what are the common symptoms of sjs

 Palmieri TL, Greenhalgh DG, Saffle JR, et al. A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century. J Burn Care Rehabil. 2002;23(2):87-96. doi:10.1097/00004630-200203000-00004

Introduction: The diffuse epidermal exfoliation seen in Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) is similar to skin loss in second degree burns, and many of these patients are referred for treatment at burn centers. Treatment can differ markedly from center to center, and mortality can range from 25% to 70%, including a considerable morbidity. However, our experience over a 15-year period from 2000 to 2015 with 40 patients found a mortality rate of only 10% (4/40). The purpose of this paper is to discuss our treatment algorithm as a model for other centers treating SJS/TENs patients.

Methods: Records were reviewed for all patients admitted to the LAC+USC burn unit between 2000 and 2015 and 40 patients were identified with biopsy-proven SJS or TENS. 

These cases were reviewed for age, gender, initial and greatest TBSA, causative drug, pre-existing medical conditions, and morbidity and mortality. All data were entered into the SPSS statistical software package and all statistical analyses were performed using this program.

Results: Our treatment algorithm focused on early referral to a specialty burn unit, immediate discontinuation of the offending drug, fluid resuscitation, nutritional supplementation, and meticulous wound care. 

Average time to transfer to a burn unit was 3.36 days. Silver-releasing antimicrobial dressings were applied to the affected skin surface and changed every 3 days. Mupirocin coated petroleum gauze was used for facial involvement. Steroids were tapered and discontinued if initiated at an outside facility (58% of patients), and starting after 2001, all patients received a course of IVIG. 

All patients received fluid resuscitation, and the majority received supplemental tube feedings (69%). Average length of total stay was 17.1 days and length of ICU stay 15.9 days. While 44% were transferred to another facility for further rehabilitative care, 37% of patients discharge to home. In patients discharged home with complete resolution of skin lesions, time to healing was an average of 14 days.

Discussion: With our 10% mortality rate in 40 patients, our study represents a relatively large study population while maintaining a relatively low mortality rate. The demographic data from our study largely aligns with the existing literature, and we therefore feel that our low mortality rate is due to our treatment algorithm, rather than to a less severe pathology in our patient population. 

This claim is supported by a standard mortality ratio of 1.68. This ratio proves a significantly improved mortality than would be expected based on disease severity on admission.

Keywords: Steven Johnson Syndrome; Toxic Epidermal Necrolysis.

 The study by Clark et al. (2021) in JAAD International investigates the impact of delayed admission to a specialist referral center on the mortality rates of patients with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). The research found that delayed admission (defined as 5 days or more after the onset of skin blistering) significantly increases mortality rates compared to early admission (within 4 days). 

Specifically, the mortality rate for delayed admissions was 37%, compared to 14% for early admissions1. 

To the Editor: Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare, severe cutaneous adverse drug reactions. The average mortality across the spectrum is 25%. 

1.  Guidelines recommend that such cases be managed in reference centers.

2.  Our study aims to evaluate the impact of

delayed admission to an SJS/TEN referral center on clinical outcomes.

A retrospective cohort study was conducted from 2005 to 2018 at the Singapore General Hospital (SGH), the national referral center for SJS/TEN.

Outcomes of interest included mortality, the incidence of bacteremia at SGH, ICU admission, and length of hospital stay.  

Admissions occurring within 4 days of skin

blistering according to clinical records were considered early admissions and delayed admissions were defined as admissions occurring 5 days or more after skin blistering. 

The consensus of the 5-day cut-off was

 based on

 1) a multi-center study in Europe, 1

wherein the median admission delay was 5-7 days across several centers and 

2) the natural history of SJS/TEN, where the disease evolves from initial blistering to hospitalization in 3 days, then progresses to maximum detachment in another 5 days.

3) A total of 123 patients with SJS/TEN were included in this study. 

There were 93 (76%) patients with early

admissions and 30 (24%) with delayed admissions.

Baseline characteristics are shown in Table I.

Univariate analyses demonstrated a significant difference in outcomes between early and late admission patients for mortality (14% vs 37%; P ¼ .007),

incidence of bacteremia (20% vs 52%; P ¼.001), rate of ICU admission (14% vs 41%; P ¼.002), and total length of stay at SGH (16 6 22 vs 28 6 23; P ¼ .01). 

A dose response relationship was demonstrated between

mortality and admission delay, with mortality increasing from 15% in those admitted within 03 days, to 19% in those admitted within 4-5 days, and to 33% in those admitted within 6 days