On this page
Study tools
Exam tags
Write your answer
Saved on this device. No marking — you are the marker.
Stem
A 60-year-old man develops painful dusky erythema and sheet-like epidermal detachment involving about 25 percent BSA with oral and ocular erosions 10 days after starting allopurinol. He is febrile and tachycardic. Outline diagnosis, severity scoring, immediate care, and the differentials you must not miss.[10][23]
Core knowledge
SJS/TEN overlap: detachment between 10 and 30 percent BSA plus widespread purpuric macules or flat atypical targets (Bastuji-Garin 1993). Cochrane 2022: rare, usually drug-triggered; tertiary-level supportive care; no systemic agent has proven mortality benefit.[23][10]
Red flags
- Pain out of proportion, rapid spread, systemic toxicity — necrotising fasciitis; delay to surgery is associated with increased mortality; LRINEC of 6 or more has sensitivity only 68.2 percent and must not rule out.[11]
- Fever plus retiform purpura — treat as meningococcaemia/purpura fulminans now; NICE: parenteral benzylpenicillin or a third-generation cephalosporin at the earliest opportunity. Adult PF series: amputations 154/190 (81 percent).[30][13]
- Anaphylaxis (urticaria, bronchospasm, hypotension) — IM adrenaline 0.01 mg/kg (1:1000), maximum 0.5 mg, repeat after 5 to 10 minutes.[18]
Key doses / thresholds
- SJS below 10 percent BSA; overlap 10 to 30 percent; TEN with spots above 30 percent.[23]
- SCORTEN (one point each): age above 40 years, malignancy, heart rate above 120/min, initial detachment above 10 percent, urea above 10 mmol/L, glucose above 14 mmol/L, bicarbonate below 20 mmol/L. TEN mortality about 30 percent; odds ratio 3.45 per point.[9]
- IM adrenaline 0.01 mg/kg, maximum single dose 0.5 mg.[18]
Questions
a) Classify this eruption on BSA and name the single most important first intervention. (3 marks)
b) List the seven SCORTEN components with thresholds. What overall TEN mortality did the derivation paper quote? (4 marks)
c) Immediate supportive bundle, and what Cochrane 2022 concluded about systemic immunomodulation. (5 marks)
d) Name two life-threatening differentials and the action that must not wait for imaging or cultures. (3 marks)
Model outline
a) SJS/TEN overlap (about 25 percent detachment). STOP allopurinol immediately; admit to ICU/burns-style care.[23][10]
b) Age above 40; malignancy; heart rate above 120; detachment above 10 percent; urea above 10 mmol/L; glucose above 14 mmol/L; bicarbonate below 20 mmol/L. TEN mortality about 30 percent.[9]
c) Fluids, wound and eye care, nutrition, infection surveillance. Cochrane: corticosteroids (methylprednisolone 4 mg/kg/day comparison), IVIG, ciclosporin, thalidomide and related agents — no proven mortality benefit; evidence certainty low.[10]
d) Necrotising fasciitis — theatre, do not wait for LRINEC or CT. Purpura fulminans/meningococcaemia — immediate parenteral benzylpenicillin or a third-generation cephalosporin.[11][30][13]
References7ShowHide
- [9]Bastuji-Garin S, Fouchard N, Bertocchi M, et al. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis J Invest Dermatol, 2000.PMID 10951229
- [10]Jacobsen A, Olabi B, Langley A, et al. Systemic interventions for treatment of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome Cochrane Database Syst Rev, 2022.PMID 35274741
- [11]Fernando SM, Tran A, Cheng W, et al. Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis Ann Surg, 2019.PMID 29672405
- [13]Klifto KM, Gurno CF, Grzelak MJ, et al. Surgical outcomes in adults with purpura fulminans: a systematic review and patient-level meta-synthesis Burns Trauma, 2019.PMID 31641673
- [18]Hearrell M, Anagnostou A Diagnosis and management of anaphylaxis J Food Allergy, 2020.PMID 39022137
- [23]Bastuji-Garin S, Rzany B, Stern RS, et al. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme Arch Dermatol, 1993.PMID 8420497
- [30]National Institute for Health and Care Excellence Fever in under 5s: assessment and initial management NICE NG143, 2019.Source