BCCCP: Erythema multiforme Critical Care Questions

Question 1 of 10

1. Question

A 58-year-old man is admitted to the ICU for septic shock. Three days after starting vancomycin and piperacillin–tazobactam, he develops dozens of symmetric, targetoid lesions on his trunk and extremities without significant mucosal involvement. Which of the following statements most accurately describes erythema multiforme (EM) as the primary diagnosis in this patient?

EM is likely the primary diagnosis due to the classic targetoid morphology, regardless of his ICU status.
EM is unlikely because it is most often triggered by herpes simplex virus and is seldom drug-induced in ICU patients.
EM is unlikely; drug-induced Stevens-Johnson syndrome/toxic epidermal necrolysis is more common in critically ill patients presenting with targetoid lesions.
EM is likely and often progresses to epidermal necrolysis in critically ill patients.

Question 2 of 10

2. Question

A 45-year-old male admitted to the ICU with severe sepsis secondary to pneumonia was started on a sulfonamide antibiotic 5 days ago. He now develops widespread purpuric macules and atypical target lesions on his trunk and extremities. He has painful erosions on his oral mucosa and conjunctivae. On examination, there is epidermal detachment involving approximately 8% of his body surface area. Which of the following is the MOST appropriate classification of this dermatologic reaction?

Erythema Multiforme Major
Stevens-Johnson Syndrome
SJS–TEN Overlap
Toxic Epidermal Necrolysis

Question 3 of 10

3. Question

A 45-year-old male presents with a 3-day history of widespread target lesions involving his arms and torso (involving approximately 8% of total body surface area) and painful erosions of his oral, ocular, and genital mucosa. He reports a recent herpes simplex virus (HSV) outbreak. Laboratory studies show mild leukocytosis. Considering his clinical presentation consistent with erythema multiforme major, what is the MOST appropriate initial pharmacologic intervention?

High-dose intravenous acyclovir
Systemic corticosteroids (e.g., methylprednisolone)
Intravenous immunoglobulin (IVIG)
Cyclosporine

Question 4 of 10

4. Question

A 45-year-old male is admitted to the ICU with rapidly progressing toxic epidermal necrolysis (TEN) involving 35% of his total body surface area. He is mechanically ventilated for airway protection and receiving norepinephrine infusion to maintain blood pressure. His renal function is normal, and the causative drug has been discontinued. Considering the severity of his condition and his stable renal function, which adjunctive pharmacotherapy agent should be prioritized to halt disease progression and improve survival?

Cyclosporine 3–5 mg/kg/day
Intravenous immunoglobulin (IVIG) 2–3 g/kg over several days
Systemic corticosteroids (e.g., high-dose methylprednisolone)
Etanercept 50 mg subcutaneously weekly

Question 5 of 10

5. Question

A 45-year-old, 70 kg man in the ICU with systemic inflammation and hypoalbuminemia (albumin 2.0 g/dL) requires intravenous methylprednisolone. Considering critical illness–related increases in corticosteroid free fraction and volume of distribution, which initial dosing strategy is most appropriate?

Initiate methylprednisolone 0.25 mg/kg/day (≈17.5 mg/day, IV) and titrate upward based on clinical response.
Administer methylprednisolone 2 mg/kg/day (≈140 mg/day, IV) and monitor total corticosteroid levels to guide dosing.
Start methylprednisolone 0.5 mg/kg/day (≈35 mg/day, IV) divided every 6 hours, assuming accelerated metabolism.
Initiate methylprednisolone 1 mg/kg/day (≈70 mg/day, IV) once daily, with close monitoring of efficacy and adverse effects.

Question 6 of 10

6. Question

A 58-year-old man in the ICU develops phenytoin-induced erythema multiforme major with widespread target lesions on skin and mucous membranes. Phenytoin has been discontinued and supportive therapy is underway. As the critical care pharmacist, you must recommend a monitoring plan that evaluates clinical response and detects potential complications. Which of the following monitoring strategies best meets these objectives?

Daily detailed clinical examination of skin and mucosal lesions with body surface area (BSA) mapping and serial photography; twice-daily point-of-care glucose checks; and daily inspections for signs of secondary bacterial infection (with cultures if indicated).
Daily pain and pruritus scores; daily complete blood count (CBC) and comprehensive metabolic panel (CMP); and C-reactive protein measured every 48 hours.
Twice-daily vital signs and hemodynamic monitoring; daily BSA estimation without photographic documentation; and weekly CMP.
Daily ophthalmology and mucosal swab cultures; daily fluid intake/output and electrolyte checks; and weekly CBC.

Question 7 of 10

7. Question

A 45-year-old male (weight 80 kg) with a history of type 2 diabetes mellitus and hypertension is admitted to the ICU for severe erythema multiforme. He was started 10 days ago on IV methylprednisolone 1 mg/kg/day (80 mg/day). On admission, his vital signs were stable (BP 120/70 mm Hg, HR 82 beats/min, T 37 °C). A morning cortisol level obtained on day 10 is 3 µg/dL (reference range 7–25 µg/dL), indicating HPA axis suppression. Skin lesions have stabilized, with no new target lesions. The critical care team plans to de-escalate corticosteroid therapy safely. Considering the risks of adrenal insufficiency and disease relapse, which of the following tapering strategies is most appropriate?

Discontinue corticosteroids immediately to minimize adrenal suppression.
Rapidly taper corticosteroids over 3–5 days, then transition to oral prednisone for discharge.
Initiate a gradual taper of corticosteroids over 1–3 weeks, with close clinical monitoring for relapse.
Maintain the current high dose of corticosteroids until all skin lesions are completely healed to prevent recurrence.

Question 8 of 10

8. Question

A 35-year-old man is being treated in the ICU for toxic epidermal necrolysis. He has tolerated enteral nutrition via a nasogastric tube for 48 hours, with stable renal and hepatic function. For the past 3 days, he has received IV methylprednisolone 40 mg once daily. His skin lesions are improving, and you plan to convert his corticosteroid therapy from IV to enteral. (Note: methylprednisolone 4 mg ≈ prednisone 5 mg.) Which of the following is the MOST appropriate conversion plan?

Discontinue IV methylprednisolone and initiate oral prednisone 40 mg once daily via nasogastric tube.
Discontinue IV methylprednisolone and initiate oral prednisone 50 mg once daily via nasogastric tube.
Discontinue IV methylprednisolone and initiate oral prednisone 60 mg once daily via nasogastric tube.
Discontinue IV methylprednisolone and initiate oral hydrocortisone 100 mg once daily via nasogastric tube.

Question 9 of 10

9. Question

A 58-year-old man with severe erythema multiforme is receiving high-dose intravenous methylprednisolone in the ICU. He develops persistent hyperglycemia (blood glucose >250 mg/dL), new fever, productive cough, and a chest X-ray showing new infiltrates consistent with pneumonia. Laboratory cultures are pending. Considering his corticosteroid therapy and acute complications, which of the following represents the most appropriate prioritized management strategy?

Initiate a basal–bolus insulin regimen, administer empiric broad-spectrum antibiotics, and continue the current methylprednisolone dose.
Start a sliding-scale insulin regimen, obtain an infectious diseases consultation, and gradually taper methylprednisolone.
Initiate a basal–bolus insulin regimen, start empiric levofloxacin monotherapy, and continue the current methylprednisolone dose.
Initiate an intravenous insulin infusion, start empiric piperacillin-tazobactam plus vancomycin, and taper methylprednisolone.

Question 10 of 10

10. Question

Formulate dosing adjustments for corticosteroids and immunomodulators in patients with significant organ dysfunction, including those on renal replacement therapy.

No dosing adjustment is necessary for corticosteroids in patients undergoing renal replacement therapy.
Immunomodulators require dose reduction in patients with liver dysfunction but not in those on renal replacement therapy.
Corticosteroid dosing should be adjusted based on the severity of organ dysfunction, including renal and hepatic impairment, and considerations should be made for those on renal replacement therapy.
Immunomodulators do not require dose adjustment regardless of organ dysfunction or renal replacement therapy.

Quiz Summary

Information

Results