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Ferdause J, Momtahena SJ, Karim R, Chowdhury AP, Hossain NT, Islam MA, Habib MB, Kadir AKMS, Haque MA. Trastuzumab-induced toxic epidermal necrolysis in a Her-2-positive metastatic breast cancer patient-A rare case report. Clin Case Rep 2024; 12:e9103. [PMID: 38915931 PMCID: PMC11194292 DOI: 10.1002/ccr3.9103] [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: 04/19/2024] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 06/26/2024] Open
Abstract
Toxic Epidermal Necrolysis (TEN) is a rare, but potentially fatal mucocutaneous reaction, that may occur due to an immunologic response to certain medications. However, TEN triggered by Trastuzumab is extremely rare. Early diagnosis, recognition, and prompt cessation of the offending drugs and initiation of steroid therapy with supportive management are the most important actions for managing TEN. Although rare, it is important to be vigilant about this potential adverse reactions associated with trastuzumab to ensure patient safety and contribute to better outcomes.
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Affiliation(s)
| | | | - Rubama Karim
- Ahsania Mission Cancer and General HospitalDhakaBangladesh
| | | | | | | | - Maruf Bin Habib
- Department of MedicineAhsania Mission Medical CollegeDhakaBangladesh
| | | | - Md Ariful Haque
- Department of Public HealthAtish Dipankar University of Science and TechnologyDhakaBangladesh
- Voice of Doctors Research SchoolDhakaBangladesh
- Department of Orthopaedic SurgeryYan'an Hospital Affiliated to Kunming Medical UniversityKunmingYunnanChina
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Stevens-Johnson syndrome in children. Curr Opin Pediatr 2022; 34:341-348. [PMID: 35836393 DOI: 10.1097/mop.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The concept of Stevens-Johnson syndrome (SJS) in children is evolving. This manuscript reviews recent advances with the lens of new terminology namely infection-triggered reactive infectious mucocutaneous eruption and drug-induced epidermal necrolysis, with the objective of integrating this novel terminology practically. RECENT FINDINGS Traditionally considered to exist on a spectrum with toxic epidermal necrolysis, SJS in children is more often caused or triggered by infections instead of medications. Proposed pediatric-specific terminology can be applied to literature to gain further insights into blistering severe cutaneous adverse reactions. SUMMARY Distinguishing infection-triggered from drug-triggered blistering reactions is useful for 3 main reasons: (1) early clinically recognizable different features such as isolated or predominant mucositis, (2) different initial management depending on trigger, (3) avoiding the label of a drug reaction on cases triggered by infection.
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Ao S, Gao X, Zhan J, Ai L, Li M, Su H, Tang X, Chu C, Han J, Wang F. Inhibition of tumor necrosis factor improves conventional steroid therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis in a cohort of patients. J Am Acad Dermatol 2022; 86:1236-1245. [PMID: 35121075 DOI: 10.1016/j.jaad.2022.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/04/2022] [Accepted: 01/19/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Systemic steroid therapies for Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) have been challenged because of their limited benefits. Whether additional tumor necrosis factor (TNF) α inhibition provides an optimized approach remains unexplored. OBJECTIVE To investigate the efficacy of TNF-α inhibition combined with a steroid to treat SJS/TEN and to identify potential biomarkers. METHODS Twenty-five patients with SJS/TEN were recruited and divided into 2 groups: 10 patients received methylprednisolone and 15 patients received etanercept plus methylprednisolone. Serum levels of granzyme B, perforin, interferon-γ, interleukin (IL) 6, IL-15, IL-18, macrophage inflammatory protein 1α, macrophage inflammatory protein 1β, and TNF-α were measured by multiplex cytokine analysis kits during the acute and resolution phases. RESULTS Compared with the steroid monotherapy, the combination therapy significantly shortened the course of the initial steroid treatment and the duration of the acute stage, hospitalization stay, and skin re-epithelialization. Although both therapies significantly reduced IL-15 levels; the combination therapy also decreased IL-6 and IL-18 levels. While the level of IL-15 was positively correlated with skin re-epithelialization time in both groups, the level of IL-6 served as an additional marker for the course of the disease in the combination therapy group. LIMITATIONS The cohort size is relatively small. CONCLUSION Additional TNF-α inhibition to steroid treatment appeared to improve outcomes for SJS/TEN.
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Affiliation(s)
- Suiting Ao
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Xuemei Gao
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Jipang Zhan
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Lu Ai
- Department of Laboratory Medicine, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Minyi Li
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Huilin Su
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Xuhua Tang
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Coco Chu
- Jill Roberts Institute for Research in Inflammatory Bowel Disease, Weill Cornell Medicine, Cornell University, New York, New York
| | - Jiande Han
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Fang Wang
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
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Shields BE, Wanat KA, Chiu YE. Undiagnosed and Rare Diseases in Critical Care. Crit Care Clin 2022; 38:243-269. [DOI: 10.1016/j.ccc.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Dermatological Manifestations in the Intensive Care Unit: A Practical Approach. Crit Care Res Pract 2020; 2020:9729814. [PMID: 33062328 PMCID: PMC7533796 DOI: 10.1155/2020/9729814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 07/23/2020] [Accepted: 09/10/2020] [Indexed: 12/04/2022] Open
Abstract
Dermatological problems are not usually related to intensive medicine because they are considered to have a low impact on the evolution of critical patients. Despite this, dermatological manifestations (DMs) are relatively frequent in critically ill patients. In rare cases, DMs will be the main diagnosis and will require intensive treatment due to acute skin failure. In contrast, DMs can be a reflection of underlying systemic diseases, and their identification may be key to their diagnosis. On other occasions, DMs are lesions that appear in the evolution of critical patients and are due to factors derived from the stay or intensive treatment. Lastly, DMs can accompany patients and must be taken into account in the comprehensive pathology management. Several factors must be considered when addressing DMs: on the one hand, the moment of appearance, morphology, location, and associated treatment and, on the other hand, aetiopathogenesis and classification of the cutaneous lesion. DMs can be classified into 4 groups: life-threatening DMs (uncommon but compromise the patient's life); DMs associated with systemic diseases where skin lesions accompany the pathology that requires admission to the intensive care unit (ICU); DMs secondary to the management of the critical patient that considers the cutaneous manifestations that appear in the evolution mainly of infectious or allergic origin; and DMs previously present in the patient and unrelated to the critical process. This review provides a characterization of DMs in ICU patients to establish a better identification and classification and to understand their interrelation with critical illnesses.
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Gao X, Tang X, Ai L, Gao Q, Liao Q, Chen M, Chen X, Zhou H, Ye Y, Li M, Han J, Wang F. Acute pancreatic injuries: A complication of Stevens-Johnson syndrome/toxic epidermal necrolysis associated with cytotoxic immunocell activation. J Am Acad Dermatol 2020; 84:644-653. [PMID: 32561372 PMCID: PMC7297678 DOI: 10.1016/j.jaad.2020.06.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/07/2020] [Accepted: 06/10/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Complications involving internal organs are usually present in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, pancreatic complications are rarely reported and studied. OBJECTIVE To summarize clinical characteristics of SJS/TEN-associated acute pancreatic injuries and to investigate underlying inflammatory mechanisms. METHODS Clinical records of 124 inpatients with SJS/TEN were reviewed. Serum levels of tumor necrosis factor α, interleukin (IL) 6, IL-18, IL-15, IL-12p70, and soluble CD56 were determined in 18 healthy donors and 17 patients with SJS/TEN, including 3 with acute pancreatic injuries. RESULTS Acute pancreatic injury was diagnosed in 7.3% of patients (9/124) in the SJS/TEN cohort. Elevation of serum transaminase level and hypoalbuminemia occurred more frequently in patients with acute pancreatic injuries compared with those without pancreatic symptoms (P = .004 and <.001, respectively). Although acute pancreatic injury did not alter mortality rate of SJS/TEN, it was associated with longer hospitalization stays (P = .008). Within the serum cytokines whose levels were elevated in SJS/TEN, only IL-18 was found to be selectively increased in patients with acute pancreatic injuries compared with those without them (P = .03). LIMITATIONS Cohort was small. CONCLUSION Acute pancreatic injury is a gastrointestinal complication of SJS/TEN in which hepatotoxicity is more likely to occur. Overexpression of IL-18 might be involved in this unique entity.
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Affiliation(s)
- Xuemei Gao
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong
| | - Xuhua Tang
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong
| | - Lu Ai
- Department of Laboratory Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong
| | - Qian Gao
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong
| | - Qiman Liao
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong
| | - Mukai Chen
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong
| | - Xiaohong Chen
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong
| | - Hui Zhou
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong
| | - Yanting Ye
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong
| | - Minyi Li
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong
| | - Jiande Han
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong.
| | - Fang Wang
- Department of Dermatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong.
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Seminario-Vidal L, Kroshinsky D, Malachowski SJ, Sun J, Markova A, Beachkofsky TM, Kaffenberger BH, Ergen EN, Mauskar M, Bridges A, Calhoun C, Cardones AR, Chen ST, Chodosh J, Cotliar J, Davis MDP, DeNiro KL, Dominguez AR, Eljure-Téllez J, Femia A, Fox LP, Guda A, Mitchell C, Mostaghimi A, Ortega-Loayza AG, Owen C, Pasieka H, Rahnama-Moghadam S, Saeed HN, Saunderson RB, Shanbhag S, Sharon VR, Strowd L, Venkatesh S, Wanat KA, Wetter DA, Worswick S, Micheletti RG. Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. J Am Acad Dermatol 2020; 82:1553-1567. [PMID: 32151629 DOI: 10.1016/j.jaad.2020.02.066] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/04/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.
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Affiliation(s)
- Lucia Seminario-Vidal
- Department of Dermatology, University of South Florida, Morsani College of Medicine, Tampa, Florida; Cutaneous Oncology Program, H. Lee Moffitt Cancer Center, Tampa, Florida.
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen J Malachowski
- Department of Internal Medicine, Medical College of Wisconsin Affiliated Hospitals, St. Joseph's Hospital, Milwaukee, Wisconsin
| | - James Sun
- Cutaneous Oncology Program, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Alina Markova
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Elizabeth N Ergen
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melissa Mauskar
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alina Bridges
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Cody Calhoun
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Adela R Cardones
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Steven T Chen
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James Chodosh
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Cotliar
- Division of Dermatology, Harbor-University of California, Los Angeles Medical Center, Los Angeles, California
| | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | | | - Arturo R Dominguez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Juliana Eljure-Téllez
- Department of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - Alisa Femia
- Ronald O. Perelman Department of Dermatology, New York University Langone Health, New York, New York
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | - Anisha Guda
- University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas
| | - Caroline Mitchell
- Vincent Center for Reproductive Biology, Department of Obstetrics, Gynecology & Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Cindy Owen
- Division of Dermatology, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Helena Pasieka
- Department of Dermatology, MedStar Washington Hospital Center, Washington, DC
| | | | - Hajirah N Saeed
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Rebecca B Saunderson
- Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Swapna Shanbhag
- Tej Kohli Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, India
| | - Victoria R Sharon
- Department of Dermatology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Lindsay Strowd
- Department of Dermatology, Wake Forest University School of Medicine, Wake Forest, North Carolina
| | - Samantha Venkatesh
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Karolyn A Wanat
- Department of Dermatology, University of Southern California, Los Angeles, California
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Scott Worswick
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert G Micheletti
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
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9
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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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Brickel N, Shaikh H, Kirkham A, Davies G, Chalker M, Yoshida P. Collaboration in pharmacovigilance: lamotrigine and fatal severe cutaneous adverse reactions - a review of spontaneous reports. Ther Clin Risk Manag 2017; 13:897-903. [PMID: 28790833 PMCID: PMC5530068 DOI: 10.2147/tcrm.s131021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pharmacovigilance presents many challenges, particularly when managing unpredictable, rare conditions, eg, severe cutaneous adverse reactions (SCARs). Such rare events are often only detected from spontaneous reports, which present their own limitations, particularly during a prolonged global launch schedule. GlaxoSmithKline’s routine pharmacovigilance includes regular reviews of global adverse event (AE) reports and aggregate data from a central safety database. Lamotrigine is one of the several antiepileptic drugs associated with SCARs. After identification of increased rates of fatal SCAR cases with lamotrigine in Japan between September and December 2014, this analysis investigated the global incidence of fatal SCARs with lamotrigine and explored whether known risk factors may have contributed to these cases. Global fatal SCAR cases reported with lamotrigine administration from launch until January 2015 were reviewed for evidence of temporal association with dosing and the presence of risk factors, including comorbidities, concomitant medications, and noncompliance with the prescribing information (PI). Worldwide, the estimated cumulative exposure to lamotrigine was >8.4 million patient-years. Globally, there were 54,513 AE reports for lamotrigine, of which 3,454 (6.3%) concerned SCARs. Of these, 122 (3.5%) had a fatal outcome (attributable and nonattributable to lamotrigine), equating to 0.01 fatal SCARs per 1,000 patient-years. In Japan (estimated cumulative exposure 141,000 patient-years), 17 fatal SCARs were reported (attributable and nonattributable), equating to 0.12 per 1,000 patient-years. Seventy-one percent of fatal SCAR cases in Japan showed evidence of noncompliance with the recommended dosing regimen; in 65% of the cases, a delay in discontinuation of lamotrigine after early signs of hypersensitivity was reported. Despite a number of limitations inherent in comparing spontaneous report data, this analysis highlights the need for adherence to the lamotrigine PI and emphasizes the importance of collaboration between global and local pharmacovigilance departments, to promptly identify and reduce the risk of rare and serious events, such as SCARs.
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Affiliation(s)
- Neil Brickel
- Global Clinical Safety and Pharmacovigilance, GlaxoSmithKline, Uxbridge, Middlesex, UK
| | - Haris Shaikh
- Global Clinical Safety and Pharmacovigilance, GlaxoSmithKline, Uxbridge, Middlesex, UK
| | - Andrew Kirkham
- Classic and Established Products, GlaxoSmithKline, Brentford, Middlesex, UK
| | - Greg Davies
- Global Clinical Safety and Pharmacovigilance, GlaxoSmithKline, Uxbridge, Middlesex, UK
| | - Michelle Chalker
- Global Clinical Safety and Pharmacovigilance, GlaxoSmithKline, Uxbridge, Middlesex, UK
| | - Pascal Yoshida
- Clinical Safety and Post-marketing Surveillance, GlaxoSmithKline KK, Tokyo, Japan
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Han F, Zhang J, Guo Q, Feng Y, Gao Y, Guo L, Hou Y, An J, Wang X, Yan B, Zheng Y, Song J, Li M, Wang G. Successful treatment of toxic epidermal necrolysis using plasmapheresis: A prospective observational study. J Crit Care 2017; 42:65-68. [PMID: 28688239 DOI: 10.1016/j.jcrc.2017.07.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/27/2017] [Accepted: 07/01/2017] [Indexed: 01/29/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a rare, severe, life-threatening skin disease and it requires urgent critical care, including admission to the intensive care unit (ICU). It is characterized by fatal sequelae and high mortality. Currently, insufficient evidence exists to support the use of any systemic adjuvant therapy, such as cyclophosphamide, intravenous immunoglobulin (IVIg), or corticosteroids. However, plasmapheresis has been increasingly valued by clinicians due to its significant efficacy and little adverse side effects. To assess the efficacy of such treatment, 28 patients who were diagnosed with TEN or SJS/TEN overlap were continuously recruited in the ICU from February 2009 to August 2016. These patients including both children and adults were randomly divided into two groups based on whether or not plasmapheresis therapy was performed after admission, which resulted in a plasmapheresis group (n=13) and a non-plasmapheresis group (n=15). Severity of the disease and the efficacy of treatments were evaluated by the severity-of-illness score for TEN. The results indicated that plasmapheresis may be superior to conventional therapies, such as IVIg or corticosteroids. Furthermore, plasmapheresis combined with other treatments might not be advantageous compared to the effect of plasmapheresis alone.
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Affiliation(s)
- Feng Han
- Intensive Care Unit, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jingjing Zhang
- Department of Emergency Medicine, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Qi Guo
- Department of Cardiology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yanjing Feng
- Department of Emergency Medicine, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Ya Gao
- Department of Emergency Medicine, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Litao Guo
- Intensive Care Unit, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yanli Hou
- Intensive Care Unit, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jingang An
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaopeng Wang
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bin Yan
- Department of Emergency Medicine, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yan Zheng
- Department of Dermatology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jingchun Song
- Intensive Care Unit, The 94th PLA Hospital, Nanchang, China
| | - Manxiang Li
- Department of Respiratory Medicine, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China.
| | - Gang Wang
- Department of Emergency Medicine, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China.
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Zimmermann S, Sekula P, Venhoff M, Motschall E, Knaus J, Schumacher M, Mockenhaupt M. Systemic Immunomodulating Therapies for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Systematic Review and Meta-analysis. JAMA Dermatol 2017; 153:514-522. [PMID: 28329382 PMCID: PMC5817620 DOI: 10.1001/jamadermatol.2016.5668] [Citation(s) in RCA: 191] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/27/2016] [Indexed: 12/13/2022]
Abstract
Importance Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are rare but severe adverse reactions with high mortality. There is no evidence-based treatment, but various systemic immunomodulating therapies are used. Objectives To provide an overview on possible immunomodulating treatments for SJS/TEN and estimate their effects on mortality compared with supportive care. Data Sources A literature search was performed in December 2012 for articles published in MEDLINE, MEDLINE Daily, MEDLINE Inprocess, Web of Science, EMBASE, Scopus, and the Cochrane Library (Central) from January 1990 through December 2012, and updated in December 2015, in the English, French, Spanish, and German languages looking for treatment proposals for SJS/TEN. Other sources were screened manually. Study Selection Initially, 157 randomized and nonrandomized studies on therapies (systemic immunomodulating therapies or supportive care) for SJS/TEN were selected. Data Extraction and Synthesis Relevant data were extracted from articles. Authors were contacted for further information. Finally, 96 studies with sufficient information regarding eligibility and adequate quality scores were considered in the data synthesis. All steps were performed independently by 2 investigators. Meta-analyses on aggregated study data (random-effects model) and individual patient data (IPD) (logistic regression adjusted for confounders) were performed to assess therapeutic efficacy. In the analysis of IPD, 2 regression models, stratified and unstratified by study, were fitted. Main Outcomes and Measures Therapy effects on mortality were expressed in terms of odds ratios (ORs) with 95% CIs. Results Overall, 96 studies (3248 patients) were included. Applied therapies were supportive care or systemic immunomodulating therapies, including glucocorticosteroids, intravenous immunoglobulins, cyclosporine, plasmapheresis, thalidomide, cyclophosphamide, hemoperfusion, tumor necrosis factor inhibitors, and granulocyte colony-stimulating factors. Glucocorticosteroids were associated with a survival benefit for patients in all 3 analyses but were statistically significant in only one (aggregated data: OR, 0.5; 95%% CI, 0.3-1.01; IPD, unstratified: OR, 0.7; 95% CI, 0.5-0.97; IPD, stratified: OR, 0.8; 95% CI, 0.4-1.3). Despite the low patient size, cyclosporine was associated with a promising significant result in the only feasible analysis of IPD (unstratified model) (OR, 0.1; 95% CI, 0.0-0.4). No beneficial findings were observed for other therapies, including intravenous immunoglobulins. Conclusions and Relevance Although all analyses, including the unstratified model, had limitations, glucocorticosteroids and cyclosporine were the most promising systemic immunomodulating therapies for SJS/TEN. Further evaluation in prospective studies is required. However, this work provides a comprehensive overview on proposed systemic immunomodulating treatments for SJS/TEN, which is of great relevance for treating physicians.
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Affiliation(s)
- Stefanie Zimmermann
- Dokumentationszentrum schwerer Hautreaktionen, Department of Dermatology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Pierre Fabre Pharma GmbH, Freiburg, Germany
| | - Peggy Sekula
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Moritz Venhoff
- Dokumentationszentrum schwerer Hautreaktionen, Department of Dermatology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Sander & Kollegen Dental Practice, Haslach im Kinzigtal, Germany
| | - Edith Motschall
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochen Knaus
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Schumacher
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen, Department of Dermatology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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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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16
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Chung WH, Wang CW, Dao RL. Severe cutaneous adverse drug reactions. J Dermatol 2016; 43:758-66. [PMID: 27154258 DOI: 10.1111/1346-8138.13430] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/16/2016] [Indexed: 12/17/2022]
Abstract
The clinical manifestations of drug eruptions can range from mild maculopapular exanthema to severe cutaneous adverse drug reactions (SCAR), including drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) which are rare but occasionally fatal. Some pathogens may induce skin reactions mimicking SCAR. There are several models to explain the interaction of human leukocyte antigen (HLA), drug and T-cell receptor (TCR): (i) the "hapten/prohapten" theory; (ii) the "p-i concept"; (iii) the "altered peptide repertoire"; and (iv) the "altered TCR repertoire". The checkpoints of molecular mechanisms of SCAR include specific drug antigens interacting with the specific HLA loci (e.g. HLA-B*15:02 for carbamazepine-induced SJS/TEN and HLA-B*58:01 for allopurinol-induced SCAR), involvement of specific TCR, induction of T-cell-mediated responses (e.g. granulysin, Fas ligand, perforin/granzyme B and T-helper 1/2-associated cytokines) and cell death mechanism (e.g. miR-18a-5p-induced apoptosis; annexin A1 and formyl peptide receptor 1-induced necroptosis in keratinocytes). In addition to immune mechanism, metabolism has been found to play a role in the pathogenesis of SCAR, such as recent findings of strong association of CYP2C9*3 with phenytoin-induced SCAR and impaired renal function with allopurinol SCAR. With a better understanding of the mechanisms, effective therapeutics and prevention for SCAR can be improved.
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Affiliation(s)
- Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospitals, Tapei, Linko and Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospitals, Tapei, Linko and Keelung, Taiwan.,Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Ro-Lan Dao
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospitals, Tapei, Linko and Keelung, Taiwan
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Park HJ, Kim YJ, Kim DH, Kim J, Park KH, Park JW, Lee JH. HLA Allele Frequencies in 5802 Koreans: Varied Allele Types Associated with SJS/TEN According to Culprit Drugs. Yonsei Med J 2016; 57:118-26. [PMID: 26632391 PMCID: PMC4696942 DOI: 10.3349/ymj.2016.57.1.118] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/30/2015] [Accepted: 07/02/2015] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are very serious forms of drug-induced cutaneous adverse reaction. SJS/TEN induced by certain drug is well known to be associated with some human leukocyte antigen (HLA) gene type. We aimed to explore HLA allele frequencies and their association with SJS/TEN according to culprit drugs in Korea. MATERIALS AND METHODS We enrolled 5802 subjects who had results of HLA typing test from August 2005 to July 2014. Total 28 SJS/TEN patients were categorized based on culprit drugs (allopurinol, lamotrigine, carbamazepine) and identified the presence of HLA-B*58:01, HLA-B*44:03, HLA-B*15:02, and HLA-A*31:01. RESULTS HLA-A*24:02 (20.5%), HLA-B*44:03 (10.0%), and HLA-Cw*01:02 (17.1%) were the most frequent type in HLA-A, -B, and -C genes, respectively. Allele frequencies of HLA-B*58:01, HLA-B*44:03, HLA-A*31:01, and HLA-B*15:02 were 7.0%, 10.0%, 5.0%, and 0.3%, respectively. In 958 allopurinol users, 9 subjects (0.9%) were diagnosed with SJS/TEN. Among them, 8 subjects possessed HLA-B*58:01 allele. SJS/TEN induced by allopurinol was more frequently developed in subjects with HLA-B*58:01 than in subjects without it [odds ratio: 57.4; confidence interval (CI) 7.12-463.50; p<0.001]. Allopurinol treatment, based on screening by HLA-B*58:01 genotyping, could be more cost-effective than that not based on screening. HLA-B*44:03 may be associated with lamotrigine-induced SJS/TEN (odds ratio: 12.75; CI 1.03-157.14; p=0.053). Among carbamazepine users, only two patients experienced SJS/TEN and possessed neither HLA-B*15:02 nor HLA-A*31:03. CONCLUSION HLA gene frequencies varied in Korea. Screening of HLA-B*58:01 before the use of allopurinol might be needed to anticipate probability of SJS/TEN.
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Affiliation(s)
- Hye Jung Park
- Division of Allergy and Immunology, Department of Internal Medicine, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Young Joo Kim
- Division of Allergy and Immunology, Department of Internal Medicine, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hyun Kim
- Division of Allergy and Immunology, Department of Internal Medicine, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Junho Kim
- Division of Allergy and Immunology, Department of Internal Medicine, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hee Park
- Division of Allergy and Immunology, Department of Internal Medicine, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Won Park
- Division of Allergy and Immunology, Department of Internal Medicine, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Lee
- Division of Allergy and Immunology, Department of Internal Medicine, Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea.
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Grando LR, Schmitt TAB, Bakos RM. Severe cutaneous reactions to drugs in the setting of a general hospital. An Bras Dermatol 2015; 89:758-62. [PMID: 25184915 PMCID: PMC4155954 DOI: 10.1590/abd1806-4841.20142997] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 10/27/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Cutaneous drug reactions are frequently found. Assessing the clinical and
epidemiological profile of severe forms is extremely relevant for their better
recognition and management. Few studies have assessed the severe forms of
cutaneous drug reactions in patients hospitalized in our setting. OBJECTIVES To assess the clinical and epidemiological aspects of severe cutaneous adverse
reactions to drugs in a tertiary hospital in Porto Alegre, Brazil. METHODS All cases of severe cutaneous adverse reactions to drugs in patients hospitalized
from January/2005 to December/2010 were retrospectively analyzed for clinical and
epidemiological variables. Cases of Stevens-Johnson Syndrome, Toxic Epidermal
Necrolysis, drug hypersensitivity syndrome or Drug Reaction with Eosinophilia and
Systemic Symptoms and acute generalized exanthematous pustulosis were included.
RESULTS An occurrence rate of 1 serious reaction for every 3,048 inpatients was found
(total of 173,767 inpatients admitted in the period). Drug Reaction with
Eosinophilia and Systemic Symptoms was the most frequent presentation. The drugs
most frequently involved were anticonvulsants (40.4%), antibiotics (26.3%), and
analgesics/anti-inflammatory drugs (10.5%). Thirty seven patients (64.9%) were
admitted to hospital because of the cutaneous drug reaction. Ten patients (17.5%)
died and in most of those (60%), the drug causing the reaction could not be
determined. CONCLUSIONS The frequency of severe cutaneous adverse reactions to drugs in our setting is
significant. Drug Reaction with Eosinophilia and Systemic Symptoms seems to be the
most frequent presentation of severe cutaneous drug reactions. Most patients
developed cutaneous drug reactions outside the hospital. Mortality rates were
higher for Toxic Epidermal Necrolysis and this presentation significantly affected
older people. Not knowing the drug causing the reaction was related to
mortality.
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19
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Villano JH, Lovell EO. Mixed signals: toxic epidermal necrolysis. Am J Med 2015; 128:254-6. [PMID: 25460525 DOI: 10.1016/j.amjmed.2014.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 11/10/2014] [Accepted: 11/10/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Janna H Villano
- Division of Medical Toxicology, Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego.
| | - Elise O Lovell
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Ill
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20
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Mawson AR, Eriator I, Karre S. Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN): could retinoids play a causative role? Med Sci Monit 2015; 21:133-43. [PMID: 25579087 PMCID: PMC4301467 DOI: 10.12659/msm.891043] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are overlapping manifestations on a spectrum of acute drug-induced conditions associated with severe blistering, skin peeling, and multi-organ damage. TEN is an eruption resembling severe scalding, with ≥30% skin detachment. SJS is a mild form of TEN, characterized histologically by epidermal keratinocyte apoptosis with dermo-epidermal separation and extensive small blisters with <10% body surface skin detachment. The syndrome can be induced by numerous medications and typically occurs 1–4 weeks after the initiation of therapy. Granulysin is found in the lesions of patients with SJS/TEN and plays a significant pathogenic role in the condition, but the overall mechanisms linking medications, granulysin, and disease manifestations remain obscure. This paper reviews evidence suggesting that the different medications implicated in SJS/TEN have the common property of interacting and synergizing with endogenous retinoids (vitamin A and its congeners), in many instances causing the latter to accumulate in and damage the liver, the main storage organ for vitamin A. It is hypothesized that liver damage leads to the spillage of toxic retinoid compounds into the circulation, resulting in an endogenous form of hypervitaminosis A and cytotoxicity with widespread apoptosis, mediated by granulysin and recognized as SJS/TEN. Subject to testing, the model suggests that symptom worsening could be arrested at onset by lowering the concentration of circulating retinoids and/or granulysin via phlebotomy or plasmapheresis or by pharmacological measures to limit their expression.
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Affiliation(s)
- Anthony R Mawson
- Behavioral and Environmental Health Unit, School of Health Sciences, College of Public Service, Jackson State University, Jackson, MS, USA
| | - Ike Eriator
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sridhar Karre
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
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Abstract
Purpura fulminans (PF) and toxic epidermal necrolysis (TEN) are rare and life-threatening diseases. TEN is a notorious epidermolytic condition, most cases of which are drug induced. TEN is a more severe variant of epidermal necrolysis than Stevens-Johnson syndrome, as it affects a greater percentage of skin surface area. PF occurs in acute severe infections, deficiencies of protein C and S, and rarely, is idiopathic. PF is a thrombotic disorder of hemorrhagic cutaneous infarction and disseminated intravascular coagulation. While the two diseases are distinct in etiology, their clinical presentations can be strikingly similar. This report illustrates the clinical overlap between PF and TEN and reveals the potential for the diseases to coincide. The case of a patient with biopsy-proven TEN who developed PF was reviewed in detail. The topics of PF and TEN were searched using the MEDLINE database to investigate the relationship between the two diseases. Our case report raises diagnostic suspicion for PF in cases of TEN, particularly in patients with rapid clinical deterioration and failure of conventional management. In addition to the case presented from our institution, a similar case has been reported in which biopsy-proven PF clinically mimicked the epidermolytic condition Stevens-Johnson syndrome. These observations reflect that, although rare, conditions of epidermal necrolysis and PF may coincide more frequently than currently recognized.
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Seczynska B, Nowak I, Sega A, Kozka M, Wodkowski M, Królikowski W, Szczeklik W. Supportive therapy for a patient with toxic epidermal necrolysis undergoing plasmapheresis. Crit Care Nurse 2014; 33:26-38. [PMID: 23908167 DOI: 10.4037/ccn2013555] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
A patient with severe toxic epidermal necrolysis underwent 2 cycles of therapeutic plasma exchange and received specialized wound care for widespread skin damage of more than 80% of his body surface area. Extensive involvement of mucous membranes, including the conjunctivas and the oropharyngeal cavity, and damage of his genitourinary organs required meticulous wound care. Daily care of injuries of tissues affected only in the most severe cases of toxic epidermal necrolysis was provided by an experienced intensive care unit nursing team. A meticulous supportive therapy regimen was a major contributing factor to this patient's remission.
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Affiliation(s)
- Bozena Seczynska
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
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Knight L, Muloiwa R, Dlamini S, Lehloenya RJ. Factors associated with increased mortality in a predominantly HIV-infected population with Stevens Johnson syndrome and toxic epidermal necrolysis. PLoS One 2014; 9:e93543. [PMID: 24695805 PMCID: PMC3973591 DOI: 10.1371/journal.pone.0093543] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 03/05/2014] [Indexed: 01/20/2023] Open
Abstract
Introduction Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening drug reactions with a higher incidence in HIV-infected persons. SJS/TEN are associated with skin and mucosal failure, predisposing to systemic bacterial infection (BSI), a major cause of death. There are limited data on risk factors associated with BSI and and mortality in HIV-infected people with SJS/TEN. Methods We conducted a retrospective study of patients admitted to a university hospital with SJS/TEN over a 3 year period. We evaluated their underlying illnesses, eliciting drugs, predictive value of bacterial skin cultures and other factors associated with mortality and BSI in a predominantly HIV-infected population by comparing characteristics of the patients who demised and those who survived. Results We admitted 86 cases during the study period and 67/86(78%) were HIV-infected. Tuberculosis was the commonest co-morbidity, diagnosed in 12/86(14%) cases. Skin cultures correlated with BSI by the same organism in 7/64(11%) cases and 6/7 were Gram-negative. Two of the 8 cases of Gram-negative BSI had an associated Gram-negative skin culture, although not always the same organism. All 8 fatalities had >30% epidermal detachment, 7 were HIV-infected, 6 died of BSI and 6 had tuberculosis. Conclusions Having >30% epidermal detachment in SJS/TEN carries an increased risk of BSI and mortality. Tuberculosis and BSI are associated with higher risk of death in SJS/TEN. Our data suggests there may be an association between Gram-negative BSI and Gram-negative skin infection.
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Affiliation(s)
- Lauren Knight
- Medical Intern, Groote Schuur Hospital, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Sipho Dlamini
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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Acute respiratory failure in patients with toxic epidermal necrolysis: clinical features and factors associated with mechanical ventilation. Crit Care Med 2014; 42:118-28. [PMID: 23989174 DOI: 10.1097/ccm.0b013e31829eb94f] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Stevens-Johnson syndrome and toxic epidermal necrolysis are severe adverse cutaneous drug reactions characterized by widespread skin and mucous membrane detachments, including bronchial mucosa, which may be associated with respiratory failure requiring mechanical ventilation. The presentation and outcome of patients requiring mechanical ventilation and the characteristics of bronchial epithelial lesions among ventilated patients are reported. Predictors of mechanical ventilation available on hospital admission were identified using univariate and multivariate logistic regressions. DESIGN Retrospective cohort study. SETTING Medical ICU and dermatology department of a tertiary care hospital, which hosts the French national referral center for toxic epidermal necrolysis. PATIENTS Patients admitted for Stevens-Johnson syndrome/toxic epidermal necrolysis over a 14-year period were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 221 patients included in the study, 56 patients (25.3%) required mechanical ventilation. None of the patients received noninvasive ventilation. Patients requiring mechanical ventilation had a larger baseline detached body surface area, higher Logistic Organ Dysfunction score, and Simplified Acute Physiology Score II, and they presented more often with shock, pulmonary infiltrates, and renal dysfunction (p < 0.0001 for all comparisons). Among patients receiving mechanical ventilation, 57% of the patients died; those having bronchial epithelial lesions (22 of 56) required intubation earlier than others (1 [1-4] vs 4 [1-6] d after hospital admission; p = 0.027). Variables associated with mechanical ventilation in multivariate analysis included serum bicarbonates less than 20 mM (odds ratio, 4.9 [95% CI, 1.1-22.7]; p = 0.041), serum urea greater than 10 mM (odds ratio, 7.0 [95% CI, 2.2-22.8]; p < 0.001), a detached body surface area between 10% and 29% (odds ratio, 3.7 [95% CI, 1.0-13.8]; p = 0.048) or greater than or equal to 30% (odds ratio, 19.7 [95% CI, 4.4-87.4]; p < 0.0001), WBCs more than 12,000/mm3 (odds ratio, 11.6 [95% CI, 2.8-48.1]; p < 0.001), blood hemoglobin less than 8 g/dL (odds ratio, 8.1 [95% CI, 1.2-55.2]; p = 0.032), and more extensive pulmonary infiltrates (odds ratio, 9.7 [95% CI, 3.6-25.9]; p < 0.0001). CONCLUSIONS Mechanical ventilation is required in one of four Stevens-Johnson syndrome/toxic epidermal necrolysis patients and is associated with a poor outcome. Prompt identification of Stevens-Johnson syndrome/toxic epidermal necrolysis patients at higher risk of intubation could help guide their early management, particularly for those having bronchial epithelial lesions.
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Abstract
Cutaneous drug reactions account for a large proportion of adverse drug reactions. Cutaneous drug reactions can be very challenging to diagnose. They can mimic many other skin diseases; this is especially evident during childhood, when viral exanthems are commonplace. Also, if a patient is taking numerous medications, establishing causality to a specific drug can be multifaceted and difficult. The purpose of this review is to highlight an approach to the diagnosis of a suspected cutaneous drug reaction in a child. We have classified different types of drug eruptions by morphology: exanthematous, urticarial, pustular, and bullous. Within each of these groups we have divided them into simple, benign, or non-febrile and complex or febrile reactions. We also include a miscellaneous group to ensure a methodical review.
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Weinand C, Xu W, Perbix W, Lefering R, Maegele M, Rathert M, Spilker G. 27 years of a single burn centre experience with Stevens–Johnson syndrome and toxic epidermal necrolysis: Analysis of mortality risk for causative agents. Burns 2013; 39:1449-55. [DOI: 10.1016/j.burns.2013.03.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Revised: 02/01/2013] [Accepted: 03/16/2013] [Indexed: 11/30/2022]
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Huskey AM, Thomas CC, Waddell JA. Occurrence of Milnacipran-Associated Morbilliform Rash and Serotonin Toxicity. Ann Pharmacother 2013; 47:e32. [DOI: 10.1345/aph.1r474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report the development of morbilliform rash and serotonin toxicity after the addition of milnacipran to a patient's medication therapy. CASE SUMMARY A 57-year-old white female presented to the emergency department because of a full-body morbilliform rash, which appeared 9 days after initiation of milnacipran 50 mg twice daily. In the emergency department the patient's vital signs were: heart rate 121 beats/min, blood pressure 180/100 mm Hg, and temperature 38.9 °C. The patient reported diarrhea, nausea, dizziness, restlessness, and increased muscle pain. Her history included recurrent breast cancer first diagnosed in 1999, hypertension, fibromyalgia, depression, osteopenia, gastroesophageal reflux disease, insomnia, and endometriosis. Her home medications included milnacipran, fluoxetine, alprazolam, zolpidem, zoledronic acid, anastrozole, doxepin, ranitidine, levocetirizine, doxazosin, tramadol, vitamin D, and ferrous gluconate. The patient's increased heart rate, blood pressure, and temperature, as well as restlessness, self-reported diarrhea and nausea, and self-reported increase in muscle pain, indicated serotonin toxicity. Milnacipran, fluoxetine, and tramadol were discontinued, while doxepin was continued. Treatment consisted of acetaminophen, diphenhydramine, methylprednisolone, promethazine, and hydralazine 10 mg intravenously. The following morning all vital signs were within normal limits and the patient's diarrhea, nausea, dizziness, restlessness, and muscle pain resolved. She was discharged the following morning. The rash had resolved after day 2 of hospital discharge, which was the fourth day after discontinuation of milnacipran. DISCUSSION Given the patient's symptoms, the timing of symptom onset, the patient's history, and findings on physical examination, as well as use of the Naranjo probability scale, milnacipran was deemed the probable cause of the morbilliform reaction and serotonin toxicity. Only 1 case report of rash and 2 case reports of serotonin syndrome associated with milnacipran have been reported. CONCLUSIONS It is important to increase awareness of the possibility of developing morbilliform rash and serotonin toxicity with milnacipran therapy, as both conditions can be associated with poor outcomes if not detected early and treated appropriately.
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Affiliation(s)
- Amanda M Huskey
- Amanda M Huskey PharmD, at time of writing, PharmD Student, College of Pharmacy, University of Tennessee, Knoxville, TN; now, PGY1 Pharmacy Practice Resident, Central Baptist Hospital, Lexington, KY
| | - Cassandra C Thomas
- Cassandra C Thomas PharmD, at time of writing, PharmD Student, College of Pharmacy, University of Tennessee; now, PGY1 Pharmacy Practice Resident, Central Arkansas Veterans Healthcare System, Little Rock, AR
| | - James Aubrey Waddell
- James Aubrey Waddell PharmD, Professor, College of Pharmacy, University of Tennessee; Oncology Pharmacist, Blount Memorial Hospital, Maryville, TN
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Abstract
Stevens-Johnson syndrome is a rare, potentially fatal drug reaction that causes necrosis of epidermal cells. Early recognition of the syndrome is essential to prevent complications. This article discusses identification, complications, and treatment of Stevens-Johnson syndrome.
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Affiliation(s)
- Karen L Cooper
- Sutter Auburn Faith Hospital, 11815 Education St, Auburn, CA 95602, USA.
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Chambel M, Mascarenhas M, Regala J, Gouveia C, Prates S. Clinical Stevens-Johnson syndrome and rufinamide: a clinical case. Allergol Immunopathol (Madr) 2013; 41:68-9. [PMID: 22306278 DOI: 10.1016/j.aller.2011.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 11/22/2011] [Accepted: 12/01/2011] [Indexed: 11/26/2022]
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Abstract
Adverse drug reactions are a difficult problem faced by clinicians in everyday practice. The mechanisms of drug hypersensitivity are not well understood. This is reflected by difficulties in their classification, which is mainly based upon the current knowledge of immunologic and nonimmunologic mechanisms, onset of symptoms (immediate or nonimmediate) and morphology. For the individual patient, the correct diagnosis and classification is important because strict avoidance of the offending drug might be of vital importance. Considerable experience is required to guide management, to interpret results of investigations and to undertake drug challenges. This article summarizes the current knowledge regarding definitions and mechanisms. However, the field of drug hypersensitivity is rapidly expanding. Modern drugs such as biological agents bare hypersensitivity risks that are potentially mediated by, so far, unknown mechanisms.
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Affiliation(s)
- Bettina Wedi
- Allergy Division, Department of Dermatology and Allergy, Hannover Medical School, Ricklinger Str. 5, D-30449 Hannover, Germany.
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Struck MF, Illert T, Schmidt T, Reichelt B, Steen M. Secondary abdominal compartment syndrome in patients with toxic epidermal necrolysis. Burns 2012; 38:562-7. [DOI: 10.1016/j.burns.2011.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 10/06/2011] [Accepted: 10/12/2011] [Indexed: 10/15/2022]
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Réplica al artículo «tratamiento de necrolisis epidérmica tóxica con ciclosporina A». Med Intensiva 2012; 36:382. [DOI: 10.1016/j.medin.2012.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 02/22/2012] [Indexed: 10/28/2022]
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Mockenhaupt M. The current understanding of Stevens-Johnson syndrome and toxic epidermal necrolysis. Expert Rev Clin Immunol 2012; 7:803-13; quiz 814-5. [PMID: 22014021 DOI: 10.1586/eci.11.66] [Citation(s) in RCA: 188] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Stevens-Johnson syndrome has long been considered to resemble erythema multiforme with mucosal involvement, but is now thought to form a single disease entity with toxic epidermal necrolysis. Although Stevens-Johnson syndrome is less severe, etiology, genetic susceptibility and pathomechanism are the same for Stevens-Johnson syndrome/toxic epidermal necrolysis. The condition is mainly caused by drugs, but also by infections and probably other risk factors not yet identified. Identification of the cause is important for the individual patient and in cases of drug-induced disease withdrawal of the inducing drug(s) has an impact on the patient's prognosis. If an infectious cause is suspected, adequate anti-infective treatment is needed. Besides this, supportive management is crucial to improve the patient's state, probably more than specific immunomodulating treatments. Despite all of the therapeutic efforts, mortality is high and increases with disease severity, patients' age and underlying medical conditions. Survivors may suffer from long-term sequelae such as strictures of mucous membranes including severe eye problems.
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Affiliation(s)
- Maja Mockenhaupt
- The German Registry on Severe Skin Reactions, Department of Dermatology, University of Freiburg, Freiburg, Germany.
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36
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Rehabilitation Considerations and Medical Management in an Adult Patient with Toxic Epidermal Necrolysis. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2012. [DOI: 10.1097/01592394-201203030-00002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Finkelstein Y, Soon GS, Acuna P, George M, Pope E, Ito S, Shear NH, Koren G, Shannon MW, Garcia-Bournissen F. Recurrence and outcomes of Stevens-Johnson syndrome and toxic epidermal necrolysis in children. Pediatrics 2011; 128:723-8. [PMID: 21890829 DOI: 10.1542/peds.2010-3322] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To report clinical course, etiology, management, and long-term outcomes of children suffering from Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). METHODS We conducted a study of all pediatric patients with SJS or TEN admitted between 2000 and 2007 to the Hospital for Sick Children and Children's Hospital Boston, and particular attention was paid to clinical manifestations, etiology, mortality, and long-term outcomes. RESULTS We identified 55 cases of SJS (n = 47), TEN (n = 5), or SJS/TEN overlap syndrome (n = 3). Drugs were identified as the most likely etiologic agent in 29 children (53%); antiepileptic drugs were the most common agents (n = 16), followed by sulfonamide antibiotics (n = 7) and chemotherapy drugs (n = 2). Acute Mycoplasma pneumoniae infection was confirmed in 12 children (22%), and herpes simplex virus was confirmed in 5 children (9%). Treatment regimens differed significantly between participating sites and included systemic antimicrobial agents (67%), systemic corticosteroids (40%), and antiviral drugs (31%). Intravenous immunoglobulin was administered to 21 children (38%), of whom 8 received concomitant systemic corticosteroids. Ten children (18%) had recurrence of SJS up to 7 years after the index episode, and 3 experienced multiple recurrences. Twenty-six children (47%) suffered long-term sequelae that mostly involved the skin and eyes. CONCLUSIONS Mortality rate in children was lower than that reported in adults, but half of affected children suffered long-term complications. The recurrence rate of SJS was high (1 in 5), which suggests vulnerability and potential genetic predisposition. In the absence of standardized management guidelines for these conditions, treatment regimens differed significantly between participating institutions.
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Affiliation(s)
- Yaron Finkelstein
- Department of Pediatrics, Divisions of Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.
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Carmona AF, Redondo AD, Peña LO, Gómez AG, Pareja JCF, Martínez JB. Tratamiento de necrólisis epidérmica tóxica con ciclosporina A. Med Intensiva 2011; 35:442-5. [DOI: 10.1016/j.medin.2010.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 09/14/2010] [Accepted: 09/24/2010] [Indexed: 10/18/2022]
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Petersen E, Keld DB, Ellermann-Eriksen S, Gubbels S, Ilkjær S, Jensen-Fangel S, Lindskov C. Failure of combination oral oseltamivir and inhaled zanamivir antiviral treatment in ventilator- and ECMO-treated critically ill patients with pandemic influenza A (H1N1)v. ACTA ACUST UNITED AC 2011; 43:495-503. [PMID: 21309638 DOI: 10.3109/00365548.2011.556144] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The objective of this study was to describe the clinical course of severe and complicated pandemic (H1N1)v infection treated with oral oseltamivir and inhaled zanamivir in a series of intensive care patients. METHODS We investigated a case series of patients with respiratory failure and a positive (H1N1)v real-time reverse transcriptase polymerase chain reaction (rRT-PCR). Treatment consisted of oseltamivir tablets 75 mg × 4 daily in a nasogastric tube plus zanamivir intravenous (i.v.) solution 25 mg × 4 daily as inhalation. Ventilator inspiratory plateau airway pressure in the ventilator was kept below 30 cmH₂O, PaO₂ above 8 kPa and pH above 7.30. If this could not be achieved, inhalational nitric oxide (NO) was added or extracorporeal membrane oxygenation (ECMO) was initiated. RESULTS Twenty-one patients were admitted, with a median age of 50 y (range 6-69 y). Five patients (23.8%) died in the intensive care unit (ICU) and 1 patient died 2 weeks after ICU discharge. Nine patients received ECMO treatment, of whom 3 died during ECMO (33.3%; 3/9) and 1 at 2 weeks after. The mortality in patients not receiving ECMO treatment was 16.6% (2/12). Sixteen patients (76%) were influenza PCR-positive on day 7 after the start of antiviral treatment. Irreversible presumed lung fibrosis complicated with pneumothorax was common. A high Murray score at admission was significantly associated with a fatal outcome. CONCLUSIONS The mortality in these patients was high despite combined antiviral treatment with oseltamivir and zanamivir. Patients shed virus for a long time despite intensive therapy. Optimal management of patients with bilateral pneumonia and respiratory failure caused by (H1N1)v still needs to be determined.
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Affiliation(s)
- Eskild Petersen
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, DK-8200 Aarhus, Denmark.
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Year in review in Intensive Care Medicine 2010: II. Pneumonia and infections, cardiovascular and haemodynamics, organization, education, haematology, nutrition, ethics and miscellanea. Intensive Care Med 2011; 37:196-213. [PMID: 21225240 PMCID: PMC3029678 DOI: 10.1007/s00134-010-2123-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 12/27/2010] [Indexed: 12/14/2022]
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de Prost N, Duong T, Brun-Buisson C, Roujeau JC. Évaluation clinique du risque de bactériémie et intérêt des cultures bactériennes cutanées au cours du syndrome de Stevens-Johnson et de la nécrolyse épidermique toxique. Ann Dermatol Venereol 2010; 137:651-2. [DOI: 10.1016/j.annder.2010.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 04/21/2010] [Indexed: 10/19/2022]
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2009: II. Neurology, cardiovascular, experimental, pharmacology and sedation, communication and teaching. Intensive Care Med 2010; 36:412-27. [PMID: 20107763 PMCID: PMC2820226 DOI: 10.1007/s00134-010-1770-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 01/13/2010] [Indexed: 01/16/2023]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A Gemelli 8, 00168 Rome, Italy.
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