CASE 䉴 A 21-year-old woman sought care the second ED discontinued the Bactrim, start-
at our emergency department (ED) for an ed her on a course of steroids by mouth, and
extensive rash that began approximately sent her home.
1 week earlier and hurt “like a sunburn.” She On this particular morning, she woke up
said that 2 weeks earlier, she’d been seen at an- feeling that her mouth was burning and her
other hospital for an incision and drainage of a throat was “closing up.” She was admitted to
thigh abscess. She was started on sulfamethox- our intensive care unit (ICU) for monitoring of
azole/trimethoprim (Bactrim) at that time. respiratory compromise related to angioede-
She returned to that ED several times, ma. She did not require intubation, but her
complaining of headache and fever, then skin began to desquamate.
went to a different ED because her lips
were swollen and she was developing a rash
(FIGURES 1A AND 1B ). Initially the rash was red, ● WHAT IS THE MOST LIKELY
slightly rough, and covered most of her body EXPLANATION FOR HER
(except for her palms and soles). Providers at CONDITION?
FIGURE 1
This 21-year-old patient had swollen lips and a rash that hurt “like a sunburn.” She said that when she woke up that morning, her mouth
was burning and her throat felt like it was “closing up.”
did not have mucosal involvement early on. Discontinuing the causative agent is the
Further complicating matters: She went to first step in treatment. In our patient’s case,
multiple EDs. Bactrim had been discontinued before she
came to our ED. The next step, ideally, is to
Labwork is of limited value transfer the patient to a burn unit where she
No laboratory values or pathologic tests can receive the same type of supportive care
are pathognomonic for SJS/TEN. Anemia burn victims require. Diligent wound care,
and lymphopenia are possible findings, fluid replacement, electrolyte monitoring,
and neutropenia is an indicator for a poor and raised ambient temperature are vital ele-
prognosis.8 Elevated liver enzymes are ments in proper care. The patient should also
common, reaching levels approximately be evaluated throughout the treatment pe-
2 to 3 times the upper limit of normal.8 riod for any ocular involvement, such as con-
All of these laboratory findings become junctivitis, keratitis, or severe dryness.10
increasingly more likely as BSA involved As is the case with burn victims, the ma-
increases.8 Our patient’s laboratory values jor risks are secondary infection and sepsis.
were unremarkable. Skin, blood, and access-line cultures should
be gathered throughout the hospitalization
to evaluate for infection. Some authorities
Tx: Discontinue drug, replace fluids believe glucocorticoids are helpful in chil-
This syndrome is potentially deadly and must dren with SJS/TEN, but the adverse effects
be treated as an emergency as soon as it is are sufficiently significant that the risks
recognized. The mortality rate is 1% to 3% for may outweigh the benefits. In adults, the
SJS and 25% to 35% for TEN.9 evidence favors the use of glucocorticoids in
xcellence
of E
Years
A PEER-REVIEWED JOURNAL
Nurse Practitioners and Physician Assistants up-to-date in clinical ing and scholarly activities has
driven many of us to pursue
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h h
testing, antiviral therapy,
I
f the golden rule of medi- for Healthcare Epidemiology of
CME/CE article
see Family, page 2 >>
h
Intriguing NP thought leaders see Influenza, page 32
the rate of vaccination against
flu among health care person-
nel has been “unacceptably low,”
in the words of Neil Fishman,
MD, President of the Society
The organization recently pub-
lished a position paper in Infec- IN THIS ISSUE
tion Control and Hospital Epide- Your Turn . . . . . . . . . . . . . . . . 1
miology in which it “endorses a
policy in which annual influenza
ECG Challenge . . . . . . . . . . . . 6
vaccination is a condition of both Malpractice Chronicle. . . . . . 7
h
initial and continued [health care Grand Rounds . . . . . . . . . . . 13
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