A 35-year-old man with tuberculosis on anti-TB therapy (isoniazid, rifampicin, pyrazinamide, ethambutol) for 3 weeks presents with high fever (39.2°C), generalized erythema, and blistering of skin and mucous membranes. On examination, he has extensive flaccid bullae and erosions affecting >50% of his body surface, including the oral cavity, conjunctivae, and genital region. His skin is tender and shows areas of epidermal detachment. Laboratory findings: WBC 11,200/μL (with left shift), hemoglobin 10.8 g/dL, albumin 2.8 g/dL, creatinine 1.8 mg/dL, and ALT 156 U/L. Blood and urine cultures are pending. What is the most appropriate immediate management?

Explanation

## Management of Toxic Epidermal Necrolysis (TEN) ### Case Analysis: TEN Diagnosis **Key Point:** This patient has TEN—defined by >30% BSA involvement with full-thickness epidermal necrosis and flaccid bullae. The clinical presentation (high fever, extensive blistering, mucosal involvement, >50% BSA) and temporal relationship to anti-TB drugs (isoniazid, rifampicin, pyrazinamide are known culprits) confirm the diagnosis. ### Immediate Management Algorithm ```mermaid flowchart TD A[Suspected TEN/SJS]:::outcome --> B[Confirm diagnosis]:::action B --> C[Discontinue offending drug immediately]:::urgent C --> D[ICU admission]:::action D --> E[Supportive care]:::action E --> F1[IV fluids + electrolyte monitoring] E --> F2[Infection surveillance] E --> F3[Ophthalmology consult] E --> F4[Nutritional support] G{Systemic corticosteroids?}:::decision D --> G G -->|Early SJS/TEN<br/>within 48 hrs| H[Consider pulse methylprednisolone]:::action G -->|Established TEN<br/>>48 hrs| I[Supportive care only]:::action J{IVIG indicated?}:::decision D --> J J -->|Fulminant course<br/>or refractory| K[Consider IVIG]:::action J -->|Standard TEN| L[Supportive care]:::action ``` ### Why Discontinuation is Mandatory **High-Yield:** The single most important intervention in TEN is **immediate discontinuation of the offending drug**. Continuing the culprit drug perpetuates the immune-mediated keratinocyte apoptosis and worsens outcomes. **Clinical Pearl:** Anti-TB drugs (especially isoniazid, rifampicin, and pyrazinamide) are among the top drug culprits for SJS/TEN in India. The temporal relationship (3 weeks of therapy) is typical for drug-induced TEN. ### Supportive Care Priorities | Intervention | Rationale | Target | |--------------|-----------|--------| | **IV fluid resuscitation** | Massive fluid loss from denuded skin (like severe burns) | Maintain UOP 0.5–1 mL/kg/hr | | **Electrolyte monitoring** | Risk of hyperkalemia (from cell death), hyponatremia (dilution) | Daily labs; correct carefully | | **Infection surveillance** | Denuded skin is a portal for bacterial/fungal infection (mortality risk) | Blood/urine cultures; prophylactic antibiotics only if infection proven | | **Ophthalmology care** | Risk of corneal ulceration, symblepharon, blindness | Daily eye examination; lubricants; avoid adhesions | | **Nutritional support** | Massive protein loss; hypermetabolic state | High-protein diet/TPN if unable to eat | | **Pain management** | Severe pain impairs healing and increases mortality | Opioids; avoid NSAIDs | ### Rationale Against Other Options **Warning:** Continuing anti-TB therapy while TEN is evolving is dangerous—the drug is the driver of the reaction. Stopping it is the only way to halt progression. **Systemic Corticosteroids:** Controversial in TEN. Evidence is weak and conflicting. They may be considered in **early SJS (within 48 hours of onset)**, but this patient is already in established TEN (>50% BSA, multi-system involvement). High-dose steroids in late TEN increase infection risk without clear benefit. **IVIG:** No strong evidence for routine use in TEN. May be considered in fulminant cases or when disease is refractory to supportive care, but is NOT first-line. **Topical antibiotics alone:** Inadequate for systemic TEN. Requires ICU-level supportive care. ### Prognosis & Mortality **Mnemonic: SCORTEN Score** — Predicts mortality in TEN - **S**ex (female = 1 point) - **C**age (>40 years = 1 point) - **O**rgan involvement (heart, lungs, GI = 1 point each) - **T**emperature (>39°C = 1 point) - **R**ate of progression (>10% BSA/day = 1 point) - **E**lectrolytes (urea >10 mmol/L = 1 point) - **N**eutrophils (>11,500/μL = 1 point) This patient has fever (39.2°C), elevated WBC, renal dysfunction, and >50% BSA—high SCORTEN score, indicating high mortality risk. Aggressive supportive care is critical. [cite:Harrison 21e Ch 56; Robbins 10e Ch 25]