65 year old man With PMHx otherwise unremarkable apart from recent hospitalization for left 2 nd digit MRSA infection decision made to attempt salvage with antibiotics as opposed to amputation ID: 775777
Download Presentation The PPT/PDF document " Rash Decisions John Wei PGY-2" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Rash Decisions
John Wei
PGY-2
Slide265 year old man
With PMHx otherwise unremarkable apart from recent hospitalization for left 2
nd
digit MRSA infection, decision made to attempt salvage with antibiotics as opposed to amputation.
He was started on Vancomycin immediately prior to discharge and following roughly 10 days of outpatient therapy was noted to have developed suspected “red man” syndrome; infusion rate was slowed the subsequent day without significant effect and he was subsequently changed to Daptomycin by ID.
Slide3Presentation
He now presents for a worsening rash over his entire body also associated with fevers up to 102 F at home (also documented in emergency room).
Slide4Initial Labs
CBC and CMP initially ordered and normal except as noted below:
Na 129
AST 95Albumin 3.0WBC 11.4
What other labs would you want to order?
Slide5Slide6Slide7Differential?
SJS/TEN
Vasculitis
Viral
exanthem
Angio-
immunoblastic
lymphadenopathy
Psoriasis
Erythema
Nodosum
Acute febrile neutrophilic dermatosis
Slide8Further Work Up
Developed kidney injury (Cr up to 1.88)
Developed Liver injury (AST up to 125)
Worsening hypoalbuminemia to 1.6Persistent leukocytosis (WBC to 26.5)Noted eosinophilia up to 1.4 (WBC 23.6)
Autoimmune Labs
C3 > 350
C4, ANCA, ANA, Hepatitis A, B, C, HHV6, CMV, EBV, all negative
Mild eosinophilia noted on peripheral smear
Slide9Eosinophilia
Slide10Dress Syndrome
Slide11Definition
The eruption is usually an exuberant
morbilliform
eruption with prominent facial edema, lymphadenopathy, fever, and, in severe cases, hypotension
Slide12Presentation
Systemic symptoms include fever (38 to 40°C [100.4 to 104°F]), malaise, lymphadenopathy, and symptoms related to visceral involvement
Delayed onset following exposure to a triggering agent.
Slide13Physical Exam
Slide14DRESS Rash
Slide15Pathogenesis
Slide16Pathogenesis
Continued
Slide17Pathologic Features
Histopathologic examination of a skin biopsy reveals a variable combination of
spongiosis
, acanthosis, interface vacuolization, a lymphocytic infiltrate in the superficial dermis, predominantly perivascular, variable presence of eosinophils, and dermal edema.
Slide18Histopathology
Figure 1: Various histopathological aspects of cutaneous infiltrates of drug rash with eosinophilia and systemic symptoms (DRESS) syndrome. (a) Spongiotic dermatitis with confluent areas of spongiosis within the epidermis associated with lymphocyte exocytosis. (b) This case of DRESS syndrome shows a marked lichenoid interface dermatitis with mild acanthosis and a heavy lymphocytic infiltrate extending from the superficial dermis to the epidermal basal layer, in which many apoptotic keratinocytes are seen. (c) This case closely resemble Sézary syndrome, with a mild perivascular infiltrate that comprises atypical lymphocytes with enlarged hyperchromatic nuclei (arrowheads and inset). (d) A large multilocular pustule is present, as usually seen in acute generalized exanthematic pustulosis.
Slide19Slide20Histopathology
Figure 2: Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome with multiple different inflammatory patterns. (a) In this unique section of a DRESS syndrome skin biopsy, three distinct inflammatory patterns can be observed: (b) a multilocular pustule (arrowheads), (c) a spongiotic dermatitis with a vesicle containing Langerhans' cells, and (d) foci of vacuolar or lichenoid interface dermatitis at the dermal–epidermal junction and within a follicular adnexa.
Slide21Slide22Systemic involvement
Slide23Etiologies?
Slide24Slide25Work Up
Slide26Slide27Treatment and Sequelae
Slide28Management Considerations
Slide29Course
Slide30Prognosis and Recovery
Slide31Outcome for our patient?
Slide32Vancomycin Induced Skin Eruptions
Red Man Syndrome
DRESS
Vancomycin hypersensitivity
Linear IgA-mediated bullous dermatosis
SJS/TEN
Interstitial Nephritis
Slide33DRESS Rash
Slide34To Reiterate
Slide35Takeaway points
Slide36MKSAP 38
Slide37References
Ortonne
, N &
Valeyrie‐Allanore
, L &
Bastuji‐Garin
, S & Wechsler, Janine & de
Feraudy
, S & Duong, Tu Anh &
Delfau
-Larue, Marie &
Chosidow
, O &
Wolkenstein
, P &
Roujeau
, J.‐C. (2015). Histopathology of drug rash with eosinophilia and systemic symptoms (DRESS): a morphologic and phenotypic study. British Journal of Dermatology. 173. . 10.1111/bjd.13683.
Tetart
F, Picard D,
Janela
B, Joly P, Musette P. Prolonged Evolution of Drug Reaction With Eosinophilia and Systemic
SymptomsClinical
, Virologic, and Biological Features.
JAMA
Dermatol
.
2014;150(2):206–207. doi:10.1001/jamadermatol.2013.6698
MKSAP Dermatology
UptoDate
Slide38Erythroderma and Acute febrile neutrophilic dermatosis
Slide39Linear IgA Bullous Dermatosis and Red Man Syndrome
Slide40SJS