Dermatological emergencies : Stevens-Johnson Syndrome

stevens johnson syndrome

Every medical student has three categories of topic division

Category 3 catches you by surprise when it makes it an entry in the ED and serves as a reminder of why it is essential always to know something about everything. Stevens-Johnson Syndrome was one of those for me. Although rare, dermatological emergencies are essential to spot and can be life-threatening if left untreated.

Stevens-Johnsons Syndrome is a rare type 4 hypersensitivity reaction which affects <10% of body surface area. It is described as a sheet-like skin loss and ulceration (separation of the epidermis from the dermis).

Toxic epidermal necrosis and Stevens-Johnsons Syndrome can be mixed. However, distinguishing between both disease can be done by looking at % of body surface area involvement.

  • < 10% BSA = Stevens-Johnsons Syndrome
  • 10-30% BSA = Stevens-Johnsons Syndrome/Toxic epidermal necrosis overlap syndrome
  • > 30%= Toxic epidermal necrosis – above image is an example of toxic epidermal necrosis.

Pathophysiology is unknown

Pathophysiology is not clearly known; however, some studies show it is due to T cells’ cytotoxic mechanism and altered drug metabolism.

Causes

The most common cause of Stevens-Johnsons Syndrome is medications. Examples are allopurinol, anticonvulsants, sulfonamide, antiviral drugs, NSAIDs, salicylates, sertraline and imidazole.

As one of the commonest cause is drug-induced, it is a vital part of history taking. Ask direct and indirect questions regarding drug intake, any new (started within 8 weeks) or old medications and previous reactions if any.

Other causes are malignancy and infections (Mycoplasma pneumonia, Cytomegalovirus infections, Herpesvirus, Hep A).

Risk Factors

The disease is more common in women and immunocompromised patients (HIV, SLE)

Clinical Presentations

  • Flu-like symptoms(1-14 symptoms)
  • Painful rash which starts on the trunk and spreads to the face and extremities.
  • Irritation in eyes
  • Mouth ulcers or soreness

Clinical Exam Findings

  • Skin manifestation – Starts as a Macular rash that turns into blisters and desquamation.
  • An important sign in SJS is Nikolsky’s sign: It is considered positive if rubbing the skin gently causes desquamation.
  • 2 types of mucosa are involved in SJS – oral and conjunctiva, which precede skin lesions.
  • Other findings in the examination may include –
  • Oral cavity – ulcers, erythema and blisters
  • Cornea – ulceration

Diseases with a similar presentation – in children, staphylococcal scalded skin syndrome can be suspected as it has a similar presentation and can be differentiated with the help of a skin biopsy.

Diagnosis

Clinical awareness and suspicion is the cornerstone step for diagnosis. Skin Biopsy shows subepidermal bullae, epidermal necrosis, perivascular lymphocytic infiltration, which help for definitive diagnosis.

Management

Adequate fluid resuscitation, pain management and monitoring of electrolytes and vital signs, basic supportive or resuscitative actions are essential, as with any emergency management.

The next step is admitting the patient to the burn-unit or ICU, arranging an urgent referral to dermatology and stopping any offending medications. If any eye symptoms are present, an ophthalmology referral is required.

Wound management is essential- debridement, ointments, topical antibiotics are commonly used to prevent bacterial infections and ease the symptoms.

Complications

  • Liver, renal and cardiac failure
  • Dehydration
  • Hypovolemic or septic shock
  • Superimposed infection
  • Sepsis
  • Disseminated intravascular coagulation
  • Thromboembolism
  • Can lead to death if left untreated

Prognosis

Prognosis of a patient with Stevens-Johnson Syndrome is assesed by the SCORTEN Mortality Assesment Tool. Each item equal to one point and it is used within the 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 the above total:

  • 0-1 Point = 3.2%
  • 2 Points = 12.1%
  • 3 Points = 35.3%
  • 4 Points = 58.3%
  • 5 Points = 90.0%

References and Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Dermatological emergencies : Stevens-Johnson Syndrome," in International Emergency Medicine Education Project, February 15, 2021, https://iem-student.org/2021/02/15/stevens-johnson-syndrome/, date accessed: May 9, 2021

Recent Blog Posts by Sumaiya Hafiz

Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol US Imaging – Illustrations

Patients with hypotension or shock have high mortality rates, and traditional physical exam techniques can be misleading. Diagnosis and initial care must be accurate and prompt to optimize patient care. Ultrasound is ideal for evaluating critically ill patients in shock, and ACEP guidelines now delineate a new category of ultrasound (US)– “resuscitative.” Bedside US allows for direct visualization of pathology and differentiation of shock states (1). The RUSH is one of the most commonly used protocols for this purpose.

The RUSH exam involves a 3-part bedside physiologic assessment simplified as “the pump,” “the tank,” and “the pipes” (2).

Pump

Tank

Rush Tank

Pipes

References and Further Reading

  1. By Organ System or Specialty Archives | Page 84 of 123 | ALiEM. https://www.aliem.com/category/emergency-medicine-clinical/system/page/84/
  2. Seif D1, Perera PMailhot TRiley DMandavia D. “Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol” Crit Care Res Pract. 2012;2012:503254.
  3. https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/
  4. https://iem-student.org/rush/
  5. https://iem-student.org/efast/
Cite this article as: Murat Yazici, Turkey, "Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol US Imaging – Illustrations," in International Emergency Medicine Education Project, May 29, 2020, https://iem-student.org/2020/05/29/rush-protocol-illustrations/, date accessed: May 9, 2021

Lower Extremity Deep Venous US Imaging – Illustrations

lower extremity us illustrations

Ultrasound evaluation for deep venous thrombosis (DVT) is one of the 11 core ultrasound applications for emergency physicians as listed in the 2008 American College of Emergency Physicians guidelines (1). Because ultrasound applications started to be implemented into medical school curriculum in many countries, learning basic ultrasound applications as early as possible will benefit medical students and junior residents. In this post, I will share lower extremity venous ultrasound illustrations with you. 

Indications

The clinical indications for performing a lower venous ultrasound examination is the suspicion of a lower extremity DVT in a swollen or discoloured leg. 

Transducer

Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.

lower extremity venous ultrasound - linear transducer

Remember Risk Factors of DVT

Wells Score for Deep Vein Thrombosis

CriteriaScore
Active cancer(treatment ongoing or within previous 6 months or palliative treatment)
1
Paralysis, paresis, or recent plaster immobilization or of the lower extremities1
Recently bedridden for 3 days or more or major surgery within the previous 12 weeks requiring general or regional anesthesia1
Localized tenderness along the distribution of the deep venous system1
Entire leg swollen1
Calf swelling > 3cm compared to asymptomatic leg (measuring 10 cm below tibial tuberosity)1
Pitting edema confined to the symptomatic leg1
Non varicose collateral superficial veins1
Previously documented DVT1
Alternative diagnosis at least as likely as DVT1
DVT evaluation algorithm
Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.
sectional anatomy of lower extremity veins

Normal DVT Ultrasound Findings

normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings

Reference and Further Reading

  1. American College of Emergency Physicians. Emergency ultrasound guidelines 2008. http://www.acep.org/WorkArea/DownloadAsset.aspx?ID=32878. February 2012.

Note: Visual drawings are inspired by the Point-of-Care ULTRASOUND Book.

Cite this article as: Murat Yazici, Turkey, "Lower Extremity Deep Venous US Imaging – Illustrations," in International Emergency Medicine Education Project, February 14, 2020, https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/, date accessed: May 9, 2021

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Hepatobiliary US Imaging – Illustrations

hepatobiliary ultrasound

Anatomy Of The Hepatobiliary System

Anatomy of the hepatobiliary system

Indications

Indications for clinicians to perform point-of-care hepatobiliary ultrasound include the evaluation of; abdominal pain, jaundice, sepsis and ascites.

Transducer

The most commonly used positions include; left lateral decubitus and supine position. A low-to medium-frequency (2–5 MHz) curvilinear ultrasound transducer will suffice for most ultrasound examinations of the gallbladder.

curvilinear transducer

Patient positioning

Patient positioning plays a vital role in the hepatobiliary ultrasound examination. Transducer position according to gallbladder; longitudinal and transverse.

Focus Points on Hepatobilary Ultrasound

focus points hepatobilary ultrasound

Patient Position and Transducer Position

Patient Position and Transducer Position​
Patient Position and Transducer Position​

Normal Hepatobiliary Ultrasound Findings

Normal Hepatobiliary Ultrasound Findings​

Pathological Hepatobiliary Ultrasound Findings

Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
Cite this article as: Murat Yazici, Turkey, "Hepatobiliary US Imaging – Illustrations," in International Emergency Medicine Education Project, November 27, 2019, https://iem-student.org/2019/11/27/hepatobiliary-us-imaging-illustrations/, date accessed: May 9, 2021

Thank you! – Clinical Image Archive Reached 28.000 views

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Diagnostic Testing

Diagnostic Testing In Emergency Medicine chapter written by Yusuf Ali Altunci from Turkey is just uploaded to the Website!

Clinical Images and Videos on Flickr reached 19.6K views

Dear medical students/interns/PGY1s and educators, we upload regularly clinical, imaging pictures and videos to our Flickr channel. Currently, 652 images and videos are in the channel, and all are free to download and use for education purposes. You can search what you need. We have 447 searchable medical tags so far. You can also view specific albums which consist of organ system or anatomic region images/videos. Please share this FOAMed resource with your peers and colleagues.

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iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

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