The recent outbreak of COVID-19 has put significant strain on the current health system and has exposed dangers previously overlooked. The pathogen known as severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), is notable for attacking the pulmonary system causing acute respiratory distress, but it can also severely affect other systems in at-risk individuals including cardiovascular compromise, gastrointestinal distress, acute kidney injury, coagulopathies, cutaneous manifestations, and ultimately death from multi-organ failure. Unfortunately, the reliability of negative test results is questionable and the high infectious burden of the virus calls for extended safety precautions, especially in symptomatic patients. We present a confirmed COVID-19 case that was transferred to our burn center for concern of Steven Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) overlap syndrome after having two negative confirmatory COVID-19 tests at an outside hospital. A 58-year-old female with a history of morbid obesity, HTN, gout, CML managed with imatinib, and chronic kidney disease presented as a transfer from a community hospital to our burn center. The patient was admitted to her community hospital with febrile, acute respiratory distress. Imaging and clinical presentation was consistent with COVID-19 and lab tests for the pathogen were ordered. During observation, while waiting for results, she was placed under patient under investigation (PUI) protocol. Once negative results were obtained, the PUI protocol was abandoned despite ongoing symptoms. Subsequently, dermatological symptoms developed and transfer to our burn center was initiated. After a second negative test result, the symptomatic patient was transferred to our burn center for expert wound management. Given the lack of resolve of respiratory symptoms and concern for the burn patient population, the patient was placed in PUI protocol and an internal COVID-19 was ordered. The patient's initial exam under standard COVID-19 airborne precautions revealed 5% total body surface area of loss of epidermis affecting bilateral thighs, bilateral arms, and face. A dermatopathological biopsy suggested a bullous drug reaction with an erythema multiform-like reaction pattern versus SJS/TEN. Moreover, the internal COVID-19 test returned positive.

Electronic cigarettes, also known as e-cigarettes (E-cig), are lithium-battery-powered devices, which became available for sale in the United States in 2017. It has gained significant popularity among younger-generation tobacco smokers due to its advertisement as a non-toxic inhalation property and a potential smoking-cessation aid. The US Food and Drug Administration (FDA) has been regulating e-cigarettes as tobacco products and not as drug-delivery devices, as many medical experts think it should be categorized. In the last few years, the medical community has encountered increasing episodes of burn injuries secondary to e-cigarette battery explosion. Explosions occur through a process known as a "thermal runaway.” This process occurs when the battery overheats and the internal battery temperature increases dangerously high, to the point of inner fire and explosion. Overcharge, puncture, external heat, short circuit, amongst others, are conditions that cause a “thermal runaway.”This is a retrospective review and analysis of six patients with superficial, partial, and full-thickness burn injuries related to e-cigarette battery explosions managed at Johns Hopkins Bayview Burn Center over the course of one year. Lund-Browder diagrams and calculations were used to assess the total body surface area (TBSA) burns. Laser Doppler imaging (LDI) was used to evaluate the indeterminate depth of the burn.Only one of our six patients required tangential excision and skin grafting. The rest of our patients were treated conservatively with complex wound care, which included the mixed combination of topical collagenase and bacitracin, collagenase and mafenide, or silver sulfadiazine as a single-agent treatment with an excellent response. Five patients were discharged home within a week, including the patient who required operative excision and auto-grafting. One patient stayed for eight days for pain control and complex wound care.Our experience with these burns has been similar to what is previously reported. Most of these burns are managed with complex wound care without any surgical interventions. The e-cigarette batteries seem more prone to failure due to an inherent weakness in their structural design. This makes them particularly susceptible to the “thermal runaway.” Therefore, we recognized the need to expand the regulation and control of the quality of these devices. Prevention of these burns will require continuing education for the community on the use of E-cig. products and its potential hazardous implications.New efforts should be made to educate the community and healthcare providers regarding the potential hazardous implication of carrying these batteries. Also, there is insufficient data to support or deny the long-term health effects of using e-cigarettes.