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Introduction

Erythema Multiforme

Minor

Social: Home situation lives with mother and father

  • Sibling: None patient currently stays at home with his mother. Patient is exposed to 1 dog that stays inside of the house, no passive smoke exposure. Smoke detector present in home. No gun present in the home sunscreen is used routinely.Patient brushes her teeth once daily and sees the dentist once a year.
  • Patient passed his newborn hearing test.
  • Vaccinations: Current
  • CC: Skin Rash after taking amoxicillin for ear infection

  • HPI: 20 month old white male in the clinic with his mother due to skin rash. The patient’s mother states the he broke out in a rash yesterday after he started medication for ear infection. The mother took him to urgent care that evening when the rash started to spread. She was told to give him Benadryl and apply calamine lotion but both are ineffective.
  • The red rash started on abdomen and spread to both arms and legs a few hours later. The mother states she continued to give the medication for the otitis media. Patient has received 3 doses of the amoxicillin and Tylenol for his fever of 102.4 last night.
  • V/S: 2 ft 9.5 in Wt: 29 lbs 4 oz BP: 88/62 Pulse: 123 02 sat: 100 % Room Air RR: 20 T: 100 BMI 18.3
  • Allergies – NKDA
  • Medications – Amoxicillin 400mg/5 ml take 6 ml twice a day by oral route for 10 days. Patient started first dose of medication yesterday.
  • PMH: Candidiasis of mouth, Diaper Candidiasis, Hydrocele, Cradle Cap, Contact Dermatitis, Acute Dermatitis, Congenital blocked tear duct
  • Surgical: Excision of testicular lesion
  • FH: Paternal Grandmother: Malignant neoplastic disease
  • Mother: Hypothyroidism
  • Social: Home situation lives with mother and father

Physical Exam:

General Appearance: Patient is a 20 month old white male he is active and alert well-groomed and fussy at times.

HEENT:Eyes: Conjunctiva: non- injected and no exudate Red reflex noted

Ears: Tympanic membrane pearly with good landmarks. Nose: no crust/ sores or nasal discharge noted nares patent noted.

Tonsils: Slight erythema noted no exudate and not enlarged.

Neck: Supple and no lymphadenopathy

Cardio: Normal S1, S2 regular rate and rhythm no murmurs noted. Femoral pulse normal

Lungs: Clear to auscultation no wheezing rales crackles, tachypnea or rhonchi noted.

GU: Normal male genitalia with no lesions or discharge. GI: Normal bowel sounds x 4 quadrants no masses hernia or tenderness on palpation. No hepatomegaly or splenomegaly noted.

Lymph: no LAD in axillae or groin

Skin: No cyanosis, good turgor, and general warmth. Moisture: dry no petechiae noted. Patient + confluent hives/target lesions to upper and lower extremities and torso. No lesions to mucous membrane. No edema to hands, feet or eyes noted.

ROS: Patient mother reports fever but no significant weight change, good appetite, no fatigue. His mother reports itchy rash all over.

No eye pain, no blurry vision, no eye redness, no eye itchiness, no eye swelling or discharge.

Patient mother denies ear pain, hearing loss, sinus pressure, drooling and facial swelling.

Patient’s mother denies Sore throat, hoarseness, chest pain, abdominal pain, nausea, vomiting, or diarrhea.

Patient’s mother denies weakness, headache, dizziness, joint swelling, insomnia sneezing or running nose.

Clarice Adams

South University

Dr. Parrott

Nursing 6435

Urticaria

Differential

Diagnoses

EM Minor

EM Minor

Erythema Multiforme Overview

Urticaria is a vascular reaction of the skin marked by the transient appearance of smooth, slightly elevated papules or plaques (wheals) that are erythematous and that are often attended by severe pruritus

Diagnoses to consider when patient presents with mucocutaneous rash:

  • Characterized by abrupt onset of 1-3cm, oval or round, well-demarcated, flat macules with a dusky gray or bullous center.
  • Classic target lesions develop symmetrically and are heaviest peripherally; they often involve palms and soles.

  • Blistering is mild, if present at all, and involves less then 10% of BSA; Minimal mucous membrane involvement and affects no more than one mucosal surface.
  • Swelling of hands and feet
  • Fatigue
  • Fever
  • Prutitis
  • Painful oral lesions unusal
  • Eye discomfort

  • Urticaria
  • Stevens-Johnson Syndrome
  • Toxic Epidermal Necrolysis
  • Fixed drug eruption
  • Acute, immune-mediated condition characterized by target-like lesions on the skin. Acute hypersensitivity reactions characterized by cutaneous and mucosal lesions.

  • Many factors have been linked to the development of EM
  • Infections - viral, bacterial, fungal (90%)
  • Drugs - NSAIDs, sulfonamides, antiepileptics, and abx (<10%)
  • Numerous others - malignancy, autoimmune disease, immunizations, radiation, sarcoidosis.

Stevens-Johnson Syndrome

Stevens-Johnsons Syndrome

  • Severe, life-threatening, blistering hypersensitivity reaction; typically preceded by a febrile respiratory illness 1-14 days before onset of lesions

  • Involvement of at least two mucous membranes is required for diagnosis - upper/lower lip, erosions of the tongue and buccal mucosa, early bilateral conjuctival injection

  • Red macules and target-like lesions coalesce to large patches favoring the face and trunk. Lesions then progress to bullae and areas of necrosis involving 10-20% of BSA.

  • True medical emergency with 5-15% mortality

Toxic Epidermal Necrolysis

Toxic Epidermal Necrolysis

  • Severe, life-threatening condition characterized by extensive skin necrosis equivalent to a second-degree burn

Greater BSA involvement (>30%) and massive, sheetlike

  • Intraepidermal blistering leads to positive Nikolsky sign - demonstrates absence of adhesion between the skin

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Management

EM Minor - Pathogenesis

Evaluation and Diagnosis

Directed toward the severity of disease on presentation

More Severe/

Mucosal Involvement

Mild Disease

Conclusion

  • History and clinical exam crucial to diagnosis
  • Hx of HSV, M. pneumoniae, or other infections
  • New medications and systemic symptoms
  • Biopsy
  • PCR for HSV
  • Serologic tests for M. pneumonia
  • Erythrocyte sedimentation rate, white blood cell count
  • Proposed mechanism in setting of HSV infection: virus is phagocytosed by Langerhans cells which then travel to the epidermis and transfer viral DNA to epidermal keratinocytes.

  • Expression of HSV genes in the skin lead to recruitment of CD4+ Th1 cells that produce IFN-gamma in response to viral antigens

  • Release of IFN-gamma initiates inflammatory cascade which ultimately recruits autoreactive T-cells
  • Symptomatic relief

  • Topical corticosteroids

  • Oral antihistamines

  • Anesthetic mouthwash
  • Oral prednisone tapered over 2-4 weeks

  • Hospitalization possible for nutrition and pain control

  • Ocular involvement can lead to keratitis, scarring, or visual impairment - f/u w/opthomologist

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Guidelines

Prognosis

  • EM minor is self-limited and will usually resolve spontaneously with supportive care
  • Spontaneous healing usually occurrs in 10 to 14 days

  • Some patients develop recurrent disease. Identify and eliminate inciting agent. For patients with HSV-induced or idiopathic EM that recurs >6 times a year, consider continuous antiviral therapy (acyclovir)

Family Practice Guidelines

American Academy of Pediatrics

Diagnosis Clinically (Target Lesions)

Follow-Up

A. See the patient in office in 1 to 2 days to evaluate initial treatment.

Consultation/Referral

A. If patient has recurrent or chronic infection, refer him or her to a physician.

B. Immediate consultation and/or hospital admission is critical if SJS is suspected.

Individual Considerations

A. Pediatrics: Systemic corticosteroids may increase risk of infection and prolong healing. Use low- to mid-potency topical corticosteroids.

References

  • Cash, J., & Glass, C. (2014). Family Practice Guidelines. New York: Springer Publishing Co.
  • Catherine E. Burns, A. M. (2013). Pediatric Primary Care Fifth Edition. U.S.A: Saunders.
  • Currie GP, Plaza JA. (2014) Diseases of the skin. In: Bope ET, Kellerman RD, eds. Conn's Current Therapy 1st ed. Philadelphia, PA: Elsevier Saunders
  • Marcdante, Karen J, Robert Kliegman, Hal Jenson, and Richard Behrman. (2011)Nelson Essentials of Pediatrics. Philadelphia: W.B. Saunders Co, .
  • Noy Keller, M. O. (2015). Nonbullous Erythema Multiforme in Hospitalized Children: A 10-Year Survey. Pediatric Dermatology Vol. 32 , 701-703.
  • Vargas-hitos, J., Manzano-gamero, M., & Jiménez-alonso, J. (2014). Erythema multiforme associated with mycoplasma pneumoniae. Infection, 42(4), 797-8.
  • William Hay Jr., M. J. (2014). Current Diagnosis and Treatment Pediatrics. McGraw Hill Education.
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