A decade of burn unit experience with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: Clinical pathological diagnosis and risk factor awareness.

Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN) is a rare and often fatal spectrum of mucocutaneous diseases usually attributable to severe adverse drug reactions. Burn units are referral centers for patients at the most extreme end of the disease continuum. Our burn center admits a much higher percentage of TEN (>30% BSA) cases than reported in most prior reviews. The purpose of this study was to analyze the diagnostic and prognostic value of variables collected on referred SJS/TEN patients. We retrospectively analyzed 94 patients admitted to our unit with a presumptive SJS/TEN diagnosis made in most cases by the referring center. Most of the diagnoses were clinical. Fifty of the 94 patients underwent biopsy when the clinical diagnosis was questionable. Of the 50 patients who underwent biopsy, 18 (36%) received an alternative diagnosis. Analysis was therefore limited to 76 patients, i.e. 44 patients felt to have firm clinical diagnoses plus 32 patients with diagnoses confirmed by biopsy. Mean age was 54.3 years (17-93) and overall gender ratio was 43 F vs. 33 M (56.6% vs. 43.4%). Mean LOS was 15.2 days (1-48) and overall mortality was 23.7% (18/76). Univariate analysis revealed percent body surface area (%BSA) did not show statistically significant association with mortality. Histopathological correlation for diagnosis is not standardized across institutions worldwide. Due to challenges in the diagnosis of SJS/TEN and the high incidence of error in clinical diagnosis, it is recommended that all patients with presumed SJS/TEN receive skin biopsies with H&E and direct immunofluorescence. We propose a diagnostic approach in order to address this need. Lack of association between %BSA and mortality suggests that all biopsy-proven SJS/TEN cases belong in specialty centers due to the unstable nature of the disease and risk for rapid progression.

Positive fungal cultures in burn patients: a multicenter review.

Fungal infections are increasingly common in burn patients. We performed this study to determine the incidence and outcomes of fungal cultures in acutely burned patients. Members of the American Burn Association's Multicenter Trials Group were asked to review patients admitted during 2002-2003 who developed one or more cultures positive for fungal organisms. Data on demographics, site(s), species and number of cultures, and presence of risk factors for fungal infections were collected. Patients were categorized as untreated (including prophylactic topical antifungals therapy), nonsystemic treatment (nonprophylactic topical antifungal therapy, surgery, removal of foreign bodies), or systemic treatment (enteral or parenteral therapy). Fifteen institutions reviewed 6918 patients, of whom 435 (6.3%) had positive fungal cultures. These patients had mean age of 33.2 +/- 23.6 years, burn size of 34.8 +/- 22.7%TBSA, and 38% had inhalation injuries. Organisms included Candida species (371 patients; 85%), yeast non-Candida (93 patients, 21%), Aspergillus (60 patients, 14%), other mold (39 patients, 9.0%), and others (6 patients, 1.4%). Systemically treated patients were older, had larger burns, more inhalation injuries, more risk factors, a higher incidence of multiple positive cultures, and significantly increased mortality (21.2%), compared with nonsystemic (mortality 5.0%) or untreated patients (mortality 7.8%). In multivariate analysis, increasing age and burn size, number of culture sites, and cultures positive for Aspergillus or other mold correlated with mortality. Positive fungal cultures occur frequently in patients with large burns. The low mortality for untreated patients suggests that appropriate clinical judgment was used in most treatment decisions. Nonetheless, indications for treatment of fungal isolates in burn patients remain unclear, and should be developed.