Life threatening skin conditions

Question 1

fever and skin rash after new medication. CBC with eosinophilia.

Answer 1

DRESS syndrome

Question 2

DRESS is a

when does it start?

Answer 2

potentially life threatening drug reaction that happens 2-8 weeks after initial exposure

Question 3

which drugs cause DRESS?

Answer 3

anticonvulsants (phenytoin or carbamazepine), allopurinol and sulfonamides (sulfasalazine) and abx (minocycline and vancomycin)
acabavir (HIV NRTI)

Question 4

fever, generalized LAD, facial edema and diffuse morbilliform rash that can progress to confluent erythema and follicular accentuation

Answer 4

DRESS presentation

Question 5

DRESS rash

Answer 5

morbilliform rash that can progress to confluent erythema and follicular accentuation

can involve the mucosa (mouth and pharynx) and doesn’t cause erosions

Question 6

what other organ systems are affected in DRESS?

Answer 6

can see liver (hepatomegaly and jaundice)
Can see kidney (acute interstitial nephritis)
Can see lung (cough and dypsnea)

Question 7

labs of DRESS

Answer 7

see eosinophilia and atypical lymphocytes and elevated hepatic transaminases

Question 8

treatment of DRESS

Answer 8

stop offending drug and this resolution can take up to 6-9 weeks

Question 9

hypersensitivity vasculitis clinical presentation

Answer 9

fever, palpable purpura and petechiae, arthralgias, LAD and elevated ESR. Seen with anticonvulsants. NO esosinophilia

Question 10

Hypereosinophilic syndrome HES) is defined by

Answer 10

profound eosinophilia >1500 and multi system involvement (Heart, GI, lungs, brain, skin, kidneys) without a identifiable cause.

Question 11

what is serum sickness like syndrome

Answer 11

seen after exposure to new drugs (antiseizure drugs, antibiotics, and infections (hep B or strep)

Can cause systemic symptoms arthralgias, and urticarial or serpiginous macular rash. This happens within 1-2 weeks after drug exposure and NO eosinophilia

Question 12

Steven Johnson syndrome

Answer 12

triggered by new medications and seen with sudden onset of mucocutaneous lesions with subsequent necrosis and sloughing of of skin. NO eosinophilia or elevation in LFTs.

Question 13

Staph toxic shock syndrome risk factors are:

Answer 13

tampon use,
nasal packing,

surgical/post partum wound infection

Question 14

what causes staph toxic shock syndrome?

Answer 14

staph aureus

exotoxin release acting as superantigens

Question 15

what are clinical features of staph toxic shock syndrome?

Answer 15

fever >102 or 38.9
hypotension
diffuse macular rash involving the palms and soles
desquamation 1-3 weeks after disease onset
vomiting and diarrhea
altered mental status without focal neurological signs

Question 16

treatment of Staph toxic shock syndrome?

Answer 16

supportive care (IVF replacement)
removal of foreign body (Tampon or nasal packing)
antibody therapy (clindamycin and vancomycin

Question 17

pt has progressive lethargy and confusion and has shaking chills and diarrhea. Had nasal packing for a nose fracture. Has fever and hypotension and tachycardia and ill. Has diffuse erythema of mucous membranes and skin and palms and soles and pitting edema of both legs

Answer 17

staph toxic shock syndrome

treat with clindamycin and vacomycin

remove nasal packing.

Question 18

desquamating rash, multiorgan failure and hypotension and diffuse erythroderma and encephalopathy

Answer 18

staph toxic shock syndrome

encephalopathy occurs due to cerebral edema.

Question 19

are there positive blood cultures in toxic shock syndrome?

Answer 19

no but should still get them if someone is septic shock

generally can culture at the infection source.

Question 20

why do we use clindamycin and vancomycin for staph toxic shock syndrome?

Answer 20

because clindamycin - helps stop /inhibits toxin production

Question 21

after recovery what is long term management for toxic shock syndrome from nasal packing?

Answer 21

eradication of S aureus with mupirocin

Question 22

what staph bacteria causes toxic shock syndrome?

Answer 22

group A strep.

Question 23

when to use vancomycin and cefepime to treat someone after a fight?

Answer 23

only use this if there’s a basal skull fracture during the fight and they develop meningitis.

Question 24

Side effects of bactrim

Answer 24

skin - Steven Johnson syndrome, TEN (toxic epidermal necrolysis) exfoliative dermatitis- seen up to 15% in HIV positive pts

Hematological: megaloblastic pancytopenia (folate deficiency)

Renal: hyperkalemia, impairs tubular secretion of Cr without affecting GFR
see crystalluria
interstitial nephritis

Question 25

difference between SJS and TEN?

Answer 25

<10% body surface area: Steven johnson syndrome
10-30% of BSA: SJS/TEN overlap
>30% of BSA: TEN

Question 26

clinical features of Steven Johnson syndrome:

Answer 26

4-28 days after exposure to trigger (2 days after repeat exposure)
acute influenzae like prodrome
rapid onset of erythematous macules, vesicles, bullae
necrosis and sloughing of epidermis
mucosal involvement

Question 27

Common triggers for Steven Johnson syndrome and TEN

Answer 27

drugs: 
allopurinol
antibiotics like bactrim or sulfonamides
anticonvulsants: carbamazepine, lamotrigene, phenytoin
NSAIDS: piroxicam
sulfasalazine

Question 28

what other common triggers can cause Steven Johnson and TEN?

Answer 28

mycoplasma pneumoniae
vaccination
Graft vs host dx

Question 29

which population of people is most vulnerable to developing Steven Johnson syndrome from antibiotics or common triggers?

Answer 29

HIV positive pts

3X more common

Question 30

initial prodrome of fever and influenza symptoms with new onset of painful red or purple macules. Skin lesions then progress to bullae formation and necrosis and sloughing

Answer 30

presentation of SJS

Can see mucosal lesions - ocular, oral, genital and respiratory surfaces

Question 31

What kills most people with SJS and TEN

Answer 31

secondary infection

Question 32

management of SJS?

Answer 32

need to be managed in hospital setting in ICU burn unit

all suspected or unnecessary medications should be immediately discontinued as prognosis of SJS or TEN improves with early removal of causative medications

Tx is supportive and wound care. Consider steroids nad IVIG in severe cases.

Question 33

pt takes bactrim for sinusitis. 5 days later states she has improved but has redness and “blisters” on her arms?

Answer 33

send to the hospital and stop bactrim immediately.

Concern for SJS

Question 34

fever, rash, LAD, and eosinophilia and elevated LFTs after starting a medication like phenytoin, carbamazepine or phenobarbital

Answer 34

anticonvulsant hypersensitivity reaction

subtype of DRESS but has a mortality rate of 10%

Question 35

anticonvulsant hypersensitivity reaction presents how long after starting a new drug?

Answer 35

seen up to 2 months after starting and see fever, rash, pharyngitis and LAD, and facial edema and can have hepatitis or nephritis

Question 36

anticonvulsant hypersensitivity reaction labs:

Answer 36

eosinophilia and anemia

can have megaloblastic anemia, hepatitis, and rhabdomyolysis

Question 37

anticonvulsant hypersensitivity reaction can be caused by

Answer 37

phenytoin, lamotrigene, allopurinol carbamazepine phenobarbital, ACEi, antidepressants, and beta blockers.

Question 38

Medications that need genetic testing prior to starting:

Answer 38

allopurinol in asians
oxcarbamazepine in asians
acabavir in HIV pts

Question 39

Rule of Nine’s for Total body surface area:

Answer 39

each lower extremity represents 18% TBSA
each upper extremity represents 9% TBSA
anterior and posterior trunk each represent 18% TBSA
head represents 9% TBSA

Question 40

necrotizing dermatitis differential

Answer 40

zinc deficiency on TPN
allopurinol toxicity
glucagonoma