key: cord-0733899-lctbn3yt
authors: Rahim, Mehek; Hong, Sung; Omidvari, Karan
title: BLAME IT ON THE PRONE: COVID-19-ASSOCIATED STEVEN-JOHNSON SYNDROME AS A MIMIC OF PRONE POSITION PRESSURE INJURY
date: 2021-10-31
journal: Chest
DOI: 10.1016/j.chest.2021.07.714
sha: b0371317c8d8e97b929b08473c0ca38931cb346d
doc_id: 733899
cord_uid: lctbn3yt

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Prone positioning (PP) in patients with acute respiratory distress syndrome (ARDS) has shown to increase ventilation and survival in conjunction with low tidal volume ventilation strategy. PP is a highly utilized treatment adjunct in patients admitted with severe COVID-19 pneumonia. One of the most common complications when in prone position is pressure sores and skin breakdown. We present a unique case of COVID-19 associated Steven Johnson Syndrome (SJS) that mimics skin blistering associated with patients placed in PP. CASE PRESENTATION: 61-year-old female with history of metabolic syndrome who was diagnosed with COVID-19 pneumonia complicated by ARDS requiring mechanical intubation was transferred to our institution for advanced circulatory support evaluation. Upon arrival, a lung protective strategy including low tidal volume as well as early PP was initiated. On day four of admission, exam revealed blistering of the oral mucosa, which was initially thought to be due to prolonged PP. Despite conservative management, the blisters progressed to mucosal erosions, a new morbilliform eruption on the trunk and extremities with intact bullae on the thighs. Punch biopsy revealed full thickness epidermal necrosis and subepidermal vesiculation consistent epidermal necrolysis, compatible with SJS. Pulse dose steroids were initiated with subsequent recovery of her skin blisters. DISCUSSION: PP in mechanically ventilated patients has been shown to decrease mortality in severe ARDS. Prone position pressure sores (PPPS) are a common complication associated with prolonged duration of PP. PPPS often manifest as stage II pressure injuries located over bony prominences of the face and are managed conservatively. SJS/toxic epidermal necrolysis (TEN) is a fatal medical emergency. It is a systemic disease that is thought to be immunologically mediated with primarily mucocutaneous manifestations, often triggered by medications or certain viral infections. Oral ulcers and blisters seen in SJS can sometimes be confused for PPPS. Given its rapid progression and associated fatality, conservatively managing SJS if confused for PPPS can lead to increased morbidity and mortality.A comprehensive medication reconciliation in our patient did not identify a trigger. which led us to suspect COVID-19¬ as the potential culprit. We hypothesize that the cytokine storm and multi-system organ dysfunction in severe COVID-19 infection is the underlying mechanism leading to SJS. To our knowledge, this is the first reported case of COVID-19 associated SJS. CONCLUSIONS: PPPS are commonly seen in PP ventilated patients. Skin blisters which do not resolve with a trial of conservative management warrant further investigation with close and thorough physical examination as they may be masking a serious underlying diagnosis. REFERENCE #1: Coppadoro, Andrea, and Guiseppe Foti. "Prone Positioning in Severe Acute Respiratory Distress Syndrome." 50 Studies Every Intensivist Should Know, 2018, pp. 129–134. doi:10.1093/med/9780190467654.003.0021. REFERENCE #2: Lerch, Marianne, et al. "Current Perspectives on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis." Clinical Reviews in Allergy & Immunology, vol. 54, no. 1, 2017, pp. 147–76. Crossref, doi:10.1007/s12016-017-8654-z. REFERENCE #3: Ibarra, Gorka, et al. "Prone Position Pressure Sores in the COVID-19 Pandemic: The Madrid Experience." Journal of Plastic, Reconstructive & Aesthetic Surgery, 2020. Crossref, doi:10.1016/j.bjps.2020.12.057. DISCLOSURES: No relevant relationships by Sung Hong, source=Web Response No relevant relationships by Karan Omidvari, source=Web Response No relevant relationships by Mehek Rahim, source=Web Response

INTRODUCTION: Prone positioning (PP) in patients with acute respiratory distress syndrome (ARDS) has shown to increase ventilation and survival in conjunction with low tidal volume ventilation strategy. PP is a highly utilized treatment adjunct in patients admitted with severe COVID-19 pneumonia. One of the most common complications when in prone position is pressure sores and skin breakdown. We present a unique case of COVID-19 associated Steven Johnson Syndrome (SJS) that mimics skin blistering associated with patients placed in PP.

CASE PRESENTATION: 61-year-old female with history of metabolic syndrome who was diagnosed with COVID-19 pneumonia complicated by ARDS requiring mechanical intubation was transferred to our institution for advanced circulatory support evaluation. Upon arrival, a lung protective strategy including low tidal volume as well as early PP was initiated. On day four of admission, exam revealed blistering of the oral mucosa, which was initially thought to be due to prolonged PP. Despite conservative management, the blisters progressed to mucosal erosions, a new morbilliform eruption on the trunk and extremities with intact bullae on the thighs. Punch biopsy revealed full thickness epidermal necrosis and subepidermal vesiculation consistent epidermal necrolysis, compatible with SJS. Pulse dose steroids were initiated with subsequent recovery of her skin blisters.

DISCUSSION: PP in mechanically ventilated patients has been shown to decrease mortality in severe ARDS. Prone position pressure sores (PPPS) are a common complication associated with prolonged duration of PP. PPPS often manifest as stage II pressure injuries located over bony prominences of the face and are managed conservatively. SJS/toxic epidermal necrolysis (TEN) is a fatal medical emergency. It is a systemic disease that is thought to be immunologically mediated with primarily mucocutaneous manifestations, often triggered by medications or certain viral infections. Oral ulcers and blisters seen in SJS can sometimes be confused for PPPS. Given its rapid progression and associated fatality, conservatively managing SJS if confused for PPPS can lead to increased morbidity and mortality.A comprehensive medication reconciliation in our patient did not identify a trigger. which led us to suspect COVID-19: as the potential culprit. We hypothesize that the cytokine storm and multi-system organ dysfunction in severe COVID-19 infection is the underlying mechanism leading to SJS. To our knowledge, this is the first reported case of COVID-19 associated SJS.

CONCLUSIONS: PPPS are commonly seen in PP ventilated patients. Skin blisters which do not resolve with a trial of conservative management warrant further investigation with close and thorough physical examination as they may be masking a serious underlying diagnosis.

Prone Positioning in Severe Acute Respiratory Distress Syndrome

Current Perspectives on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis