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Good Morning!! . Morning Report: Thursday, April 19th. Erythema Multiforme. Some Background Info….

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Good morning

Good Morning!!

Morning Report: Thursday, April 19th


Erythema multiforme

ErythemaMultiforme


Some background info

Some Background Info…

  • EM is an acute, immune-mediated condition characterized by the appearance of distinctive target-like lesions on the skin, often accompanied by erosions or bullae involving the oral, genital, and/or the ocular mucosae

    • EM major: EM with mucosal involvement

    • EM minor: EM without mucosal involvement

  • EM major and SJS are different diseases with distinct causes


Epidemiology

Epidemiology

  • Incidence <1%

  • Occurs most frequently in young adults (b/t 20-40 yo)

  • Slight male predominance


Etiology

Etiology

  • Infections

  • Medications

  • Malignancy

  • AI disease

  • Immunizations

  • Radiation

  • Sarcoidosis

  • Menstruation


Etiology1

Etiology

  • Infections (90%)

    • HSV

    • Mycoplasmapneumoniae*

  • Medications (<10%)

    • NSAIDs

    • Sulfonamides

    • Antiepileptics

    • Antibiotics


Pathogenesis

Pathogenesis

  • Cell-mediated immune process directed against viral antigens deposited in lesional skin

  • Genetic susceptibility


Cutaneous features

Cutaneous Features


Mucous membrane involvement

Mucous Membrane Involvement


Systemic symptoms

Systemic Symptoms

  • Uncommon in mild cases of EM, but can be seen in cases with significant mucosal involvement

    • Fever

    • Malaise

    • Myalgias

    • Cough and respiratory symptoms (EM related to Mycoplasma)


Evaluation

Evaluation

  • Labs

    • Non-specific findings:

      • Elevated ESR

      • Elevated WBC ct

      • Elevated liver enzymes

    • If any suspicion, may test for:

      • HSV (DFA, viral Cx, PCR)

      • M. pneumoniae (serology)

  • Skin biopsy

    • If diagnosis is in question

Epidermal cell apoptosis, basal cell vacuolar degeneration, lymphocytic exocytosis, and a dermal lymphocytic infiltrate are present.


Disease course

Disease Course

  • HSV-associated EM lesions usually appear 2-17 days after an outbreak (avg. 8 days)

  • Lesions appear over 3-5 days and disappear over ~2 weeks (self-limited)

  • Usually do not scar, but may leave an area of postinflammatoryhyperpigmentation that may remain for months


Disease course1

Disease Course

  • Recurrent EM

    • Frequent episodes over many years

    • Most cases due to HSV infection

  • Persistent EM

    • Uninterrupted occurrence of typical and atypical EM lesions


Treatment

Treatment

  • Varies according to severity:

    • Mild

      • Symptomatic treatment

        • Topical corticosteroids

        • Oral antihistamines

        • MMW

    • Severe

      • Supportive care

        • Nutrition/ hydration

        • Pain control

      • ?Oral glucocorticoids

      • Ophthalmology exam


Treatment1

Treatment

  • Inciting agents

    • Little data on the effect of acute treatment of inciting infection on the severity or duration of EM

      • Two case series show treatment with oral antivirals after the appearance of HSV-associated EM does NOT affect the clinical course

      • No formal studies on the effect of treatment of other infectious causes of EM

    • Treatment should be instituted as appropriate for management of active infection


A question

A Question…

  • You are evaluating a 7 yo girl with a 2 day h/o rash without fever or other symptoms. The only notable finding on PE are round, erythematous, thin plaques, each of which has a central violaceous discoloration or blister. The lesions are concentrated on the extremities, including the hands and feet, with relative sparing of the trunk. Of the following, the most likely diagnosis is:

    • A. Erythemamigrans

    • B. Erythemamultiforme

    • C. SJS

    • D. TEN

    • E. Urticaria


Thanks for your attention

Thanks for your attention!!

Noon Conference: Dr. Dawkins, Toddler GU Issues


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