Erythema Multiforme Versus Stevens–Johnson Syndrome/Toxic Epidermal Necrolysis: Subtle Difference in Presentation, Major Difference in Management

Abstract

Erythema multiforme and Stevens–Johnson syndrome/toxic epidermal necrolysis are immune-mediated epidermal conditions with variable clinical presentations. Although their clinical presentations often overlap, they have distinct etiologies and potential outcomes, which necessitate specific management strategies. This case is presented to highlight the subtle differences and review management given that Stevens–Johnson syndrome/toxic epidermal necrolysis can rapidly become life-threatening. The need for astute diagnostic work-up and accuracy is magnified in the military setting given operations in austere environments and availability of medical and medical evacuation resources. Herein, we present a less common case of bullous erythema-multiforme, the diagnostic approach, and clinical differential with special attention to the importance of the military physician.

Clinical parameters and biological markers associated with acute severe ocular complications in Stevens-Johnson syndrome and toxic epidermal necrolysis

“…The clinical parameters and ocular findings were collected during the acute phase of SJS/TEN, within 8–12 days of symptom onset 51 .When the acute ocular severity differed between the eyes, the eye with greater severity was chosen for evaluation. If both eyes were symmetrically severe, the right eye was selected.…”

“…Serum (30 ml) was collected from patients registered in the ThaiSCAR database while admitted to KCMH during the acute phase of SJS/TEN, within 8–12 days of symptom onset 51 . Undiluted samples were stored at − 80 °C until biomarker measurement.…”

Piroxicam Yang Diduga Sebagai Agen Penyebab Steven-Johnson Syndrome : Sebuah Laporan Kasus

“…Tetapi terdapat beberapa variasi pada morfologi lesi (sehingga disebut "multiforme") dapat berupa lesi papul atau plak, bullae atau papul atau plak hemoragik (pada mukosa). 17 SJS yang terjadi pada pasien ini kemungkinan disebabkan oleh konsumsi obatobatan NSAID berupa Piroxicam. SJS dapat disebabkan oleh infeksi, vaksinasi, penyakit sistemik, makanan atau obat-obatan.…”

Differential Diagnosis of Lesions

“…Both SJS and EM present with atypical lesions and mucosal erosions. However, atypical lesions of SJS are macular compared with papular lesions that are present in EM (French et al, 2012; Newkirk, Fomin, & Braden, 2020). Management of acute episodes of EM includes assessing the need for hospitalization or outpatient treatment.…”

“…Patients with painful oral lesions should also be treated with lidocaine oropharyngeal viscous solutions (Bean & Quezada, 1983; de Risi-Pugliese, Sbidian, Ingen-Housz-Oro, & Le Cleach, 2019; Zoghaib et al, 2019). In patients presenting in the emergency department with lesions, it is essential that a nurse practitioner distinguish EM from other differential diagnoses such as SJS and TEN to determine the proper treatment and if discharge home or inpatient admission is needed (Newkirk et al, 2020). When working with patients with comorbidities and at risk for dehydration, it is clinically appropriate to admit patients in observation for fluid replacements and monitoring.…”