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van Nispen C, Long B, Koyfman A. High risk and low prevalence diseases: Stevens Johnson syndrome and toxic epidermal necrolysis. Am J Emerg Med 2024; 81:16-22. [PMID: 38631147 DOI: 10.1016/j.ajem.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/04/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are serious conditions that carry a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of SJS/TEN, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION SJS/TEN is a rare, delayed hypersensitivity reaction resulting in de-epithelialization of the skin and mucous membranes. The majority of cases are associated with medication or infection. Clinicians should consider SJS/TEN in any patient presenting with a blistering mucocutaneous eruption. Evaluation of the skin, mucosal, pulmonary, renal, genital, and ocular systems are essential in the diagnosis of SJS/TEN, as well as in the identification of complications (e.g., sepsis). Laboratory and radiological testing cannot confirm the diagnosis in the ED setting, but they may assist in the identification of complications. ED management includes stabilization of airway and breathing, fluid resuscitation, and treatment of any superimposed infections with broad-spectrum antibiotic therapy. All patients with suspected SJS/TEN should be transferred and admitted to a center with burn surgery, critical care, dermatology, and broad specialist availability. CONCLUSIONS An understanding of SJS/TEN can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Christiaan van Nispen
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
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Gu Y, Shih STF, Geevasinga N, Chan L, Frew JW, Sebaratnam DF. Economic Evaluation of HLA-B*15:02 Genotyping for Asian Australian Patients With Epilepsy. JAMA Dermatol 2024; 160:631-640. [PMID: 38717780 PMCID: PMC11079793 DOI: 10.1001/jamadermatol.2024.1037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/12/2024] [Indexed: 05/12/2024]
Abstract
Importance The HLA-B*15:02 allele has been associated with an increased risk of carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis in specific Asian populations (including Han Chinese, Malaysian, Thai, and Vietnamese individuals). While HLA-B*15:02 genotype testing in Asian populations is recommended by several international prescribing guidelines, it is not subsidized by the Medicare Benefits Schedule in Australia. Objective To evaluate the cost-effectiveness of HLA-B*15:02 genotyping in Asian Australian patients with epilepsy. Design, Setting, and Participants A model with components of decision analysis and Markov simulation was developed to simulate clinical trajectories of adult Asian Australian patients with newly diagnosed epilepsy being considered for carbamazepine treatment. Cost-effectiveness and cost-utility analyses over a lifetime time horizon were conducted from the perspective of the Australian health care sector. The study was conducted in May 2023 and data analysis was performed from August 2023 to November 2023. Intervention No HLA-B*15:02 genotyping and the empirical initiation of treatment with carbamazepine vs HLA-B*15:02 genotyping and the initiation of treatment with valproate in allele carriers. Main Outcomes and Measures Life-years (LYs), quality-adjusted life-years (QALYs), and costs in 2023 Australian dollars (A$); incremental cost-effectiveness ratios. Results HLA-B*15:02 screening was associated with an additional mean cost of A$114 (95% CI, -A$83 to A$374; US$76; 95% CI, -US$55 to US$248) and a reduction in 0.0152 LYs (95% CI, 0.0045 to 0.0287 LYs) but improvement by 0.00722 QALYs (95% CI, -0.0247 to -0.01210) compared with no screening, resulting in an incremental cost-effectiveness ratio of A$15 839 per QALY gained (US$10 523 per QALY). Therefore, universal genotyping for Asian Australian individuals was cost-effective compared with current standards of practice at the A$50 000 per QALY willingness-to-pay threshold. Sensitivity analyses demonstrated that the intervention remained cost-effective across a range of costs, utilities, transition probabilities, and willingness-to-pay thresholds. At the A$50 000 per QALY willingness-to-pay threshold, universal screening was the preferred strategy in 88.60% of simulations. Conclusions and Relevance The results of this economic evaluation suggest that HLA-B*15:02 screening represents a cost-effective choice for Asian Australian patients with epilepsy who are being considered for treatment with carbamazepine.
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Affiliation(s)
- Yaron Gu
- Faculty of Medicine and Health, University of New South Wales, Kensington, New South Wales, Australia
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Sophy T. F. Shih
- The Kirby Institute, University of New South Wales Medicine and Health, Sydney, New South Wales, Australia
| | - Nimeshan Geevasinga
- School of Medicine, Western Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Linda Chan
- Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - John W. Frew
- Faculty of Medicine and Health, University of New South Wales, Kensington, New South Wales, Australia
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Laboratory of Translational Cutaneous Medicine, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Deshan F. Sebaratnam
- Faculty of Medicine and Health, University of New South Wales, Kensington, New South Wales, Australia
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
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Wang T, Yang J, Yang F, Cheng Y, Huang Z, Li B, Yang L, Xing Q, Luo X. The association between HLA-B variants and amoxicillin-induced severe cutaneous adverse reactions in Chinese han population. Front Pharmacol 2024; 15:1400239. [PMID: 38863977 PMCID: PMC11165025 DOI: 10.3389/fphar.2024.1400239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/07/2024] [Indexed: 06/13/2024] Open
Abstract
Background Amoxicillin (AMX) is among the most prescribed and the best tolerated antimicrobials worldwide. However, it can occasionally trigger severe cutaneous adverse reactions (SCAR) with a significant morbidity and mortality. The genetic factors that may be relevant to AMX-induced SCAR (AMX-SCAR) remain unclear. Identification of the genetic risk factor may prevent patients from the risk of AMX exposure and resume therapy with other falsely implicated drugs. Methodology Four patients with AMX-SCAR, 1,000 population control and 100 AMX-tolerant individuals were enrolled in this study. Both exome-wide and HLA-based association studies were conducted. Molecular docking analysis was employed to simulate the interactions between AMX and risk HLA proteins. Results Compared with AMX-tolerant controls, a significant association of HLA-B*15:01 with AMX-SCAR was validated [odds ratio (OR) = 22.9, 95% confidence interval (CI): 1.68-1275.67; p = 7.34 × 10-3]. Moreover, 75% carriers of HLA-B*15:01 in four patients with AMX-SCAR, and the carrier frequency of 10.7% in 1,000 control individuals and 11.0% in 100 AMX-tolerant controls, respectively. Within HLA-B protein, the S140 present in all cases and demonstrated the strongest association with AMX-SCAR [OR = 53.5, p = 5.18 × 10-4]. Molecular docking results also confirmed the interaction between AMX and S140 of the HLA-B protein, thus eliminating the false-positive results during in association analysis. Conclusion Our findings suggest that genetic susceptibility may be involved in the development of AMX-SCAR in Han Chinese. However, whether the HLA-B variants observed in this study can be used as an effective genetic marker of AMX-induced SCAR still needs to be further explored in larger cohort studies and other ethnic populations.
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Affiliation(s)
- Ting Wang
- Children’s Hospital of Fudan University, Institutes of Biomedical Sciences of Fudan, Shanghai, China
| | - Jin Yang
- Department of Allergy and Immunology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
- Research Center of Allergy and Diseases, Fudan University, Shanghai, China
| | - Fanping Yang
- Department of Allergy and Immunology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
- Research Center of Allergy and Diseases, Fudan University, Shanghai, China
| | - Ye Cheng
- Children’s Hospital of Fudan University, Institutes of Biomedical Sciences of Fudan, Shanghai, China
| | - Zichong Huang
- College of Chemistry, Green Catalysis Center, Zhengzhou University, Zhengzhou, China
| | - Bei Li
- Children’s Hospital of Fudan University, Institutes of Biomedical Sciences of Fudan, Shanghai, China
| | - Linlin Yang
- Department of Pharmacology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Qinghe Xing
- Children’s Hospital of Fudan University, Institutes of Biomedical Sciences of Fudan, Shanghai, China
| | - Xiaoqun Luo
- Department of Allergy and Immunology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
- Research Center of Allergy and Diseases, Fudan University, Shanghai, China
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Ogiji ED, Aboheimed N, Ross K, Voller C, Siner R, Jensen RL, Jolly CE, Carr DF. Greater mechanistic understanding of the cutaneous pathogenesis of Stevens-Johnson syndrome/toxic epidermal necrolysis can shed light on novel therapeutic strategies: a comprehensive review. Curr Opin Allergy Clin Immunol 2024:00130832-990000000-00126. [PMID: 38753537 DOI: 10.1097/aci.0000000000000993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
PURPOSE OF REVIEW Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) are severe cutaneous adverse drug reactions (SCARs) characterized by widespread epithelial detachment and blistering, which affects the skin and mucocutaneous membranes. To date, therapeutic interventions for SJS/TEN have focused on systematic suppression of the inflammatory response using high-dose corticosteroids or intravenous immunoglobulin G (IgG), for example. No targeted therapies for SJS/TEN currently exist. RECENT FINDINGS Though our understanding of the pathogenesis of SJS/TEN has advanced from both an immunological and dermatological perspective, this knowledge is yet to translate into the development of new targeted therapies. SUMMARY Greater mechanistic insight into SJS/TEN would potentially unlock new opportunities for identifying or repurposing targeted therapies to limit or even prevent epidermal injury and blistering.
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Affiliation(s)
- Emeka D Ogiji
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Department of Pharmacology and Therapeutics, Ebonyi State University, Abakaliki, Nigeria
| | - Nourah Aboheimed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Department of Pharmacy Practice, Princess Nourah bint Abdulrahman University, Saudi Arabia
| | - Kehinde Ross
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University
| | - Calum Voller
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Ryan Siner
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Rebecca L Jensen
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Carol E Jolly
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Daniel F Carr
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
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Copaescu AM, Li L, Blumenthal KG, Trubiano JA. How to Define and Manage Low-Risk Drug Allergy Labels. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1095-1106. [PMID: 38724164 DOI: 10.1016/j.jaip.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 06/06/2024]
Abstract
Risk stratification in drug allergy implies that specific risk categories (eg, low, moderate, and high) classify historical drug hypersensitivity reactions. These risk categories can be based on reaction phenotypic characteristics, the timing of the reaction and evaluation, the required reaction management, and individual characteristics. Although a multitude of frameworks have been described in the literature, particularly for penicillin allergy labels, there has yet to be a global consensus, and approaches continue to vary between allergy centers. Immune-mediated drug allergies can sometimes be confirmed using skin testing, but a negative drug challenge is required to demonstrate tolerance and remove the allergy from the electronic health record ("delabel" the allergy). Even for quintessential IgE-mediated drug allergy, penicillin allergy, recent data reveal that a direct oral challenge, without prior skin testing, is an appropriate diagnostic strategy in those who are considered low-risk. Drug allergy pathogenesis and clinical manifestations may vary depending on the culprit drug, and as such, the optimal approach should be based on risk stratification that considers individual patient and reaction characteristics, the likely hypersensitivity reaction phenotype, the drug class, and the patient's clinical needs. This article will describe low-risk drug allergy labels, focusing on β-lactam and sulfonamide antibiotics, nonsteroidal anti-inflammatory drugs, iodinated contrast media, and common chemotherapeutics. This review will also address practical management approaches using currently available risk stratification and clinical decision tools.
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Affiliation(s)
- Ana Maria Copaescu
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Medicine, Austin Health, the University of Melbourne, Heidelberg, VIC, Australia; Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada; The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada.
| | - Lily Li
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Wash
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, VIC, Australia
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Hung SI, Mockenhaupt M, Blumenthal KG, Abe R, Ueta M, Ingen-Housz-Oro S, Phillips EJ, Chung WH. Severe cutaneous adverse reactions. Nat Rev Dis Primers 2024; 10:30. [PMID: 38664435 DOI: 10.1038/s41572-024-00514-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 06/15/2024]
Abstract
Severe cutaneous adverse reactions (SCARs), which include Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (also known as drug-induced hypersensitivity syndrome), acute generalized exanthematous pustulosis, and generalized bullous fixed drug eruption, are life-threatening conditions. The pathogenesis of SCARs involves T cell receptors recognizing drug antigens presented by human leukocyte antigens, triggering the activation of distinct T cell subsets. These cells interact with keratinocytes and various immune cells, orchestrating cutaneous lesions and systemic manifestations. Genetic predisposition, impaired drug metabolism, viral reactivation or infections, and heterologous immunity influence SCAR development and clinical presentation. Specific genetic associations with distinct SCAR phenotypes have been identified, leading to the implementation of genetic screening before prescription in various countries to prevent SCARs. Whilst systemic corticosteroids and conventional immunomodulators have been the primary therapeutic agents, evolving strategies, including biologics and small molecules targeting tumour necrosis factor, different cytokines, or Janus kinase signalling pathways, signify a shift towards a precision management paradigm that considers individual clinical presentations.
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Affiliation(s)
- Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Department and Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen (dZh), Department of Dermatology, Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Mayumi Ueta
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Saskia Ingen-Housz-Oro
- Dermatology Department, AP-HP, Henri Mondor Hospital, Reference Centre for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Université Paris Est Créteil EpiDermE, Créteil, France
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei/Linkou branches, and Chang Gung University, Taoyuan, Taiwan.
- Department of Dermatology, Chang Gung Memorial Hospital, Xiamen branch, Xiamen, China.
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Curtis KK, Dillan MM, Sharma TR, Piktel J. COVID-19 infection increases the development of Stevens-Johnson syndrome and toxic epidermal necrolysis: A retrospective cohort analysis. J Am Acad Dermatol 2024:S0190-9622(24)00417-1. [PMID: 38423469 DOI: 10.1016/j.jaad.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/15/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Kristen K Curtis
- Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Meghan M Dillan
- Department of Emergency Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Timmie R Sharma
- Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Dermatology, University Hospitals, Cleveland, Ohio
| | - Joseph Piktel
- Department of Emergency Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Emergency Medicine, Metrohealth Medical Center, Cleveland, Ohio
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Aoul AT, Al-Nasseri A, Hall C, He C, Abernathy J. Stevens-Johnson Syndrome in a Patient on Concomitant Treatment with Levetiracetam and Trimethoprim/Sulfamethoxazole. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e942982. [PMID: 38247161 PMCID: PMC10812293 DOI: 10.12659/ajcr.942982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/19/2023] [Accepted: 12/12/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Trimethoprim/sulfamethoxazole and levetiracetam are commonly prescribed medications in the treatment of infections and seizures, respectively. Despite their known efficacy, each has a reputation for triggering severe and sometimes life-threatening cutaneous adverse drug reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. Although the mechanism of such cutaneous adverse drug reactions cannot be fully explained, it is thought to be a type IV T cell and NK cells-mediated hypersensitivity reaction that leads to keratinocyte apoptosis and epidermal necrosis. It is also thought that cutaneous adverse drug reactions are also linked to a patient's genetic predispositions, especially the human leukocyte antigens profiles and the N-acetyl transferase 2 phenotypic variation. CASE REPORT We describe a case of Stevens-Johnson syndrome in a severely ill 51-year-old man who was treated in an outside health care facility simultaneously with Trimethoprim/sulfamethoxazole and levetiracetam. The patient presented to our Emergency Department with Stevens-Johnson syndrome believed to possibly be related to the combination of these 2 agents. CONCLUSIONS The concomitant use of Trimethoprim/sulfamethoxazole and levetiracetam might have been responsible for heightening the potential of these 2 medications to trigger an unfortunate adverse drug reaction, but no formal culprit was able to be identified and no in vivo study was performed, due to ethical considerations. Thus, through this case report we strive to increase awareness of the potential risk of simultaneously prescribing these 2 medications.
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Affiliation(s)
- Amel Tabet Aoul
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL, USA
| | - Abraheim Al-Nasseri
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL, USA
| | - Chase Hall
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL, USA
| | - Chun He
- Department of Pathology, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL, USA
| | - John Abernathy
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL, USA
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Butranova O, Zyryanov S, Gorbacheva A, Asetskaya I, Polivanov V. Drug-Induced Anaphylaxis: National Database Analysis. Pharmaceuticals (Basel) 2024; 17:90. [PMID: 38256923 PMCID: PMC10821106 DOI: 10.3390/ph17010090] [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: 11/27/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
(1) Background: National health system databases represent an important source of information about the epidemiology of adverse drug reactions including drug-induced allergy and anaphylaxis. Analysis of such databases may enhance the knowledge of healthcare professionals regarding the problem of drug-induced anaphylaxis. (2) Methods: A retrospective descriptive analysis was carried out of spontaneous reports (SRs) with data on drug-induced anaphylaxis (SRsAs) extracted from the Russian National Pharmacovigilance database (analyzed period 2 April 2019-21 June 2023). The percentage of SRsAs among SRs of drug-induced allergy (SRsDIAs) was calculated, as well as of pediatric, elderly, and fatal SrsAs. Drugs involved in anaphylaxis were assessed among total SRsAs, pediatric, and elderly SRsAs, and among fatal SRsAs. Demographic parameters of patients were assessed. (3) Results: SRsAs were reported in 8.3% of SRsDIAs (2304/27,727), the mean age of patients was 48.2 ± 15.8 years, and females accounted for 53.2% of cases. The main causative groups of drugs were antibacterials (ABs) for systemic use (44.6%), local anesthetics (20.0%), and cyclooxygenase (COX) inhibitors (10.1%). Fatal SRsAs were reported in 9.5% (218/2304) of cases, the mean age of patients was 48.0 ± 16.7 years, and females accounted for 56.4% of cases. Pediatric SRsAs accounted for 3.9% of pediatric SRsDIAs and 5.8% of all SRsAs, with a mean age of 11.8 ± 4.5 years, and females acccounted for 51.9% of cases. Elderly SRsAs accounted for 2% of elderly SRsDIAs and 2.8% of all SRsAs, and the mean age was 73.0 ± 5.3 years, and females accounted for 43.5% of cases. ABs caused 40% of SRsAs in the elderly, 42.9% in children, and 50% of fatal SRsAs. (4) Conclusions: Our study revealed a relatively high proportion of anaphylaxis among SRs of drug-induced allergy. ABs were the most prevalent causative agents, especially in fatal SRsAs.
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Affiliation(s)
- Olga Butranova
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia Named after Patrice Lumumba (RUDN), 6 Miklukho-Maklaya St., 117198 Moscow, Russia; (S.Z.); (A.G.); (I.A.)
| | - Sergey Zyryanov
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia Named after Patrice Lumumba (RUDN), 6 Miklukho-Maklaya St., 117198 Moscow, Russia; (S.Z.); (A.G.); (I.A.)
- Moscow City Health Department, City Clinical Hospital No. 24, State Budgetary Institution of Healthcare of the City of Moscow, Pistzovaya Srt. 10, 127015 Moscow, Russia
| | - Anastasia Gorbacheva
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia Named after Patrice Lumumba (RUDN), 6 Miklukho-Maklaya St., 117198 Moscow, Russia; (S.Z.); (A.G.); (I.A.)
| | - Irina Asetskaya
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia Named after Patrice Lumumba (RUDN), 6 Miklukho-Maklaya St., 117198 Moscow, Russia; (S.Z.); (A.G.); (I.A.)
| | - Vitaly Polivanov
- Pharmacovigilance Center, Information and Methodological Center for Expert Evaluation, Record and Analysis of Circulation of Medical Products under the Federal Service for Surveillance in Healthcare, 4-1 Slavyanskaya Square, 109074 Moscow, Russia;
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Martinez JD, Cardenas JA, Soria M, Saenz LM, Estrada K, Delgado SM, Ionescu MA, Busila C, Tatu AL. Role of Silver Nitrate Spray for Skin Wound Care in Patients with Toxic Epidermal Necrolysis: Our Experience in 4 Patients. Life (Basel) 2023; 13:2341. [PMID: 38137943 PMCID: PMC10744695 DOI: 10.3390/life13122341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/04/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are examples of severe cutaneous adverse reactions to drugs (SCARs) with several international recommendations for global medical management, ranging from pharmacological systemic therapy to skin wound care. There is no defined best management of the skin wounds in SJS/TEN. The care of wounds is essential to initiate re-epithelialization. Our objective is to improve the cicatrization process, avoiding scarring due to deepening of the wounds, as well as prevent infections, achieve pain control, and avoid loss of serum proteins, fluids, and electrolytes. In this retrospective case series, we highlight the value of systemic therapy and the use of silver nitrate for wound management in four patients with TEN.
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Affiliation(s)
- Jose Dario Martinez
- Department of Internal Medicine, Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico
| | - Jesus Alberto Cardenas
- Department of Rheumatology, Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico;
| | - Manuel Soria
- Dermatology Department, Hospital Civil, Guadalajara 44630, Mexico;
| | - Luis Manuel Saenz
- Medical Students, Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 64460, Mexico; (L.M.S.); (K.E.); (S.M.D.)
| | - Kattya Estrada
- Medical Students, Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 64460, Mexico; (L.M.S.); (K.E.); (S.M.D.)
| | - Sergio Maximo Delgado
- Medical Students, Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 64460, Mexico; (L.M.S.); (K.E.); (S.M.D.)
| | - Marius-Anton Ionescu
- Department of Dermatology, University Hospital Saint Louis, 75010 Paris, France;
| | - Camelia Busila
- “Sf. Ioan” Emergency Clinical Paediatric Hospital, 800179 Galati, Romania
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, 800008 Galati, Romania;
| | - Alin Laurentiu Tatu
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, 800008 Galati, Romania;
- Dermatology Department, “SfantaCuvioasaParascheva” Hospital of Infectious Diseases, 800179 Galati, Romania
- Multidisciplinary Integrated Center of Dermatological Interface Research MIC-DIR (Centrul Integrat Multidisciplinar de Cercetare de InterfataDermatologica—CIM-CID), “Dunărea de Jos” University, 800201 Galati, Romania
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Griffith V, Ramnot A, Resnik SR, Resnik BI. A case of Stevens-Johnson syndrome treated with oral cyclosporine. J Family Med Prim Care 2023; 12:3425-3428. [PMID: 38361872 PMCID: PMC10866270 DOI: 10.4103/jfmpc.jfmpc_1162_23] [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] [Received: 07/16/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 02/17/2024] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) can occur at any age and are commonly caused by adverse drug events. Rapid diagnosis of SJS/TEN is imperative, followed by immediate cessation of offending agent and induction of appropriate treatment. Cyclosporine, a calcineurin inhibitor, has been reported to have a promising therapeutic effect in SJS/TEN patients with few side effects. Diagnosis of SJS/TEN in children is especially challenging as many of the symptoms mimic that of an upper respiratory infection, or other viral entities such as cocksackie A, roseola, or herpes simplex virus. We recommend initiating cyclosporine modified treatment, especially in children, upon any suspicion of SJS/TEN in a patient in order to halt the disease progression as early as possible.
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Affiliation(s)
- Victoria Griffith
- Department of Graduate Medical Education, Memorial Healthcare, Pembroke Pines, FL, United States
| | - Amanda Ramnot
- Department of Internal Medicine, University of Miami/Jackson Health Systems, Miami, FL, United States
| | - Sydney R. Resnik
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Barry I. Resnik
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Department of Dermatology, Resnik Skin Institute, Aventura, FL, United States
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12
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Lee EY, Copaescu AM, Trubiano JA, Phillips EJ, Wolfson AR, Ramsey A. Drug Allergy in Women. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3615-3623. [PMID: 37805007 DOI: 10.1016/j.jaip.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/21/2023] [Accepted: 09/27/2023] [Indexed: 10/09/2023]
Abstract
Across all settings, women self-report more drug allergies than do men. Although there is epidemiologic evidence of increased drug allergy labeling in postpubertal females, the evidence base for female sex as a risk factor for true immune-mediated drug hypersensitivity reactions (DHRs), particularly in fatal drug-induced anaphylaxis, is low. A focus on the known immunologic mechanisms described in immediate and delayed DHR, layered on known hormonal and genetic sex differences that drive other immune-mediated diseases, could be the key to understanding biological sex variations in DHR. Particular conditions that highlight the impact of drug allergy in women include (1) pregnancy, in which a drug allergy label is associated with increased maternal and fetal complications; (2) multiple drug intolerance syndrome, associated with anxiety and depression; and (3) female-predominant autoimmune medical conditions in the context of mislabeling of the drug allergy or increased underlying risk. In this review, we describe the importance of drug allergy in the female population, mainly focusing on the epidemiology and risk, the mechanisms, and the associated conditions and psychosocial factors. By performing a detailed analysis of the current literature, we provide focused conclusions and identify existing knowledge gaps that should be prioritized for future research.
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Affiliation(s)
- Erika Yue Lee
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Eliot Phillipson Clinician-Scientist Training Program, University of Toronto, Toronto, Ontario, Canada
| | - Ana Maria Copaescu
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada; Research Institute of McGill University Health Centre, McGill University, McGill University Health Centre, Montreal, Quebec, Canada; Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Vanderbilt University Medical Centre, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Mass
| | - Allison Ramsey
- Rochester Regional Health, Rochester, NY; Clinical Assistant Professor of Medicine, Department of Allergy/Immunology/Rheumatology, University of Rochester, Rochester, NY.
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Line J, Saville E, Meng X, Naisbitt D. Why drug exposure is frequently associated with T-cell mediated cutaneous hypersensitivity reactions. FRONTIERS IN TOXICOLOGY 2023; 5:1268107. [PMID: 37795379 PMCID: PMC10546197 DOI: 10.3389/ftox.2023.1268107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
Cutaneous hypersensitivity reactions represent the most common manifestation of drug allergy seen in the clinic, with 25% of all adverse drug reactions appearing in the skin. The severity of cutaneous eruptions can vastly differ depending on the cellular mechanisms involved from a minor, self-resolving maculopapular rash to major, life-threatening pathologies such as the T-cell mediated bullous eruptions, i.e., Stevens Johnson syndrome/toxic epidermal necrolysis. It remains a significant question as to why these reactions are so frequently associated with the skin and what factors polarise these reactions towards more serious disease states. The barrier function which the skin performs means it is constantly subject to a barrage of danger signals, creating an environment that favors elicitation. Therefore, a critical question is what drives the expansion of cutaneous lymphocyte antigen positive, skin homing, T-cell sub-populations in draining lymph nodes. One answer could be the heterologous immunity hypothesis whereby tissue resident memory T-cells that express T-cell receptors (TCRs) for pathogen derived antigens cross-react with drug antigen. A significant amount of research has been conducted on skin immunity in the context of contact allergy and the role of tissue specific antigen presenting cells in presenting drug antigen to T-cells, but it is unclear how this relates to epitopes derived from circulation. Studies have shown that the skin is a metabolically active organ, capable of generating reactive drug metabolites. However, we know that drug antigens are displayed systemically so what factors permit tolerance in one part of the body, but reactivity in the skin. Most adverse drug reactions are mild, and skin eruptions tend to be visible to the patient, whereas minor organ injury such as transient transaminase elevation is often not apparent. Systemic hypersensitivity reactions tend to have early cutaneous manifestations, the progression of which is halted by early diagnosis and treatment. It is apparent that the preference for cutaneous involvement of drug hypersensitivity reactions is multi-faceted, therefore this review aims to abridge the findings from literature on the current state of the field and provide insight into the cellular and metabolic mechanisms which may contribute to severe cutaneous adverse reactions.
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Affiliation(s)
| | | | | | - Dean Naisbitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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14
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Antibiotic-associated Stevens-Johnson syndrome. Drug Ther Bull 2023; 61:133. [PMID: 37536751 DOI: 10.1136/dtb.2023.000041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Overview of: Lee EY, Knox C, Phillips EJ. Worldwide prevalence of antibiotic-associated Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis. JAMA Dermatol 2023;159:384-392.
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