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Yun T, Koo Y, Chae Y, Lee D, Kim H, Yang MP, Kang BT, Kang BT. Successful Treatment With Prednisolone and Mycophenolate Mofetil in a Dog With Recurrent Erythema Multiforme Minor. Top Companion Anim Med 2023; 52:100755. [PMID: 36586578 DOI: 10.1016/j.tcam.2022.100755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/12/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
A 3-year-old neutered male miniature poodle dog was referred with a 19-month history of unresolved dermatological signs despite long-term treatment. On physical examination, the dog had severe multifocal erythematous non-blanching patches and scales in the ventral trunk. Dermatological examination revealed Malassezia infection. Considering the history, clinical signs, and degree of infection, the possibility of a drug eruption appeared higher than that of Malassezia dermatitis. Therefore, bathing in lukewarm water was performed for 4 weeks without any other treatment, but there was no improvement. Subsequently, treatment for Malassezia dermatitis and differentiation from allergic dermatitis were performed, but there was still no improvement. A biopsy was performed, with the histopathology revealing lymphocytic interface dermatitis with keratinocyte apoptosis. Based on the histopathologic evaluation and clinical signs, the dog was diagnosed with erythema multiforme (EM) minor. Immunosuppressive therapy with prednisolone (1 mg/kg PO, twice daily) was initiated and had a good therapeutic effect. However, the lesion recurred after tapering the prednisolone dose (0.5 mg/kg PO, every other day). Therefore, steroid-sparing agents were added to the prednisolone regimen. Ciclosporin, azathioprine, and human intravenous immunoglobulin were administered in combination with prednisolone. Yet again, the lesion recurred when the dose of prednisolone was tapered to 0.5 mg/kg once daily. Mycophenolate mofetil (20 mg/kg PO, twice daily) was then added to the immunosuppressive regimen as a steroid-sparing agent, and complete remission was achieved and maintained even when the dose of prednisolone was tapered to 0.5 mg/kg every other day. This is the first reported case of recurrent EM successfully treated with a combination of prednisolone and mycophenolate mofetil, and this treatment option should be considered for recurrent EM.
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Affiliation(s)
- Taesik Yun
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, South Korea
| | - Yoonhoi Koo
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, South Korea
| | - Yeon Chae
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, South Korea
| | - Dohee Lee
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, South Korea
| | - Hakhyun Kim
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, South Korea
| | - Mhan-Pyo Yang
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, South Korea
| | - Byeong-Teck Kang
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, South Korea.
| | - Byeong-Teck Kang
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk 28644, South Korea.
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Du Y, Wang F, Liu T, Jin X, Zhao H, Chen Q, Zeng X. Recurrent oral erythema multiforme: a case series report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 129:e224-e229. [DOI: 10.1016/j.oooo.2019.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/16/2019] [Accepted: 11/19/2019] [Indexed: 12/29/2022]
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Mocanu A, Ivanov A, Alecsa M, Lupu VV, Lupu A, Starcea IM, Miron OT, Gavrilovici C, Miron IC. Uncommon erythema multiforme in small children: experience of a single Romanian pediatric unit: Two case reports. Medicine (Baltimore) 2019; 98:e17895. [PMID: 31725635 PMCID: PMC6867757 DOI: 10.1097/md.0000000000017895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 09/24/2019] [Accepted: 10/09/2019] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Erythema multiforme (EM) is an immune-mediated disease with mucocutaneous localization and plurietiologic determinism. The term "multiforme" refers to the variety of aspects that the lesions can take from patient to patient and during evolution in a single patient. PATIENT CONCERNS We have selected 2 cases of small children diagnosed with different etiology of EM to illustrate the importance of a correct and fast diagnosis. Case 1 involves a 2-year-old girl from a rural area who presented with fever and pruritic erythematous papular eruption. The onset of the symptoms was 3 days before presentation with fever and ulcerative lesions on the oral and labial mucosa, followed by the appearance of erythematous macular lesions, with progressive confluence to intense pruritic patches. The 2nd involves a 2-year-old boy with fever, loss of appetite, productive cough, and petechiae. He had corticosensible immune thrombocytopenia from the age of 6 months, with many recurrences. The patient received treatment with ampicillin/sulbactam and symptomatics for an erythemato-pultaceous angina. During the 2nd day of treatment the patient developed an erythematous macular eruption on the face, scalp, trunk, and limbs, with bullae formation. DIAGNOSES The 1st patient was diagnosed based on biologic findings: positive inflammatory syndrome, elevated level of anti-Mycoplasma pneumoniae immunoglobulin M antibodies and immunoglobulin E. Histopathologic examination described papillary dermal edema, inflammatory infiltrate, and lymphocyte exocytosis. In the 2nd case, the hemoleucogram identified 12,000/mm platelets and the medulogram aspect was normal. Serology for Epstein-Barr virus was negative. The diagnosis was EM secondary to M pneumoniae infection in case 1 and secondary to administration of ampicillin/sulbactam in case 2. INTERVENTIONS In both cases, etiopathogenic treatment consisting of steroidal antiinflammatory drugs, antihistamines was administered. Because of specific etiology, the 1st case received antibiotics. OUTCOMES The evolution was favorable in 10 to 14 days; the patients were discharged after etiopathogenic treatment consisting of steroidal antiinflammatory drugs, antihistamines, and/or antibiotics. LESSONS Performing a detailed clinical examination, medical history of drug use, infection or general diseases can establish a good diagnosis of EM. Histopathologic examination can help. The treatment is etiologic, pathogenic, and symptomatic. EM usually has a self-limited evolution.
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Affiliation(s)
- Adriana Mocanu
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Anca Ivanov
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Mirabela Alecsa
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Vasile Valeriu Lupu
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Ancuta Lupu
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- Vth Pediatric Department, Sf. Maria Emergency Hospital for Children, Iasi, Romania
| | - Iuliana Magdalena Starcea
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Oana Tatiana Miron
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
| | - Cristina Gavrilovici
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
| | - Ingrith Crenguta Miron
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”
- IVth Pediatric Department
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Liu RF, Chen CB, Hui RC, Kuan YZ, Chung WH. The effect of levamisole in the treatment of recalcitrant recurrent erythema multiforme major: An observational study. J Dermatol Sci 2018; 92:38-44. [DOI: 10.1016/j.jdermsci.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/25/2018] [Accepted: 08/05/2018] [Indexed: 01/12/2023]
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Kechichian E, Ingen-Housz-Oro S, Sbidian E, Hemery F, Bernier C, Fite C, Delaunay J, Staumont-Sallé D, Toukal F, Dupin N, Abasq C, Samimi M, Picard C, Hebert V, Prost C, Monfort JB, Milpied B, Wolkenstein P, Chosidow O. A large epidemiological study of erythema multiforme in France, with emphasis on treatment choices. Br J Dermatol 2018; 179:1009-1011. [DOI: 10.1111/bjd.16928] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- E. Kechichian
- Department of Dermatology; APHP; Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny; 94010 Créteil France
| | - S. Ingen-Housz-Oro
- Department of Dermatology; APHP; Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny; 94010 Créteil France
- Department of Dermatology; EA 7379 - EpiDermE, Université Paris Est; Créteil France
| | - E. Sbidian
- Department of Dermatology; APHP; Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny; 94010 Créteil France
- Department of Dermatology; EA 7379 - EpiDermE, Université Paris Est; Créteil France
- Department of Dermatology; Université Paris Est UPEC; Créteil France
| | - F. Hemery
- Department of Medical Information; APHP; Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny; 94010 Créteil France
| | - C. Bernier
- Department of Dermatology; CHU Nantes; Nantes France
| | - C. Fite
- Department of Dermatology; APHP, Hôpital Bichat; Paris France
| | - J. Delaunay
- Department of Dermatology; CHU Angers; Angers France
| | - D. Staumont-Sallé
- Department of Dermatology; Hôpital Claude Huriez - CHRU Lille; Lille France
| | - F. Toukal
- Department of Dermatology; Hôpital Saint André Bordeaux; Bordeaux France
| | - N. Dupin
- Department of Dermatology; APHP, Hôpital Tarnier; Paris France
| | - C. Abasq
- Department of Dermatology; Department of Dermatology; CHU Brest; Brest France
| | - M. Samimi
- Department of Dermatology; CHU de Tours; Tours France
| | - C. Picard
- Department of Dermatology; CHU de Caen; Caen France
| | - V. Hebert
- Department of Dermatology; CHU de Rouen; Rouen France
| | - C. Prost
- Department of Dermatology; APHP, Hôpital Avicenne; Bobigny France
| | - J.-B. Monfort
- Department of Dermatology; APHP, Hôpital Tenon; Paris France
| | - B. Milpied
- Department of Dermatology; Hôpital Saint André Bordeaux; Bordeaux France
| | - P. Wolkenstein
- Department of Dermatology; APHP; Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny; 94010 Créteil France
- Department of Dermatology; EA 7379 - EpiDermE, Université Paris Est; Créteil France
- Department of Dermatology; Université Paris Est UPEC; Créteil France
| | - O. Chosidow
- Department of Dermatology; APHP; Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny; 94010 Créteil France
- Department of Dermatology; EA 7379 - EpiDermE, Université Paris Est; Créteil France
- Department of Dermatology; Université Paris Est UPEC; Créteil France
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6
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Maderal AD, Lee Salisbury P, Jorizzo JL. Desquamative gingivitis. J Am Acad Dermatol 2018; 78:851-861. [DOI: 10.1016/j.jaad.2017.04.1140] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/30/2017] [Indexed: 10/17/2022]
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Abstract
Mycophenolate mofetil (MMF) is an immunosuppressive drug the efficiency of which has been established in renal transplantation. Recent studies suggest that it may also be effective in the treatment of variant skin diseases especially if the skin lesions are triggered by lymphocytes. Studies have shown efficacy in autoimmune bullous dermatoses, atopic dermatitis and psoriasis. However, there are no placebo-controlled trials that support the use of MMF as first line therapy in these skin diseases.
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Affiliation(s)
- M Hartmann
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - A Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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Abstract
Mycophenolate mofetil (MMF) is an immunosuppressive drug the efficiency of which has been established in renal transplantation. Recent studies suggest that it may also be effective in the treatment of variant skin diseases especially if the skin lesions are triggered by lymphocytes. Studies have shown efficacy in autoimmune bullous dermatoses, atopic dermatitis and psoriasis. However, there are no placebo-controlled trials that support the use of MMF as first line therapy in these skin diseases.
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Affiliation(s)
- M Hartmann
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany.
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Chang VS, Chodosh J, Papaliodis GN. Chronic Ocular Complications of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: The Role of Systemic Immunomodulatory Therapy. Semin Ophthalmol 2016; 31:178-87. [PMID: 26959145 DOI: 10.3109/08820538.2015.1114841] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, but potentially blinding diseases that affect the skin and mucous membranes. Although the cutaneous manifestations tend to be self-limited and resolve without sequelae, the chronic ocular complications associated with SJS/TEN can persist despite local therapy. Poor understanding of the underlying pathophysiology and lack of a standardized clinical approach have resulted in a paucity of data in regards to suitable treatment options. Inflammatory cellular infiltration and elevated levels of ocular surface cytokines in the conjunctival specimens of affected patients give credence to an underlying immunogenic etiology. Furthermore, the presence of ongoing ocular surface inflammation and progressive conjunctival fibrosis in the absence of exogenous aggravating factors suggest a possible role for systemic immunomodulatory therapy (IMT). We review in detail the proposed immunogenesis underlying chronic ocular SJS/TEN and the possible utility of systemic IMT.
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Affiliation(s)
- Victoria S Chang
- a Department of Ophthalmology , Harvard Medical School, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
| | - James Chodosh
- a Department of Ophthalmology , Harvard Medical School, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
| | - George N Papaliodis
- a Department of Ophthalmology , Harvard Medical School, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
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Shephard M, Hodgson T, Hegarty AM. Vesiculobullous disorders affecting the oral cavity. Br J Hosp Med (Lond) 2014; 75:502-8. [PMID: 25216166 DOI: 10.12968/hmed.2014.75.9.502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Martina Shephard
- Specialist Registrar in Oral Medicine, Eastman Dental Hospital, UCLH Foundation NHS Trust London, London
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12
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Yager JA. Erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis: a comparative review. Vet Dermatol 2014; 25:406-e64. [PMID: 24990284 DOI: 10.1111/vde.12142] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Human erythema multiforme (EM) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) are separate conditions. There is no consensus on classification criteria for the eponymous diseases in animals. RESULTS Animal EM is very different from 90% of human EM, which is herpes virus associated (HAEM). Animals lack acrally distributed, typical raised targets. Unlike canine parvovirus 'EM', HAEM is not an active infection. Animal EM is often attributed to drugs, but this is rarely proved. Conversely, human and animal SJS/TEN are almost identical, life-threatening disorders of epidermal necrosis and detachment, typically triggered by drugs (occasionally by infectious agents). Both EM and SJS/TEN are mediated by cytotoxic lymphocyte responses against altered keratinocytes (infectious agents or drugs). Apoptosis results from direct cytotoxicity or through soluble mediators, namely Fas ligand, granzymes, perforin and granulysin. Diagnosis in humans is clinicopathological, with emphasis on clinical lesions; histopathology confirms the pathological process as interface (cytotoxic) dermatitis. Human EM is self-limiting; only recurrent and rare persistent cases require antiviral/immunosuppressive therapies. Drug-induced EM responds to drug withdrawal. Idiopathic canine EM (>40%) is usually chronic, refractory to treatment and may represent heterogeneous conditions. Early identification and removal of the causative drug and high-quality supportive care are critical in SJS/TEN. Mortality rate is nevertheless high. CONCLUSIONS AND CLINICAL IMPORTANCE (1) Histopathological lesions do not reliably differentiate EM, SJS and TEN. (2) A multicentre study to develop a consensus set of clinical criteria for EM and SJS/TEN in animals is overdue. (3) No adjunctive therapies, including intravenous immunoglobulin and ciclosporin, have met evidence-based standards.
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Affiliation(s)
- Julie A Yager
- Department of Pathobiology, University of Guelph, Guelph, Ontario, Canada, N1G2W1
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Turnbull N, Hawkins D, Atkins M, Francis N, Roberts N. Persistent erythema multiforme associated with Epstein-Barr virus infection. Clin Exp Dermatol 2013; 39:154-7. [PMID: 24313260 DOI: 10.1111/ced.12243] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2013] [Indexed: 11/30/2022]
Abstract
Erythema multiforme (EM) is a common, self-limiting condition. Recurrent EM is a well-recognised variant, often associated with herpes simplex virus infection. It is frequently managed with prophylactic aciclovir. Anecdotal reports suggest that recurrent EM may be associated with the use of corticosteroids. Persistent EM, however, is a rare variant, with few cases reported in the literature. It has a protracted course often with atypical and inflammatory lesions. It has been associated with occult viral infections, particularly Epstein-Barr Virus (EBV), as well as inflammatory bowel disease and malignancy. We report a case of EM associated with EBV infection.
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Affiliation(s)
- N Turnbull
- Department of Dermatology, Chelsea and Westminster Hospital, London, UK
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Li J, Chong AH, Green J, Kelly R, Baker C. Mycophenolate use in dermatology: A clinical audit. Australas J Dermatol 2013; 54:296-302. [DOI: 10.1111/ajd.12042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 02/04/2013] [Indexed: 01/27/2023]
Affiliation(s)
- Jane Li
- Department of Dermatology; St. Vincent's Hospital Melbourne; Melbourne Victoria Australia
| | - Alvin H Chong
- Department of Dermatology; St. Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Skin and Cancer Foundation Inc.; Melbourne Victoria Australia
| | - Jack Green
- Department of Dermatology; St. Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Skin and Cancer Foundation Inc.; Melbourne Victoria Australia
| | - Robert Kelly
- Department of Dermatology; St. Vincent's Hospital Melbourne; Melbourne Victoria Australia
| | - Christopher Baker
- Department of Dermatology; St. Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Skin and Cancer Foundation Inc.; Melbourne Victoria Australia
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Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol 2012; 51:889-902. [PMID: 22788803 DOI: 10.1111/j.1365-4632.2011.05348.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Erythema multiforme (EM) is an uncommon, immune-mediated disorder that presents with cutaneous or mucosal lesions or both. In herpes simplex virus (HSV)-associated EM, the findings are thought to result from cell-mediated immune reaction against viral antigen-positive cells that contain the HSV DNA polymerase gene (pol). The target lesion, with concentric zones of color change, represents the characteristic cutaneous finding seen in this disorder. Although EM can be induced by various factors, HSV infection continues to be the most common inciting factor. Histopathologic testing and other laboratory investigations may be used to confirm the diagnosis of EM and to differentiate it from other clinical imitators. Imitators of EM include urticaria, Stevens-Johnson syndrome, fixed drug eruption, bullous pemphigoid, paraneoplastic pemphigus, Sweet's syndrome, Rowell's syndrome, polymorphus light eruption, and cutaneous small-vessel vasculitis. Because disease severity and mucosal involvement differ among patients, treatment should be tailored to each patient, with careful consideration of treatment risk vs benefit. Mild cutaneous involvement of EM can be managed primarily with a goal of achieving symptomatic improvement; however, patients with HSV-associated recurrent EM and idiopathic recurrent EM require treatment with antiviral prophylaxis. Inpatient hospitalization may be required for patients with severe mucosal involvement that causes poor oral intake and subsequent fluid and electrolyte imbalance. With this review, we strive to provide guidance to the practicing dermatologist in the evaluation and treatment of a patient with EM.
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Affiliation(s)
- Olayemi Sokumbi
- Department of Dermatology, Mayo Clinic, Rochester, MN 55905, USA
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Wetter DA, Davis MDP. Recurrent erythema multiforme: clinical characteristics, etiologic associations, and treatment in a series of 48 patients at Mayo Clinic, 2000 to 2007. J Am Acad Dermatol 2009; 62:45-53. [PMID: 19665257 DOI: 10.1016/j.jaad.2009.06.046] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 05/05/2009] [Accepted: 06/10/2009] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recurrent erythema multiforme (EM) is a condition of substantial morbidity. Our efforts toward the etiologic attribution and treatment of recurrent EM have been less fruitful than those previously described. OBJECTIVE We sought to further characterize clinical characteristics, etiologic associations, and treatment of recurrent EM. METHODS We conducted a retrospective review of patients with recurrent EM seen between 2000 and 2007. RESULTS Of 48 patients (mean age at disease onset, 36.4 years), 28 (58%) were female (mean duration of recurrent EM, 6 years). Thirty (63%) patients had oral involvement. Herpes simplex virus caused recurrent EM in 11 (23%) patients, and the cause remained unknown in 28 (58%). In all, 37 (77%) patients received systemic corticosteroids, 33 (69%) received continuous antiviral treatment, and 23 (48%) used immunosuppressive or anti-inflammatory agents. Sixteen of 33 patients receiving continuous antiviral treatment had either partial or complete disease suppression. Patients had varied responses to immunosuppressants, with mycophenolate mofetil providing partial or complete response in 6 of 8 patients. Features of recalcitrant cases included clinicians' inability to identify a specific cause, lack of improvement with continuous antiviral therapy, severe oral involvement, extensive corticosteroid therapy, and immunosuppressive therapy (two or more agents). LIMITATION This study is retrospective. CONCLUSIONS More than half of patients in this study did not have an identifiable cause for recurrent EM, and herpes simplex virus was found less frequently than reported in previous studies. Response to systemic treatments, including continuous antivirals and immunosuppressants, was varied and often times suboptimal.
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Affiliation(s)
- David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota.
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17
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Mycophenolate mofetil in dermatology. J Am Acad Dermatol 2009; 60:183-99; quiz 200-2. [DOI: 10.1016/j.jaad.2008.08.049] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 08/01/2008] [Accepted: 08/11/2008] [Indexed: 11/17/2022]
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Ang GS, Simpson SA, Reddy AR. Mycophenolate mofetil embryopathy may be dose and timing dependent. Am J Med Genet A 2008; 146A:1963-6. [PMID: 18570296 DOI: 10.1002/ajmg.a.32420] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Mycophenolate mofetil (MMF) is an immunosuppressive agent that has now been recognized as teratogenic in humans. A pattern of malformations from in utero exposure to MMF has recently been described, and includes cleft lip and palate, microtia and atresia of the external auditory canal. We present a nulliparous mother who had taken MMF for recurrent erythema multiforme for the first 5 weeks of her pregnancy, and developed a spontaneous miscarriage during the seventh week of pregnancy. For her second pregnancy, she took MMF on her own accord for four days in the seventh week after her last menstrual period. The newborn had bilateral microtia, absence of the external auditory canals, and right iris and chorioretinal coloboma, consistent with the pattern recognized as part of the MMF embryopathy phenotype. As the newborn was not exposed to other immunosuppressive agents in utero, we believe that the phenotype described to be the result of the teratogenic effect of MMF. The spontaneous miscarriage in the first pregnancy may be due to the higher dose and longer duration of MMF exposure. The second pregnancy, with MMF exposure of 4 days, proceeded to term with the resultant phenotype. We conclude that the effect and severity of the embryopathy may be dependent on the dose, timing, and duration of MMF exposure. The manufacturer and the United States Food and Drug Administration have now disseminated information regarding the teratogenic risk of MMF. Women should be fully counseled and advised about contraception during the course of treatment with MMF.
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Affiliation(s)
- Ghee Soon Ang
- Department of Paediatric Ophthalmology, Royal Aberdeen Children's Hospital, Aberdeen, United Kingdom
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Hazin R, Ibrahimi OA, Hazin MI, Kimyai-Asadi A. Stevens-Johnson syndrome: pathogenesis, diagnosis, and management. Ann Med 2008; 40:129-38. [PMID: 18293143 DOI: 10.1080/07853890701753664] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Cutaneous drug reactions are the most common type of adverse drug reaction. These reactions, ranging from simple pruritic eruptions to potentially life-threatening events, are a significant cause of iatrogenic morbidity and mortality. Stevens-Johnson syndrome (SJS) is a serious and potentially life-threatening cutaneous drug reaction. Although progress has been made in the management of SJS through early detection, prompt hospitalization, and immediate cessation of offending agents, the prevalence of permanent disabilities associated with SJS remains unchanged. Nevertheless, despite being a problem that is global in scope, government and health care agencies worldwide have yet to find a consensus on either diagnostic criteria or therapy for this disorder. Here, we provide the internist and emergency room physician with a brief review the SJS literature and summarize the latest recommended interventions with the hope of improving early recognition of this disease and prevention of permanent sequelae and mortality that frequently complicate SJS.
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Affiliation(s)
- Ribhi Hazin
- Harvard University, Faculty of Arts and Sciences, Cambridge, MA, USA
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Al-Johani KA, Fedele S, Porter SR. Erythema multiforme and related disorders. ACTA ACUST UNITED AC 2007; 103:642-54. [PMID: 17344075 DOI: 10.1016/j.tripleo.2006.12.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2006] [Revised: 12/12/2006] [Accepted: 12/12/2006] [Indexed: 01/07/2023]
Abstract
Erythema multiforme (EM) and related disorders comprise a group of mucocutaneous disorders characterized by variable degrees of mucosal and cutaneous blistering and ulceration that occasionally can give rise to systemic upset and possibly compromise life. The clinical classification of these disorders has often been variable, thus making definitive diagnosis sometimes difficult. Despite being often caused by, or at least associated with, infection or drug therapy, the pathogenic mechanisms of these disorders remain unclear, and as a consequence, there are no evidence-based, reliably effective therapies. The present article reviews aspects of EM and related disorders of relevance to oral medicine clinical practice and highlights the associated potential etiologic agents, pathogenic mechanisms and therapies.
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Affiliation(s)
- Khalid A Al-Johani
- Division of Medical, Surgical and Diagnostic Sciences, Eastman Dental Institute for Oral Health Care Sciences, University College of London, London, England
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Arca E, Köse O, Erbil AH, Nişanci M, Akar A, Gür AR. A 2-year-old girl with Stevens--Johnson syndrome/toxic epidermal necrolysis treated with intravenous immunoglobulin. Pediatr Dermatol 2005; 22:317-20. [PMID: 16060867 DOI: 10.1111/j.1525-1470.2005.22407.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Toxic epidermal necrolysis and Stevens-Johnson syndrome are severe skin reactions, usually to drugs, associated with a widespread destruction of the epidermis. Widespread purpuric macules and epidermal detachment of less than 10% of the body surface is indicative of Stevens-Johnson syndrome, whereas epidermal detachment between 10% and 30% is called Stevens-Johnson-toxic epidermal necrolysis overlap. Epidermal detachment involving more than 30% of the total body surface is designated as toxic epidermal necrolysis. These generalized reactions are known to occur in association with various drugs. Treatment is primarily supportive care, and there are no specific therapy regimens. Therapeutic modalities such as corticosteroids, cyclosporin, thalidomide, cyclophosphamide, and plasmapheresis, usually based on a symptomatic approach, have been tried in single patients or in small series. Intravenous immunoglobulin has recently been shown to provide rapid improvement in all three of these skin reactions. We report a 2-year-old girl who developed Stevens-Johnson syndrome-toxic epidermal necrolysis overlap after receiving ampicillin-sulbactam for an upper respiratory tract infection. She was treated successfully with a 4-day course of intravenous immunoglobulin.
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Affiliation(s)
- Ercan Arca
- Department of Dermatology, Gülhane Military Medical Academy, School of Medicine, Etlik, Ankara, Turkey.
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