PMC9609431_01
Skin images during intensive care unit (ICU) admission. Soot was observed mainly on his anterior chest and neck, and skin had turned grayish white, suggesting third-degree burns on the admission day (A). Erythema multiforme was seen in the anterior thorax. Erosion of the buttocks appeared and Nikolsky's phenomenon was positive on day 30 (B,C). Improvement of erythema multiforme and erosion on trunk and buttocks were observed after steroid-pulse therapy on day 37 (D,E). Successful engraftment after five times skin grafting on day 120 (F).
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His anterior chest and posterior neck were covered with soot, and the skin in these areas had turned a grayish white (Fig. 1A). Nikolsky phenomenon and oral mucosal lesions were observed, especially on the back and extremities (Fig. 1B,C). On day 37, the erythema began to fade (Fig. 1D, E). Thereafter, an additional debridement for the anterior thoracic region on day 59, STSG for anterior neck, shoulder, and thoracic (from lower abdomen skin) on day 73, and STSG for lateral neck (from posterior aspect of both thighs) on day 87 were performed under general anesthesia (Fig. 1F).
Time course of treatment of a 68-year-old man affected with TEN during the treatment of severe burns. On day 1, treatment with large amounts of fluids with ventilator management were performed in ICU. On day 8, vancomycin and ampicillin/sulbactam were initiated for burns-site infections. On day 17, ampicillin/sulbactam was terminated because of the skin rash appeared mainly on the lateral abdomen. Cefepime dihydrochloride hydrate was driven to start because acinetobacter baumannii was detected from a blood culture on day 20. On the same day, vancomycin was switched to daptomycin because of the deterioration of renal function. From day 30, the rash on the trunk and extremities rapidly worsened, all antimicrobial agents were terminated and systemic administration of 40 mg/day prednisolone was initiated as a treatment for erythema multiforme. The rash was developed to TEN on day 35, steroid-pulse therapy (methylprednisolone 1,000 mg/day) for 3 days was initiated. The skin rash was gradually disappeared and steroid therapy was tapered. On day 41, he was discharged from ICU. From day 31 to 43, renal replacement therapy was required because of the deterioration of renal function. TEN, toxic epidermal necrolysis; ICU, intensive care unit; BT, body temperature; CHDF, continuous hemodiafiltration; CRP, C-reactive protein; mPSL, methylprednisolone; STSG, split-thickness skin grafts.
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An overview of the hospital is shown in Figure 2.