Presented by: Dr. Henry Foong
Ipoh, Malaysia
Ipoh, Malaysia
Abstract: Five Year-old boy with E. multiforme
The patient is a 5 year old boy presented with 3 day history of fever and generalised skin eruptions. Apparently it started with superficial lower lip erosion and the next day he had high fever and generalised skin eruptions on trunk, the upper and lower extremities. There was no family history of similar skin problems.
O/E he was afebrile. Generalised erythematous macules and plaques were noted on the face, trunk and extremities. The lesions were distributed acrally. Some of the macules had sharp margin round shape with concentric rings within it. A vesicle was noted on the centre of the macules. Few typical round macules were noted on the palms and soles. Clinically he has erythema multiforme major
TWBC 14, 900 (N11.4% L75.4% E2%) ESR 19. Mycoplasma antibody is negative. He is now empirically on oral acyclovir and oral clarithromycin.
The most likely cause of the EM is HSV infection in this patient. Wonder if you would use systemic corticosteroids in this patient?
Based upon the clinical presentation, I would classify this eruption as erythema multiforme minor (acral distribution of erythematous wheals, target or iris lesions, and involvement with one mucous membrane site). EM major (Stevens-Johnson syndrome) entails at least two sites of mucous membrane involvement, and is usually much more severe.
ReplyDeleteWhile HSV is a known cause of EM minor, other viruses and drugs have been implicated as causative agents.
In my experience, most cases of EM minor are self-limited and resolve on their own in 5 to 15 days.
If the patient is symptomatic, I generally prescribe an antihistamine, such as diphenydramine, hydroxyzine or cetirizine. If systemic steroids are prescribed, I would limit the course to no more than 3 to 5 days to avoid any secondary untoward effects.
In these cases watchful waiting is generally adequate.
Hurwitz, Sydney. Erythema Multiforme: A Review of Its Characteristics, Diagnostic Criteria, and Management. Pediatrics in Review 1990;11;217
(http://pedsinreview.aappublications.org/content/11/7/217)