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Management and outcome of Stevens–Johnson syndrome and toxic epidermal necrolysis in patients admitted to Kenyatta National Hospital. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0512-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a delayed-type hypersensitivity reaction to drugs. They represent true medical emergencies and an early recognition and appropriate management is decisive for the survival. SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms. The difference between SJS, SJS/TEN overlap, and TEN is defined by the degree of skin detachment: SJS is defined as skin involvement of < 10%, TEN is defined as skin involvement of > 30%, and SJS/TEN overlap as 10-30% skin involvement. The diagnosis of different degrees of epidermal necrolysis is based on the clinical assessment in conjunction with the corresponding histopathology. The mortality rates for SJS and TEN have decreased in the last decades. Today, the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is available for SJS/TEN severity assessment. Drugs with a high risk of causing SJS/TEN are anti-infective sulfonamides, anti-epileptic drugs, non-steroidal anti-inflammatory drugs of the oxicam type, allopurinol, nevirapine, and chlormezanone. Besides conventional drugs, herbal remedies and new biologicals should be considered as causative agents. The increased risk of hypersensitivity reactions to certain drugs may be linked to specific HLA antigens. Our understanding of the pathogenesis of SJS/TEN has improved: drug-specific T cell-mediated cytotoxicity, genetic linkage with HLA- and non-HLA-genes, TCR restriction, and cytotoxicity mechanisms were clarified. However, many factors contributing to epidermal necrolysis still have to be identified, especially in virus-induced and autoimmune forms of epidermal necrolysis not related to drugs. In SJS/TEN, the most common complications are ocular, cutaneous, or renal. Nasopharyngeal, esophageal, and genital mucosal involvement with blisters, erosions as well as secondary development of strictures also play a role. However, in the acute phase, septicemia is a leading cause of morbidity and fatality. Pulmonary and hepatic involvement is frequent. The acute management of SJS/TEN requires a multidisciplinary approach. Immediate withdrawal of potentially causative drugs is mandatory. Prompt referral to an appropriate medical center for specific supportive treatment is of utmost importance. The most frequently used treatments for SJS/TEN are systemic corticosteroids, immunoglobulins, and cyclosporine A.
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Estrella-Alonso A, Aramburu JA, González-Ruiz MY, Cachafeiro L, Sánchez MS, Lorente JA. Toxic epidermal necrolysis: a paradigm of critical illness. Rev Bras Ter Intensiva 2018; 29:499-508. [PMID: 29340540 PMCID: PMC5764563 DOI: 10.5935/0103-507x.20170075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 04/05/2017] [Indexed: 01/08/2023] Open
Abstract
Toxic epidermal necrolysis is an adverse immunological skin reaction secondary in
most cases to the administration of a drug. Toxic epidermal necrolysis,
Stevens-Johnson syndrome, and multiform exudative erythema are part of the same
disease spectrum. The mortality rate from toxic epidermal necrolysis is
approximately 30%. The pathophysiology of toxic epidermal necrolysis is similar
in many respects to that of superficial skin burns. Mucosal involvement of the
ocular and genital epithelium is associated with serious sequelae if the
condition is not treated early. It is generally accepted that patients with
toxic epidermal necrolysis are better treated in burn units, which are
experienced in the management of patients with extensive skin loss. Treatment
includes support, elimination, and coverage with biosynthetic derivatives of the
skin in affected areas, treatment of mucosal involvement, and specific
immunosuppressive treatment. Of the treatments tested, only immunoglobulin G and
cyclosporin A are currently used in most centers, even though there is no solid
evidence to recommend any specific treatment. The particular aspects of the
treatment of this disease include the prevention of sequelae related to the
formation of synechiae, eye care to prevent serious sequelae that can lead to
blindness, and specific immunosuppressive treatment. Better knowledge of the
management principles of toxic epidermal necrolysis will lead to better disease
management, higher survival rates, and lower prevalence of sequelae.
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Affiliation(s)
| | - José Antonio Aramburu
- Instituto de Investigación Sanitaria del Hospital Universitario de Getafe - Madrid, Spain.,Universidad Europea - Madrid, Spain
| | - Mercedes Yolanda González-Ruiz
- Instituto de Investigación Sanitaria del Hospital Universitario de Getafe - Madrid, Spain.,Universidad Europea - Madrid, Spain
| | - Lucía Cachafeiro
- Hospital Universitario La Paz-Cantoblanco-Carlos III, Instituto de investigación IdiPaz - Madrid, Spain
| | - Manuel Sánchez Sánchez
- Hospital Universitario La Paz-Cantoblanco-Carlos III, Instituto de investigación IdiPaz - Madrid, Spain
| | - José A Lorente
- Instituto de Investigación Sanitaria del Hospital Universitario de Getafe - Madrid, Spain.,Universidad Europea - Madrid, Spain.,CIBER de Enfermedades Respiratorias - Madrid, Spain
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Wolf B, Sadoff R, Nannini V. Toxic Epidermal Necrolysis: A Dermatologic Emergency and the Role of the Oral and Maxillofacial Surgeon. J Oral Maxillofac Surg 2018; 76:1688-1694. [DOI: 10.1016/j.joms.2018.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/14/2018] [Accepted: 02/14/2018] [Indexed: 12/19/2022]
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Micheletti RG, Chiesa-Fuxench Z, Noe MH, Stephen S, Aleshin M, Agarwal A, Boggs J, Cardones AR, Chen JK, Cotliar J, Davis MDP, Dominguez A, Fox LP, Gordon S, Hamrick R, Ho B, Hughey LC, Jones LM, Kaffenberger BH, Kindley K, Kroshinsky D, Kwong BY, Miller DD, Mostaghimi A, Musiek A, Ortega-Loayza AG, Patel R, Posligua A, Rani M, Saluja S, Sharon VR, Shinkai K, John JS, Strickland N, Summers EM, Sun N, Wanat KA, Wetter DA, Worswick S, Yang C, Margolis DJ, Gelfand JM, Rosenbach M. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Multicenter Retrospective Study of 377 Adult Patients from the United States. J Invest Dermatol 2018; 138:2315-2321. [PMID: 29758282 DOI: 10.1016/j.jid.2018.04.027] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/14/2018] [Accepted: 04/05/2018] [Indexed: 12/19/2022]
Abstract
Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare, severe mucocutaneous reaction with few large cohorts reported. This multicenter retrospective study included patients with SJS/TEN seen by inpatient consultative dermatologists at 18 academic medical centers in the United States. A total of 377 adult patients with SJS/TEN between January 1, 2000 and June 1, 2015 were entered, including 260 of 377 (69%) from 2010 onward. The most frequent cause of SJS/TEN was medication reaction in 338 of 377 (89.7%), most often to trimethoprim/sulfamethoxazole (89/338; 26.3%). Most patients were managed in an intensive care (100/368; 27.2%) or burn unit (151/368; 41.0%). Most received pharmacologic therapy (266/376; 70.7%) versus supportive care alone (110/376; 29.3%)-typically corticosteroids (113/266; 42.5%), intravenous immunoglobulin (94/266; 35.3%), or both therapies (54/266; 20.3%). Based on day 1 SCORTEN predicted mortality, approximately 78 in-hospital deaths were expected (77.7/368; 21%), but the observed mortality of 54 patients (54/368; 14.7%) was significantly lower (standardized mortality ratio = 0.70; 95% confidence interval = 0.58-0.79). Stratified by therapy received, the standardized mortality ratio was lowest among those receiving both steroids and intravenous immunoglobulin (standardized mortality ratio = 0.52; 95% confidence interval 0.21-0.79). This large cohort provides contemporary information regarding US patients with SJS/TEN. Mortality, although substantial, was significantly lower than predicted. Although the precise role of pharmacotherapy remains unclear, co-administration of corticosteroids and intravenous immunoglobulin, among other therapies, may warrant further study.
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Affiliation(s)
- Robert G Micheletti
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zelma Chiesa-Fuxench
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Megan H Noe
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sasha Stephen
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria Aleshin
- Division of Dermatology, University of California–Los Angeles, Los Angeles, California, USA
| | - Ashwin Agarwal
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Boggs
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adela R Cardones
- Department of Dermatology, Duke University, Durham, North Carolina, USA
| | - Jennifer K Chen
- Department of Dermatology, Stanford Hospital and Clinics, Redwood City, California, USA
| | | | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Arturo Dominguez
- Department of Dermatology, University of Texas, Southwestern, Dallas, Texas, USA
| | - Lindy P Fox
- Department of Dermatology, University of California–San Francisco, San Francisco, California, USA
| | - Shayna Gordon
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ronald Hamrick
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Baran Ho
- Department of Dermatology, University of California–Davis, Davis, California, USA
| | - Lauren C Hughey
- Department of Dermatology, University of Alabama, Birmingham, Birmingham, Alabama, USA
| | - Larry M Jones
- Department of Surgery, Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | - Kimball Kindley
- Department of Dermatology, University of Virginia, Charlottesville, Virginia, USA
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford Hospital and Clinics, Redwood City, California, USA
| | - Daniel D Miller
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Musiek
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Raj Patel
- True Dermatology, Alabaster, Alabama, USA
| | - Alba Posligua
- Department of Dermatology, State University of New York–Buffalo, Buffalo, New York, USA
| | - Monica Rani
- Dermatology and Aesthetics, Chicago, Illinois, USA
| | - Sandeep Saluja
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
| | - Victoria R Sharon
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York, USA
| | - Kanade Shinkai
- Department of Dermatology, University of California–San Francisco, San Francisco, California, USA
| | - Jessica St John
- Department of Dermatology, Harvard University, Boston, Massachusetts, USA
| | - Nicole Strickland
- Department of Dermatology, University of Texas, Southwestern, Dallas, Texas, USA
| | - Erika M Summers
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
| | - Natalie Sun
- Department of Dermatology, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina, USA
| | - Karolyn A Wanat
- Department of Dermatology, University of Iowa, Iowa City, Iowa, USA
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott Worswick
- Division of Dermatology, University of California–Los Angeles, Los Angeles, California, USA
| | - Caroline Yang
- Department of Dermatology, Brown University, Providence, Rhode Island, USA
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joel M Gelfand
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Misha Rosenbach
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Al-Kathiri L, Mercyamma V, Al-Najjar T. A Case of Toxic Epidermal Necrolysis Successfully Treated with Low Dose Intravenous Immunoglobulins and Systemic Corticosteroid. Oman Med J 2018; 33:356-359. [PMID: 30038738 DOI: 10.5001/omj.2018.65] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Toxic epidermal necrolysis (TEN), a severe form of Stevens-Johnson syndrome, is an acute life-threatening adverse drug reaction with a mortality rate of approximately 30%. Primary treatment of TEN is usually supportive. The use of intravenous immunoglobulin (IVIG) and corticosteroids are still uncertain, as there are only a limited number of studies comparing the usefulness of these treatments. We report a case of a Filipino male patient who developed TEN, most likely due to one of the medications he received during his course of illness. The patient was admitted to Sultan Qaboos Hospital, Salalah, with fever and diffuse painful maculopapular eruption, which became vesicular and bullous after few days, followed by shedding of large sheets of the epidermis. The patient was admitted initially under medical care, and a diagnosis of TEN was considered later. All unnecessary drugs were discontinued, and the patient was shifted to the burns unit. In addition to standard supportive treatment, a combination therapy of systemic steroid and a low-dose IVIG (1.2 g/kg) divided over three days was administered. This low-dose regimen of IVIG has a pharmacoeconomic benefit compared with the previous cumulative dose (3 g/kg), which is usually given by dermatologists in other institutions to patients with TEN. The outcome was excellent, and the condition recovered almost completely two weeks after starting the treatment without sequelae.
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Affiliation(s)
- Lutfi Al-Kathiri
- Department of Dermatology, Sultan Qaboos Hospital, Salalah, Oman
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57
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Bojinca VC, Bojinca M, Gheorghe M, Birceanu A, Iosif CI, Balanescu SM, Balanescu AR. Stevens-Johnsons syndrome or drug-induced lupus - a clinical dilemma: A case report and review of the literature. Biomed Rep 2018; 9:37-41. [PMID: 29930803 PMCID: PMC6007037 DOI: 10.3892/br.2018.1098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/14/2018] [Indexed: 12/20/2022] Open
Abstract
Tumor necrosis factor inhibitors are the first biological agents used in the treatment of rheumatoid arthritis (RA) to have yielded satisfactory results in terms of clinical improvement and radiologic progression, but they are also associated with the possibility of occurrence of a number of autoimmune systemic events [drug-induced lupus (DIL), vasculitis, sarcoidosis] and localized adverse events [uveitis, psoriasis, interstitial lung disease, erythema multiforme including the major form Stevens-Johnson syndrome (SJS)]. During treatment with TNF inhibitors, many patients develop positivity for antinuclear, antihistone and anti-double stranded DNA antibodies, though only a minority of patients will develop clinical manifestations and approximately less than 1% will fulfill the classification criteria for systemic lupus erythematosus. Mucocutaneous manifestations are the most frequent manifestations of DIL following treatment with TNF inhibitors, and can be severe and occasionally difficult to differentiate from erythema multiforme/SJS. Stopping the causative drug (the TNF inhibitor) and general supportive measures are usually sufficient in mild forms, but in moderate to severe forms, systemic glucocorticoids and sometimes immunosuppressive drugs are required. The present report presents the case of a patient with rheumatoid arthritis who developed severe recurrent cutaneous reactions and positive autoantibodies during TNF inhibitor treatment, with difficulties in differential diagnosis and treatment. A review of the literature is also presented.
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Affiliation(s)
- Violeta Claudia Bojinca
- Department of Internal Medicine and Rheumatology, 'Sfanta Maria' Hospital, 011172 Bucharest, Romania.,Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania
| | - Mihai Bojinca
- Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania.,Department of Internal Medicine and Rheumatology, 'Dr Ion Cantacuzino' Hospital, 020475 Bucharest, Romania
| | - Madalina Gheorghe
- Department of Internal Medicine and Rheumatology, 'Sfanta Maria' Hospital, 011172 Bucharest, Romania
| | - Adelina Birceanu
- Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania.,Department of Pathology 'Sfanta Maria' Hospital, 011172 Bucharest, Romania
| | | | - Serban Mihai Balanescu
- Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania.,Department of Cardiology, 'Elias' Hospital, 011461 Bucharest, Romania
| | - Andra Rodica Balanescu
- Department of Internal Medicine and Rheumatology, 'Sfanta Maria' Hospital, 011172 Bucharest, Romania.,Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania
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Toxic epidermal necrolysis data from the CELESTE multinational registry. Part II: Specific systemic and local risk factors for the development of infectious complications. Burns 2018; 44:1561-1572. [PMID: 29903602 DOI: 10.1016/j.burns.2018.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 03/13/2018] [Accepted: 03/19/2018] [Indexed: 12/20/2022]
Abstract
The aim of the study was to identify the most important systemic and local risk factors for the development of infectious complications in patients with toxic epidermal necrolysis (TEN). MATERIAL AND METHODOLOGY This is a multicentric study that included all patients with TEN who were hospitalized between 2000-2015 in specialized centres in the Czech Republic and Slovakia. The total catchment area included a population of over 12.5 million inhabitants. The actual implementation of the project was carried out using data obtained from the CELESTE (Central European LyEll Syndrome: Therapeutic Evaluation) registry, wherein specific parameters related to epidemiological indicators and infectious complications in patients with TEN were evaluated as a retrospective analysis. RESULTS A total of 38 patients (97%) of the group were treated with corticosteroids. The comparison of patients with different doses of corticosteroids did not exhibit a statistically significant effect of corticosteroid administration on the development of infectious complications (p=0.421). There was no effect of the extent of the exfoliated area on the development of infectious complications in this area. The average extent of the exfoliated area was 66% TBSA (total body surface area) in patients with reported infectious complications and 71% TBSA (p=0.675) in patients without infectious complications. In the case of the development of an infectious complication in the bloodstream (BSI), the increasing effect of the SCORTEN (SCORe of Toxic Epidermal Necrosis) value was monitored during hospitalization. Within 5days from the beginning of the hospitalization, the average SCORTEN value was 2.7 in 6 patients with BSI and 3.0 in 32 patients without BSI (p=0.588). In the period after the 15th day of hospitalization, 7 patients with BSI had an average SCORTEN value of 3.4, and 16 patients without BSI had an average SCORTEN value of 2.5 (p=0.079). In the case of low respiratory tract infection (LRTI), the effects of the necessity for artificial pulmonary ventilation and the presence of tracheostomy were monitored. The statistically significant effect of mechanical ventilation on the development of LRTI occurred only during the period of 11-15days from the beginning of the hospitalization (p=0.016). The effect of the tracheostomy on the development of LRTI was proven to be more significant. CONCLUSION We did not find any statistically significant correlation between the nature of immunosuppressive therapy and the risk of developing infectious complications. We failed to identify statistically significant risk factors for the development of BSI. Mechanical ventilation and tracheostomy increase the likelihood of developing LRTIs in patients with TEN.
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Liang Y, Chu Y, Xu Z, Ma L. Successful treatment of a female pediatric patient with carbamazepine-induced toxic epidermal necrolysis: Active wound care and systemic therapy. Pediatr Investig 2018; 2:114-118. [PMID: 32851244 PMCID: PMC7331447 DOI: 10.1002/ped4.12040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/19/2018] [Indexed: 12/19/2022] Open
Abstract
We describe a 6-year-old female patient who developed carbamazepine-associated toxic epidermal necrolysis. With active wound care, systemic methylprednisolone and intravenous immunoglobulin pulse therapies and multidisciplinary supportive care, the patient improved significantly. This case indicates that improving the management of Stevens-Johnson syndrome/Toxic epidermal necrolysis patients requires attention not only to the process of wound management but also to individual supportive care and active therapeutic intervention. Only through this can standardized care, including muco-cutaneous and visceral wound care, be delivered to provide high-quality care with improved clinical prognosis and quality of life.
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Affiliation(s)
- Yuan Liang
- Department of DermatologyBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Yan Chu
- Department of DermatologyBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Zigang Xu
- Department of DermatologyBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Lin Ma
- Department of DermatologyBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
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Papp A, Sikora S, Evans M, Song D, Kirchhof M, Miliszewski M, Dutz J. Treatment of toxic epidermal necrolysis by a multidisciplinary team. A review of literature and treatment results. Burns 2018; 44:807-815. [PMID: 29627131 DOI: 10.1016/j.burns.2017.10.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 10/27/2017] [Accepted: 10/30/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are mucocutaneous hypersensitivity reactions, usually to drugs or their metabolites. TEN is the most severe involving greater than 30% of the total body surface area (TBSA). Management of these patients usually benefits from a large multidisciplinary team for both wound and medical management. Treatment of these patients varies between centers and physicians and there is lack of a standardized treatment protocol in the medical literature. OBJECTIVES To review the literature and complete a retrospective review of patients treated at Vancouver General Hospital over a 11-year period. METHODS A retrospective chart review of all patients diagnosed with SJS/TEN and treated at Vancouver General Hospital from 2001 to 2011 was completed. Data collected include patient demographics, time to transfer to a burn center, SCORTEN calculation, suspected cause of TEN, %TBSA involved, length of stay in hospital and ICU, medications, dressings, infections/cultures, fluids, mucosal involvement, teams involved, associated complications, morbidity and mortality. Data is reported quantitatively. RESULTS A total of 67 patients were identified (28 SJS, 21 SJS/TEN overlap, 18 TEN). In SJS/TEN overlap and TEN patients, oral mucosa and trunk were the primary sites involved. SCORTEN calculations were highest in the TEN group. Plastic surgery was consulted in 53% of TEN cases, 52% of SJS/TEN cases and 25% of SJS cases. Patients were admitted to a burn unit in 74% of TEN cases, 57% of TEN/SJS cases and 21% of SJS cases. Time from symptoms to diagnosis and transfer to a burn unit was highest for TEN patients. Time from presentation to diagnosis was highest in SJS/TEN overlap. Triggers were identified in 67-82% of cases. Treatment varied widely. Patients were treated conservatively, with steroids, IVIg, and cyclosporine alone or in combination. Observed mortality was higher than predicted by SCORTEN for patients treated with IVIg and lower for those treated with Cyclosporin. Dressings varied greatly and were often changed throughout a patients stay. Total mortality was 20.9% being the highest in the TEN group (35%). CONCLUSIONS SJS and TEN are a spectrum of severe mucocutaneous reactions that have unclear treatment recommendations within the literature and within our Level 1 hospital. Information gleaned from this research will help educate physicians involved in the treatment and management of patients with these diagnoses and has resulted in development of treatment guidelines in our hospital.
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Affiliation(s)
- Anthony Papp
- Division of Plastic Surgery, Vancouver General Hospital, Canada.
| | - Sheena Sikora
- Division of Plastic Surgery, Vancouver General Hospital, Canada
| | - Morgan Evans
- Division of Plastic Surgery, Vancouver General Hospital, Canada
| | - Diana Song
- Division of Plastic Surgery, Vancouver General Hospital, Canada
| | - Mark Kirchhof
- Department of Dermatology and Skin Science, University of British Columbia, Canada
| | - Monica Miliszewski
- Department of Dermatology and Skin Science, University of British Columbia, Canada
| | - Jan Dutz
- Department of Dermatology and Skin Science, University of British Columbia, Canada
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Mustafa SS, Ostrov D, Yerly D. Severe Cutaneous Adverse Drug Reactions: Presentation, Risk Factors, and Management. Curr Allergy Asthma Rep 2018; 18:26. [PMID: 29574562 DOI: 10.1007/s11882-018-0778-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF STUDY Immune-mediated adverse drug reactions occur commonly in clinical practice and include mild, self-limited cutaneous eruptions, IgE-mediated hypersensitivity, and severe cutaneous adverse drug reactions (SCAR). SCARs represent an uncommon but potentially life-threatening form of delayed T cell-mediated reaction. The spectrum of illness ranges from acute generalized exanthematous pustulosis (AGEP) to drug reaction with eosinophilia with systemic symptoms (DRESS), to the most severe form of illness, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). RECENT FINDINGS There is emerging literature on the efficacy of cyclosporine in decreasing mortality in SJS/TEN. The purpose of our review is to discuss the typical presentations of these conditions, with a special focus on identifying the culprit medication. We review risk factors for developing SCAR, including HLA alleles strongly associated with drug hypersensitivity. We conclude by discussing current strategies for the management of these conditions.
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Affiliation(s)
- S Shahzad Mustafa
- Allergy and Clinical Immunology, Rochester Regional Health System, Rochester, NY, USA. .,University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - David Ostrov
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Daniel Yerly
- Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Bern, Switzerland
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62
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Chong I, Chao A. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Treatment With a Biologic: A Case Report. Perm J 2018; 21:16-060. [PMID: 28488978 DOI: 10.7812/tpp/16-060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION One of the most dangerous dermatologic emergencies is Stevens-Johnson Syndrome (SJS)/toxic epidermal necrolysis (TEN). Although a rare disease, it can often lead to significant mortality. CASE PRESENTATION In this case report, we present a 77-year-old man who developed a sloughing rash that was secondary to a nonsteroidal anti-inflammatory drug. In addition to the recommended supportive care, the patient was treated with etanercept, a new, less commonly used intervention. DISCUSSION We provide a brief review of SJS/TEN. Nonsteroidal anti-inflammatory drugs are a rare cause of SJS/TEN, and additionally, the use of biologics is a novel treatment modality for SJS/TEN.
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Affiliation(s)
- Ian Chong
- Attending Physician in Emergency Medicine at the Zion Medical Center in San Diego, CA.
| | - Alice Chao
- Attending Physician in Emergency Medicine at the Santa Clara Medical Center in CA.
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Tachibana K, Hamada T, Tsuchiya H, Shibata T, Fujii K, Kobayashi K, Iwatsuki K. Ethosuximide-induced Stevens-Johnson syndrome: Beneficial effect of early intervention with high-dose corticosteroid therapy. J Dermatol 2018; 45:592-595. [DOI: 10.1111/1346-8138.14253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 01/12/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Kota Tachibana
- Department ofDermatology; Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences; Okayama Japan
| | - Toshihisa Hamada
- Department ofDermatology; Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences; Okayama Japan
| | - Hiroki Tsuchiya
- Department ofChild Neurology; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Takashi Shibata
- Department ofChild Neurology; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Kazuyasu Fujii
- Department ofDermatology; Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences; Okayama Japan
- Department of Dermatology; Kagoshima University; Kagoshima Japan
| | - Katsuhiro Kobayashi
- Department ofChild Neurology; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Keiji Iwatsuki
- Department ofDermatology; Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences; Okayama Japan
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The use of Biobrane ® for wound coverage in Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis. Burns 2017; 43:1464-1472. [DOI: 10.1016/j.burns.2017.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 03/13/2017] [Accepted: 03/19/2017] [Indexed: 12/14/2022]
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Abstract
During the past decade, major advances have been made in the accurate diagnosis of severe cutaneous adverse reactions (SCARs) to drugs, management of their manifestations, and identification of their pathogenetic mechanisms and at-risk populations. Early recognition and diagnosis of SCARs are key in the identification of culprit drugs. SCARS are potentially life threatening, and associated with various clinical patterns and morbidity during the acute stage of Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reactions with eosinophilia and systemic symptoms, and acute generalised exanthematous pustulosis. Early drug withdrawal is mandatory in all SCARs. Physicians' knowledge is essential to the improvement of diagnosis and management, and in the limitation and prevention of long-term sequelae. This Seminar provides the tools to help physicians in their clinical approach and investigations of SCARs.
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Affiliation(s)
- Tu Anh Duong
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France.
| | - Laurence Valeyrie-Allanore
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France
| | - Pierre Wolkenstein
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France; EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val-de-Marne, Créteil, France
| | - Olivier Chosidow
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France; EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val-de-Marne, Créteil, France; French Satellite of the Cochrane Skin Group, Créteil, France; INSERM, Centre d'Investigation Clinique 1430, Créteil, France
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66
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Improving mortality outcomes of Stevens Johnson syndrome/toxic epidermal necrolysis: A regional burns centre experience. Burns 2017; 44:603-611. [PMID: 29029855 DOI: 10.1016/j.burns.2017.09.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/25/2017] [Accepted: 09/15/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Stevens Johnson Syndrome/toxic epidermal necrolysis (SJS/TEN) are rare, potentially fatal desquamative disorders characterised by large areas of partial thickness skin and mucosal loss. The degree of epidermal detachment that occurs has led to SJS/TEN being described as a burn-like condition. These patients benefit from judicious critical care, early debridement and meticulous wound care. This is best undertaken within a multidisciplinary setting led by clinicians experienced in the management of massive skin loss and its sequelae. In this study, we examined the clinical outcomes of SJS/TEN overlap & TEN patients managed by our regional burns service over a 12-year period. We present our treatment model for other burn centres treating SJS/TEN patients. METHODS A retrospective case review was performed for all patients with a clinical diagnosis of TEN or SJS/TEN overlap admitted to our paediatric and adult burns centre between June 2004 and December 2016. Patient demographics, percentage total body surface area (%TBSA), mucosal involvement, causation, severity of illness score (SCORTEN), length of stay and survival were appraised with appropriate statistical analysis performed using Graph Pad Prism 7.02 Software. RESULTS During the study period, 42 patients (M26; F: 16) with TEN (n=32) and SJS/TEN overlap (n=10) were managed within our burns service. Mean %TBSA of cutaneous involvement was 57% (range 10-100%) and mean length of stay (LOS) was 27 days (range 1-144 days). We observed 4 deaths in our series compared to 16 predicted by SCORTEN giving a standardised mortality ratio (SMR) of 24%. CONCLUSION Management in our burns service with an aggressive wound care protocol involving debridement of blistered epidermis and wound closure with synthetic and biological dressings seems to have produced benefits in mortality when compared to predicted outcomes.
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Cartotto R. Burn Center Care of Patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Clin Plast Surg 2017; 44:583-595. [DOI: 10.1016/j.cps.2017.02.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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69
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Creamer D, Walsh SA, Dziewulski P, Exton LS, Lee HY, Dart JKG, Setterfield J, Bunker CB, Ardern-Jones MR, Watson KMT, Wong GAE, Philippidou M, Vercueil A, Martin RV, Williams G, Shah M, Brown D, Williams P, Mohd Mustapa MF, Smith CH. U.K. guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016. Br J Dermatol 2017; 174:1194-227. [PMID: 27317286 DOI: 10.1111/bjd.14530] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 12/11/2022]
Affiliation(s)
- D Creamer
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - S A Walsh
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - P Dziewulski
- St Andrews Centre for Plastic Surgery and Burns, Mid Essex Hospital Services NHS Trust, Chelmsford, CM1 7ET, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - H Y Lee
- Dermatology Unit, Singapore General Hospital, Singapore
| | - J K G Dart
- Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, U.K
| | - J Setterfield
- Mucosa and Salivary Biology, Dental Institute, King's College London, Guy's Campus, Great Maze Pond, London, SE1 9RT, U.K
| | - C B Bunker
- University College Hospital, London, NW1 2BU, U.K
| | - M R Ardern-Jones
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, U.K
| | - K M T Watson
- Department of Dermatology, Orpington Hospital, Orpington, Kent, BR6 9JU, U.K
| | - G A E Wong
- Department of Dermatology, University Hospital of South Manchester NHS Foundation Trust, Manchester, M23 9LT, U.K
| | - M Philippidou
- Department of Histopathology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - A Vercueil
- Intensive Care Medicine, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - R V Martin
- St Andrews Centre for Plastic Surgery and Burns, Mid Essex Hospital Services NHS Trust, Chelmsford, CM1 7ET, U.K
| | - G Williams
- Late of the Burns Centre, Chelsea and Westminster NHS Foundation Trust, London, SW10 9NH, U.K
| | - M Shah
- Department of Burns and Plastic Surgery, University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, M23 9LT, U.K
| | - D Brown
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
| | - P Williams
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - C H Smith
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
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Abstract
INTRODUCTION/BACKGROUND Xeroform® is a petrolatum-based fine mesh gauze containing 3% bismuth tribromophenate. Bismuth, similar to other metals, has antimicrobial properties. Xeroform® has been used for decades in burn and plastic surgery as a donor site dressing and as a covering for wounds or partial thickness burns. Despite this, the antimicrobial spectrum of Xeroform® remains largely unknown. We examined the in-vitro efficacy of Xeroform® against common burn pathogens using zone-of-inhibition methodology in a commercial research facility. METHODS/DESIGN Pure strains of 15 common burn pathogens including Methicillin-resistant Staphylococcus aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA), Staphylococcus epidermidis, Pseudomonas aeruginosa, Enterobacter cloacae, Escherichia coli, Candida albicans, Vancomycin resistant Enterococcus, Acinetobacter baumennii, Klebsiella pneumonia, Extended spectrum beta-lactamase producing Klebsiella, Beta hemolytic Streptococcus pyogenes, Proteus mirabilis, Serratia marcescens, and Salmonella enterica ssp. Enterica were inoculated at a strength of 106-1010 CFU/ml onto appropriate agar plates. A sterile 1 in2 Xeroform® square was placed in the center of each plate, and the Zone of Inhibition (ZOI) was measured following 18-24h of incubation at 37°C. A second bismuth pharmaceutical (bismuth subsalicylate, Pepto-Bismol®) was then tested using the same methodology against the same strains of MRSA, MSSA, E. coli, K. pneumonia and S. marcescens. Finally, 3% w/v bismuth tribromophenate in glycerol suspension was tested against 13 burn pathogens for antimicrobial activity independent of the Xeroform® dressing by measure of Zone of Inhibition. RESULTS/FINDINGS For Xeroform®, none of the fifteen pathogens had a measurable zone of inhibition on any plate. Bismuth subsalicylate showed a zone of inhibition for MSSA in 3 plates (mean of 47.2mm), in one of three plates for MRSA (13.8mm), and in one of three plates for S. marcesens (89.6mm). There was no zone of inhibition seen for K. pneumonia or E. coli. Bismuth tribromophenate, when not bound to Xeroform® showed activity against 12 of 13 pathogens. CONCLUSIONS/IMPLICATIONS While bismuth subsalicylate, and bismuth tribromophenate unbound to Xeroform® demonstrate antimicrobial activity, it appears that Xeroform® dressings do not. The utility of Xeroform® in burn medicine may relate more to use as an impervious dressing than to antimicrobial effect. Donor sites are clean surgical wounds and clean partial thickness burns may have minimal colonization present. In such circumstances, an inactive and impervious dressing may be all that is necessary to promote wound healing.
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González-Herrada C, Rodríguez-Martín S, Cachafeiro L, Lerma V, González O, Lorente JA, Rodríguez-Miguel A, González-Ramos J, Roustan G, Ramírez E, Bellón T, de Abajo FJ. Cyclosporine Use in Epidermal Necrolysis Is Associated with an Important Mortality Reduction: Evidence from Three Different Approaches. J Invest Dermatol 2017. [PMID: 28634032 DOI: 10.1016/j.jid.2017.05.022] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Several immunomodulatory agents are used in the treatment of epidermal necrolysis, but evidence of their efficacy is limited. The Autonomous Community of Madrid has two reference burn units to which all patients with epidermal necrolysis are referred. One burn unit has mostly used cyclosporine (CsA), and the other has used non-CsA therapies (mainly high-dose intravenous immunoglobulin). The allocation of patients to one or the other burn unit was mainly based on proximity, resembling a random assignment. Thus, we took advantage of this "natural experiment" to estimate the mortality risk ratio (MRR) of CsA (n = 26) compared with non-CsA (n = 16) treatment using hospital as an instrumental variable over the period from 2001 to 2015. We also computed the observed versus expected (O/E) MRR in a case series of 49 CsA-treated patients (including 23 patients from other regions treated in Madrid), and using the Score for Toxic Epidermal Necrolysis (i.e., SCORTEN) scale to estimate the expected values. The instrumental variable-based MRR of CsA versus non-CsA was 0.09 (95% confidence interval = 0.00-0.49). The O/E analysis also showed a reduction in mortality risk (MRROE = 0.42; 95% confidence interval = 0.14-0.99). We identified five other case series of CsA-treated patients providing MRROE and meta-analyzed their results. The pooled MRROE (including from this study) was 0.41 (95% confidence interval = 0.21-0.80). All three approaches consistently show that CsA reduces the mortality in epidermal necrolysis patients.
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Affiliation(s)
| | - Sara Rodríguez-Martín
- Clinical Pharmacology Unit, Príncipe de Asturias University Hospital, Department of Biomedical Sciences, University of Alcalá, Institute for Health Research IRYCIS, Alcalá de Henares, Madrid, Spain
| | - Lucía Cachafeiro
- Burn Unit, Intensive Care Unit, La Paz University Hospital, Madrid, Spain
| | - Victoria Lerma
- Clinical Pharmacology Unit, Príncipe de Asturias University Hospital, Department of Biomedical Sciences, University of Alcalá, Institute for Health Research IRYCIS, Alcalá de Henares, Madrid, Spain
| | - Olga González
- Dermatology Department, University Hospital of Getafe, Getafe, Madrid, Spain
| | - José A Lorente
- Burn Unit, Intensive Care Unit, University Hospital of Getafe, Getafe, Madrid, Spain; Respiratory Diseases Networking Biomedical Research Centre (CibeRes), Madrid, Spain; European University of Madrid, Madrid, Spain
| | - Antonio Rodríguez-Miguel
- Clinical Pharmacology Unit, Príncipe de Asturias University Hospital, Department of Biomedical Sciences, University of Alcalá, Institute for Health Research IRYCIS, Alcalá de Henares, Madrid, Spain
| | | | - Gaston Roustan
- Dermatology Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Elena Ramírez
- Clinical Pharmacology Department, La Paz University Hospital, Madrid, Spain
| | - Teresa Bellón
- Drug Hypersensitivity Laboratory, Institute for Health Research IdiPAZ, La Paz University Hospital, Madrid, Spain
| | - Francisco J de Abajo
- Clinical Pharmacology Unit, Príncipe de Asturias University Hospital, Department of Biomedical Sciences, University of Alcalá, Institute for Health Research IRYCIS, Alcalá de Henares, Madrid, Spain.
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Toxic Epidermal Necrolysis-like Reaction After Hematopoietic Stem Cell Transplantation in Children. J Pediatr Hematol Oncol 2017; 39:254-258. [PMID: 28267083 DOI: 10.1097/mph.0000000000000820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study report clinical course, etiology, management, and long-term outcome of children who developed toxic epidermal necrolysis-like reaction (TEN-LR) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We retrospectively collected children with TEN-LR occurring after allo-HSCT performed in 2 pediatric bone marrow units between 2005 and 2014. We identified 6 cases of TEN-LR of 322 patients (1.8%). Possible triggers of TEN included antibiotics, antiepileptics, antimycotics, and Mycoplasma infection. In 3 patients TEN-LR occurred concurrently with severe multiorgan acute graft versus host disease. The management of TEN included administration of high doses of intravenous immunoglobulins and steroids (n=6), anti-tumor necrosis factor (n=3), and plasmapheresis (n=3) and whenever possible, discontinuation of the potentially causative drugs. Four patients (66%) reached a complete clinical response of TEN-LR after a median of 11.2 days. Two children (34%) are presently alive, 1 with long-term ocular sequelae. TEN-LR is a potentially lethal complication that may occur after HSCT also in pediatric patients. In our experience, TEN-LR and acute graft versus host disease probably coexisted and an overlap between the 2 forms is suggested. The multidisciplinary approaches involving specialized nurses, hematologists, dermatologists, burn surgeons, and infectious disease specialists is crucial to treat these patients.
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73
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Hermiz SJ, Diegidio P, Ortiz-Pujols S, Garimella R, Weber DJ, van Duin D, Hultman CS. Life-threatening Skin Disorders Treated in the Burn Center: Impact of Health care-associated Infections on Length of Stay, Survival, and Hospital Charges. Clin Plast Surg 2017; 44:597-602. [PMID: 28576248 DOI: 10.1016/j.cps.2017.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article reviews a single burn center experience with life-threatening skin disorders, over a 10-year period. It explores the incidence of health care-associated infections and the impact on length of stay, hospital charges, and mortality.
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Affiliation(s)
- Steven J Hermiz
- Department of Surgery, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Paul Diegidio
- Department of Surgery, University of North Carolina School of Medicine, 7038 Burnett-Womack, Campus Box 7195, Chapel Hill, NC 27599, USA
| | - Shiara Ortiz-Pujols
- Department of Surgery, University of North Carolina School of Medicine, 7038 Burnett-Womack, Campus Box 7195, Chapel Hill, NC 27599, USA
| | - Roja Garimella
- Alpert Medical School, Brown University, Providence, RI 02903, USA
| | - David J Weber
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
| | - David van Duin
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
| | - Charles Scott Hultman
- Department of Surgery, University of North Carolina School of Medicine, 7038 Burnett-Womack, Campus Box 7195, Chapel Hill, NC 27599, USA.
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74
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Tocco-Tussardi I, Huss F, Presman B. Microbiological findings and antibacterial therapy in Stevens-Johnson syndrome/toxic epidermal necrolysis patients from a Swedish Burn Center. J Cutan Pathol 2017; 44:420-432. [PMID: 28075032 DOI: 10.1111/cup.12894] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 11/24/2016] [Accepted: 01/09/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Superimposed infections/sepsis are the major cause of morbidity/mortality in Stevens-Johnson syndrome/Toxic Epidermal Necrolysis (SJS/TEN). It is a delicate balance between avoiding new pharmaceuticals and prophylactically treat an incipient infection. The objective of this study was to investigate the rates and types of infection-microbials and antibiotics involved in SJS/TEN patients. MATERIALS AND METHODS Microbiology and clinical data were collected for SJS/TEN patients admitted to our Burn Center from January 2010 through January 2016. RESULTS A total of 24 patients were admitted over the study period. There were 303 bacterial cultures taken whereof 113 (37.3%) were positive (median of 4.4 per patient). Twenty-two (91.7%) patients had at least 1 positive sample recorded. Fifteen (62.5%) patients had a confirmed episode of sepsis with skin being the most common source of colonization (77.8%). Eleven (45.8%) patients received empiric antibiotic therapy at referral facility/prior to admission to our Center. Patients who grew a higher number of different species were significantly less likely to have received early empiric antimicrobial therapy (P < .001). CONCLUSION Secondary bacterial infection and sepsis were a highly common finding in our patient population. Despite the risk of resistance and further immunological provocation, empirical antibiotic treatment might have a place in clinical management.
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Affiliation(s)
- Ilaria Tocco-Tussardi
- Uppsala Burn Centre, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Fredrik Huss
- Uppsala Burn Centre, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Benjamin Presman
- Uppsala Burn Centre, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
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Toxic epidermal necrolysis: The past, the guidelines and challenges for the future. J Plast Reconstr Aesthet Surg 2016; 69:733-735. [PMID: 27287211 DOI: 10.1016/j.bjps.2016.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 04/26/2016] [Indexed: 01/17/2023]
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76
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Bremnes ØM, Grimstad Ø, Bremnes KE. [A woman with fever, red eyes and widespread rashes]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1731-1734. [PMID: 27830909 DOI: 10.4045/tidsskr.16.0207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
| | - Øystein Grimstad
- Nevro-, hud- og revmatologisk avdeling Universitetssykehuset Nord-Norge
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77
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Bai M, Yu Y, Huang C, Liu Y, Zhou M, Li Y, Ma F, Jing R, Zhao L, Li L, Wang P, He L, Sun S. Continuous venovenous hemofiltration combined with hemoperfusion for toxic epidermal necrolysis: a retrospective cohort study. J DERMATOL TREAT 2016; 28:353-359. [PMID: 27653468 DOI: 10.1080/09546634.2016.1240326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM The current treatments of toxic epidermal necrolysis (TEN) are limited to the discontinuation of a suspect medication and supportive measures. We conducted a retrospective study to evaluate the efficacy of adding continuous venovenous hemofiltration (CVVH) and hemoperfusion (HP) to the conventional treatment for TEN. METHODS TEN patients who were admitted to our center between January 2008 and May 2016 were considered as candidates. The included patients were divided into the CVVH&HP group (n = 34) and the conventional group (n = 34) according to their accepted therapies during hospital stay. RESULTS The patients in the conventional group had a significantly reduced 28-day survival proportion compared with patients in the CVVH&HP group (73.5 versus 91.2%, p = .047). The adjusted results demonstrated that the conventional group had a significantly higher risk of 28-day mortality as well. Moreover, patients in the CVVH&HP group were associated with significantly shorter hospital stay, rash, fever, and antibiotic durations. However, the addition of CVVH&HP to conventional treatment did not significantly increase the in-hospital cost. CONCLUSIONS In conclusion, CVVH&HP might be a safe and effective adjuvant therapy for TEN. Further well-designed studies are warranted to obtain robust evidence.
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Affiliation(s)
- Ming Bai
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Yan Yu
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Chen Huang
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Yirong Liu
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Meilan Zhou
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Yangping Li
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Feng Ma
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Rui Jing
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Lijuan Zhao
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Li Li
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Pengbo Wang
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Lijie He
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Shiren Sun
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
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Contou D, Flores-Paraire L, Ortonne N, Chosidow O, de Prost N. Crystal-clear blister fluid with low albumin concentration during toxic epidermal necrolysis. Burns 2016; 42:1360-1. [DOI: 10.1016/j.burns.2016.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 03/31/2016] [Indexed: 10/21/2022]
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McCullough M, Burg M, Lin E, Peng D, Garner W. Steven Johnson Syndrome and Toxic Epidermal Necrolysis in a burn unit: A 15-year experience. Burns 2016; 43:200-205. [PMID: 27554629 DOI: 10.1016/j.burns.2016.07.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 07/22/2016] [Accepted: 07/23/2016] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The diffuse epidermal exfoliation seen in Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) is similar to skin loss in second degree burns, and many of these patients are referred for treatment at burn centers. Treatment can differ markedly from center to center, and mortality can range from 25% to 70%, including a considerable morbidity. However, our experience over a 15-year period from 2000 to 2015 with 40 patients found a mortality rate of only 10% (4/40). The purpose of this paper is to discuss our treatment algorithm as a model for other centers treating SJS/TENs patients. METHODS Records were reviewed for all patients admitted to the LAC+USC burn unit between 2000 and 2015 and 40 patients were identified with biopsy-proven SJS or TENS. These cases were reviewed for age, gender, initial and greatest TBSA, causative drug, pre-existing medical conditions, and morbidity and mortality. All data were entered into the SPSS statistical software package and all statistical analyses were performed using this program. RESULTS Our treatment algorithm focused on early referral to a specialty burn unit, immediate discontinuation of the offending drug, fluid resuscitation, nutritional supplementation, and meticulous wound care. Average time to transfer to a burn unit was 3.36 days. Silver-releasing antimicrobial dressings were applied to the affected skin surface and changed every 3 days. Mupirocin coated petroleum gauze was used for facial involvement. Steroids were tapered and discontinued if initiated at an outside facility (58% of patients), and starting after 2001, all patients received a course of IVIG. All patients received fluid resuscitation and the majority received supplemental tube feedings (69%). Average length of total stay was 17.1 days and length of ICU stay 15.9 days. While 44% were transferred to another facility for further rehabilitative care, 37% of patients discharge to home. In patients discharged home with complete resolution of skin lesions, time to healing was an average of 14 days. DISCUSSION With our 10% mortality rate in 40 patients, our study represents a relatively large study population while maintaining a relatively low mortality rate. The demographic data from our study largely aligns with the existing literature, and we therefore feel that our low mortality rate is due to our treatment algorithm, rather than to a less severe pathology in our patient population. This claim is supported by a standard mortality ratio of 1.68. This ratio proves a significantly improved mortality than would be expected based on disease severity on admission.
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Affiliation(s)
- M McCullough
- Division of Plastic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States.
| | - M Burg
- Division of Plastic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - E Lin
- Division of Plastic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - D Peng
- Department of Dermatology, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - W Garner
- Division of Plastic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
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Graves C, Faraklas I, Maniatis K, Panter E, La Force J, Aleem R, Zavala S, Albrecht M, Edwards P, Cochran A. Nutrition in Toxic Epidermal Necrolysis. Nutr Clin Pract 2016; 31:836-840. [DOI: 10.1177/0884533616642746] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Caran Graves
- Burn Center at the University of Utah and the Department of Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Iris Faraklas
- Burn Center at the University of Utah and the Department of Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | | | | | - Jessica La Force
- University of California, Davis Medical Center, Sacramento, California, USA
| | - Razia Aleem
- Loyola University Medical Center, Maywood, Illinois, USA
| | - Sarah Zavala
- Loyola University Medical Center, Maywood, Illinois, USA
| | | | | | - Amalia Cochran
- Burn Center at the University of Utah and the Department of Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe dermatologic reactions with mucocutaneous involvement that carry elevated mortality rates. They differ along a spectrum of severity based upon body surface area affected. These conditions, usually caused by a drug or infection, are believed to result from cell-mediated and often drug-specific cytotoxic reactions against keratinocytes, leading to widespread dermal-epidermal detachment. Studies attempting to identify potential curative therapies such as intravenous immune globulin (IVIG) and corticosteroids remain inconclusive. However, improved outcomes have been demonstrated by early withdrawal of offending medications, early transfer to an intensive care unit or burn unit, and aggressive supportive care. Due to the rare incidence of SJS and TEN, its recurrence among survivors hints at future vulnerability for these patients, and notorious offending medications should thus be avoided. This clinical review will highlight the diagnostic and therapeutic challenges posed by SJS and TEN, while emphasizing the need to maintain them high on the emergency medicine physician's differential. The review will also detail the supportive measures to take for preventing the rapid progression of mucocutaneous complications and subsequent sepsis-related mortality.
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82
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Young JB, Gondek SP, Troche M, Summitt JB, Rae L, Thayer WP, Kahn SA. The use of porcine xenografts in patients with toxic epidermal necrolysis. Burns 2016; 42:1728-1733. [PMID: 27350163 DOI: 10.1016/j.burns.2016.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 03/31/2016] [Accepted: 06/02/2016] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) can be challenging to treat due to pain with wound care and ongoing fluid loss. The purpose of this study is to determine the role of porcine xenograft as a modality for wound coverage. MATERIAL AND METHODS A retrospective review from 2006 to 2014 was performed at a regional burn center on all patients admitted with the diagnosis of SJS (<10% TBSA involvement), SJS/TEN overlap (10-30% TBSA involvement), and TEN (>30% TBSA involvement). Patients who received porcine xenograft had physiologic and biochemical parameters compared in the 24h before and after graft placement. In addition, xenograft patients were compared to historical controls that received traditional wound care which included silver impregnated dressings. Outcomes and variables collected included intravenous fluid given, urine output, pain scores (1-10), pain medication for wound care, biochemical markers, skin infections, hospital length of stay, and mortality. RESULTS Eight patients had placement of a porcine xenograft. Median age was 50 years (IQR 41, 66) and 2 were male. Median % TBSA affected was 76 (IQR 64, 80). The median amount of fluid (ml/kg/day/%TBSA) administered decreased from 1.45 (IQR 1.03, 1.78) to 0.9 (IQR 0.65, 1.08) after xenograft placement (p=0.02). The median amount of intravenous fluid (ml/kg/day/%TBSA) administered in the treatment group and historical control group was 0.9 (IQR 0.65, 1.08) and 0.8 (IQR 0.7, 1.47) respectively (p=0.72). The median amount of urine output (ml/kg/day) in the treatment group and historical control group was 34.2 (IQR 22, 44.38) and 22 (IQR 11.25, 38.13) respectively (p=0.17). Pain scores significantly decreased from 5.5 (IQR 2.5, 8.25) pre-xenograft to 2.8 (IQR 0.75, 4) post-xenograft placement (p=0.03). There was a significant difference in pain scores between the treatment group and historical control group, 2.8 (IQR 0.75, 4) and 6 (IQR 5, 8) respectively (p=0.02). Each study patient underwent moderate sedation for wound care prior to xenograft placement and one study patient required one moderate sedation for wound care after xenograft placement. One patient in the xenograft placement group was diagnosed with a cutaneous infection compared to 4 patients in the historical control group (p=0.63). The mortality was 12.5% in each group. CONCLUSIONS Placement of a porcine xenograft in patients with SJS, SJS/TEN overlap, or TEN is associated with a significant reduction in intravenous fluid use, pain scores, and pain medication. Further study with larger sample sizes is warranted to evaluate for statistically significant differences in outcomes after porcine xenograft placement for SJS, SJS/TEN overlap or TEN.
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Affiliation(s)
- Jason B Young
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21(st) Ave South, 404 Medical Arts Building, Nashville, TN 37212, United States
| | - Stephen P Gondek
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21(st) Ave South, 404 Medical Arts Building, Nashville, TN 37212, United States
| | - Maria Troche
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21(st) Ave South, 404 Medical Arts Building, Nashville, TN 37212, United States
| | - J Blair Summitt
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21(st) Ave South, 404 Medical Arts Building, Nashville, TN 37212, United States
| | - Lisa Rae
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21(st) Ave South, 404 Medical Arts Building, Nashville, TN 37212, United States
| | - Wesley P Thayer
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21(st) Ave South, 404 Medical Arts Building, Nashville, TN 37212, United States
| | - Steven A Kahn
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of South Alabama Medical Center, 2451 Fillingim Street, Suite 10-I, Mobile, AL 36617, United States.
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83
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Wolkenstein P, Wilson Y. Toxic epidermal necrolysis: the past, the guidelines and challenges for the future. Br J Dermatol 2016; 174:1171-3. [DOI: 10.1111/bjd.14682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- P. Wolkenstein
- Department of Dermatology Hôpital Henri‐Mondor APHP UPEC Créteil France
| | - Y.T. Wilson
- The Burn Centre Birmingham Children's Hospital and University Hospital Birmingham Birmingham U.K
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84
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UK guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults 2016. J Plast Reconstr Aesthet Surg 2016; 69:e119-e153. [DOI: 10.1016/j.bjps.2016.01.034] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/14/2016] [Indexed: 12/13/2022]
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Sofos SS, Ewing J, Hughes LC, James MI. Toxic epidermal necrolysis and concurrent granulomatosis with polyangiitis (Wegener's granulomatosis). Management of a rare case and review of the literature. Scars Burn Heal 2016; 2:2059513116642129. [PMID: 29799572 PMCID: PMC5965317 DOI: 10.1177/2059513116642129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Toxic epidermal necrolysis (TEN) is a rare, acute life-threatening mucocutaneous
disorder that is characterised by epidermal loss/exfoliation exceeding 30% total
body surface area (TBSA) and is on a spectrum that includes erythema multiforme
and Stevens–Johnson syndrome (SJS). It is estimated that 80% of TEN cases are
related to medication reactions; the association based on the recognition that
TEN usually develops 1–3 weeks following administration of the suspect drug. It
is agreed that primary treatment consists of prompt withdrawal of causative
drugs and transfer to a regional burn unit. Transfer to a burn unit, no more
than 7 days after onset of symptoms, has been acknowledged as reducing the risk
of infections, hospital length of stay and infection-related mortality. Due to
the uncertainty surrounding TEN pathogenesis, several different modalities have
been proposed for the treatment of TEN, including high-dose intravenous
immunoglobulins, plasmapheresis, cyclophosphamide, cyclosporine and systemic
steroids; however, these therapies are relatively ineffective. The use of
systemic corticosteroids for treatment of TEN has in particular been deemed
controversial due to associations with increased infections leading to greater
length of hospital stay and increased mortality. Granulomatosis with polyangiitis (GPA), formerly known as Wegener’s
granulomatosis, is a rare relapsing-remitting disorder of unknown aetiology,
characterised by granulomatosis inflammation and necrotising vasculitis
predominantly affecting small- to medium-sized vessels. While a 5-year survival
rate of 75–83% is now realised, relapse and associated morbidity is of
concern. The established treatment for GPA follows the recommendations of the French
National Authority for Health (HAS) for systematic necrotising vasculitis. With
induction treatment, it is recommended that GPA be treated with a combination of
systemic corticosteroids and immunosuppressants. A review of the literature failed to identify any previous case where both of
these conditions coincide. Our search was conducted through databases which
included MEDLINE, PubMed, Scopus, AMED, CINAHL and EMBASE, using keywords: toxic
epidermal necrolysis, Wegener’s granulomatosis, granulomatosis with
polyangiitis. We submit the rare case of a 22-year-old woman who presented to
our regional burn unit with both GPA and TEN, and we discuss the presentation,
investigation and multidisciplinary management of the patient, as well as
reviewing the literature regarding these two conditions. Toxic epidermal necrolysis is a potentially fatal condition where there is a
large area of skin exfoliated after the body’s reaction to a particular
medication. Its treatment is largely by stopping the medication that is thought
to have caused this reaction and also by regular dressings, thus keeping the
area clean from any infection. Granulomatosis with polyangiitis, also known as
Wegener’s granulomatosis, is another potentially fatal condition. Its treatment
is very specific; however, this treatment may be harmful to a patient with toxic
epidermal necrolysis. We describe the management of a patient who presented with
both conditions, which is an extremely rare event. We describe the diagnosis and
treatment during the patient’s inpatient stay at a regional burns unit. From
this case report we have shown insight into the multidisciplinary management
needed to manage such a complex patient, who made a full recovery.
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Affiliation(s)
| | - J Ewing
- Whiston Hospital, Prescot, UK
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86
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Zhang F, Zhou J. Toxic epidermal necrolysis: 13 years of experience in the management at a Department of Dermatology in China. Cutan Ocul Toxicol 2016; 36:19-24. [PMID: 27079364 DOI: 10.3109/15569527.2016.1141416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The study aimed to investigate the efficacy of our therapeutic options on toxic epidermal necrolysis (TEN) patients. METHODS After giving informed consent, patients affected by TEN were included in the study between January 2001 and December 2013. Suspected causative drugs, onset to hospitalization, complications, management, outcome, laboratory investigations of blood tests and therapeutic options were recorded and analyzed. SCORTEN scoring system was used to evaluate the complications and the survival rate. Therapeutic interventions included immediate withdrawal of any potentially fatal drug, nursing care, supportive therapy, high-dose corticosteroids, antibiotics, plasma therapy, intravenous immunoglobulins (IVIG) and traditional Chinese medicine (TCM). Blood tests were taken as a result of clinical outcome. RESULTS Total 21 consecutive patients (10 males and 11 females, mean age 33 years) were included in the study. Cefalexin, paracetamol, quick cold capsules, compound aminopyrine phenacetin tablets, carbamazepine, propylthiouracil, sulfonamide, ampicillin, and phenylbutazone were suspected to be the causative agents. All patients received high-dose dexamethasone or methylprednisolone therapy. Eighteen patients received the administration of antibiotics. Twelve patients received plasma infusions, and 11 patients were given albumin. Only 2 patients applied IVIG. Additionally, 3 and 14 cases were intravenously injected with QKL and Xiyanping, respectively. The average score of SCORTEN was 2.52 and the average percentage of total body surface area was 68.8%. The mortality rate in our study was 19%. CONCLUSION The therapeutic options in our study, including nursing care, corticosteroid, anti-inflammatory and TCM are effective for the treatment of TEN.
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Affiliation(s)
- Feng Zhang
- a Department of Dermatology , The First Affiliated Hospital of Harbin Medical University , Harbin , PR China and
| | - Jin Zhou
- b Department of Hematology , The First Affiliated Hospital of Harbin Medical University , Harbin , PR China
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87
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Morbidity and Mortality of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in United States Adults. J Invest Dermatol 2016; 136:1387-1397. [PMID: 27039263 DOI: 10.1016/j.jid.2016.03.023] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 03/08/2016] [Accepted: 03/16/2016] [Indexed: 11/24/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening disorders. Our study objective was to describe the incidence, costs of care, length of stay, comorbidities, and mortality of SJS and TEN in US adults. The Nationwide Inpatient Sample 2009-2012, containing a 20% sample of all US hospitalizations, was analyzed. We used a validated approach involving International Classification of Disease, 9th edition, Clinical Modification codes to identify SJS, SJS/TEN, and TEN (n = 2,591, n = 502, and n = 564, respectively). The mean estimated incidences of SJS, SJS/TEN, and TEN were 9.2, 1.6, and 1.9 per million adults per year, respectively. SJS/TEN was associated with nonwhite race, particularly Asians (odds ratio = 3.27, 95% confidence interval = 3.02-3.54) and blacks (odds ratio = 2.01, 95% confidence interval = 1.92-2.10). Significantly prolonged length of stay and higher costs of care (SJS: 9.8 ± 0.3 days, $21,437 ± $807; SJS/TEN: 16.5 ± 1.0 days, $58,954 ± $5,238; TEN: 16.2 ± 1.0 days, $53,695 ± $4,037) were observed compared with all other admissions (4.7 ± 0.02 days, $11,281 ± $98). Mean adjusted mortality was 4.8% for SJS, 19.4% for SJS/TEN, and 14.8% for TEN. SJS, SJS/TEN, and TEN pose a substantial health care burden. Predictors of mortality included increasing age, increasing number of chronic conditions, infection (septicemia, pneumonia, tuberculosis), hematological malignancy (non-Hodgkin's lymphoma, leukemia), and renal failure (P ≤ 0.03 for all). Further studies are needed to confirm mortality findings to improve prognostication of SJS/TEN.
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88
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Lim VM, Do A, Berger TG, Nguyen AH, DeWeese J, Malone JD, Jordan K, Hom F, Tuffanelli L, Fillari P, Siu S, Grossman R. A decade of burn unit experience with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: Clinical pathological diagnosis and risk factor awareness. Burns 2016; 42:836-43. [PMID: 26847613 DOI: 10.1016/j.burns.2016.01.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 01/06/2016] [Accepted: 01/07/2016] [Indexed: 12/31/2022]
Abstract
Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN) is a rare and often fatal spectrum of mucocutaneous diseases usually attributable to severe adverse drug reactions. Burn units are referral centers for patients at the most extreme end of the disease continuum. Our burn center admits a much higher percentage of TEN (>30% BSA) cases than reported in most prior reviews. The purpose of this study was to analyze the diagnostic and prognostic value of variables collected on referred SJS/TEN patients. We retrospectively analyzed 94 patients admitted to our unit with a presumptive SJS/TEN diagnosis made in most cases by the referring center. Most of the diagnoses were clinical. Fifty of the 94 patients underwent biopsy when the clinical diagnosis was questionable. Of the 50 patients who underwent biopsy, 18 (36%) received an alternative diagnosis. Analysis was therefore limited to 76 patients, i.e. 44 patients felt to have firm clinical diagnoses plus 32 patients with diagnoses confirmed by biopsy. Mean age was 54.3 years (17-93) and overall gender ratio was 43 F vs. 33 M (56.6% vs. 43.4%). Mean LOS was 15.2 days (1-48) and overall mortality was 23.7% (18/76). Univariate analysis revealed percent body surface area (%BSA) did not show statistically significant association with mortality. Histopathological correlation for diagnosis is not standardized across institutions worldwide. Due to challenges in the diagnosis of SJS/TEN and the high incidence of error in clinical diagnosis, it is recommended that all patients with presumed SJS/TEN receive skin biopsies with H&E and direct immunofluorescence. We propose a diagnostic approach in order to address this need. Lack of association between %BSA and mortality suggests that all biopsy-proven SJS/TEN cases belong in specialty centers due to the unstable nature of the disease and risk for rapid progression.
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Affiliation(s)
- Victoria M Lim
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA.
| | - Annie Do
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| | - Timothy G Berger
- University of California San Francisco, 1701 Divisadero St, San Francisco, CA 94115, USA
| | - Austin H Nguyen
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| | - Jeffrey DeWeese
- Bothin Burn Center, Saint Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109, USA
| | - J David Malone
- Bothin Burn Center, Saint Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109, USA
| | - Kathleen Jordan
- Bothin Burn Center, Saint Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109, USA
| | - Fred Hom
- Bothin Burn Center, Saint Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109, USA
| | - Lucia Tuffanelli
- Bothin Burn Center, Saint Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109, USA
| | - Paula Fillari
- Bothin Burn Center, Saint Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109, USA
| | - Shirley Siu
- Bothin Burn Center, Saint Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109, USA
| | - Richard Grossman
- Bothin Burn Center, Saint Francis Memorial Hospital, 900 Hyde St, San Francisco, CA 94109, USA
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Williams R, Hodge J, Ingram W. Indications for intubation and early tracheostomy in patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Am J Surg 2016; 211:684-688.e1. [PMID: 26860621 DOI: 10.1016/j.amjsurg.2015.12.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) result in epidermal sloughing and mucositis. There are no published guidelines for intubation and early tracheostomy in this patient population. METHODS A retrospective chart review of 40 patients admitted from 2010 to 2015 with SJS and TEN was conducted. Descriptive statistics and significance were calculated. RESULTS Of the 43% of patients who underwent early tracheostomy, 100% had oral involvement while the initial total body surface area (TBSA) was 70% or more in 41% of patients (P < .05). TBSA progressed 15% or more in 53% of patients with 6% having airway involvement and a neurologic diagnosis mandating intubation. Mortality was 17%. CONCLUSIONS Indications for intubation and early tracheostomy for SJS and TEN are documented oral involvement plus one of the following: initial TBSA 70% or more; progression of TBSA involved from hospital day 1 to hospital day 3, 15% TBSA or more; underlying neurologic diagnosis preventing airway protection; and documented airway involvement on direct laryngoscopy.
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Affiliation(s)
- Rachael Williams
- Emory University School of Medicine and Grady Health System, 69 Jesse Hill Jr. Drive, SE, Atlanta, GA, 30303, USA.
| | - Juvonda Hodge
- Emory University School of Medicine and Grady Health System, 69 Jesse Hill Jr. Drive, SE, Atlanta, GA, 30303, USA
| | - Walter Ingram
- Emory University School of Medicine and Grady Health System, 69 Jesse Hill Jr. Drive, SE, Atlanta, GA, 30303, USA
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90
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Secondary bacterial infection and empirical antibiotic use in toxic epidermal necrolysis patients. J Burn Care Res 2015; 35:518-24. [PMID: 24988228 DOI: 10.1097/bcr.0000000000000062] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this study was to determine rates of positive bacterial cultures in patients with extensive toxic epidermal necrolysis, the rate of bacteremia, whether empirical antibiotics had been commenced, and their effectiveness when commenced. The authors conducted a retrospective chart review of patients with extensive toxic epidermal necrolysis between January 2001 and December 2012 admitted to the Victorian Adult Burns Service, Melbourne, Australia, with respect to the amount of positive cultures, number and type of organisms identified, whether empirical antibiotics had been commenced, and whether antibiotics were effective against organisms cultured. A total of 27 patients were admitted over the study period of 11 years. Seventeen of these patients developed at least one positive bacterial culture. Patients who grew positive cultures had a longer length of stay in intensive care unit and in hospital overall compared with patients who did not grow positive cultures. Thirty-five positive cultures were collected overall, with empirical antibiotics commenced in 22 cases. In terms of sensitivity, antibiotics were appropriate in 19 cases. Four patients developed bacteremia, two of whom died. This study does not dispute the generally accepted practice of avoiding prophylactic antibiotics in toxic epidermal necrolysis patients, but in the context of a relatively low rate of bacteremia in this patient population, advises appropriate and targeted empirical antibiotic use where clinical infection is suspected.
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Extensive toxic epidermal necrolysis versus acute graft versus host disease after allogenic hematopoietic stem-cell transplantation: challenges in diagnosis and management. J Burn Care Res 2015; 35:e431-5. [PMID: 24476990 DOI: 10.1097/bcr.0000000000000040] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Toxic epidermal necrolysis (TEN) is a rare complication after allogeneic hematopoietic stem-cell transplantation and carries high mortality rates. Graft-vs-host disease (GVHD) is also a life-threatening complication, and potentially indistinguishable from TEN because of similar clinical symptoms. However, current therapeutic recommendations differ between these two conditions, thereby posing a diagnostic dilemma. The authors, herein, present a complicated postoperative course after bone marrow transplantation with concurrent gastrointestinal and hepatic GVHD, and extensive epidermolytic disease compatible with both severe cutaneous GVHD and TEN. An early consult to a specialized burn service, and prompt transfer to a burn intensive care unit with extensive supportive care and nursing are of paramount importance in the management of immunosuppressed patients with TEN. Better understanding of the pathogenesis of TEN and GVHD after hematopoietic stem-cell transplantation, further treatment strategies, and more advanced diagnostic techniques are still needed to achieve acceptable mortality rates.
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92
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Diphoorn J, Cazzaniga S, Gamba C, Schroeder J, Citterio A, Rivolta AL, Vighi GD, Naldi L. Incidence, causative factors and mortality rates of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in northern Italy: data from the REACT registry. Pharmacoepidemiol Drug Saf 2015; 25:196-203. [PMID: 26687641 DOI: 10.1002/pds.3937] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/13/2015] [Accepted: 11/23/2015] [Indexed: 11/09/2022]
Abstract
PURPOSE Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but severe cutaneous adverse drug reactions. We assessed incidence, drug exposure and mortality, analysing data obtained from the Lombardy Registry of Severe Cutaneous Reactions (REACT). METHODS Data were collected from hospitals in the Italian Lombardy region (9,502,272 people). A trained monitor was sent to the reporting hospital to collect data on drug exposure and clinical features. The algorithm for drug causality for epidermal necrolysis algorithm was applied to assess drug causality. Defined Daily Dose (DDD) was used to express drug consumption. RESULTS From April 2009 to November 2014, 17 cases of TEN and 59 cases of SJS were collected. The overall incidence rate was 1.40 cases (95%CI, 1.12-1.76) per million people per year. A total of 15 cases died during hospitalization with a mortality rate of 16.9% for SJS and 29.4% for TEN. Overall, 55.4% of cases had a probable or very probable relation with drug exposure. In a total of five patients (6.6%), no causative drug for the reaction was identifiable. Allopurinol contributed to the highest number of cases (23 cases), while the highest incidence based on more than one case reported was observed for cotrimoxazole and lamotrigine, with 5.37 cases (95%CI, 2.09-13.80) and 3.54 (95%CI, 1.21-10.42) per 10 million DDD/year, respectively. CONCLUSIONS We confirmed that SJS and TEN are rare adverse cutaneous reactions. As expected, mortality was influenced by the degree of skin detachment. The profile of drugs associated with the reactions was in agreement with data from other surveillance systems.
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Affiliation(s)
- Janouk Diphoorn
- Department of Dermatology, Papa Giovanni XXIII Hospital, Bergamo, Italy.,Centro Studi GISED, Bergamo, Italy.,Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Simone Cazzaniga
- Centro Studi GISED, Bergamo, Italy.,Department of Dermatology, Inselspital University Hospital, Bern, Switzerland
| | - Chiara Gamba
- Department of Dermatology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Jan Schroeder
- Allergology and Immunology Unit, Niguarda Ca' Granda Hospital, Milano, Italy
| | - Antonella Citterio
- Burn/Intensive Care Department, Niguarda Ca' Granda Hospital, Milano, Italy
| | - Alma Lisa Rivolta
- Regional Center of Pharmacovigilance, Lombardy Region, Milano, Italy
| | - Giuseppe Danilo Vighi
- Quality, Privacy and Clinical Risk Unit, Niguarda Ca' Granda Hospital, Milano, Italy
| | - Luigi Naldi
- Department of Dermatology, Papa Giovanni XXIII Hospital, Bergamo, Italy.,Centro Studi GISED, Bergamo, Italy
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94
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Kohanim S, Palioura S, Saeed HN, Akpek EK, Amescua G, Basu S, Blomquist PH, Bouchard CS, Dart JK, Gai X, Gomes JAP, Gregory DG, Iyer G, Jacobs DS, Johnson AJ, Kinoshita S, Mantagos IS, Mehta JS, Perez VL, Pflugfelder SC, Sangwan VS, Sippel KC, Sotozono C, Srinivasan B, Tan DTH, Tandon R, Tseng SCG, Ueta M, Chodosh J. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis--A Comprehensive Review and Guide to Therapy. I. Systemic Disease. Ocul Surf 2015; 14:2-19. [PMID: 26549248 DOI: 10.1016/j.jtos.2015.10.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 09/01/2015] [Accepted: 10/15/2015] [Indexed: 01/06/2023]
Abstract
The intent of this review is to comprehensively appraise the state of the art with regard to Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to the ocular surface complications and their management. SJS and TEN represent two ends of a spectrum of immune-mediated, dermatobullous disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. The widespread keratinocyte death seen in SJS/TEN is rapid and irreversible, and even with early and aggressive intervention, morbidity is severe and mortality not uncommon. We have divided this review into two parts. Part I summarizes the epidemiology and immunopathogenesis of SJS/TEN and discusses systemic therapy and its possible benefits. We hope this review will help the ophthalmologist better understand the mechanisms of disease in SJS/TEN and enhance their care of patients with this complex and often debilitating disease. Part II (April 2016 issue) will focus on ophthalmic manifestations.
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Affiliation(s)
- Sahar Kohanim
- Vanderbilt Eye Institute, Vanderbilt University School of Medicine, Nashville, TN
| | - Sotiria Palioura
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Hajirah N Saeed
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | - Esen K Akpek
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Guillermo Amescua
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Sayan Basu
- LV Prasad Eye Institute, Hyderabad, India
| | | | | | - John K Dart
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - Xiaowu Gai
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | | | - Darren G Gregory
- Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, Aurora, CO
| | - Geetha Iyer
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, India
| | - Deborah S Jacobs
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA; Boston Foundation for Sight, Boston, MA
| | | | | | | | - Jodhbir S Mehta
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
| | - Victor L Perez
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | - Chie Sotozono
- Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Bhaskar Srinivasan
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, India
| | - Donald T H Tan
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
| | - Radhika Tandon
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Delhi, India
| | - Scheffer C G Tseng
- Ocular Surface Center, Ocular Surface Research & Education Foundation, Miami, FL
| | - Mayumi Ueta
- Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - James Chodosh
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.
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95
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Wu J, Lee YY, Su SC, Wu TS, Kao KC, Huang CC, Chang WC, Yang CH, Chung WH. Stevens-Johnson syndrome and toxic epidermal necrolysis in patients with malignancies. Br J Dermatol 2015. [PMID: 26218033 DOI: 10.1111/bjd.14052] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Malignancy is known to be associated with an increased mortality rate in patients with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, risk factors contributing to the poor prognosis of patients with SJS/TEN with malignancies remain undefined. OBJECTIVES To explore the potential involvement of malignancy and its related factors contributing to the poor outcome of SJS/TEN, in a retrospective study. METHODS In total 517 patients with SJS/TEN were enrolled. Forty-seven who sustained various types of malignancies were analysed for numerous malignancy-related factors, including cancer types, clinical stages and chemotherapies given or not before the onset of SJS/TEN. RESULTS We found that the mortality rate of patients with SJS/TEN with malignancies was higher than that of patients without malignancies (32%, 15/47 vs. 8·5%, 40/470, respectively) (P < 0·001). The use of phenytoin was significantly higher in the malignancy group. The presence of hepatocellular carcinoma (80%, four of five; P < 0·001; odds ratio 43) and colorectal cancer (67%, two of three; P = 0·022; odds ratio 21·5) significantly increased the death rate of patients with SJS/TEN, whereas lung cancer and urothelial carcinoma did not. Patients who had received ongoing or recent chemotherapy showed higher mortality than those without chemotherapy (P = 0·022; odds ratio 4·95). Furthermore, among the 47 patients with SJS/TEN with malignancies, lower serum albumin, haemoglobin and platelet count were detected in the deceased patients than in the surviving patients before the onset of SJS/TEN. CONCLUSIONS Our results suggest that several factors related to malignancies, such as specific cancer types, chemotherapy and malnutrition, may contribute to poor prognosis in patients with malignancies developing SJS/TEN.
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Affiliation(s)
- J Wu
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Y Y Lee
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - S C Su
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - T S Wu
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Infectious Disease, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan
| | - K C Kao
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Thoracic Medicine, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan
| | - C C Huang
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Thoracic Medicine, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan
| | - W C Chang
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Hematology-Oncology, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan
| | - C H Yang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - W H Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
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Abstract
Owing to the rare, yet serious nature of toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS), the authors would like to describe our experience with 41 pediatric patients to contribute to the current clinical understanding of the disease. From records at a single institution, 41 patients ≤18 years of age with a diagnosis of SJS or TEN were retrospectively identified. Data were obtained from the hospital's medical record, and a variety of variables were collected, including causative agent, percentage of total body surface area (%TBSA) slough, ocular involvement, medical treatment, operative procedures, time to wound closure, ventilator days, intensive care unit length of stay, and associated hospital mortality. Of the pediatric TEN patients included, the mean epidermal sloughing was 39.7 ± 26% TBSA. The presumptive inciting agent was a medication in 90% of cases. Mycoplasma pneumoniae was implicated in two cases (5%). The average time between onset of symptoms and burn intensive care unit admission was 3.6 ± 2.0 days. Acutely, 73% of patients exhibited ocular involvement, 90% needed supplemental enteral nutritional support, and 51% required mechanical ventilation. On average, subjects spent 19.9 ± 13.9 days in the intensive care unit. While acute mortality was 0%, 100% of patients still experienced long-term complications and 30% required follow-up procedures. When compared to current literature, the outcomes of our patients were similar to that of pediatric TEN at other institutions. While acute mortality is typically better within the pediatric population, patients still experience a significant level of morbidity and have serious long-term sequelae.
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97
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Oen I, van der Vlies C, Roeleveld Y, Dokter J, Hop M, van Baar M. Epidemiology and costs of patients with toxic epidermal necrolysis: a 27-year retrospective study. J Eur Acad Dermatol Venereol 2015; 29:2444-50. [DOI: 10.1111/jdv.13352] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 07/07/2015] [Indexed: 11/29/2022]
Affiliation(s)
- I.M.M.H. Oen
- Burn Centre; Maasstad Hospital; Rotterdam the Netherlands
| | - C.H. van der Vlies
- Burn Centre; Maasstad Hospital; Rotterdam the Netherlands
- Department of Surgery; Maasstad Hospital; Rotterdam the Netherlands
| | | | - J. Dokter
- Burn Centre; Maasstad Hospital; Rotterdam the Netherlands
| | - M.J. Hop
- Association of Dutch Burn Centres; Burn Centre; Maasstad Hospital; Rotterdam the Netherlands
| | - M.E. van Baar
- Association of Dutch Burn Centres; Burn Centre; Maasstad Hospital; Rotterdam the Netherlands
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98
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Bansal S, Garg VK, Sardana K, Sarkar R. A clinicotherapeutic analysis of Stevens-Johnson syndrome and toxic epidermal necrolysis with an emphasis on the predictive value and accuracy of SCORe of Toxic Epidermal Necrolysis. Int J Dermatol 2015; 54:e18-26. [PMID: 25534407 DOI: 10.1111/ijd.12466] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The SCORTEN scale (SCORe of Toxic Epidermal Necrolysis) is widely used to predict mortality in patients with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). Although it is largely a useful tool, the predictive ability of the scale is variable, and modifications to the existing scale have been suggested. In addition, there is controversy regarding the roles of active therapy and conservative management. OBJECTIVES This study was conducted to assess outcomes in SJS/TEN patients managed conservatively and to analyze the predictive performance of SCORTEN. METHODS Sixty patients were studied prospectively from October 2008 to September 2011. The accuracy of SCORTEN in predicting mortality was analyzed on days 1, 3, and 5 of admission. All patients were managed conservatively. RESULTS The discriminative power of SCORTEN was acceptable, being best on day 5. The agreement between actual and predicted mortality was poor, as indicated by a low P-value of the Hosmer-Lemeshow statistic. Only three parameters (heart rate, blood urea, and serum bicarbonate) were found to be significant on multivariate analysis, and all of these represented components within the original SCORTEN scale. The mortality rate was 16.7%. All deaths occurred within the first two weeks (8-12 days). CONCLUSIONS Serial analysis using SCORTEN is better than analysis performed only on day 1. Although the scale is largely useful, its performance is influenced by the demographic profile of the study population; minor modifications based on the population studied may increase the predictive accuracy of the original SCORTEN. In addition, conservative management is a valid therapeutic option, is preferable to treatment with steroids and immunosuppressants, and is highly recommended.
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Affiliation(s)
- Shuchi Bansal
- Department of Dermatology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
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99
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Maximus S, Phelan M, Joe VC. Patients With Burns Versus Patients With Complex Skin and Soft-Tissue Disease: An Analysis of Outcomes in the United States. J Burn Care Res 2015; 37:e125-30. [PMID: 26379188 DOI: 10.1097/bcr.0000000000000307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
With the incidence of burns decreasing nationally, burn units are caring for more patients with nonburn conditions. The American Burn Association National Burn Repository does not currently report data regarding patients cared for in burn units without a diagnosis of burn. Using the National Inpatient Sample, we examined if there was a difference in characteristics and outcomes of patients admitted for burns compared with those with a primary admitting diagnosis of necrotizing skin infections and soft-tissue infections and exfoliative skin conditions. This is a retrospective study querying the National Inpatient Sample database to identify 56,102 patients from 2007 to 2012 who were admitted with a diagnosis of a burn (burn group). This group was then compared with 375,857 patients who had a primary admitting diagnosis of a necrotizing skin and/or soft-tissue infection or exfoliative skin conditions (nonburn group). Clinical and demographic variables were analyzed to determine characteristics of each patient group including length of stay, disposition, complications, comorbidities, and mortality. The average age of the nonburn group was 63.7 years, whereas the average age of the burn group was 40.1 years. Overall length of stay was higher in the nonburn patients than in burn patients (10.5 vs 8.4 days, P < .001). Nonburn patients had a higher rate of medical comorbidities. Nonburn patients had higher rates of mortality (6.9% vs 2.7%) and complications. After adjusting for confounders, such as age, gender, ethnicity, and comorbidities, the nonburn group was found to have higher rates of all recorded complications. Burn patients were more likely to undergo a major operating room procedure (39.3% vs 28.1%) and routine discharge (68.4% vs 26.3%) compared with the nonburn group. Patients with necrotizing skin and soft-tissue infections and exfoliative skin conditions are older, have more comorbidities, higher complication rates, and higher mortality rates than burn patients. Given these findings, burn units may need to adjust their resource utilization, competencies, and research priorities to improve the quality of care being delivered to these two different populations.
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Affiliation(s)
- Steven Maximus
- From the University of California Irvine Medical Center, Orange
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100
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Rizzo JA, Johnson R, Cartie RJ. Pediatric Toxic Epidermal Necrolysis: Experience of a Tertiary Burn Center. Pediatr Dermatol 2015; 32:704-9. [PMID: 26227567 DOI: 10.1111/pde.12657] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pediatric toxic epidermal necrolysis (TEN) is a rare and potentially fatal skin disease with a multitude of causative factors and no consensus on treatment guidelines and, as a result, it has a variety of short- and long-term outcomes. We present the experience of a large specialty burn center to share our diagnostic and treatment principles. METHODS A retrospective review from 1989 to 2010 at the Joseph M. Still Burn Center was performed to find patients with a diagnosis of Steven-Johnson syndrome (SJS) or TEN. Information was obtained on demographic and physiologic parameters such as age, race, total body surface area involved, treatments, hospital stay, and need for ventilator support. RESULTS We identified SJS or TEN in 21 patients. Prescription drugs were the most common etiology (in 15 patients), with antibiotics as the most common causative agent. Histology confirmed the clinical diagnosis of TEN in 14 patients. Our treatment plan included a multidisciplinary team, early initiation of intravenous immunoglobulin, bronchoscopy, strict management of electrolyte and fluid balances, and meticulous surgical wound care. Mortality was 9.5%. CONCLUSION Our experience in treating this rare but devastating disease affords us the opportunity to share the diagnostic dilemmas we faced and the treatment principles we used to treat this unique patient population successfully.
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Affiliation(s)
- Julie A Rizzo
- Institute of Surgical Research, U.S. Army, Fort Sam Houston, Texas
| | - Rebekah Johnson
- Department of Surgery, Dwight David Eisenhower Army Medical Center, Ft. Gordon, Georgia
| | - Richard J Cartie
- Pediatric Intensive Care Services, Joseph M. Still Burn Centers, Augusta, Georgia
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