Difference between revisions of "Stevens-Johnson syndrome and toxic epidermal necrolysis"

(Clinical Features)
(DDx)
Line 29: Line 29:
 
*Examine eyes/mucosal surfaces
 
*Examine eyes/mucosal surfaces
  
==DDx==
+
==Differential Diagnosis==
*Erythema Multiforme
+
*[[Erythema Multiforme]]
*Staphlococcal scalded skin syndrome
+
*[[Staphlococcal scalded skin syndrome]]
*Erythroderma
+
*[[Erythroderma]]
*Toxic Shock Syndrome
+
*[[Toxic Shock Syndrome]]
*Drug eruption
+
[[*Drug eruption]]
  
 
==Treatment==
 
==Treatment==

Revision as of 13:30, 31 October 2014

Background

  • SJS and TEN exist on a spectrum of disease
    • SJS involves <10% of BSA
    • TEN involves >30% of BSA
  • Dermatologic emergency
  • Causes:
    • Drugs - many. Common offensive agents include: quinolones, sulfa, PCN, ASA, acetaminophen, carbamazepine, NSAIDs, phenytoin, corticosteroids, immunizations
    • Malignancy - lymphoma
    • Idiopathic
    • Infectious

Clinical Features

Stevens–Johnson syndrome
  • Often have prodrome (fever, URI symptoms, HA, malaise)
  • Macular rash
    • +/- Target lesions
    • Usually starts centrally, spreads peripherally, and may become confluent
    • May be painful
    • May have +Nikolsky sign (denude when touched)
  • Mucous membranes can be severely affected
    • Eye involvement can be severe
  • In severe cases, respiratory tract and GI involvement may occur

Work-Up

  • CBC
  • Chem
  • ESR
  • CXR
  • Examine eyes/mucosal surfaces

Differential Diagnosis

*Drug eruption

Treatment

  • Removal of inciting cause if identified
  • Fluid replacement - treat shock w/ IV fluids according to burn protocols
  • Infection control
  • Wound care
  • Use of IVIG, plasmapheresis, and corticosteroids are controversial but may be beneficial

Disposition

  • Admit to burn unit or ICU

Prognosis

Validated with SCORTEN mortality assessment:

One point for each of the following assessed within 1st 24 hours of admission:

  • Age >/= 40 years (OR 2.7)
  • Heart Rate >/= 120 beats per minute (OR 2.7)
  • Cancer/Hematologic malignancy (OR 4.4)
  • Body surface area on day 1  >10% (OR2.9)
  • Serum urea level (BUN) >28mg/dL (>10mmol/L) (OR 2.5)
  • Serum bicarbonate <20mmol/L (OR 4.3)
  • Serum glucose > 252mg/dL (>14mmol/L) (OR5.3)

Predicted mortality based on above total:

Score 0-1 (3.2%)

2  (12.1%)

3  (35.3%)

4  (58.3%)

5+  (90.0%)

Source

  • Tintinalli
  • Rosen's
  • UpToDate
  • Sylvie Bastuji-Garin, Nathalie Fouchard*, M Bertocchi*, Jean-Claude Roujeau*, Jean Revuz* and Pierre Wolkenstein. SCORTEN: A Severity-of-Illness Score for Toxic Epidermal Necrolysis. Journal of Investigative Dermatology (2000) 115, 149–153
  • Rob Cartotto, MD, FRCS(C), Mike Mayich, BSc, Duncan Nickerson, MD, FRCS(C), Manuel Gomez, MD, MSc. SCORTEN Accurately Predicts Mortality Among Toxic Epidermal Necrolysis Patients Treated in a Burn Center. J Burn Care Res 2008;29:141–146