Approach to the acute, generalized, blistering patient

Acute blistering diseases on the burn ward: Beyond Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

OBJECTIVE

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis are on a spectrum of rare reactions primarily attributable to drugs. Timely diagnosis, cessation of the offending drug and burn center care are associated with favorable outcomes. Acute blistering disease has a wide differential diagnosis, including autoimmune bullous disease and other drug reactions. The aim of our study was to identify the final diagnosis in patients transferred for widespread blistering disease and to identify clinical features at admission predicting final diagnosis.

METHODS

We performed a 5-year retrospective chart review (2006-2011) of the clinical features at admission of patients transferred to a burn ward with widespread blistering disease. Clinical features at admission were compared between patients.

RESULTS

12 patients had a final diagnosis of Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis and 7 patients had an alternative final diagnosis. Skin detachment surface area at admission was superior in the Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis group. Presence of tense bullae and pustules was associated with an alternative final diagnosis.

CONCLUSION

Extensive skin detachment surface and morphological features (tense bullae, pustules) were statistically significant clinical clues to final diagnosis. Patients transferred for widespread blistering disease should be thoroughly evaluated in order to exclude other causes of acute blistering disease.

Definitions and mechanisms of drug hypersensitivity

Adverse drug reactions are a difficult problem faced by clinicians in everyday practice. The mechanisms of drug hypersensitivity are not well understood. This is reflected by difficulties in their classification, which is mainly based upon the current knowledge of immunologic and nonimmunologic mechanisms, onset of symptoms (immediate or nonimmediate) and morphology. For the individual patient, the correct diagnosis and classification is important because strict avoidance of the offending drug might be of vital importance. Considerable experience is required to guide management, to interpret results of investigations and to undertake drug challenges. This article summarizes the current knowledge regarding definitions and mechanisms. However, the field of drug hypersensitivity is rapidly expanding. Modern drugs such as biological agents bare hypersensitivity risks that are potentially mediated by, so far, unknown mechanisms.

Paraneoplastic pemphigus in a burn intensive care unit: case report and review of the literature

Paraneoplastic pemphigus is a rare cause of acute diffuse blistering in the adult patient. It commonly presents with subepidermal blistering, epidermal necrosis, and symptoms of mucosal irritation, such as conjunctivitis and vaginal ulceration. Because of its rarity, it is frequently misdiagnosed as Stevens-Johnson syndrome or toxic epidermal necrolysis. In this study, the authors will describe clinical and histologic manifestations of paraneoplastic pemphigus. This case report describes a 45-year-old woman with paraneoplastic pemphigus who was admitted and treated in a burn intensive care unit. Although initially diagnosed with Stevens-Johnson syndrome, the patient had progression of desquamation when potentially offending medications were discontinued. Diffuse adenopathy was noted on examination, and biopsy confirmed a low-grade lymphoma. Paraneoplastic pemphigus is a rare but important cause of acute diffuse blistering in adults. This disorder should be considered in the differential diagnosis of patients with diffuse blistering.