{"id":5561,"date":"2025-03-06T00:01:00","date_gmt":"2025-03-06T08:01:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=5561"},"modified":"2025-10-01T11:38:24","modified_gmt":"2025-10-01T19:38:24","slug":"usmle-step-1-question-of-the-day-skin-blistering-2","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-skin-blistering-2","title":{"rendered":"USMLE\u00ae Step 1 Question of the Day:\u00a0Skin blistering"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-skin-blistering-2\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\" >The correct answer to today\u2019s USMLE\u00ae Step 1 Question is\u2026<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-skin-blistering-2\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-skin-blistering-2\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-skin-blistering-2\/#Major_Takeaway\" >Major Takeaway&nbsp;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-skin-blistering-2\/#References\" >References&nbsp;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-skin-blistering-2\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Each week, Osmosis shares a USMLE\u00ae Step 1-style practice question to test your knowledge of medical topics. Today\u2019s case features a 38-year-old man with a fever and skin blistering after recent medication use. Can you determine the cause of his symptoms?<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 38-year-old man is brought to the emergency department to evaluate diffuse skin blistering. Around four days ago, the patient developed fevers, muscle aches, and malaise. He attributed the symptoms to a viral infection. This morning, he noticed multiple bullae on his skin all over his body. He has also experienced ulceration and desquamation of the lips and oropharynx, which has made it difficult for him to eat or drink. The patient has recently been prescribed trimethoprim-sulfamethoxazole for cellulitis and acetaminophen to treat an ankle sprain. He has been taking lamotrigine for seizure prevention for the past ten years. He received a tetanus booster shot one week ago. Temperature is 39.2\u00b0C (103\u00b0F), blood pressure is 153\/82 mmHg, and pulse is 93\/min. Physical examination reveals the following:<\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"356\" height=\"519\" src=\"https:\/\/hm-healthdigital-multisite.go-vip.net\/osmosisblog\/wp-content\/uploads\/sites\/2\/2025\/02\/image_962033.png\" alt=\"An image of a man with blistering on his face to demonstrate what Stevens-Johnson\/TEN looks like.\" class=\"wp-image-5562\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/02\/image_962033.png 356w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/02\/image_962033.png?resize=206,300 206w\" sizes=\"auto, (max-width: 356px) 100vw, 356px\" \/><figcaption class=\"wp-element-caption\">Image source: Wikimedia Commons<\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Painful lesions are present on over 5% of the patient\u2019s skin. Which of the following factors <em>most likely<\/em> precipitated this patient\u2019s current condition?\u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Tetanus booster vaccination<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Trimethoprim-sulfamethoxazole use<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Acetaminophen use<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Recent upper respiratory tract infection<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Lamotrigine use<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\"><\/span>The correct answer to today\u2019s USMLE\u00ae Step 1 Question is\u2026<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Trimethoprim-sulfamethoxazole use<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the Main Explanation, let\u2019s look at the incorrect answer explanations. Skip to the bottom if you want to learn more about the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Tetanus booster vaccination<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Vaccinations are a rare and highly debatable cause of Stevens-Johnsons syndrome (SJS)\/toxic epidermal necrolysis (TEN). Instead, medications cause almost 90% of SJS\/TEN cases in the United States.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Acetaminophen use<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Acetaminophen is an unlikely cause of SJS\/TEN and is not commonly implicated. Another component of this patient\u2019s history places him at greater risk for developing SJS\/TEN.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Recent upper respiratory tract infection<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Patients with SJS\/TEN may have a prodromal phase characterized by non-specific, flu-like symptoms such as fever, malaise, cough, and myalgias. However, viral infections are a rare and poorly documented cause of SJS\/TEN.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Lamotrigine use<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Lamotrigine is an anticonvulsant associated with around 9% of SJS\/TEN cases. Most cases of SJS\/TEN occur during the first eight weeks of therapy, making it unlikely for this patient, who has been taking it for many years. Additionally, antibiotics (e.g., trimethoprim-sulfamethoxazole, \ua7b5-lactams) are more commonly implicated as the underlying cause of SJS\/TEN.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents with painful skin bullae and ulcerations, along with desquamation of mucosal surfaces. Given 5% of the patient\u2019s skin is involved, his presentation is most consistent with Stevens-Johnsons syndrome (SJS). Of note, if skin involvement had exceeded 10%, the patient would have been diagnosed with toxic epidermal necrolysis (TEN).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">SJS and TEN are characterized by painful vesicles\/bullae on the skin, along with ulceration of mucosal membranes. SJS\/TEN most often results from an adverse reaction to medications. Trimethoprim-sulfamethoxazole is most commonly implicated in SJS\/TEN and is the underlying cause of around 26% of cases in the United States. Other medications that may trigger SJS\/TEN include \ua7b5-lactam antibiotics, anticonvulsants (e.g., lamotrigine, phenytoin), allopurinol, and NSAIDs.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Less commonly, SJS\/TEN can arise after infection by pathogens such as Mycoplasma pneumoniae and herpes simplex virus.<\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"534\" height=\"239\" src=\"https:\/\/hm-healthdigital-multisite.go-vip.net\/osmosisblog\/wp-content\/uploads\/sites\/2\/2025\/03\/image_375293.png\" alt=\"Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)\n* Severe type IV hypersensitivity reaction\n* Adverse drug reaction\n- penicillin\n- sulfonamides\n- allopurinol\n- anti-epileptic medications, especially lamotrigine\n\n* Infections ~ Mycoplasma Pneumonia\" class=\"wp-image-5568\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/03\/image_375293.png 534w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/03\/image_375293.png?resize=300,134 300w\" sizes=\"auto, (max-width: 534px) 100vw, 534px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Trimethoprim-sulfamethoxazole<\/strong> is the most common cause of Stevens-Johnson syndrome (SJS)\/toxic epidermal necrolysis (TEN) in the United States. <strong>\ua7b5-lactam<\/strong> <strong>antibiotics<\/strong>, <strong>anticonvulsants<\/strong>, <strong>allopurinol<\/strong>, and <strong>NSAIDs<\/strong> have also been identified as triggers. Less commonly, SJS\/TEN can arise due to an infection.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Micheletti, R.G., Chiesa-Fuxench, Z., Noe, M.H., et al. (2018) Steven-Johnson syndrome\/toxic epidermal necrolysis: A multicenter retrospective study of 377 adult patients from the United States. <em>The Journal of Investigative Dermatology<\/em>. 138(11), 2315-2321. Doi: 10.1016\/j.jid.2018.04.027.&nbsp;<\/li>\n\n\n\n<li>Oakley, A.M., Krishnamurthy, K. (2020) \u201cStevens-Johnson syndrome\u201d. StatPearls [Internet]. Web Address: <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK459323\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK459323\/<\/a>.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch the Osmosis video:\u00a0<a href=\"https:\/\/www.osmosis.org\/learn\/stevens-johnson-syndrome\">Stevens-Johnson Syndrome<\/a><\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><a href=\"https:\/\/www.osmosis.org\/plans\/md\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/hm-healthdigital-multisite.go-vip.net\/osmosisblog\/wp-content\/uploads\/sites\/2\/2024\/10\/Blog_Display_Ads_MOBILE3_2023.png\" alt=\"\" class=\"wp-image-4729\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/10\/Blog_Display_Ads_MOBILE3_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/10\/Blog_Display_Ads_MOBILE3_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more USMLE\u00ae Step 1 practice questions? Try Osmosis by Elsevier today! Access your&nbsp;<em><strong><a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a><\/strong><\/em>&nbsp;and discover why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Get ready for the USMLE\u00ae Step 1 exam with a case study on skin blistering and Stevens-Johnson syndrome. Learn to identify common triggers, including medications like trimethoprim-sulfamethoxazole, and understand the importance of recognizing and addressing this serious condition. Test your clinical knowledge and prepare effectively for Step 1!<\/p>\n","protected":false},"author":202,"featured_media":5564,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,16,1366,1369,44],"tags":[449,445,187,448,450,245,149,451,446,447,185],"class_list":["post-5561","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-do","category-questions","category-step-1-questions","category-step-1","tag-clinical-cases","tag-dermatology","tag-exam-preparation","tag-medical-diagnosis","tag-medication-reactions","tag-nursing-education","tag-patient-care","tag-step-1","tag-stevens-johnson-syndrome","tag-toxic-epidermal-necrolysis","tag-usmle"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 1 Question of the Day:\u00a0Skin blistering - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-of-the-day-skin-blistering-2\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 1 Question of the Day:\u00a0Skin blistering - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Get ready for the USMLE\u00ae Step 1 exam with a case study on skin blistering and Stevens-Johnson syndrome. Learn to identify common triggers, including medications like trimethoprim-sulfamethoxazole, and understand the importance of recognizing and addressing this serious condition. 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