erythema multiforme
Introduction
Polymorphic erythema The erythema multiformeexudativum (EME) is an acute exudative inflammation of the skin-mucosal disease, also known as erythema multiforme (EM). Because this disease has the outstanding performance characteristics of exudation, it should be called polymorphic exudative erythema more accurately, and it is completely summarized from the name of the disease. basic knowledge The proportion of sickness: 0.004% - 0.006% Susceptible people: no specific population Mode of infection: non-infectious Complications: sepsis
Cause
Polymorphic erythema
Since the etiology of polymorphic exudative erythema has not been clarified so far, the etiology is more.
First, drug allergic reactions
Mainly refers to those who have allergies, they are likely to cause allergic reactions after using certain drugs, how many different forms of erythema, blisters, erosions, etc. appear on the skin and mucous membranes, common sensitizing drugs Such as sulfonamides, antibiotics, barbiturates, phenylbutazone, antipyretics, randin or carbamazepine.
Second, immune factors
Many scholars have studied the relationship between immunity and polymorphic exudative erythema, and believe that immune factors are also a possible factor in the pathogenesis. For example, Kraeger et al. (1973) measured macrophage aggregating activity in 5 patients with polymorphic exudative erythema. (macrophage aggregation activity, MAA), in which 2 cases of MAA increased, Safai et al (1975) reported elevated serum and blister IgG levels in two patients with bullous polymorphic exudative erythema diagnosed clinically and histologically. Phenomenon, while the early blister fluid decreased in the complement components, immune complexes increased, Kazmicrowski et al (1978) used direct immunofluorescence to observe 17 cases of polymorphic exudative erythema skin sections, found all specimens damaged early within 24h of the onset In both, C3 and/or IgM deposition is shown on the small blood vessels of the papillary layer.
Third, the virus infection
Soltz-Szots (1963) reported that polymorphic exudative erythema was induced by herpes simplex virus vaccine in the treatment of recurrent herpes simplex, and Shelley (1967) subcutaneously injected herpes simplex virus vaccine with 0.01 ml to replicate polymorphic exudative erythema. In addition to herpes simplex virus, Coxsackie virus, measles virus, Echovirus, poliovirus, etc. can all be used as antigens to induce the disease, so polymorphic exudative erythema is recognized as a An allergic reaction.
Fourth, bacterial infection
It is mainly a pyogenic cocci infection, which causes disease as an antigen, including hemolytic streptococcus, staphylococcus, brucella, diphtheria, erysipelas, and the like.
5. Mycoplasma infection
It is currently believed that Mycoplasma pneumoniae is a pathogen causing human disease. For example, Lyell et al. (1967) isolated Mycoplasma pneumoniae from 2/13 cases of erythema of severe polymorphic exudative erythema, and the titer of complement-binding antibody increased. Mycoplasma pneumoniae, oral mycoplasma and human mycoplasma type I were isolated from the oropharynx of 5 other patients with polymorphic exudative erythema. The pathogenic effect of mycoplasma is currently considered to be explained in two aspects: on the one hand, mycoplasma membrane and Its metabolites directly adhere to the respiratory tract and cause disease, and the other is an allergic reaction.
Six other factors
Such as the patient's mental stress, excessive fatigue, food allergies, lesion infection, and even suffering from cold can induce the disease.
Prevention
Polymorphic erythema prevention
1. Prevention and control of infection, protective isolation, because the child is easy to concomitant infection, those who live in a single room or live in a room with infected children, open the door and window regularly, and disinfect with a dynamic air disinfection machine 2 times, 2 h/time, keep the room temperature at 24~26°C, keep the child in a state of no sweat or sweat, strictly control the number of accompanying people and the number of visits, wet the floor of the ward with chlorine-containing disinfectant 1~2 times/d and wipe Bedside tables, chairs, doors and windows 1 time / d, sheets, quilt cover and clothing are used after autoclaving, and timely replacement, cotton products are appropriate, all treatment, inspection and care, medical staff wash hands in time, and use new Jie Ling spray hands disinfection, thermometer, sphygmomanometer and other fixed use, and related education for family members, no cases of this group of concurrent infection.
2. Skin care, effective skin care can prevent infection, promote skin damage as soon as possible, is the key to ensure the treatment effect, specific measures:
(1) Put the child in a temperature and humidity environment, insist on daily replacement of sheets, bedding, keep clean, clean, trim the nails of children, and wrap your hands with gloves or gauze to avoid scratching the skin, pay attention to Keep the skin wrinkles clean and dry, regularly turn over, prevent skin pressure, avoid rubbing the skin, parents should wash their hands with soap before and after contact with children, if necessary, use Xinjie Ling spray disinfection to avoid skin infection.
(2) Itching, redness and blisters in the skin, calamine lotion to relieve itching, skin mucous membranes if damaged, erosive, exudate, wet with 1:10 iodine or 2% boric acid (20~30 min/time), there is a large amount of antibiotic ointment after the blister fluid in the bullae, such as Baidubang protection.
(3) The perianal, perineal and other special parts are smashed with physiological saline, and severely washed with 1:10 iodine, then protected with comfrey oil or citric acid ointment.
(4) promptly clean the affected area of the molt, dandruff, skin during the recovery period, dry skin, pain, lithosperm oil protection, close observation of the progress, distribution and nature of the rash, in order to timely treatment, after treatment of most children 3~5 d crusting, gradually falling off and growing new skin, no case of skin infection in this group.
3. Eye care, 11 cases of eye damage occurred in this group, use a cotton swab to wash the eyes with saline, pay attention to clear secretions, peel off the suede and eyelashes, and then use rifampicin, tobacco or more Wei eye drops, alternating use, 2 ~ 3 times / d, two people collaborated, 11 cases of no ocular complications.
4. Oral care, most children have lip and mucous membrane erosion, encourage larger children to gargle with 5% sodium bicarbonate, if necessary, use sputum 2~3 times / d, for small children can use 2.5 % sodium bicarbonate or Yikou cleans the mouth to prevent the occurrence of thrush; children with perioral dry skin are coated with cod liver oil protection, and most children recover from 5 to 7 days.
5. Urinary tract care, encourage children to drink more water, urinate to wash the urethra naturally, prevent urinary tract infections, use hot compresses for dysuria, listen to running water or gently press the bladder area to help them solve the problem, this group of 3 children After the above method, the prescription could not be relieved, the catheter was instructed according to the doctor's advice, and the urine routine examination was performed regularly. The bladder was rinsed daily with the antibiotic solution. The time of the catheter was not more than 1 week, and 2 cases had no abnormal changes in urine culture.
6. Dietary care, give high-calorie, nutrient-rich, digestible liquid or semi-liquid diet, fasting irritating foods to avoid irritating mouth ulcers; disable allergic foods such as fish, shrimp, milk, etc., to prevent re-allergy and induce rash For those who have difficulty eating, follow the doctor's advice to give intravenous supplements to ensure adequate nutrition and calories, and promote skin repair.
7. Application of special drug care.
(1) Glucocorticoid can inhibit immune response and alleviate the damage of allergic reaction to the human body. High-dose methylprednisolone shock treatment is very effective for early treatment of severe exudative polymorphic erythema, but it is easy to cause arrhythmia. Increased blood sugar, high blood pressure, digestive tract ulcers and other adverse reactions, so the heart rate, blood pressure, blood sugar, electrolytes and observing the digestive tract should be monitored during use. For children with poor constitution, enter the methionine intravenously before entering the hormone. or oral Gifford to protect the gastric mucosa to prevent the occurrence of stress ulcers, no case of stress ulcers and arrhythmia occurred in this case group, 3 cases of hypertension, normalization by diuretic and oral antihypertensive drugs, 1 case of concurrent Severe liver damage and diabetes death.
(2) Intravenous gamma globulin is a pure biological product extracted from the blood of healthy people. During the input process, it is necessary to closely observe whether there is fever, chills, rash and other side reactions. When using an infusion pump, it should be slow and fast, and stabilize within 12 hours. Input, no adverse reactions occurred in this group of patients during the input process.
Complication
Polymorphic erythema complications Complications sepsis
In severe cases, toxicemia can occur, and sometimes it can be caused by bacterial infection and death from pneumonia or sepsis.
Symptom
Polymorphous erythema symptoms common symptoms edema joint pain pruritus keratitis acute disease local burning
Diagnosis based on clinical manifestations:
1. Acute sudden, the cause is unknown, and sometimes may be related to drug allergic reactions.
2. Local acute exudative inflammation, oral mucosal congestion (or blistering), erosion, exudate, oozing (spontaneous or stimulating), so that the red part of the lips often has purple blood stasis, when the condition is not controlled, The blood stasis is thickened and shaped like purpura. The lesions in the mucous membrane of the mouth can be noticed by blood in the sputum. The skin is target erythema. If it is a severe case, in addition to the oral cavity, the skin manifests in addition to the eye or genitals. Damage to the place.
The disease has self-limiting; it occurs in young men and young adults; the onset is rapid, there are many headaches, discomfort, dry mouth, sore throat, burnout and other prodromal symptoms; joint pain and body temperature rise during attack, generally divided into light and heavy Two.
First, light
The mild type of the disease mainly refers to the onset of oral mucosa or associated skin lesions, and generally the systemic symptoms are mild.
Oral mucosa
Damage to the oral mucosa can occur alone or simultaneously or sequentially with the skin, and the lesion can occur anywhere in the oral mucosa.
(1) lip
The incidence of polymorphic exudative erythema in the oral cavity is 70%. In the lip, damage occurs, so the lip is a good site for the disease, and the lower lip is more common. Local congestion, edema, and appearance on the mucosa at the beginning. The erythema is not as obvious as the skin erythema and the boundary is clear. The oral mucosa is easy to cause blistering due to speech, frictional movement of eating, so it is often difficult to see the blistering period. Check the common intramucosal mucosa, and the red lip mucosa is larger or smaller. The erosion surface, exudation, and slow spontaneous or stimulating oozing, resulting in thickening of the blood stasis layer; eventually forming a purple-black sputum-like blood sputum, in the words, eating and pulling the lip is likely to cause bleeding In the morning, the upper and lower lips can be seen to stick together, and the red part of the lips is covered with purple and black blood, which cannot be opened.
(2) internal cavity
The incidence of oral cavity is mostly in the cheek, and its clinical manifestations are mainly congestion, edema, erosion, exudation, and the phenomenon of oozing is not as obvious as the lip, and its oozing phenomenon is easily ignored due to sputum secretion and flushing. Some patients in the consultation will recall that the sputum contains blood.
2. Skin performance
The appearance of polymorphic exudative erythema on the skin is obvious, mainly found in the hands, the back of the foot and the extremities of the extremities or the appearance of various forms of round or elliptical erythema, often scattered symmetrically, the initial erythema is bright red Color, can be slightly convex, gradually transform into dark red, in the development of the lesion, the erythema is centrifugally enlarged, so the outer ring is bright red, the inner circle is second, the center is the old dark red, like the color ring, or similar The target ring, now called the skin target erythema, is the skin characteristic of the disease. Blisters can also appear in the center of the erythema. Even the blister has bleeding spots, sometimes deep blistering and not bulging.
The patient felt local burning and itching discomfort.
Second, heavy
Heavy refers to the serious type of the disease. In 1922, Stevens and Johnson first reported the polymorphic exudative erythema of the oral mucosa with eye disease, which is a serious type of the disease, also known as the Sjou syndrome (Stevens-Johnson) Syndrome), in addition to systemic symptoms, and multiple organ damage.
1. General condition
Systemic symptoms are obvious, heavier, such as elevated body temperature, even up to 40 ° C, headache, sore throat, and even joint pain, blood test shows the total number of white blood cells and lymphocytes rise, ESR sharply accelerated, see the patient's acute illness when visiting The face is flushed, the eyes are closed, the burnout is less, and even the collapse is near.
2. Oral mucosa or lip
Local congestion, edema, accompanied by large or small erosion surface, exudation, oozing, increased sputum, lip red lesions sometimes have blood stasis, affecting speech and eating due to pain.
3. Skin
The skin has typical target erythema, varying in size and size, and similar erythema can overlap or fuse.
4. Eyes
Generally, the eyes are acute inflammation, combined with membrane congestion, bloated, internal erosion, more secretions, shame-like, manifested as conjunctivitis or keratitis, and sometimes various levels of inflammation in the eye.
5. Pussy
Genital, anal mucosa can be congestion, erosion, pain and discomfort.
6. Other
Can also be complicated by bronchitis, bronchitis and pneumonia.
The above-mentioned damage of multiple organs is mainly caused by congestion, edema and erosion in the oral cavity, target erythema on the skin, and other 1 or 2 lesions, and the diagnosis can be established. This multi-organ lesion is multi-turn. Erosive ectodermal disease, now collectively referred to as Stevens-Johnson syndrome.
Examine
Polymorphic erythema examination
Epithelial keratinization, intracellular or extracellular edema, inflammatory cells in the epithelial layer, mainly monocytes and polymorphonuclear cells; epithelial or subepithelial blister formation; epithelial surface tissue may have severe liquefaction degeneration; due to blisters Lower basal cell degeneration, epithelial blister can become subepithelial blister; basement membrane becomes thin or disappear; lamina propria has inflammatory cell infiltration, which is eosinophils and polymorphonuclear cells; especially small blood vessels dilate, hyperemia, blood vessels The endothelial cells are swollen and there is red blood cell exudation.
Diagnosis
Diagnosis and differentiation of polymorphic erythema
Diagnosis based on clinical manifestations:
1. Acute sudden, the cause is unknown, and sometimes may be related to drug allergic reactions.
2. Local acute exudative inflammation, oral mucosal congestion (or blisters), erosion, exudation, oozing (spontaneous or stimulating), so that the labia often has purple blood stasis, when the condition is not controlled, The blood stasis is thickened and shaped like purpura. The lesions in the mucosa of the mouth may notice the bloody phenomenon in the sputum, and the skin is the target erythema; if it is a severe case, the eye or genitals are combined except for the oral and skin manifestations. Damage to the place.
