One last quiz session Anna Petersen MD, PGY-3 1/11/13

Almost 8 yr old F, previously healthy, who presented with a crusted shut painful mouth, red left eye, and cough. She first started having a cough ~10 days PTA and grandmother noted red eyes at this time. She went to an Instacare and was diagnosed with viral conjunctivitis. Her vision was normal and RSS (-). She took Sudafed for 4 days; her eyes stayed slightly red, and cough continued, but she did not seem to worsen. Four days PTA developed 2 white sores on the inside of her cheeks and sore throat. She also had some low grade fevers, decreased oral intake, and less energy.

 She went to see her PCP 3 days ago, and also had a red blotchy rash on the back of both her knees which her PCP believed was eczema. Her PCP prescribed amoxicillin (?) which she felt helped a little, but she didn't get all the way better. The two days before presentation, her lips and tongue started getting really painful and crusting, despite Grandmas attempt at vaseline and wet soaks. They bled easily when wiping the crust away. She also developed a red sore on her left cheek. Her PO intake decreased to almost none. She also c/o a painful, sore tongue.

 PMH: Eczema (?), no seasonal allergies, no asthma, no history of skin infections or herpes PSH: T&A and tubes at age 4 IMMS: up to date, flu this year already MEDICATIONS: Motrin, Sudafed, and Amoxicillin recently; MVI regularly ALLERGIES: NKDA DIET: normal for age, no recent additives FAMILY : no family members with skin infections, MRSA, or herpes. SOCIAL : Lives with parents and grandparents. New dog on 12/7/12. No sick contacts. DEVELOPMENTAL: Normal development

 No fever, no congestion, no pruritis with rash, no n/v/d, normal mental status Decreased eating/drinking ability, (+)pain, some fatigue

Saw her PCP on the morning of admission, who was worried for dehydration, and she was a direct admit.

GENERAL: Pale girl awake, quiet and shy, uncomfortable, in hospital gown. HEAD: NCAT. EYES: PERRL, EOMI, conjugate gaze, scleral and conjunctival injection on lateral side of left eye. Bil erythema and swelling near lacrimal ducts with yellowish crusted discharge. EARS: TMs clear bil, nml light reflex and landmarks. NOSE: Nares patent, no discharge or obstruction. MOUTH: lips crusted together with dried exudate. small straw sized hole left open. lips brightly erythematous and edematous; very friable. Patient unable to extend jaw or talk easily due to not opening lips.

CV: Normal rate, rhythm, and S1/S2, no murmur, rub or gallop. Cap refill<2s. LUNGS: CTAB, no wheezes, rales, or rhonchi. No incr WOB. ABD: soft, non-tender, non-distended with active bowel sounds and no masses or HSM EXT: all extremities warm and well perfused. No cyanosis, clubbing, or edema. BACK: no abnormalities noted. GU: normal Female external genitalia, Tanner stage 1. NEURO: awake and alert, cranial nerves II-XII grossly intact, grossly normal strength and tone, patellar tendon reflexes normal. SKIN: Small papule on left check that is erythematous with small central scab.

 Patient's mouth is extremely dry with large dry dark red and brown crusting. The top and bottom lip are connected by this crusting with a pin head size hole in the crusting. Applied a warm wash cloth to the lips to help soften crusting. Gently removed 80%-90% of the crusting. Lips bled slightly. Patient's inside of the mouth is also very sore with some moist lesions noted in the mouth however it was slightly difficult to fully assess. Tried to clean inside of the mouth with pink mouth swabs and cold water, but this was too painful for the patient. Applied Sween 24 to the lips.

8 yr old female with cough, conjunctivitis, and mucositis.

Fixed drug reaction Erythema mulitforme SJS/TEN Exfoliative erythroderma Cocksackie mucositis HSV 1, 2 (primary) Cutaneous HSV Ocular HSV Eczema herpeticum SSSS

Irritant Contact Dermatitis Allergic Contact Dermatitis

Pemphigus Vulgaris Bullous Pemphigoid Mucous Membrane Pemphigoid Benign chronic bullous dermatosis of childhood

Bullous pemphigoid Dermatitis herpetiformis Drug eruptions Leukocytoclastic vasculitis Lupus erythematosus Pityriasis rosea Polymorphic light eruption Stevens-Johnson syndrome Toxic epidermal necrolysis Urticaria Urticarial vasculitis Viral exanthems

VRP PCR HSV PCR or culture Routine culture of affected surface* Mycoplasma PCR

 SJS and toxic epidermal necrolysis have traditionally been considered the most severe forms of erythema multiforme (EM). It was proposed that EM major is distinct from SJS and TEN on the basis of clinical criteria. The proposed concept is to separate an EM spectrum from an SJS/TEN spectrum. Grade 1: SJS mucosal erosions and epidermal detachment <10% Grade 2: Overlap SJS/TEN epidermal detachment from 10% - 30% Grade 3: TEN epidermal detachment > 30%

 Vesiculobullous disease of the skin, mouth, eyes, and genitals. The disease occurs most often in children and young adults. The cutaneous eruption is preceded by symptoms of an upper respiratory tract infection

Initial symptoms are fever, stinging eyes, and pain with swallowing. They precede cutaneous manifestations by 1 to 3 days Bullae occur suddenly 1 to 14 days after the prodromal symptoms, appearing on the conjunctivae and mucous membranes of the nares, anorectal junction, vulvovaginal region, and urethral meatus. Ulcerative stomatitis leading to hemorrhagic crusting is the most characteristic feature.

 Etiology:
#1 = Drugs, Drugs, Drugs # 2 = Atypical infections Upper respiratory tract infection Mycoplasma pneumoniae GI disorders Herpes simplex virus

Possible causes should be sought diligently so that recurrences can be avoided

Antibiotics Chloramphenicol Macrolides Penicillin Quinolones Sulfonamides

Anticonvulsants Carbamazepine Lamotrigine Phenobarbital Phenytoin Valproate

Allopurinol NSAIDs

 Treatment
Stevens-Johnson syndrome associated with herpes simplex virus early use of acyclovir and prednisone Comfort/Supportive care Wound care Music therapy

 Habif: Clinical Dermatology, 5th ed.