EM:RAP COMMENTARY
Trust Me, This Is the Worst “Acne” of Your Life! Brittney DeClerck, MD*; Paul Jhun, MD; Aaron Bright, MD; Mel Herbert, MD *Corresponding Author. E-mail: [email protected]. 0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.12.016
SEE RELATED ARTICLE, P. 146. [Ann Emerg Med. 2015;65:147-150.] Editor’s note: Annals has partnered with EM:RAP, enabling our readers without subscriptions to the EM:RAP service to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine.
ANNALS CASE A 55-year-old woman presented to the emergency department (ED) with a 2-week history of a pruritic rash and progressive weakness. The eruption, first affecting the abdomen, appeared 9 days after initiation of vancomycin and cefepime (Figure 1). The patient had a temperature of 38.4 C (101.1 F) and a pulse rate of 160 beats/min. Physical examination revealed diffuse, edematous, erythematous plaques with overlying pustules and isolated bullae (Figure 2). The oral mucosa was not involved. Laboratory investigation identified an elevated lactate level of 6.4 mmol/L and leukocytosis of 28.910^9/L.1 To paraphrase Indiana Jones.rashes, why did it have to be rashes? When you take a look at these images, the rash is pretty impressive, and the patient sounds sick. A decision to admit this patient is probably the easy part. But what’s your working diagnosis and what should you do next? Is this purpura fulminans in evolution or some autoimmune reaction? Do you give empiric antibiotics? Do you give empiric corticosteroids? Read on.
MAKING SOME SENSE OF DRUG RASHES Emergency physicians are taught to recognize several key lifethreatening diseases with classic dermatologic manifestations: necrotizing fasciitis, Stevens-Johnson syndrome (SJS), and Kawasaki disease, to name a few. For drug-induced rashes, let’s be honest: most of us think that if we are not looking at SJS, toxic epidermal necrolysis (TEN), or anaphylaxis, then the patient is probably out of the woods. Now, don’t get me wrong; most drug-induced rashes can generally be lumped into a diagnosis of “drug rash not otherwise specified” and patients can be discharged with supportive care and told to follow up with their primary physician.2 But there are a few critical, can’t-miss, drug-induced rashes in addition to SJS, TEN, and anaphylaxis that are potentially life-threatening. Volume 65, no. 2 : February 2015
BEYOND ANAPHYLAXIS When you crack open medical textbooks (do people do that anymore?) and focus on the life-threatening, drug-induced rashes, the classic diagnosis is urticaria in the setting of anaphylaxis (kind of an easy one). Other than anaphylaxis, there are 5 drug-induced rashes that you need to consider and recognize. Here’s a simple mnemonic to remember them, ABCDs: Acute generalized exanthematous pustulosis (AGEP) Bullous diseases, drug-induced Captopril (angiotensin-converting enzyme [ACE] inhibitor)-induced angioedema Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome SJS/TEN
BACK TO THE BASICS Here’s a shocker for you: the patient’s medication history is critical to developing a suspicion or a drug-induced rash. Ask the patient about medications received in the past 1 to 2 months, along with associated symptoms (eg, fever, itching, skin pain).
LESION, LOCATION, AND ASSOCIATED FINDINGS Fortunately for us on the front lines, each of these potentially life-threatening drug rashes presents with different types of lesions3,4: 1. tiny pustules concentrated in the skin folds: AGEP 2. medium to large blisters: drug-induced bullous reactions 3. facial swelling and urticaria: angioedema/anaphylaxis 4. maculopapular rash: DRESS syndrome 5. gray/purple skin, blisters, erosions, skin sloughing off: SJS/TEN Another critical step in evaluating a suspected drug rash is looking for mucous membrane (eg, SJS/TEN) and intertriginous or skin fold (eg, AGEP) involvement. Last, look for additional associated findings. Serum CBC count (looking for leukocytosis found in AGEP, eosinophilia and leukocytosis in DRESS syndrome, or cytopenias found in SJS/TEN), basic metabolic panel (looking for renal impairment found in DRESS syndrome), and liver function tests (looking for transaminitis found in DRESS syndrome) can help you sort out the situation. Take a look at the Table, where we put these Annals of Emergency Medicine 147
DeClerck et al
EM:RAP Commentary Table. Comparison of severe drug-induced cutaneous reactions. Drug Reaction
Interval
AGEP
Trust Me, This Is the Worst “Acne” of Your Life! Brittney DeClerck, MD*; Paul Jhun, MD; Aaron Bright, MD; Mel Herbert, MD *Corresponding Author. E-mail: [email protected]. 0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.12.016
SEE RELATED ARTICLE, P. 146. [Ann Emerg Med. 2015;65:147-150.] Editor’s note: Annals has partnered with EM:RAP, enabling our readers without subscriptions to the EM:RAP service to enjoy their commentary on Annals publications. This article did not undergo peer review and may not reflect the view and opinions of the editorial board of Annals of Emergency Medicine.
ANNALS CASE A 55-year-old woman presented to the emergency department (ED) with a 2-week history of a pruritic rash and progressive weakness. The eruption, first affecting the abdomen, appeared 9 days after initiation of vancomycin and cefepime (Figure 1). The patient had a temperature of 38.4 C (101.1 F) and a pulse rate of 160 beats/min. Physical examination revealed diffuse, edematous, erythematous plaques with overlying pustules and isolated bullae (Figure 2). The oral mucosa was not involved. Laboratory investigation identified an elevated lactate level of 6.4 mmol/L and leukocytosis of 28.910^9/L.1 To paraphrase Indiana Jones.rashes, why did it have to be rashes? When you take a look at these images, the rash is pretty impressive, and the patient sounds sick. A decision to admit this patient is probably the easy part. But what’s your working diagnosis and what should you do next? Is this purpura fulminans in evolution or some autoimmune reaction? Do you give empiric antibiotics? Do you give empiric corticosteroids? Read on.
MAKING SOME SENSE OF DRUG RASHES Emergency physicians are taught to recognize several key lifethreatening diseases with classic dermatologic manifestations: necrotizing fasciitis, Stevens-Johnson syndrome (SJS), and Kawasaki disease, to name a few. For drug-induced rashes, let’s be honest: most of us think that if we are not looking at SJS, toxic epidermal necrolysis (TEN), or anaphylaxis, then the patient is probably out of the woods. Now, don’t get me wrong; most drug-induced rashes can generally be lumped into a diagnosis of “drug rash not otherwise specified” and patients can be discharged with supportive care and told to follow up with their primary physician.2 But there are a few critical, can’t-miss, drug-induced rashes in addition to SJS, TEN, and anaphylaxis that are potentially life-threatening. Volume 65, no. 2 : February 2015
BEYOND ANAPHYLAXIS When you crack open medical textbooks (do people do that anymore?) and focus on the life-threatening, drug-induced rashes, the classic diagnosis is urticaria in the setting of anaphylaxis (kind of an easy one). Other than anaphylaxis, there are 5 drug-induced rashes that you need to consider and recognize. Here’s a simple mnemonic to remember them, ABCDs: Acute generalized exanthematous pustulosis (AGEP) Bullous diseases, drug-induced Captopril (angiotensin-converting enzyme [ACE] inhibitor)-induced angioedema Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome SJS/TEN
BACK TO THE BASICS Here’s a shocker for you: the patient’s medication history is critical to developing a suspicion or a drug-induced rash. Ask the patient about medications received in the past 1 to 2 months, along with associated symptoms (eg, fever, itching, skin pain).
LESION, LOCATION, AND ASSOCIATED FINDINGS Fortunately for us on the front lines, each of these potentially life-threatening drug rashes presents with different types of lesions3,4: 1. tiny pustules concentrated in the skin folds: AGEP 2. medium to large blisters: drug-induced bullous reactions 3. facial swelling and urticaria: angioedema/anaphylaxis 4. maculopapular rash: DRESS syndrome 5. gray/purple skin, blisters, erosions, skin sloughing off: SJS/TEN Another critical step in evaluating a suspected drug rash is looking for mucous membrane (eg, SJS/TEN) and intertriginous or skin fold (eg, AGEP) involvement. Last, look for additional associated findings. Serum CBC count (looking for leukocytosis found in AGEP, eosinophilia and leukocytosis in DRESS syndrome, or cytopenias found in SJS/TEN), basic metabolic panel (looking for renal impairment found in DRESS syndrome), and liver function tests (looking for transaminitis found in DRESS syndrome) can help you sort out the situation. Take a look at the Table, where we put these Annals of Emergency Medicine 147
DeClerck et al
EM:RAP Commentary Table. Comparison of severe drug-induced cutaneous reactions. Drug Reaction
Interval
AGEP
