Diagnostic Tests for Stevens-Johnson Syndrome
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Erythema [Erythroderma]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If erythema isn’t associated with anaphylaxis, obtain a detailed health history. (See Differential diagnosis: Erythema, pages 310 and 311.) Find out how long the patient has had the erythema and where it first began. Has he had any associated pain or itching? Has he recently had a fever, an upper respiratory tract infection, or joint pain? Does he have a history of skin disease or other illness? Does he or anyone in his family have allergies, asthma, or eczema? Find out if he has been exposed to someone who has had a similar rash or who is now ill. Did he have a recent fall or injury in the erythematous area?
Obtain a complete drug history, including recent immunizations. Ask about food intake and exposure to chemicals.
Begin the physical examination by assessing the extent, distribution, and intensity of erythema. Look for edema and other skin lesions, such as urticaria, scales, papules, and purpura. Examine the affected area for warmth, and gently palpate it to check for tenderness or crepitus.
Cultural Cue: Dark-skinned patients may have difficulty recognizing erythema; as a result, they may present with associated diseases in a more advanced state.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Stomatitis:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Head, eyes, ears, nose, and throat (HEENT). Based on the history, a focused physical examination of the HEENT is necessary. Look for signs of trauma. Examine the conjunctiva and nasal mucosa for inflammatory changes or ulcerations. Evaluate the patient for coexisting upper respiratory signs and symptoms such as rhinorrhea, sinus tenderness to palpation, and otitis media. Inspect facial skin for vesicles from HSV or varicella-zoster or other lesions such as echymoses, malar rash, or viral exantham. Look for facial asymmetry. Varicella-zoster can cause facial nerve paralysis, called the “Ramsay Hunt syndrome.” Evaluate preauricular, postauricular, and cervical lymph node chains. Finally, evaluate the oral cavity, documenting the size, location, and appearance of the lesion.
B. Additional physical examination. Based on findings from the HEENT examination, additional physical examination might include (a) pulmonary examination for viral pneumonitis or pulmonary findings in autoimmune diseases; (b) abdominal and rectal examination for Crohn’s disease or ulcerative colitis; (c) genitourinary examination for mucosal ulcers in Behçet’s disease and Stevens–Johnson syndrome, and for signs of syphilis or gonorrhea; (d) a general skin examination looking for viral exanthemas, drug eruptions, lichen planus, pemphigus, pemphigoid, and SLE; and (e) a musculoskeletal examination for signs of SLE, Reiter’s syndrome, or other autoimmune diseases (3).
Testing
A. Clinical laboratory testing should be guided by history and physical findings. A potassium hydroxide wet mount is useful in the diagnosis of candidiasis. Viral and bacterial cultures can be obtained from swabs of oral lesions, but viral cultures are usually more helpful than bacterial cultures. Darkfield microscopy can be performed from swabs of syphilis chancres or plaques. Cytologic scrapings of premalignant or malignant lesions, prepared in a manner similar to a Pap smear, are not a substitute for biopsy of suspected oral neoplasia (2,4).
B. Diagnostic imaging is indicated only in selected cases such as coexisting sinus disease [“mini” sinus computed tomogram (CT)], coexisting neck mass or lymphadenopathy suggestive of malignant disease (head and neck CT), suspected metastatic disease (chest x-ray study; CT of the head, abdomen, and chest), or trauma (cervical spine series; cranial CT; dental Panorex films). If HSV is suspected, cranial magnetic resonance imaging (MRI) may be useful to evaluate the temporal lobes. A chest x-ray study is also indicated in suspected lower respiratory tract disease such as viral or autoimmune pneumonitis or secondary bacterial pneumonia. If a severe lip laceration has occurred, plain films can help to rule out mandibular condylar fractures or tooth fractures.
Diagnostic assessment
The diagnosis of stomatitis depends on synthesis of the aforementioned key historical, physical examination, laboratory, and imaging elements. All oral ulcers that do not heal, as well as white or reddish-white lesions that do not resolve in 2 weeks, need biopsy to rule out malignancy (2,4).
References
1. Yeatts D, Burns JC. Common oral mucosal lesions in adults. Am Fam Physician 1991;44:2043–2050.
2. Silverman S. Oral cancer, 4th ed. Hamilton, Ontario: BC Decker, 1998.
3. Salisbury PL, Jorizzo JL. Oral ulcers and erosions. Adv Dermatol 1993;8:31–79.
4. Mashberg A, Samit A. Early diagnosis of asymptomatic oral and oropharyngeal squamous cell cancer. CA Cancer J Clin 1995;45:328–351.
5. Laskaris G. Oral manifestations of infectious diseases. Dent Clin N Am 1996;40:
395–423.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Erythema Multiforme:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Description of lesions
1. The rash begins as a round erythematous papule, which enlarges up to 1 to 2 cm over 24 to 48 hours. The periphery of the lesion is erythematous and raised or edematous. The center becomes more cyanotic looking and can be white/yellow or gray. This is the pathognomonic “target lesion,” but it may not be present in all cases. If a blister forms in the middle, the term “iris lesion” is more appropriate.
2. Lesions are generally symmetrical, with acral to central spread including extensor surfaces, face, palms, and soles. Mucosal lesions indicate a more severe type; bullae with sloughing in large sheets suggests TEN.
B. Systemic signs
1. Systemic signs are present in the more serious Stevens–Johnson syndrome and TEN.
2. Systemic signs include high fever, involvement of eyes with corneal ulceration, pulmonary findings, widespread cutaneous involvement, or pneumonia, indicating higher morbidity and mortality.
Testing
A. Biopsy. The history and physical examination will be most helpful in making the diagnosis; however, biopsy of an early lesion helps to confirm it and exclude others. The differential diagnosis would include urticaria, vasculitis, fixed drug eruptions, and bullous pemphigoid.
B. Other tests. If underlying infection is suspected, laboratory tests including a complete blood count, throat culture, antistreptolysin-O titer, slide test for infectious mononucleosis, and hepatitis screen may be indicated. A chest x-ray study may be needed if Mycoplasma pneumoniae, histoplasmosis, coccidiomycosis, or TB is suspected. Skin tests or serum complement fixation titers for infectious agents may be needed.
Diagnostic assessment
A. If the history and physical examination are consistent with the diagnosis of EM, a symmetric, fixed, discrete, round, erythematous rash is seen, which lasts 1 to 6 weeks from onset to healing, which is self-limited, acute, or episodic in nature. If biopsy supports the diagnosis, then the clinical criteria for EM have been met.
B. Cause. Then, determine the most likely cause in order to remove the antigenic stimulus, whether this means stopping a drug, treating an infection, or invoking preventative measures such as avoiding a drug or providing prophylaxis for recurrent HSV.
C. Determining which subtype of EM is present helps dictate treatment and anticipate prognosis.
References
1. Fitzpatrick TB, Johnson RA, Polano MK, Suurmond D, Wolff K. Color atlas and synopsis of clinical dermatology, 2nd ed. New York: McGraw-Hill, 1992:474–477.
2. Goldberg GN. Erythema multiforme controversies and recent advances. Adv Dermatol 1987;2:73–90.
3. Huff JC. Erythema multiforme. In: Sams WM, Lynch PJ, eds. Principles and practice of dermatology, 2nd ed. New York: Churchill Livingstone, 1996:483–490.
4. Stampien TM, Schwartz RA. Erythema multiforme. Am Fam Physician 1992;46(4):
1171–1176.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Patterned Erythema:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Sun-exposed areas of the face, the “V” of the neck (but not under the chin), and the dorsum of the hands and feet are common distributions for photodermatitis.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Erythema:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical examination by assessing the extent, distribution, and intensity of erythema. Look for edema and other skin lesions, such as hives, scales, papules, and purpura. Examine the affected area for warmth, and gently palpate it to check for tenderness or crepitus.
CULTURAL CUE:Dark-skinned patients may have difficulty recognizing erythema; as a result, they may present with associated diseases in a more advanced state.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Erythema [Erythroderma]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If erythema isn't associated with anaphylaxis, obtain a detailed health history. Find out how long the patient has had the erythema and where it first began. Has he had associated pain or itching? Has he recently had a fever, upper respiratory tract infection, or joint pain? Does he have a history of skin disease or other illness? Does he or anyone in his family have allergies, asthma, or eczema? Find out if he has been exposed to someone who has had a similar rash or who's now ill. Did he have a recent fall or injury in the area of erythema?
Obtain a complete drug history, including recent immunizations. Ask about food intake and exposure to chemicals.
Begin the physical examination by assessing the extent, distribution, and intensity of erythema. Look for edema and other skin lesions, such as hives, scales, papules, and purpura. Examine the affected area for warmth, and gently palpate it to check for tenderness or crepitus.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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