Presented by Dr. Henry Foong,
Ipoh, Malaysia
Abstract: 41 yo man with short history of toxic
erythema
HPI: The patient is a 41 yr
old restaurant worker who presented with 5 day history of bilateral and
symmetrical erythema over the loins, groins and knees.
About a week ago, he had a
furunculosis on upper back and was prescribed Augmentin. Two days later he
developed high fever and was treated with ciprofloxacin by a physician. A day
later he noticed itchy rashes on both thighs and since then, the macular
erythema spread symmetrically to the loins, upper shoulders and knees. He has no fever.
His past medical history was
non-contributory.
Examination showed bilateral
and symmetrical diffuse erythema on the thighs, knees, loins and upper
shoulders. Over the loins, there was symmetrical and bilateral edematous
areas with vesicles over a background of
erythema. His scalp, oral cavity and
genitalia were clear.
Clinical Photos:
TWBC 3200 (N 85.1% L 10.3%
E0 .5% M3.4% B 0.8%)
ESR 36
Diagnosis: Toxic erythema
Differentials: Streptococcal/Staph cellulitis
Questions and Comments: The presence of blisters /edema on the loin
is worrying. In the meantime what would
you recommend for this patient? Would you use corticosteroids in this patient?
I have stopped both augmentin and ciprofloxacin. In terms of dressing, I used
wet compress with dil. KMNO4.Have I missed anything?
References:
1. Miyahara A, et. al. A new proposal for a clinical-oriented
subclassification of baboon syndrome and a review of baboon syndrome. Asian Pac
J Allergy Immunol. 2011 Jun;29(2):150-60
Source: Department of
Pediatrics, Tokyo Medical University. miyahara.pediatrics@gmail.com
Abstract
OBJECTIVE: To review baboon
syndrome (BS). Data Sources: Date sources were obtained from PubMed and Google
Scholar: Photographs of baboon syndrome were obtained from our patient.
STUDY SELECTIONS: PubMed and
Google Scholar were searched up to June 30, 2010. The search terms were
"baboon syndrome", "SDRIFE" and "thimerosal
allergy". Reverse references from relevant articles and Google Scholar
were also used. As BS is a classical disease and cases of offending agents were
relatively old, some references were more than five years old. In order to
gather as many cases of offending agents as possible, more than 50 references
were collected.
RESULTS AND CONCLUSION: We
divided BS into as 4 groups; classical baboon syndrome, topical drug-induced
baboon syndrome, systemic drug-induced baboon syndrome and symmetrical
drug-related intertriginous and flexural exanthema (SDRIFE). The pathomechanism
of BS is still unknown. A delayed type of hypersensitivity reaction, a recall
phenomenon, pharmacologic interaction with immune-receptors and anatomical
factors may be involved in the causation of BS.
This valuable article is available in Free full text
2. Tan SC, Tan JW. Symmetrical drug-related intertriginous and
flexural exanthema. Curr Opin Allergy Clin Immunol. 2011 Aug;11(4):313-8.
Department of Rheumatology,
Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore.
Sze_Chin_Tan@ttsh.com.sg
Abstract
PURPOSE OF REVIEW:
Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE),
previously termed drug-related baboon syndrome, is a benign and self-limiting
type IV hypersensitivity reaction characterized by symmetrical erythema
involving the gluteal and intertriginous areas in the absence of systemic
involvement. It may also occur in the absence of previous drug exposure.
RECENT FINDINGS: Antibiotics,
in particular beta-lactams, comprise the majority of causes of SDRIFE. Other
drugs which have been implicated include antihypertensives, radiocontrast
media, chemotherapeutic agents, and biologics. Histology of lesional skin is
variable with predominance of superficial perivascular inflammatory cell
infiltrates. Outcomes of allergy tests are variable with positive delayed
intradermal tests reported for penicillin V, allopurinol; positive patch tests
for erythromycin, mitomycin, nystatin, pseudoephdrine; positive lymphocyte
transformation tests for erythromycin; and positive drug provocation tests for
clindamycin, cimetidine, corticosteroids, terbinafine, and valacyclovir.
SUMMARY: Diagnosis of SDRIFE
is dependent upon recognition of the clinical morphology and distribution of
the rash, and its temporal relationship to the use of the suspected drug.
Outcomes of in-vivo and in-vitro tests have been inconsistent, and thus may not
be useful in the identification of the putative drug.
How are his renal functions? I would worry about Staph Scalded Skin Syndrome as well.
ReplyDeleteThanks for your comments. His renal and liver function were normal. Swab taken from the blistering area on the right loin did not grow any pathogens. So far there are no new lesions.
ReplyDeleteFrom Sunil Dogra, Chandigarh, India: "" Dear Henry, thanks for this case presentation - uncommon, this presentation can be consistent with SDRIFE.
ReplyDeleteTreatment: Stop suspected drugs, Short course oral corticosteroids, bland emollient locally, avoid local antiseptics, Mild topical corticosteroids if required, antihistamines and comfortable clothing. There are instances when there is no definite history of prior drug intake in recent past. Often takes 1 week to 10 days for rash to subside.
Drug Rash vs Viral rash: Viral exanthem often has prodrome, Cephalocaudal spread, cervical, auricular lymphadenopathy common. Very minimal itching unlike drug rash, Constitutional symptoms including arthralgia more common in viral rash, target lesions, mucosal erosions more common with drug rash, palms soles more often involved in drug rash."