TEACHING BANGSAL 8TH AUGUST 2014

Ms. S (Lontara 3 AB R4B1) / Toksik Epidermal Nekrolisis

First Condition 01/08/2014
A woman 40 years old came to Wahidin Sudirohusodo Hospital with main
complains of exfoliating skin, wound and pain which occur all over her body 3
weeks ago. She also complain fever and short of breath since 6 days ago. At first,
the patient complains of ear discharge which arises 1 month ago and went to Ear
Nose Throat department and received cefadroxil. After 3 days she took the
medicine, red spots started to appear all over the body and felt itchy. She was
admitted into the into the Gowa Hospital for 7 days but there was no
improvement. Thus, she ask to be discharge. She applied turmeric all over her
body and her skin start to exfoliate. Thus she came back to Gowa Hospital and
transferred to Wahidin Sudirohusodo Hospital.
Dermatovenerology status:
Location
: Regio Generalisata
Efflorescence
: Squama, erosion, crust, madidans
A : TEN
R/ - IVFD D5% : Nacl 0,9% : RL ( 1:1:1 ) 20 drops per minute
- Inj. dexamethasone 1amp/8h/iv ( 3:3:3 )
- Transfusion WB 750 cc/24 jam
- Kenalog in ora base ( for lips )
- O2 2 liter/minute
Last Condition 07-08-2014
6th days of Treatmment
S : Skin exfoliate entire body (+), lips wound (+), difficult to swallow, wound at
the abdomen (+).
P : Dermatovenerology status:
Location
: Regio Generalisata
Efflorescence
: squama, erosion, crust, madidans
A : TEN
R /- IVFD D5% : Nacl 0,9% : RL ( 1:1:1 ) 20 drop per minute
- Inj. dexamethasone 1amp/8h/iv ( 3:3:3 )
- Transfusion WB 750 cc/24 jam
- Kenalog in ora base ( for lips )

DISCUSSION
TOXIC EPIDERMAL NECROLYSIS
Definition
Toxic Epidermal Necrolysis (TEN) is an acute life-threatening mucocutaneus
reaction which characterized by mucous membrane erosion, necrolysis, and
extensive epidermal detachment. The difference between SJS and TEN is the
involvement of body surface area (BSA), < 10% BSA: SJS,10-30% BSA:
overlapping SJS-TEN, > 30% : TEN.
Epidemiology
SJS and TEN are very rare cases. Cases incidence of SJS : 1-6 cases per
million persons-years. Cases incidence of TEN : 0,4-1,2 cases per million
persons-years. Occurs at any ages, increasing risk : age after the 4th decade.
Women > Men.
Etiology
Primary cause is drugs, high risk drugs : sulfonamide antibacterial, aromatic
anticonvulsant, allopurinol, oxicam NSAID, lamotrigine, and nevirapine. Other
etiologies is Mycoplasma pneuomoniae infection, vaccination, graft-versus-host
disease, and radiation.
Clinical manifestasion
Patient can be have a prodromal symptoms ( 1-14 days) such as fever, sore
throat, chills, headache, malaise. The mucocutaneous lesions can occur macule
that develope into papules, vesicles, bullae, urticarial plaques, or confluent
erythema. Mucosal lesions such as hemorrhage and crust on lips, erosions in
mouth covered by necrotic white pseudomembrane, ulcerative stomatitis on
mouth, painful erosions can occur on genital and erosive conjunctivitis can occur
on eyes.
Diagnosis
History Taking : Non-specific symptom (1-3 days) can occur such as fever,
stinging eyes, pain upon swallowing headache, rhinitis, myalgia. Epidermal
necrolysis usually occur 8 weeks after drugs consumption. Initial lesion can be
erythema macula (body trunks, then spread to other body sites). Physical
Examination on skin can be found irregular-shaped erythema,
hyperpigmentations, purpuric macule, targetoid lesion, confluent necrotic lesions,
nikolsky sign (+), lesions evolve into flaccid blisters . Mucous membrane:
buccal, ocular, genital mucous, painful erythema and erosion, impaired function
(impaired alimentation, photophobia, conjunctival synechiae, dysuria).
Dermatopathology examination we can found sparse apoptotic keratinocytes

(suprabasal layers) which rapidly evolve to a fullthickness EN and sub-epidermal

detachment and mononuclear cell infiltrate.
Therapy
Symptomatic treatment is manage replacement of IV fluid and electrolytes and
Nutrition support (nasogastric tube). Environmental temperature : 28C 30C. If
any lesion on eyes we can give artificial tears, antibiotic or antiseptic
eyedrops,vitamin A, mechanical disruption of early synechiae and should be
examined daily by an ophthalmologist. The mouth should be rinsed several times
a day with antiseptic or antifungal solution. Because of importance of
immunologic and cytotoxic mechanisms, a large number of immnusupressive and
anti-inflammatory therapies have been tried to halt the progression of the disease.
The use corticosteroid is still controversial. Some studies found that such therapy
could prevent the extension of the disease when giving during the early phase.
Cyclosporin is a powerful immunosuppressive agent associated with biologic
effect that may theoretically be useful in treatment of TEN with doses
Cyclosporin 3 mg/kg/day. Plasmapharesis or Hemodialysis : prompt the removal
of the offending drugs, its metabolites, or inflammatory mediators. Anti-TNF
monoclonal antibodies have been successfully used to treat a few patient.
Complication
The acute phase, sepsis is the most common complication. The other
complication such us bronchopneumonia, acute tubular necrosis, renal failure,
penile scar, or vaginal stenosis, esophageal stricture,corneal ulcer, anterior uveitis,
panophtalmitis, and blindness can occur in TEN.

Ms. N (Lontara 3 R4 B1) / Herpes Zoster Sinistra dd/vesicobulosa disease

First Condition 05/08/2014
A Woman 57 years old came to RS Wahidin with main complains of blistering
around the neck. Patient came with clustered nodule around cheeks and neck on
left side, it arise around 7 days ago. Initially only slightly vesicle on cheeks then
after two days the vesicle become more and spread to around left ear. The vesicle
contains pus then it blistering. On second day after the lesion arise, she admitted
on Jeneponto hospital for five days. Then she was consulted to Wahidin
Sudirohusodo Hospital. Patient complaint itchy and pain on the lesion. History of
medication at Jeneponto hospital is Ceftriaxone, gentamicin cream,
dexamethason, ketorolac and ranitidine.
Dermatovenerology status:
Location
: Regio fascialis, Regio colli sinistra
Efflorescence
: Vesicle eritematous, pustule, bulla, erosion, ekskoriation.
A : Herpes Zoster Sinistra dd/vesicobulous disease
R/ - Acyclovur 5 x 400 gr
- Tramadol 2 x 1
- Fuson cream ( for blushing lesion )
- Neurodex 1 x 1
- Cetirizine 3 x tab
- Metilprednisolon 3 x 1 tab
Last Condition 07-08-2014
2st days of Treatment
S : Large pustule on the left cheek and left neck, pain (+), Itchy (+)
O : Dermatovenerology status:
Location
: Regio fascialis, Regio colli sinistra
Efflorescence
: Vesicle eritematous, pustule, bulla, erosion, ekskoriation
A : Herpes Zoster
R/ -Acyclovur 5 x 400 gr
- Tramadol 2 x 1
- Fuson cream ( for blushing lesion )
- Neurodex 1 x 1
- Cetirizine 3 x tab
- Metilprednisolon 3 x 1 tab

DISCUSSION
HERPES ZOSTER
Definition
Herpes zoster is a disease that is caused by infection from Varicella-Zoster
Virus that attack the mucosa and the skin. This infection is due to the reactivation
of virus after the primary infection.
Epidemiology
Distribution is the same with varicella Reactivation of virus due to varicella
sometimes varicella are asymptomatic the transmission of virus is through air
from varicella patient.
Pathophysiologi and transmision
Airborne droplets are the usual route of transmission of primary varicella
(chickenpox), although direct contact with vesicular fluid is another mode of
spread. The incubation period ranges from 11 to 20 days. The affected individual
has the ability to infect others until all of the vesicles have crusted. During
primary varicella infection, viremia follows an initial 2 to 4 days of replication
within regional lymph nodes. The virus travels to the epidermis by invasion of
capillary endothelial cells approximately 14 to 16 days post exposure VZV
subsequently travels from cutaneous and mucosal lesions to invade dorsal root
ganglion cells, where it remains until reactivation at a later date. Herpes zoster
appears upon reactivation of VZV, which may occur spontaneously or may be
induced by stress, fever, radiation therapy, tissue damage (i.e. trauma) or
immunosuppression. During a herpes zoster infection, the virus continues to
replicate in the affected dorsal root ganglion and produces a painful ganglionitis.
A person with zoster can infect another with varicella (i.e. chickenpox) if the
susceptible person comes into direct contact with vesicular fluid. Individuals with
chickenpox or shingles, however, cannot directly give another person shingles,
because herpes zoster is caused by the reactivation of latent VZV.
Clinical Manifestation
- Early onset can be found in the form of macula erythema that will later
develop into cluster of vesicle with it base erythematous and edema in a
short period of time.
- Predilection location are mostly found at the thorax region. Even though
they can also be found at other region.
Hyperesthesia vesicles which are typical signs, fluid-filled vesicles that can be
pustules and crusting. These lesions cause pain that is felt like a burning or
punctured-pin. These lesions are usually distributed unilateral and most often the
superficial area from the spinal nerves can be accompanied by prodromal
symptoms like fever, headache, malaise, bone pain and itching. Can be
accompanied by lymphadenopathy and disorder of the trigeminal nerve, facial
nerve (Ramsay Hunt syndrome) and optic nerve thus can cause bell's palsy ,
vertigo, and nystagmus. Can provide sequelae such as postherpetic neuralgia
which is a pain that arises in the healed area that more than a month after the
disease cured.

Diagnosis
Herpes Zoster lesions difficult to diagnose in the absence of erythematous
vesicle lesions and mostly similar to the lesions caused by impetigo, contact
dermatitis, scabies and most frequently caused by HSV lesions.
Tzank
Test
can be done to detect the presence or absence of giant cells which is a sign of
herpes virus infections.Direct fluorescent antibody staining (DFA) is a rapid and
sensitive screening. Examination by PCR can also detect the presence of VZV
DNA virus quickly.
Treatment & Management
Acyclovir 400mg 5x1/day
Tramadol 50mg 2x1/ day
Amitriptilin 12,5 0-0-1/day
Methylprednisolon 4mg 4x4x4/day
Neurodex 1-1-0
Acyclovir cream 5gr
Fuson cream (asam fusidik) 5gr
Prevention
Prevention is by vaccination in the elderly, vaccine zostavax. Generally
the vaccine is used for prevention in the elderly. It is also given to children for the
prevention of herpes zoster which caused by varicella zoster virus.