A 34-year-old woman comes to the office due to a 10-day history of malaise, fever, headache, and nasal discharge. Her symptoms initially improved with an oral decongestant and nasal glucocorticoid spray but then worsened. Medical history is notable for moderate, persistent asthma and gastroesophageal reflux disease. The patient is allergic to penicillin and experienced a skin reaction when given penicillin as a child.
Temperature is 38.3 C (101 F). Physical examination shows focal tenderness over the right frontal sinus. The lungs are clear to auscultation.
Trimethoprim-sulfamethoxazole is prescribed. Five days later, the patient calls to report that the headaches have improved but she has developed redness and "some blisters" on her arms. Which of the following is the best response to this patient's concerns?

Question

A 34-year-old woman comes to the office due to a 10-day history of malaise, fever, headache, and nasal discharge.  Her symptoms initially improved with an oral decongestant and nasal glucocorticoid spray but then worsened.  Medical history is notable for moderate, persistent asthma and gastroesophageal reflux disease.  The patient is allergic to penicillin and experienced a skin reaction when given penicillin as a child.
Temperature is 38.3 C (101 F).  Physical examination shows focal tenderness over the right frontal sinus.  The lungs are clear to auscultation.
Trimethoprim-sulfamethoxazole is prescribed.  Five days later, the patient calls to report that the headaches have improved but she has developed redness and "some blisters" on her arms.  Which of the following is the best response to this patient's concerns?

Quizplus · Accepted Answer

11ec193a_9777_53f9_853d_3f392a1830d5_MD0002_00 This patient's description of her rash is concerning for Stevens-Johnson syndrome (SJS) due to trimethoprim-sulfamethoxazole. SJS and toxic epidermal necrolysis (TEN) are related clinical syndromes characterized by acute epidermal necrosis and are differentiated based on the percentage of body surface involved. By convention, SJS denotes <10% of body surface area involvement, >30% is designated as TEN, and 10%-30% is SJS/TEN overlap. SJS and TEN are commonly triggered by medications (eg, sulfonamides) and are up to 3 times more common in patients with HIV. SJS presents with an initial prodrome of fever and influenza-like symptoms, followed by rapid onset of painful erythematous or purpuric macules. The skin lesions then progress to bullae formation with necrosis and sloughing. Mucosal lesions (eg, ocular, oral, genital, respiratory surfaces) are also present in most cases. Secondary infections are common in SJS and TEN, and fatalities may occur despite treatment. Patients should be evaluated immediately and managed in a hospital setting, often in an intensive care burn unit (Choices B and C). All suspected and unnecessary medications should be immediately discontinued as the prognosis of SJS or TEN improves with early removal of causative medications (Choice A). Treatment is supportive and involves wound care, with consideration for systemic glucocorticoids and/or intravenous immune globulin in moderate to severe cases. (Choice D) Antihistamines are effective for mild allergic reactions but ineffective in treating SJS or TEN. Educational objective: Patients with suspected Stevens-Johnson syndrome or toxic epidermal necrolysis should be immediately evaluated and managed in a hospital setting. In addition, immediate discontinuation of the suspected causative medication(s) and all other unnecessary medications is mandatory. __________ References: Stevens-Johnson syndrome and toxic epidermal necrolysis: an update. (http://www.ncbi.nlm.nih.gov/pubmed/26481651) Effects of treatments on the mortality of Stevens-Johnson syndrome and toxic epidermal necrolysis: A retrospective study on patients included in the prospective EuroSCAR Study. (http://www.ncbi.nlm.nih.gov/pubmed/17919775)

A 34-Year-Old Woman Comes to the Office Due to a 10-Day