication
Infection can set it off especially in patients with risk factors including HIV, lupus, underlying malignancy, and genetic factors
SATAN for the most common drugs
Sulfa, Allopurinol, Tetracyclines, Anticonvulsants, and NSAIDS
Anti-epileptics include carbamazepine, lamictal, phenobarb, and phenytoin
Can have a curious course
Hypersensitivity reaction can develop while taking medication, or even one to four weeks after exposure
In pediatric population, mycoplasma pneumonia and herpes simplex have been identified as precipitating infections
Patients often have a prodrome 1-3 days prior to the skin lesions appearing
May complain of fever, myalgias, headaches, URI symptoms, and malaise
Rash may be the sole complaint
Starts as dark purple or erythematous lesions with purpuric centers that progress to bullae
Skin surrounding the lesions detaches from the dermis with just light pressure (Nikolsky Sign)
Up to 95% of patients will have mucous membrane lesions
~85% will have conjunctival lesions
Symptoms: Burning or itching eyes, a cough or sore throat, pain with eating, pain with urinating or defecating
Differential Diagnosis: SSSS, autoimmune bullous diseases, bullous fixed drug eruption, erythema multiforme, thermal burns, phototoxic reactions, and TSS
SJS is a clinical diagnosis
Basic workup: CBC, chemistry panel, LFTs, and a UA
Treatment
Supportive care
IV fluid repletion guided by TBSA affected, as well as electrolyte, protein, and energy supplementation
Consider protecting airway if significant oral mucosal involvement
Stop the offending agent (if there is one)
Advanced wound care and pain control
Consults: Derm to do a biopsy, +/- ophthalmology, gyn / urology to prevent strictures or contractures
Consider transferring to a burn center
Dispo:
Low threshold for ICU admission
SCORTEN ( max of 7 points)
1 point each for
Age over 40
Current cancer
>30% body surface area affected
HR >120
BUN >28
Glucose >240
Bicarb <20
Score of 2 points or higher should -> ICU
Take Home Points
SJS may begin like the flu, with lesions appearing 1-3 days after the prodrome starts
Have to have a high suspicion for SJS because it is deadly. It’s a clinical diagnosis — derm biopsy is supportive
A thorough history and physical exam are key. Remember the characteristic rash and bullae, and always look in the mouth and eyes. Ask about dysuria, sore throat, and eye irritation, as well as preceding medications or infections. Think SATAN!
Prompt supportive care focused on ABCs and IVF repletion are critical. These patients can get sick really fast, so consider an ICU or burn unit.
References:
Barrett W. Quick Consult: Symptoms: Rash, Dysuria, and Mouth Sores. Emergency Medicine News. 41(4): 15-16, April 2019.
Bivins H, Comes J. Stevens-Johnson Syndrome. Rosen and Barkin’s 5-Minute Emergency Medicine Consult. 2015; 1076-1077.
Ergen EN, Hughey LC. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. JAMA Dermatol.2017;153(12):1344. doi:10.1001/jamadermatol.2017.3957
Gerull R, Nelle M, Schaible T. Toxic epidermal necrolysis and Stevens-Johnson syndrome: A review. Crit Care Med. 2011; 39:1521-1532.
Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Current Perspectives on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Clin Rev Allergy Immunol. 2018;54(1):147-76.
McNeil, D. (2019). Measles Cases Surpass 700 as Outbreak Continues Unabated. [online] Nytimes.com. Available at: https://www.nytimes.com/2019/04/29/health/measles-outbreak-cdc.html [Accessed 6 May 2019].
Mustafa SS, Ostrov D, Yerly D. Severe Cutaneous Adverse Drug Reactions: Presentation, Risk Factors, and Management. Curr Allergy Asthma Rep. 2018;18(4):26.
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