Workshop: Fever and Rash

Question 1

Consider ___ ___ ___ ___(SCAR) when patients
present with fever and rash

Answer 1

Consider Severe Cutaneous Adverse Reactions (SCAR) when patients present with fever and rash

Question 3

different SCARS

Answer 3

morbiliform drug eruption

DRESS: drug reaction eosinophilia systemic symptoms

SJS/TEN

Question 4

T/F DRESS syndome is acute

Answer 4

false. it takes longer to occur, like 50-60 days.

Question 5

most important thing when suspecting a SCARS occurrence

Answer 5

stop the offending agent. If youa re considered a drug rash- STOP the culprit medications.

In this situation, the morphology of the rash is not as important but rather:
• Is the patient systemically well?

• Is there fever?
• ** Is there skin sloughing or necrosis, blistering?

Question 6

classic rash

Answer 6

urticaria-like raised patches… classic mubiliform rash

Question 7

classic rash

Answer 7

erythematous pin point papules that are coalescing into a white spread plaque. morbiliform rash.

Question 8

Answer 8

mobiliform rash coalescing into plaque

Question 9

what else might you want to know to help differneitate a mobiliform eruption from a SCAR?

Answer 9

fever/systemically well?

drug history chronology

SA involvemnet

family clinic or emergency

Question 10

most common of all medication-induced drug rashes. which part of the body does it NOT occur?

Answer 10

mobiliform or exanthematous drug eruption

• most common of all medication-induced drug rashed
• red macules and papules that often arise on the trunk and spread symmetrically to involve the proximal extremities

- palms, soles, and mucous membranes generally not a feature.

Question 11

how is this morphology different than a morbiliform rash?

Answer 11

it is more widespread plaque. facial involvement. this is a more extreme morbiliform picture– erythroderma or DRESS syndrome: Drug Reaction with Eosinophilia and Systemic Symptoms

erythroderma is not a diagnosis– it’s a descriptor for widespread erythematous rash

Question 12

which demographic is more associated with DRESS syndrome? what is a hall mark trait? what other systemic symptoms occur?

Answer 12

higher incidents in african, caribbean people

• 2-8 weeks after drug starting with SYSTEMIC FEVER AND RASH Athat starts on face, upper trunk
• EDEMA OF FACE is hallmark
• lymph nodes are enlarged and liver hepatitis is associated. there’s also systemic symptoms like myocardidits, interstitial pneumonitis, interstitial nephritis, thyroiditisi

Question 13

note:

Question 14

Answer 14

erythematous plaque with erosion centrally and impending necrosi. looks like TEN or SJS

Question 15

key sign of SJS or TEN

Answer 15

nicholsky’s sign; rolled up epidermis causing an erosion. there is extensive exfoliation of epidermis due to death of keratinocytes

Question 16

Answer 16

oral erosion and necorsis due to SJS/TEN

Question 17

note:

Question 18

which alleles have a higher chance of developing SJS or TEN

Answer 18

HLA alleles

• HLA alleles** have an awareness to check for this prior to starting
medications!
• HLA-B*1502 in Asians and East Indians with carbamazepine
• HLA-B*5801 in Han Chinese with allopurinol
• HLA-A*3101 Europeans with carbamazepine

Question 19

characteristic papule

Answer 19

target papule: three rings which can be seen in SJS or erythema multiforme (related to HSV)

Question 20

Answer 20

erythema multiforme (related to HSV)

Question 21

Answer 21

erythema multiforme (related to HSV)

Question 22

how is erythema multiforme different than other severe adverse cutaneous drug reactions?

Answer 22

on palms/soles

• clsasic mucositis
  3. classic target papules
• related to HSV

Question 23

erythema multiform major vs minor

Answer 23

• EM MINOR= target lesions with little or no mucosal involvement and no
systemic symptoms • EM MAJOR= papular target lesions with severe mucosal involvement and
systemic features

Question 24

T/F EM can progress to TEN

Answer 24

false.No risk to progress to TEN or SJS. EM almost always precedes HSV, whereas TEN and SJS is drug-induced often.

Question 25

a person presents with fever and rash with recurrent abscesses in the grown and axilla

Answer 25

hydradenitis suppurativa

• there are sinus tract scars.

Question 26

mechanism of hidradenitits suppurative:

Occlusion of follicle by ____ leads to accumulation of debris and ____ formation; ___ of ___ ____ allows introduction of its contents, including keratin and bacteria into surrounding dermis

Answer 26

Occlusion of follicle by hyperkeratosis leads to accumulation of debris and cyst formation; rupture of hair follicle allows introduction of its contents, including keratin and bacteria into surrounding dermis

Question 27

Answer 27

extreme Hidradenitis suppurativa

Question 28

SCAR:

_____: a morbilliform-like with systemic symtpoms and visceral involvement, facial swelling; late onset

_____: an epidermal necrosis with erosions and skin + MUCOSAL sloughing; needs ICU admission and close monitoring

___ ____: NOT a drug reaction but rather immune
response to HSV; popular target lesions on acral sites with mucositis

___ _____: inflammatory nodules, carbuncles,
abscesses in axillae and inguinal areas

Answer 28

DRESS: a morbilliform-like with systemic symtpoms and visceral involvement, facial swelling; late onset

SJS/TEN: an epidermal necrosis with erosions and skin + MUCOSAL sloughing; needs ICU admission and close monitoring

ERYTHEMA NODOSUM: NOT a drug reaction but rather immune response to HSV; popular target lesions on acral sites with mucositis

HYDRADENTITIS SUPPURTIVA: inflammatory nodules, carbuncles,
abscesses in axillae and inguinal areas