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Cao R, Xu T. Steven-Johnson Syndrome/Toxic Epidermal Necrolysis is Associated with PD-1/PD-L1 Inhibitors Usage: A Case Series. Br J Hosp Med (Lond) 2024; 85:1-11. [PMID: 39347662 DOI: 10.12968/hmed.2024.0477] [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: 10/01/2024]
Abstract
Aims/Background The increasing adoption of inhibitors of programmed cell death-1 (PD-1) and its ligand, programmed death-ligand 1 (PD-L1), in the treatment of multiple cancer types in China has started to garner broader attention due to the occurrence of immune-related adverse events (irAEs), especially life-threatening skin reactions such as Steven-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). Isolated case reports have described SJS/TEN associated with PD-1/PD-L1 inhibitors usage. In this paper, we presented a series of cases of SJS/TEN following the use of PD-1/PD-L1 inhibitors in a dermatology hospital located in Zhejiang Province of China in the past several years, summarizing characteristics of these cases and providing a reference of management. Methods We retrospectively reviewed all the medical records of inpatients diagnosed with SJS/TEN in the Hangzhou Third People's Hospital from 2012 to 2024. We analyzed and compared the situation of SJS/TEN onset, types of PD-1/PD-L1 inhibitors used, score of severity, laboratory findings, and essential therapies of the patients who had received PD-1/PD-L1. Results We identified 12 SJS/TEN patients who had been treated with PD1/PD-L1 inhibitors: sintilimab had been used in six patients; tislelizumab in two cases; toripalimab, keytruda and cadonilimab each in one case; and an unknown prescription in one case. The longest duration between the first PD-1/PD-L1 inhibitor dose and the SJS/TEN diagnosis recorded was nine months whereas the shortest was 11 days. Half of the selected patients received chemotherapy at the same time. More than two types of therapies were applied to the cases, except for two cases with mild SJS. Conclusion This study unveils a potential, under-recognized cause of SJS/TEN in the cancer patients after analyzing the cases of SJS/TEN in cancer patients with prior exposure to PD-1/PD-L1 inhibitors. This paper also provides clue about the prominent features of SJS/TEN aforesaid, offering insights on the effective management measures for optimizing clinical safety.
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Affiliation(s)
- Riqu Cao
- Department of Dermatology, Hangzhou Third People's Hospital, Hangzhou, Zhejiang, China
| | - Tianhong Xu
- Department of Dermatology, Hangzhou Third People's Hospital, Hangzhou, Zhejiang, China
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Xiaodong Z, Min W, Liming L, Jinsong H, Xiao Q, Yuemei L, Yijin W. Toxic epidermal necrolysis following heart transplantation may caused by cefoperazone sodium and sulbactam sodium. J Cardiothorac Surg 2024; 19:542. [PMID: 39307887 PMCID: PMC11418188 DOI: 10.1186/s13019-024-03025-x] [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: 05/20/2024] [Accepted: 08/30/2024] [Indexed: 09/25/2024] Open
Abstract
BACKGROUND The outcome of heart transplantation is significantly affected by perioperative infections. Individualised immunosuppression strategies are essential to reduce the risk of such infections. CASE PRESENTATION We report the successful management of a 56-year-old male patient diagnosed with dilated cardiomyopathy who underwent heart transplantation. During the perioperative period, the patient was prescribed cefoperazone sodium and sulbactam sodium, which induced a severe skin reaction: toxic epidermal necrolysis (TEN). The patient was treated with prednisone, immunoglobulins, etanercept, and other active immunomodulatory measures, together with an individualised anti-rejection regimen and physical therapy. The systemic rash resolved within a month, and the patient was successfully discharged after surgery. CONCLUSION Effective management of heart transplantation necessitates balancing immunosuppression and infection prevention. Individualised immunosuppressive strategies are critical for optimal clinical outcomes.
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Affiliation(s)
- Zeng Xiaodong
- Department of Cardiac Surgery Intensive Care Unit, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
| | - Wu Min
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, China
| | - Lei Liming
- Department of Cardiac Surgery Intensive Care Unit, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
| | - Huang Jinsong
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, China
| | - Qi Xiao
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, 510080, China
| | - Liang Yuemei
- Guangzhou Health Science College, Guangzhou, Guangdong, 510000, China
| | - Wu Yijin
- Department of Cardiac Surgery Intensive Care Unit, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China.
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Zhang X, Huang D, Lou D, Si X, Mao J. Stevens-Johnson Syndrome/Toxic epidermal necrolysis complicated with fulminant type 1 diabetes mellitus: a case report and literature review. BMC Endocr Disord 2024; 24:172. [PMID: 39218880 PMCID: PMC11367887 DOI: 10.1186/s12902-024-01683-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening skin lesion triggered by hypersensitive drug reaction. They are characterized by extensive epidermal necrosis and skin exfoliation. Fulminant type 1 diabetes mellitus (FT1DM) is featured by a rapid-onset of hyperglycemia with ketoacidosis due to severely destroyed β-cell function. Fulminant type 1 diabetes mellitus as a sequela of SJS/TEN has rarely been reported. CASE PRESENTATION We present a 73-year-old female patient who developed SJS/TEN skin allergic reaction after taking carbamazepine and phenytoin for 35 days. Then, hyperglycemia and diabetic ketoacidosis occurred 20 days after discontinuation of antiepileptic drugs. A very low serum C-peptide level (8.79 pmol/l) and a near-normal glycosylated hemoglobin level met the diagnostic criteria for fulminant T1DM. Intravenous immunoglobulin (IVIG) and insulin were promptly administered, and the patient recovered finally. CONCLUSIONS This rare case indicates that monitoring blood glucose is necessary in SJS/TEN drug reaction, and comprehensive therapy with rehydration, insulin, antibiotics, and IVIG may improve the prognosis.
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Affiliation(s)
- Xiaofang Zhang
- Department of Endocrinology and Metabolism, Shaoxing People's Hospital, Zhejiang Province, China, 312000
| | - Dihua Huang
- Department of Endocrinology and Metabolism, Shaoxing People's Hospital, Zhejiang Province, China, 312000
| | - Dajun Lou
- Department of Endocrinology and Metabolism, Shaoxing People's Hospital, Zhejiang Province, China, 312000
| | - Xuwei Si
- Department of Endocrinology and Metabolism, Shaoxing People's Hospital, Zhejiang Province, China, 312000
| | - Jiangfeng Mao
- Department of endocrinology, Peking Union Medical College Hospital, Beijing, China, 100730.
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Mansilla-Polo M, Martín-Torregrosa D, Abril-Pérez C. Atypical targetoid lesions. Semergen 2024; 50:102228. [PMID: 38554608 DOI: 10.1016/j.semerg.2024.102228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 04/02/2024]
Affiliation(s)
- M Mansilla-Polo
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Instituto de Investigación Sanitaria (IIS) La Fe, Valencia, Spain.
| | - D Martín-Torregrosa
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Instituto de Investigación Sanitaria (IIS) La Fe, Valencia, Spain
| | - C Abril-Pérez
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Instituto de Investigación Sanitaria (IIS) La Fe, Valencia, Spain
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Cheng J, Li H, Li Y, Li X, Wang J, Huang X, Cui X. Toxic epidermal necrolysis caused by phenobarbital: a case report and literature review. Front Pharmacol 2024; 15:1433506. [PMID: 39148552 PMCID: PMC11324585 DOI: 10.3389/fphar.2024.1433506] [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: 05/16/2024] [Accepted: 07/22/2024] [Indexed: 08/17/2024] Open
Abstract
Background Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are rare, life-threatening immunologic reactions. Previous relevant literature has provided limited information regarding this disease's genetic susceptibility and management principles. Objectives This study aimed to describe a phenobarbital-induced TEN case report with HLA-B*15:02 and HLA-B*58:01 negative, CYP2C19*1/*2. In addition, we revised the existing literature on phenobarbital-induced SJS/TEN to explore its clinical characteristics. Methods We describe a woman undergoing treatment with Phenobarbital for status epilepticus who developed classic cutaneous findings of TEN. A systematic search was conducted in the PubMed, Medline, WanFang, and CNKI databases from 1995 to 2023. The search terms used were "Stevens-Johnson Syndrome," "Toxic Epidermal Necrolysis," and "Phenobarbital." Results We report a case of TEN resulting from phenobarbital; it tested negative for the HLA-B*15:02 and HLA-B*58:01 allele and CYP2C19*1/*2 intermediate metabolism. Supportive treatment with steroids and antihistamines resulted in complete resolution of the skin lesions and improvement in clinical symptoms after 14 days. Physicians and clinical pharmacists should be aware of these potential phenobarbital-related adverse events and closely monitor patients with first-time use of phenobarbital. Among 19 cases were identified in the literature, with 11 (57.9%) cases of SJS, 6 (31.6%) cases of TEN, and 2 (7.2%) cases of SJS-TEN/DRESS overlap. A total of 5 (26.3%) did not survive, of which 4 (21.1%) were under 12 years old and 1 (5.3%) was over 12 years old. Conclusion Phenobarbital-induced SJS/TEN may still occur in patients who test negative for HLA-B*15:02 and HLA-B*58:01, CYP2C19*1/*2. Most cutaneous adverse events occur early in the course of Phenobarbital therapy and should be closely monitored early in the course of treatment. In addition, Phenobarbital should be used with caution in patients with a history of asthma and allergy to antipyretics and analgesics.
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Affiliation(s)
- Jie Cheng
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
- Department of Clinical Pharmacy Laboratory, The First Affiliated Hospital of Baotou Medical College, Baotou, China
| | - Hui Li
- Department of Neurology, Fei Xian People's Hospital, Linyi, China
| | - Yan Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Xiao Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Jianjun Wang
- Department of Neurosurgery, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Neurosurgery, Jinan, China
| | - Xin Huang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - XueYan Cui
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
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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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Green EA, Fogarty K, Ishmael FT. Penicillin Allergy: Mechanisms, Diagnosis, and Management. Med Clin North Am 2024; 108:671-685. [PMID: 38816110 DOI: 10.1016/j.mcna.2023.08.009] [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: 06/01/2024]
Abstract
Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.
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Affiliation(s)
- Estelle A Green
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Kelan Fogarty
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Faoud T Ishmael
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA; Mount Nittany Health, 1850 East Park Avenue, State College, PA 16803, USA.
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Yang X, Xu S. Tislelizumab-Induced Toxic Epidermal Necrolysis-Like Cutaneous Adverse Reaction: Rare Complication of Immune Checkpoint Inhibitor Therapy. Am J Ther 2024; 31:e470-e474. [PMID: 38976533 DOI: 10.1097/mjt.0000000000001682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Affiliation(s)
- Xiaoqin Yang
- Department of Dermatology, Shanghai Pudong New Area People's Hospital, Shanghai, 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; 90:1300-1302. [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] [MESH Headings] [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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Morgan AM, Li ZI, Garra S, Bi AS, Gonzalez-Lomas G, Jazrawi LM, Campbell KA. Patient-reported allergies are associated with increased rate of postoperative stiffness after arthroscopic rotator cuff repair. J Shoulder Elbow Surg 2024; 33:1050-1057. [PMID: 37839628 DOI: 10.1016/j.jse.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Several risk factors have been identified for the development of postoperative shoulder stiffness, and there has been increasing interest in orthopedic literature regarding patient-reported allergy (PRA) as an identifiable risk factor for adverse outcomes. The purpose of this study is to determine whether PRAs are associated with subsequent rates of diagnosis of adhesive capsulitis (AC) or return to the operating room for postoperative shoulder stiffness within 2 years after arthroscopic rotator cuff repair (ARCR). METHODS Current Procedural Terminology surgical billing codes were used to retrospectively identify patients who underwent ARCR at a single urban academic institution from January 2012 to December 2020 with minimum 2-year follow-up. Lysis of adhesions (LOA), manipulation under anesthesia (MUA), and AC of the shoulder were further queried within 2 years postoperatively for the ipsilateral shoulder. Patients were excluded if they had undergone ipsilateral MUA/LOA or received a diagnosis of AC before the index procedure. Demographic characteristics and medical comorbidities (hypertension, diabetes, hyperlipidemia, and hypothyroidism) were extracted from electronic medical records. Baseline characteristics were compared between patients with and without PRAs. Multivariate logistic regression analyses were performed to determine the association of the presence of PRAs overall, as well as the presence of 1, 2, or 3 or more PRAs, with subsequent MUA/LOA or diagnosis of AC within 2 years postoperatively. RESULTS Of 7057 patients identified in the study period, 6583 were eligible for the final analysis. The mean age was 56.6 ± 11.7 years, and the mean body mass index was 29.1 ± 5.6. Overall, 19.3% of patients (n = 1271) reported at least 1 allergy, and 7.1% (n = 469) had >1 PRA. A total of 44 patients (0.7%) underwent subsequent ipsilateral MUA/LOA within 2 years postoperatively, whereas 93 patients (1.4%) received a diagnosis of ipsilateral AC in the same time frame. PRAs were significantly associated with subsequent diagnosis of AC (odds ratio [OR]: 2.39; 95% confidence interval [CI]: 1.45-3.92; P < .001), but not MUA/LOA (OR: 1.97, 95% CI: 1.26-3.61; P = .133). Patients with 2 PRAs had greater odds of being diagnosed with AC than patients with 1 PRA (OR: 2.74; 95% CI: 1.14-5.99; P = .012). Although this association was nonsignificant for MUA/LOA, patients with 2 PRAs (OR: 2.67; 95% CI: 0.96-8.80; P = .059) demonstrated a similar statistical trend. CONCLUSION PRAs are associated with increased odds of receiving a diagnosis of AC within 2 years after ARCR but were not found to be associated with return to the operating room for postoperative stiffness.
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Affiliation(s)
- Allison M Morgan
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA.
| | - Zachary I Li
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Sharif Garra
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Andrew S Bi
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | | | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Kirk A Campbell
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
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Lin M, Gong T, Ruan S, Lv X, Chen R, Su X, Cheng B, Ji C. Emerging Insights into Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Induced by Immune Checkpoint Inhibitor and Tumor-Targeted Therapy. J Inflamm Res 2024; 17:2337-2351. [PMID: 38645875 PMCID: PMC11032673 DOI: 10.2147/jir.s454673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/04/2024] [Indexed: 04/23/2024] Open
Abstract
Objective Anticancer drugs have revolutionized tumor therapy, with cutaneous toxicities such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) being common immune-related adverse events. The debate over the efficacy of systemic corticosteroids in treating these conditions persists, while tumor necrosis factor (TNF)-alpha inhibitors show promise. This study aims to evaluate the effectiveness and safety of combination therapy involving the TNF-α inhibitor adalimumab for SJS/TEN induced by anticancer drugs. Methods A literature review of SJS/TEN cases induced by anticancer drugs from 1992 to 2023 was conducted, alongside an analysis of patients admitted to the First Affiliated Hospital of Fujian Medical University during the same period. Clinical characteristics, skin healing time, mortality, and adverse events were evaluated in two treatment groups: SJS/TEN patients treated with targeted anticancer therapies and immunotherapies. Results Among the 27 patients studied (18 with SJS or SJS-TEN overlapping and 9 with TEN), combination therapy with adalimumab significantly reduced mucocutaneous reepithelization time and healing duration compared to corticosteroid monotherapy. Patients receiving adalimumab combined with corticosteroids had lower actual mortality rates than those on corticosteroid monotherapy. The combination therapy also showed a trend towards reducing standardized mortality rates based on the Score of Toxic Epidermal Necrolysis (SCORTEN). Conclusion The findings suggest that adalimumab in combination with corticosteroids provides significant clinical benefits and is safer than corticosteroids alone for treating SJS/TEN induced by targeted anticancer therapies and immunotherapies. This study contributes valuable insights into potential treatment strategies for severe cutaneous adverse reactions to anticancer drugs, highlighting the importance of exploring alternative therapies such as TNF-α inhibitors in managing these conditions effectively.
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Affiliation(s)
- Min Lin
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350000, People’s Republic of China
| | - Ting Gong
- Department of Central Laboratory, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350000, People’s Republic of China
| | - Shifan Ruan
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350000, People’s Republic of China
| | - Xiaoqing Lv
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350000, People’s Republic of China
| | - Rongying Chen
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350000, People’s Republic of China
| | - Xinhong Su
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350000, People’s Republic of China
| | - Bo Cheng
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350000, People’s Republic of China
| | - Chao Ji
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350000, People’s Republic of China
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Smaha KM, Prosser JD, Chan JT. Toxic Epidermal Necrolysis Secondary to Iodine Versus Methimazole in a Pediatric Patient With Complex Autoimmune Disease. Cureus 2024; 16:e57618. [PMID: 38707124 PMCID: PMC11069421 DOI: 10.7759/cureus.57618] [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] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
We report a case of a 17-year-old girl who developed toxic epidermal necrolysis (TEN) secondary to preoperative iodine administration before thyroidectomy for Graves' disease. Past medical history was significant for COVID-19 and multisystem inflammatory syndrome in Children (MISC-C), with subsequent diagnoses of type 1 diabetes mellitus (T1DM), Addison disease, and Graves' disease. Her Graves disease was initially managed with methimazole. While there are reported cases of Stevens-Johnson syndrome (SJS) and TEN due to methimazole, the patient had discontinued methimazole over one month prior. Therefore, she likely represents the first case of TEN reported secondary to potassium iodide solution in a pediatric patient. Given the rarity of TEN in pediatric patients, our case highlights the challenges in managing complex autoimmune conditions and underscores the importance of careful medication choices in such cases.
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Affiliation(s)
- Katlyn M Smaha
- Pediatric Endocrinology, Medical College of Georgia at Augusta University, Augusta, USA
| | - John D Prosser
- Pediatric Otolaryngology, Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, USA
| | - Jacqueline T Chan
- Pediatric Endocrinology, University of Utah Health, Salt Lake City, USA
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Akgun Z, Palamar M, Egrilmez S, Yagci A, Barut Selver O. Severity Classification of Limbal Stem Cell Failure Due to Steven Johnson Syndrome in the Light of the Classification Consensus of Limbal Stem Cell Deficiency. Eye Contact Lens 2024; 50:159-162. [PMID: 38305421 DOI: 10.1097/icl.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVES To examine and to understand the limbal stem-cell deficiency (LSCD) because of Steven-Johnson syndrome (SJS) in line with the new classification system for the first time in the literature. METHODS Medical records of patients with LSCD because of SJS were reviewed retrospectively. In addition to demographic data and ophthalmologic or systemic findings, anterior segment photographs of the patients were reviewed retrospectively. Limbal stem-cell deficiency severity was graded according to the classification published by the Limbal Stem Cell Working Group. RESULTS Twenty-four eyes of 14 patients with eye involvement secondary to SJS were included in the study. The mean age of the patients was 36.09±16.70 (9-58) years and the female-to-male ratio was 11:3. The anterior segment photographs of the patients were evaluated by two independent masked observers. Limbal stem-cell deficiency severity was graded according to the classification published by Deng et al. Corneal opacity was divided into three stages according to the area of involvement. Corneal opacity was classified as Stage I if the central 5 mm region of the cornea was not affected, as Stage II if the central 5 mm region of the cornea was affected, and as Stage III if the entire corneal surface was affected. Limbal involvement was classified as Stage A if it was below 50%, as Stage B if it was between 50% and 100%, and as Stage C if it was 100%. CONCLUSION This is the first study in the literature to describe and classify LSCD because of SJS, according to the new LSCD classification. Consistent with the results, LSCD follows a bimodal distribution. Most patients demonstrated severe (Stage III-32.14%) or mild (Stage IA-21.42%) LSCD.
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Affiliation(s)
- Zeynep Akgun
- Faculty of Medicine, Department of Ophthalmology, Ege University, Izmir, Turkey
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14
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Chandran C, Santra M, Rubin E, Geary ML, Yam GHF. Regenerative Therapy for Corneal Scarring Disorders. Biomedicines 2024; 12:649. [PMID: 38540264 PMCID: PMC10967722 DOI: 10.3390/biomedicines12030649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 05/09/2024] Open
Abstract
The cornea is a transparent and vitally multifaceted component of the eye, playing a pivotal role in vision and ocular health. It has primary refractive and protective functions. Typical corneal dysfunctions include opacities and deformities that result from injuries, infections, or other medical conditions. These can significantly impair vision. The conventional challenges in managing corneal ailments include the limited regenerative capacity (except corneal epithelium), immune response after donor tissue transplantation, a risk of long-term graft rejection, and the global shortage of transplantable donor materials. This review delves into the intricate composition of the cornea, the landscape of corneal regeneration, and the multifaceted repercussions of scar-related pathologies. It will elucidate the etiology and types of dysfunctions, assess current treatments and their limitations, and explore the potential of regenerative therapy that has emerged in both in vivo and clinical trials. This review will shed light on existing gaps in corneal disorder management and discuss the feasibility and challenges of advancing regenerative therapies for corneal stromal scarring.
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Affiliation(s)
- Christine Chandran
- Corneal Regeneration Laboratory, Department of Ophthalmology, Mercy Vision Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA; (C.C.); (M.S.); (E.R.); (M.L.G.)
| | - Mithun Santra
- Corneal Regeneration Laboratory, Department of Ophthalmology, Mercy Vision Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA; (C.C.); (M.S.); (E.R.); (M.L.G.)
| | - Elizabeth Rubin
- Corneal Regeneration Laboratory, Department of Ophthalmology, Mercy Vision Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA; (C.C.); (M.S.); (E.R.); (M.L.G.)
| | - Moira L. Geary
- Corneal Regeneration Laboratory, Department of Ophthalmology, Mercy Vision Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA; (C.C.); (M.S.); (E.R.); (M.L.G.)
| | - Gary Hin-Fai Yam
- Corneal Regeneration Laboratory, Department of Ophthalmology, Mercy Vision Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA; (C.C.); (M.S.); (E.R.); (M.L.G.)
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
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15
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Yang LW, Zhang LJ, Zhou BB, Lin XY, Chen YT, Qin XY, Tian HY, Ma LL, Sun Y, Jiang LD. Efficacy of borneol-gypsum in skin regeneration and pain control in toxic epidermal necrolysis: A case report. World J Clin Cases 2024; 12:1290-1295. [PMID: 38524518 PMCID: PMC10955549 DOI: 10.12998/wjcc.v12.i7.1290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/18/2023] [Accepted: 02/07/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Toxic epidermal necrolysis (TEN) is a life-threatening dermatological emergency mainly induced by drug hypersensitivity reactions. Standard management includes discontinuation of culprit drug and application of immunomodulatory therapy. However, mortality remains high due to complications like septic shock and multiorgan failures. Innovative approaches for skin care are crucial. This report introduces borneol-gypsum, a traditional Chinese drug but a novel dressing serving as an adjuvant of TEN therapy, might significantly improve skin conditions and patient outcomes in TEN. CASE SUMMARY A 38-year-old woman diagnosed with eosinophilic granulomatosis with polyangiitis experienced gangrenous complications and motor nerve involvement. After initial treatment of high-dose corticosteroids and cyclophosphamide, symptom of foot drop improved, absolute eosinophil counts decreased, while limb pain sustained. Duloxetine was added to alleviate her symptom. Subsequently, TEN developed. Additional topical application of borneol-gypsum dressing not only protected the skin lesions from infection but also significantly eased localized pain. This approach demonstrated its merit in TEN management by promoting skin healing and potentially reducing infection risks. CONCLUSION Borneol-gypsum dressing is a promising adjuvant that could significantly improve TEN management, skin regeneration, and patient comfort.
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Affiliation(s)
- Lu-Wei Yang
- Department of Rheumatology, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361100, Fujian Province, China
| | - Li-Juan Zhang
- Department of Rheumatology, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361100, Fujian Province, China
| | - Bin-Bin Zhou
- Department of Rheumatology, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361100, Fujian Province, China
| | - Xin-Yu Lin
- Department of Dermatology, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361100, Fujian Province, China
| | - Yu-Ting Chen
- Department of Dermatology, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361100, Fujian Province, China
| | - Xiao-Yu Qin
- Department of Ophthalmology, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361100, Fujian Province, China
| | - Hui-Ying Tian
- Department of Nursing, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361100, Fujian Province, China
| | - Li-Li Ma
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai 200030, China
| | - Ying Sun
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai 200030, China
| | - Lin-Di Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai 200030, China
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16
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Enescu CD, Elder AJ, Deirawan H, Moossavi M. To Debride or Not to Debride: A Review of Wound Management for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Cureus 2024; 16:e55350. [PMID: 38559535 PMCID: PMC10981949 DOI: 10.7759/cureus.55350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are immune-mediated skin reactions with high mortality as a result of severely compromised skin barrier function. Currently, there is no consensus on the topical management of these conditions. Some advocate for surgical debridement of affected skin as a means of preventing infection and facilitating reepithelialization with synthetic and biological wound coverage. Others prefer a conservative approach that relies on leaving the blistered skin in situ. A consensus is lacking, primarily due to the rarity of the disease and the lack of high-quality evidence supporting one particular form of management. The goal of this review is to explore and compare the two treatment approaches for SJS and TEN, namely conservative management and surgical debridement.
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Affiliation(s)
- Christina D Enescu
- Department of Dermatology, Wayne State University School of Medicine, Detroit, USA
| | - Adam J Elder
- Department of Medical Education, Wayne State University School of Medicine, Detroit, USA
| | - Hany Deirawan
- Department of Dermatology, Wayne State University School of Medicine, Detroit, USA
| | - Meena Moossavi
- Department of Dermatology, Wayne State University School of Medicine, Detroit, USA
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17
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Sufiawati I, Amalia T, Dewi TS, Wisaksana R. The Association Between Oral Mucosal Lesions and Oral Health-Related Quality of Life Using the Validated Indonesian Version of OHIP-14 Among People Living with HIV/AIDS. HIV AIDS (Auckl) 2024; 16:9-16. [PMID: 38348377 PMCID: PMC10860594 DOI: 10.2147/hiv.s452154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/05/2024] [Indexed: 02/15/2024] Open
Abstract
Background Oral mucosal lesions in human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) patients, posing a concern for healthcare professionals, impact their oral health-related quality of life (OHRQoL). This study aimed to evaluate the association between oral mucosal lesions and OHRQoL as measured by the validated Indonesian version of the oral health impact profile-14 questionnaire (OHIP-14) among people living with HIV/AIDS (PLWHA). Methods A cross-sectional study was conducted at the Central Referral Hospital in West Java, Indonesia. The validity of OHIP-14 was evaluated in 30 PLWHA using inter-item corrected correlation, while reliability was assessed through Cronbach's alpha and kappa coefficient agreement. Subsequently, a consecutive sample of 110 PLWHA self-completed the validated Indonesian version of OHIP-14 and underwent an oral examination. The association between oral mucosal lesions and OHRQoL was analyzed using the chi-squared test. Results The validity test of the OHIP-14 questionnaire produced a rcount > 0.189, meaning that all question items were valid and could be used to describe OHRQoL. The reliability test of the OHIP-14 questionnaire produced a Cronbach's alpha value of 0.960 (> 0.7), which means that overall, the OHIP-14 questionnaire is reliable and feasible to be used to assess OHRQoL. Among the 110 enrolled participants, 61.8% were female and 38.2% were male, with the mean age 23.5 years old, the majority of them (59.1%) had been taking antiretrovirals (ARV), and (81.5%) had good QoL. There was a statistically significant relationship between oral lesions and quality of life (p<0.05), particularly acute pseudomembranous candidiasis, angular cheilitis, recurrent intraoral herpes, and Stevens-Johnson syndrome. Conclusion This study indicated a significant association between oral mucosal lesions and OHRQoL in PLWHA. The successfully validated Indonesian version of the OHIP-14 questionnaire serves as a reliable and effective tool for assessing OHRQoL among PLWHA.
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Affiliation(s)
- Irna Sufiawati
- Department of Oral Medicine, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
| | - Tuty Amalia
- Oral Medicine Residency Program, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
| | - Tenny Setiani Dewi
- Department of Oral Medicine, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
| | - Rudi Wisaksana
- Department of Internal Medicine, Dr. Hasan Sadikin Central General Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
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18
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Ozhathil DK, Powell CM, Corley CV, Golovko G, Song J, El Ayadi A, Wolf SE, Kahn SA. A retrospective analysis of mortality risk and immunosuppressive therapy for Stevens-Johnson Syndrome and toxic epidermal necrolysis syndrome using the TriNetX research network. Burns 2024; 50:75-86. [PMID: 37734977 DOI: 10.1016/j.burns.2023.08.009] [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: 03/30/2023] [Revised: 07/17/2023] [Accepted: 08/16/2023] [Indexed: 09/23/2023]
Abstract
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) exist on a spectrum of autoimmune conditions which cause epidermal detachment and keratinocyte necrosis. Due to the rare incidence of these conditions, a dramatic heterogeneity in treatment algorithms exists. To better appreciate pharmacologic immunosuppressive therapies' impact on survival, the authors queried a multi-institutional data network. Data for this study was extracted from TriNetX Research Network, a platform that contains ICD-9/ICD-10 coding data from a consortium of international healthcare organizations. Seventy-one institutions were queried to identify adult patients diagnosed with SJS, TEN or SJS-TEN Overlap. Cohorts were created based on the therapy received: systemic steroids (SS), diphenhydramine (DH), cyclosporine (CS), intravenous immunoglobulin (IVIG), tumor necrosis factor alpha inhibitors (TNFαi), or a combination of treatments. Cohorts were then propensity matched with patients who received supportive care. Patients who only received one of the above treatments showed no significant reduction in 90-day mortality. Patients who received CS or IVIG as part of their multitherapy showed a significantly increased risk of death when compared to supportive care (CS: RR = 1.583, 95% CI [1.119, 2.240]; IVIG: RR = 2.132, 95% CI [1.485, 3.059]). Despite their frequent utilization, this study's analysis suggests that none of these therapies confer significant 90-day mortality survival over supportive care alone. These results highlight the heterogeneity of therapies and emphasize the need for critical prospective appraisal of their outcomes in SJS and TEN.
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Affiliation(s)
- Deepak K Ozhathil
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA.
| | - Carter M Powell
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA
| | - Caroline V Corley
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA
| | - George Golovko
- 301 University Boulevard, Department of Pharmacology, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Juquan Song
- 301 University Boulevard, Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Amina El Ayadi
- 301 University Boulevard, Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Steven E Wolf
- 301 University Boulevard, Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Steven A Kahn
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA
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19
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Stanley EA, Zhang L, O'Hara J, Haertsch P, Maitz P. The seven-fold rise in incidence of Stevens-Johnson syndrome & toxic epidermal necrolysis: Associations with COVID-19 and the vaccine. Burns 2024; 50:87-92. [PMID: 37730480 DOI: 10.1016/j.burns.2023.06.016] [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: 01/11/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 09/22/2023]
Abstract
Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) is a rare, potentially life threatening mucocutaneous hypersensitivity reaction resulting in desquamation of the skin and mucosa. These patients are managed on burns units due to the widespread desquamation. We report the largest case series of participants developing SJS/TEN in the setting of recent COVID infection or vaccination. We found a seven-fold increase in SJS/TEN since the COVID pandemic. This increase correlates with an increase in COVID infections and vaccination rates. We explore the immunopathological relationships between COVID and SJS/TEN and propose theories for possible associations.
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Affiliation(s)
- Edward A Stanley
- Burns Unit, Concord Repatriation General Hospital, Australia; School of Medicine, The University of Sydney, Australia.
| | - Lois Zhang
- Department of Dermatology, Concord Repatriation General Hospital, Australia
| | - Justine O'Hara
- Burns Unit, Concord Repatriation General Hospital, Australia; School of Medicine, The University of Sydney, Australia
| | - Peter Haertsch
- Burns Unit, Concord Repatriation General Hospital, Australia; School of Medicine, The University of Sydney, Australia
| | - Peter Maitz
- Burns Unit, Concord Repatriation General Hospital, Australia; School of Medicine, The University of Sydney, Australia
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20
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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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Hao L, Cai W, Zeng Z, Geng X, Li Q, Chen H, Zhang Y, Ding J. Toxic epidermal necrolysis after injection of sclerosing agent and medical adhesive into oesophageal variceal ligation in a patient with a malignant liver tumour: A case report. Exp Ther Med 2024; 27:20. [PMID: 38125343 PMCID: PMC10728904 DOI: 10.3892/etm.2023.12309] [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: 11/25/2022] [Accepted: 10/13/2023] [Indexed: 12/23/2023] Open
Abstract
Chronic liver disease can cause an increase in portal sinus pressure, which may lead to rupture and bleeding of esophageal and gastric varices. Oesophageal variceal ligation, with use of sclerosing agent and tissue glue injection is commonly used in clinical practice to address oesophageal bleeding. A 58-year-old male patient with chronic liver disease was treated with oesophageal variceal ligation, sclerosing agent and tissue glue injection due to oesophageal and gastric variceal bleeding. After 2 days, the skin of the patient exhibited erythema to different degrees. After 10 days of dexamethasone treatment, the whole-body rash worsened, and a severe skin reaction appeared that was suggestive of toxic epidermal necrolysis (TEN). Strict mucosal care was provided, and corticosteroids, γ globulin and adalimumab were concurrently used for treatment. After 20 days, the patient recovered from the skin problems. To the best of our knowledge, TEN after endoscopic surgery has rarely been reported in the relevant literature. Furthermore, when patients being treated with multiple drugs have erythema multiforme, physicians should be alert to the possibility of its development into TEN. The present case report summarizes the treatment methods for patients with TEN, providing a practical clinical basis and direction for the future diagnosis and treatment of the condition.
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Affiliation(s)
- Liangchao Hao
- Department of Dermatology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
- Department of Plastic Surgery, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
| | - Wei Cai
- Department of Dermatology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
| | - Zhaomu Zeng
- Department of Neurosurgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi 330000, P.R. China
| | - Xiuchao Geng
- School of Medicine, Taizhou University, Taizhou, Zhejiang 318000, P.R. China
| | - Qiang Li
- School of Medicine, Taizhou University, Taizhou, Zhejiang 318000, P.R. China
| | - Hong Chen
- Department of Dermatology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
| | - Yuhao Zhang
- Department of Neurosurgery, Cancer Centre, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang 310000, P.R. China
| | - Juan Ding
- Department of Dermatology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
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22
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Gomes Ferreira S, Fernandes L, Santos S, Ferreira S, Sequeira J. Dipyrone (Metamizole)-Induced Stevens-Johnson Syndrome. Cureus 2024; 16:e53122. [PMID: 38420072 PMCID: PMC10899118 DOI: 10.7759/cureus.53122] [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] [Accepted: 01/28/2024] [Indexed: 03/02/2024] Open
Abstract
Stevens-Johnson Syndrome (SJS), a severe mucocutaneous hypersensitivity reaction primarily triggered by drugs, poses a low-incidence, high-mortality challenge. This report explores its clinical nuances and emphasizes supportive care as the mainstay of treatment. A 74-year-old female, burdened with a complex medical history, presented with a non-pruritic macular rash escalating to skin and oral mucosal involvement. A recent introduction of dipyrone (metamizole) implicated drug-induced SJS. Histopathological confirmation guided treatment involving supportive care, corticosteroids, and wound care, resulting in clinical improvement. The case underscores the significance of histopathological confirmation and thorough medication history in navigating SJS complexities, especially in patients with comorbidities like connective tissue disease. A successful multidisciplinary approach and the decision for post-discharge monitoring highlight the intricate management challenges. This case illuminates the intricate interplay of medication-induced hypersensitivity, comorbidities, and management challenges in SJS. Optimal outcomes require prompt diagnosis, trigger identification, and a multidisciplinary treatment approach, emphasizing ongoing research and clinical vigilance.
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Affiliation(s)
- Sérgio Gomes Ferreira
- Internal Medicine, Hospital São Sebastião, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, PRT
| | - Luís Fernandes
- Internal Medicine, Hospital São Sebastião, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, PRT
| | - Sara Santos
- Internal Medicine, Hospital São Sebastião, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, PRT
| | - Sofia Ferreira
- Internal Medicine, Hospital São Sebastião, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, PRT
| | - Joana Sequeira
- Internal Medicine, Hospital São Sebastião, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, PRT
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23
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Lv P, Huang J, Yang Q, Yang T, Cao X, Liu O, Zhang Z. Analysis of circRNA profiles and clinical value in Stevens-Johnson syndrome and toxic epidermal necrolysis. Exp Dermatol 2023; 32:2084-2093. [PMID: 37750014 DOI: 10.1111/exd.14939] [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: 02/26/2023] [Revised: 08/22/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
Severe cutaneous adverse drug reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), are challenging to be early diagnosed and evaluate their prognoses. This investigation aimed to analyse the expression profiles of SJS/TEN in peripheral blood mononuclear cells (PBMC) and assess the correlation between circular RNA (circRNA) and disease severity. Sixteen SJS/TEN patients and sixteen controls were enrolled and serum samples of both groups were obtained. CircRNA expression profiles in three SJS/TEN patients and three controls were detected by RNA sequencing and bioinformatic analyses were then performed. The differentially expressed circRNAs were verified by quantitative polymerase chain reaction (qPCR). Then, analysing the correlation of circRNAs with the toxic epidermal necrolysis-specific severity of illness score (SCORTEN) and the epidermal detachment area. A total of 134 circRNAs were differentially expressed in the PBMCs of SJS/TEN individuals, according to our results. The qPCR showed that three circRNAs (hsa_circ_0000711, hsa_circ_0083619 and hsa_circ_0005615) were down-regulated, and one circRNA (hsa_circ_0003028) was up-regulated, which were compatible with the sequencing findings. The concentration of hsa_circ_0083619 was closely associated with the SCORTEN scale (r = -0.581, p = 0.037) and the epidermal detachment area (r = -0.576, p = 0.039). The circRNA-miRNA-mRNA prediction network was used to construct the hsa_circ_0083619/miR-18a-5p/BCL2L10 axis. The hsa_circ_0083619 could serve as a disease severity indicator for SJS/TEN. Through bioinformatics analysis, we speculated that hsa_circ_0083619/miR-18a-5p/BCL2L10 axis might play a role in SJS/TEN pathogenesis.
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Affiliation(s)
- Pan Lv
- Department of Dermatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jiangxia Huang
- Department of Dermatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qianru Yang
- Department of Dermatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ting Yang
- Department of Dermatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xianwei Cao
- Department of Dermatology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ougen Liu
- Department of Dermatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhibin Zhang
- Department of Dermatology, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Paterno JM, Breslow Z, Mamo MA, Mercado E. A Multifactorial Case of Stevens-Johnson Syndrome With Atypical Features. Cureus 2023; 15:e49289. [PMID: 38143660 PMCID: PMC10748208 DOI: 10.7759/cureus.49289] [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] [Accepted: 11/22/2023] [Indexed: 12/26/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) is a severe mucocutaneous reaction that has a broad spectrum of causes and risk factors that include medications and other infectious causes such as Mycoplasma. In this case report, a patient with multiple comorbidities that confounded the presentation of Stevens-Johnson syndrome is observed. The patient was a 29-year-old female with a past medical history of recurrent cerebrovascular accident (CVA) who presented for an evaluation of chest pain. After empiric vancomycin was started for suspicion of endocarditis, our patient developed altered mental status, mucositis, and a painful erythematous erosion on her chest concerning for vasculitis, but after treatment and pathological review, it was found to be Stevens-Johnson syndrome. It is important to not forget the wide variety of risk factors for developing Stevens-Johnson syndrome and some of its unique associated presenting symptoms.
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Affiliation(s)
- Jennifer M Paterno
- Family Medicine, Hospital Corporation of America (HCA) Florida St. Petersburg Hospital, St. Petersburg, USA
| | - Zach Breslow
- Internal Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Mufit A Mamo
- Family Medicine, Hospital Corporation of America (HCA) Florida St. Petersburg Hospital, St. Petersburg, USA
| | - Edgar Mercado
- Critical Care, Hospital Corporation of America (HCA) Florida St. Petersburg Hospital, St. Petersburg, USA
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Schroeder JW, Caputo V, Guida S, Conte F, Paolino G, Bonoldi E, Baruffaldi Preis FW, Rongioletti F. Stevens-Johnson syndrome and toxic epidermal necrolysis: 11-year retrospective experience in a high-complexity tertiary hospital in Milan, Italy. Clin Dermatol 2023; 41:712-720. [PMID: 37716583 DOI: 10.1016/j.clindermatol.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe drug-induced hypersensitivity reactions characterized by widespread epidermal necrosis, mucous membrane erosions, and systemic findings. We have provided our 11-year experience from a Milan, Italy tertiary hospital managing SJS/TEN, evaluating the clinical and histopathologic features plus the impact on mortality. We retrospectively analyzed 28 patients diagnosed with SJS/TEN based on the clinical and histopathologic findings, according to the classification criteria of multiple studies. We assessed the dermatographics, comorbidities, drug history, lesion characteristics, clinical findings, treatments, blood tests, and outcomes. Severity scores (SCORTEN, Re-SCORTEN, ABCD-10) were used for treatment evaluation and mortality prediction. Data were statistically analyzed, and significant factors associated with mortality were identified. We found that among the 28 patients, 89.2% had comorbidities, mainly cardiovascular diseases, and 21.4% had autoimmune disorders. All patients had received systemic therapy (46.6% monotherapy, 53.6% combination therapy), with systemic steroids (71.4%) and intravenous immunoglobulins (67.8%) being common treatments. There were complications, including systemic infections (67.9%) and septic shock (10.7%). The overall mortality rate was 17.8%. The statistical analysis indicated that malignancy, a high ABCD-10 score, and a high neutrophil-to-lymphocyte ratio were significantly associated with mortality. The extent of affected body surface area did not correlate significantly with mortality. This study provides insights into SJS/TEN management, revealing factors influencing mortality in a high-complexity tertiary hospital setting.
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Affiliation(s)
- Jan W Schroeder
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Valentina Caputo
- Unit of Pathological Anatomy and Cytogenetics, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefania Guida
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Dermatology Clinic, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesca Conte
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Paolino
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Emanuela Bonoldi
- Unit of Pathological Anatomy and Cytogenetics, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Franco Rongioletti
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Dermatology Clinic, IRCCS San Raffaele Hospital, Milan, Italy.
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Yan Q, Liu X, Lei H, Liu R, Hu Y. Analysis of clinical features of oxcarbazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis. Front Med (Lausanne) 2023; 10:1232969. [PMID: 37881633 PMCID: PMC10597665 DOI: 10.3389/fmed.2023.1232969] [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: 06/01/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
Background Stevens-Johnson syndrome (SJS) is considered a hypersensitivity syndrome affecting the skin and mucous membranes. It has been reported that an anticonvulsant drug, oxcarbazepine, may cause Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN). However, the clinical features of oxcarbazepine-induced Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) remain ambiguous. This article aims to explore the clinical features of SJS/TEN. Methods Systematic searches of several Chinese and English databases were conducted for case reports published on PubMed, EMBASE, Web of Science, MEDLINE, CNKI from January 1, 2007 to March 1, 2023. Results A total of seventeen patients (10 males and 7 females) were included in this study, including nine adult patients and eight pediatric patients. The results showed that males seem to have a higher prevalence of SJS/TEN than females, and SJS/TEN usually occurs within 2 weeks after administration of oxcarbazepine (OXC). The main clinical manifestations among the included patients were rashes or maculopapules (17 cases, 100%), fever (11 cases, 64.7%), mucosal lesions (15 cases, 88.2%), conjunctivitis with/without ocular discharge (12 cases, 70.6%), and blisters (12 cases, 70.6%). After stopping OXC or switching to other drugs that treat primary disease as well as treatment with IVIG, glucocorticoid, anti-allergy, and fluid replacement, eight of the included patients recovered completely, and another eight of the included patients reported symptomatic improvement, while the prognosis of one of the included patients was not reported. Conclusion Diverse clinical signs and symptoms of SJS/TEN might result in misinterpretation and delayed diagnosis. It should be identified and treated immediately to avoid significant consequences and potentially jeopardize patients' lives.
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Affiliation(s)
- Qingzi Yan
- Department of Clinical Pharmacy, Xiangtan Central Hospital, Xiangtan, China
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Neagu TP, Tiglis M, Peride I, Niculae A. Toxic Epidermal Necrolysis, A Serious Side Effect of Tenoxicam Use: A Case Report. Healthcare (Basel) 2023; 11:2195. [PMID: 37570435 PMCID: PMC10418430 DOI: 10.3390/healthcare11152195] [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: 06/26/2023] [Revised: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
Tenoxicam, a selective cyclooxygenase (COX)-2 inhibitor, has potent analgesic and anti-inflammatory effects and is frequently used for out-of-hospital pain control. Even though other non-steroidal anti-inflammatory drugs were incriminated in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) appearance, the literature is scarce regarding this agent. We report a case of tenoxicam-induced toxic epidermal necrolysis, detailing the multidisciplinary approach in a patient presenting skin detachment of 90% of the total body surface area, with concomitant ocular, oral, nasal, and vaginal mucosae involvement. A skin biopsy confirmed the diagnosis. The immediate cessation of the incriminated drug and rapid initiation of systemic steroids, along with topical therapies, and isolation into a specific environmental condition to limit skin infection were the cornerstones of therapeutic management. The patient was discharged with skin hyperpigmentation area and mild anxiety as long-term sequels. This report emphasized that severe or complicated cases should be transferred to a specialized burn center to reduce mortality risk and long-term morbidity.
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Affiliation(s)
- Tiberiu Paul Neagu
- Clinical Department No. 11, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Mirela Tiglis
- Department of Anesthesia and Intensive Care, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
| | - Ileana Peride
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Andrei Niculae
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
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Wilkerson RG. Drug Hypersensitivity Reactions. Immunol Allergy Clin North Am 2023; 43:473-489. [PMID: 37394254 DOI: 10.1016/j.iac.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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29
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Saito Y, Abe R. New insights into the diagnosis and management of Stevens-Johnson syndrome and toxic epidermal necrolysis. Curr Opin Allergy Clin Immunol 2023; 23:271-278. [PMID: 37284785 DOI: 10.1097/aci.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE OF REVIEW Recent studies have been clarifying the pathogenesis and early diagnostic markers of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Additionally, the efficacy of tumor necrosis factor alpha inhibitors is attracting attention. This review provides) recent evidence for the diagnosis and management of SJS/TEN. RECENT FINDINGS Risk factors for the development of SJS/TEN have been identified, particularly the association between HLA and the onset of SJS/TEN with specific drugs, which has been intensively studied. Research on the pathogenesis of keratinocyte cell death in SJS/TEN has also progressed, revealing the involvement of necroptosis, an inflammatory cell death, in addition to apoptosis. Diagnostic biomarkers associated with these studies have also been identified. SUMMARY The pathogenesis of SJS/TEN remains unclear and effective therapeutic agents have not yet been established. As the involvement of innate immunity, such as monocytes and neutrophils, in addition to T cells, has become clear, a more complex pathogenesis is predicted. Further elucidation of the pathogenesis of SJS/TEN is expected to lead to the development of new diagnostic and therapeutic agents.
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Affiliation(s)
- Yuki Saito
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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30
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Nikitina EA, Fomina DS, Markina UA, Andreev SS, Streltsov YV, Kruglova TS, Lebedkina MS, Karaulov AV, Lysenko MA. Positive experience with TNF-α inhibitor in toxic epidermal necrolysis resistant to high-dose systemic corticosteroids. Front Med (Lausanne) 2023; 10:1210026. [PMID: 37554504 PMCID: PMC10404849 DOI: 10.3389/fmed.2023.1210026] [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: 04/21/2023] [Accepted: 07/03/2023] [Indexed: 08/10/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, potentially life-threatening syndromes characterized by the development of necrotic epidermal and mucosal lesions. The most common etiologic cause of SJS/TEN is drug-induced mechanisms. The group of drugs with high potential risk includes sulfonamides, anticonvulsants, non-steroidal anti-inflammatory drugs (NSAIDs), allopurinol, phenobarbital, etc. There is no gold standard treatment algorithm for SJS/TEN. In medical practice, systemic glucocorticosteroids (sGCS), intravenous immunoglobulin (IVIG), plasmapheresis, and cyclosporine are used empirically and in various combinations. Recently published studies have demonstrated the efficacy of TNF-α inhibitors as a promising approach in SJS/TEN, including cases resistant to high-dose sGCS, with etanercept and infliximab being the most commonly used drugs. In a large multicenter study by Zhang J et al. (XXXX), 242 patients treated with etanercept, sGCS, or a combination of both had lower mortality compared to the control group. A shorter skin healing time was documented compared to sGCS monotherapy, thus reducing the risk of secondary infections. The published data show a high efficacy with THF-α inhibitor blockade, but the safety of TNF-α inhibitors in patients with SJS/TEN is still questionable due to the paucity of available information. As all clinical research data should be accumulated to provide reliable evidence that the use of TNF-α inhibitors may be beneficial in SJS/TEN, we report a case of etoricoxib-associated SJS with progression to TEN in a 50-year-old woman who was refractory to high-dose sGCS therapy.
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Affiliation(s)
- Ekaterina A. Nikitina
- City Clinical Hospital No. 52, Moscow, Russia
- The First Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Daria S. Fomina
- City Clinical Hospital No. 52, Moscow, Russia
- The First Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | | | | | | | | | | | - Alexander V. Karaulov
- The First Sechenov Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Maryana A. Lysenko
- City Clinical Hospital No. 52, Moscow, Russia
- Department of General Therapy, Pirogov Russian National Research Medical University, Moscow, Russia
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Gong T, Zhang P, Ruan SF, Xiao Z, Chen W, Lin M, Zhong Q, Luo R, Xu Q, Peng J, Cheng B, Chen F, Chen L, Chung WH, Ji C. APOA4 as a novel predictor of prognosis in Stevens-Johnson syndrome/toxic epidermal necrolysis: A proteomics analysis from two prospective cohorts. J Am Acad Dermatol 2023; 89:45-52. [PMID: 36963506 DOI: 10.1016/j.jaad.2023.02.058] [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: 01/05/2023] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening adverse drug reactions. Conventional systemic therapies are of limited efficacy and often exhibit strong side effects. OBJECTIVE To assess the efficacy and safety of the combination treatment with a tumor necrosis factor-α antagonist adalimumab and delineate the underlying mechanisms. METHODS We evaluated the efficacy and safety of the combination therapy with adalimumab by comparing 2 treatment cohorts of SJS/TEN patients. Patient plasma samples were collected for proteomics analysis. RESULTS The combination therapy with adalimumab significantly shortened the time to mucocutaneous re-epithelization and healing, with reduced side effects caused by corticosteroids. Plasma proteomic profiling showed that apolipoprotein A-IV (APOA4) was one of the most significant differentially expressed proteins. Multivariate regression analysis revealed that APOA4 level was significantly associated with prognosis parameter of SJS/TEN (P = .004), but not with disease severity score (severity-of-illness score for toxic epidermal necrolysis [SCORTEN]) (P = .118). Thus further research will be helpful to effectively incorporate APOA4 into current SCORTEN-driven protocols. LIMITATIONS The cohort size is relatively small. Both cohorts had low overall SCORTEN scores. CONCLUSION Adalimumab in combination with corticosteroids demonstrates significant clinical benefits over corticosteroids alone in SJS/TEN patients. Moreover, APOA4 may serve as a novel prognostic marker of SJS/TEN.
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Affiliation(s)
- Ting Gong
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Central Laboratory, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Peng Zhang
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Shi-Fan Ruan
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Zhixun Xiao
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Wen Chen
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Min Lin
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Qingmei Zhong
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Renwei Luo
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Qiuyun Xu
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Jiamei Peng
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Bo Cheng
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Fa Chen
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
| | - Lihong Chen
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, and Keelung, Taiwan.
| | - Chao Ji
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Key Laboratory of Skin Cancer of Fujian Higher Education Institutions, Fujian Medical University, Fuzhou, Fujian, China.
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Moshirfar M, Masud M, Harvey DH, Payne C, Bruce E, Ronquillo YC, Hoopes PC. The Multifold Etiologies of Limbal Stem Cell Deficiency: A Comprehensive Review on the Etiologies and Additional Treatment Options for Limbal Stem Cell Deficiency. J Clin Med 2023; 12:4418. [PMID: 37445454 DOI: 10.3390/jcm12134418] [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: 04/22/2023] [Revised: 06/16/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Given the various ocular manifestations of limbal stem cell insufficiency, an awareness of the genetic, acquired, and immunological causes and associated additional treatments of limbal stem cell deficiency (LSCD) is essential for providers. We performed a comprehensive review of the literature on the various etiologies and specific therapies for LSCD. The resources utilized in this review included Medline (PubMed), Embase, and Google Scholar. All English-language articles and case reports published from November 1986 through to October 2022 were reviewed in this study. There were collectively 99 articles on these topics. No other exclusion criteria were applied. Depending on the etiology, ocular manifestations of limbal stem cell deficiency range from dry eye syndrome and redness to more severe outcomes, including corneal ulceration, ocular surface failure, and vision loss. Identifying the source of damage for LSCD is critical in the treatment process, given that therapy may extend beyond the scope of the standard protocol, including artificial tears, refractive surgery, and allogeneic stem cell transplants. This comprehensive review of the literature demonstrates the various genetic, acquired, and immunological causes of LSCD and the spectrum of supplemental therapies available.
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Affiliation(s)
- Majid Moshirfar
- Hoopes Vision Research Center, Hoopes Vision, Draper, UT 84020, USA
- John A. Moran Eye Center, School of Medicine, University of Utah, Salt Lake City, UT 84132, USA
- Utah Lions Eye Bank, Murray, UT 84107, USA
| | - Maliha Masud
- School of Medicine, University of Nevada Reno, Reno, NV 89557, USA
| | - Devon Hori Harvey
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Carter Payne
- Hoopes Vision Research Center, Hoopes Vision, Draper, UT 84020, USA
| | - Elayna Bruce
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | | | - Philip C Hoopes
- Hoopes Vision Research Center, Hoopes Vision, Draper, UT 84020, USA
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McKinley BJ, Allen ME, Michels N. Photodistributed Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and proposal for a new diagnostic classification. Eur J Med Res 2023; 28:188. [PMID: 37303053 DOI: 10.1186/s40001-023-01142-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 05/15/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Ultraviolet radiation (UVR) exposure is commonly reported as a risk factor for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, minimal evaluation of photo-induced SJS/TEN has been conducted. Thus, this review identifies all cases of SJS/TEN that are linked to an acute exposure of UVR and outlines the unifying characteristics of these cases. Furthermore, the theoretical pathogenesis, differential diagnoses, and proposed diagnostic criteria are defined. METHODS PubMed, Google Scholar, and other databases and websites were searched from inception to September 2021 to identify studies that met inclusion criteria. The following keywords were utilized: "Stevens-Johnson syndrome" and "toxic epidermal necrolysis" with "ultraviolet," "photodistributed," "photo-induced," "photosensitivity," and "photo." One reviewer assessed study characteristics, with confirmation by a second. The risk of bias was assessed independently by another. RESULTS Thirteen patient cases were identified, all reporting ultraviolet radiation prior to rash onset and an underlying causal drug. Case classifications included 7/13 SJS and 6/13 TEN. All cases described the rash as photodistributed with UVR exposure prior to rash onset (delay of 1-3 days) and a causal drug. 10 cases provided evidence that the photodistributed rash lacked linear demarcation (as in a sunburn) with satellite target-like lesions. No cases described a flu-like prodrome. DISCUSSION Mucositis, palmar and plantar rash, a positive Nikolsky sign, and a prolonged disease course can help distinguish from photosensitive reactions, while a negative direct immunofluorescence test is important to distinguish from other photo-induced disorders. CONCLUSION Physicians should be aware that UVR may precipitate SJS/TEN in patients taking susceptible drugs. After a 24-h delay from UVR exposure, a non-distinct, photodistributed rash appears with no flu-like prodrome and progresses for at least 48 h to include vesiculobullous eruptions and mucous membrane involvement. Photodistributed SJS/TEN appears to be photo-drug-induced with a unique onset and rash presentation that should be recognized as a distinct diagnosis.
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Affiliation(s)
- Blake Jeffrey McKinley
- Department of Internal Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
| | - Mitchell Edger Allen
- Department of Primary Care, Rocky Vista University College of Osteopathic Medicine, Ivins, UT, 84738, USA
| | - Nicole Michels
- Department of Medical Humanities and Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine, 8401 S. Chambers Road, Parker, CO, 80134, USA.
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Zhang N, Su T, Yan J, Zhang M, Zhao S, Liu C, Chen T. Case report: Successful immunomodulators combined with electromagnetic field therapy in a patient with methazolamide-induced Steven Johnson syndrome/toxic epidermal necrolysis overlap. Front Med (Lausanne) 2023; 10:1192920. [PMID: 37305125 PMCID: PMC10248229 DOI: 10.3389/fmed.2023.1192920] [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: 03/24/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Methazolamide is used to treat patients with glaucoma. However, as a sulfonamide derivative, methazolamide shares the same adverse reaction profile as other sulfa-based medications. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare delayed-type hypersensitivity cutaneous reactions with high morbidity and mortality. Here, we report a severe SJS/TEN overlap syndrome in an 85-year-old Chinese male patient who received methazolamide 25 mg twice daily for his left eye glaucoma. The causal relationship between SJS/TEN and methazolamide was categorized as "highly likely" on the algorithm for assessing drug causality for epidermal necrolysis. In addition to the treatments with methylprednisolone and immunoglobulin, we used a special electromagnetic spectrum therapeutic apparatus to provide skin wound care. The patient had a thoroughly satisfying recovery. This is the first case report to use electromagnetic field therapy in a patient with SJS/TEN. We share our experience here and suggest that electromagnetic field therapy can provide advanced skin wound care and facilitate the recovery of SJS/TEN.
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Affiliation(s)
- Naiju Zhang
- Department of Pharmacy, First Affiliated Hospital of Bengbu Medical College, Institute of Emergency and Critical Care Medicine, Anhui Engineering Technology Research Center of Biochemical Pharmaceutical, Bengbu, Anhui, China
| | - Tianjiao Su
- Key Laboratory of Immunology in Chronic Diseases, Department of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Jingwen Yan
- Key Laboratory of Immunology in Chronic Diseases, Department of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Mei Zhang
- Key Laboratory of Immunology in Chronic Diseases, Department of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Shousong Zhao
- Key Laboratory of Immunology in Chronic Diseases, Department of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Chuanmiao Liu
- Key Laboratory of Immunology in Chronic Diseases, Department of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Tianping Chen
- Department of Cardiology, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
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35
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Tóth G, Lukács A, Schirra F, Sándor GL, Killik P, Maneschg OA, Nagy ZZ, Szentmáry N. Ophthalmic Aspects of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Narrative Review. Ophthalmol Ther 2023:10.1007/s40123-023-00725-w. [PMID: 37140876 PMCID: PMC10157599 DOI: 10.1007/s40123-023-00725-w] [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: 03/09/2023] [Accepted: 04/19/2023] [Indexed: 05/05/2023] Open
Abstract
The aim of our review article was to summarize the current literature on Stevens-Johnson syndrome (SJS) and its severe form, toxic epidermal necrolysis (TEN). SJS/TEN is a serious, rare multi-system, immune-mediated, mucocutaneous disease with a significant mortality rate that can lead to severe ocular surface sequelae and even to bilateral blindness. Restoration of the ocular surface in acute and chronic SJS/TEN is challenging. There are only limited local or systemic treatment options for SJS/TEN. Early diagnosis, timely amniotic membrane transplantation and aggressive topical management in acute SJS/TEN are necessary to prevent long-term, chronic ocular complications. Although the primary aim of acute care is to save the life of the patient, ophthalmologists should regularly examine patients already in the acute phase, which should also be followed by systematic ophthalmic examination in the chronic phase. Herein, we summarize actual knowledge on the epidemiology, aetiology, pathology, clinical appearance and treatment of SJS/TEN.
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Affiliation(s)
- Gábor Tóth
- Dr. Rolf M. Schwiete Center for Limbal Stem Cell and Congenital Aniridia Research, Saarland University, Kirrberger Str. 100, 66424, Homburg/Saar, Germany.
- Department of Ophthalmology, Semmelweis University, Mária Utca 39, 1085, Budapest, Hungary.
| | - Andrea Lukács
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Utca 41, 1085, Budapest, Hungary
| | - Frank Schirra
- Argos Augenzentrum, Faktoreistraße 4, 66111, Saarbrücken, Germany
| | - Gábor L Sándor
- Department of Ophthalmology, Semmelweis University, Mária Utca 39, 1085, Budapest, Hungary
| | - Petra Killik
- Department of Ophthalmology, Semmelweis University, Mária Utca 39, 1085, Budapest, Hungary
| | - Otto A Maneschg
- Department of Ophthalmology, Semmelweis University, Mária Utca 39, 1085, Budapest, Hungary
| | - Zoltán Z Nagy
- Department of Ophthalmology, Semmelweis University, Mária Utca 39, 1085, Budapest, Hungary
| | - Nóra Szentmáry
- Dr. Rolf M. Schwiete Center for Limbal Stem Cell and Congenital Aniridia Research, Saarland University, Kirrberger Str. 100, 66424, Homburg/Saar, Germany
- Department of Ophthalmology, Semmelweis University, Mária Utca 39, 1085, Budapest, Hungary
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Memon S, Ahmed N, Nasir Memon M, Zahoor F, Afzal G. Linezolid and Ciprofloxacin-Induced SJS/TEN (Stevens-Johnson Syndrome/Toxic Epidermolysis Necrosis) Overlap in a Patient With Borderline Personality Disorder During a Single Hospital Stay: A Difficult Case to Manage. Cureus 2023; 15:e39242. [PMID: 37342736 PMCID: PMC10277191 DOI: 10.7759/cureus.39242] [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] [Accepted: 05/19/2023] [Indexed: 06/23/2023] Open
Abstract
SJS/TEN (Stevens-Johnson syndrome/toxic epidermolysis necrosis) is a T-cell mediated hypersensitivity syndrome in which cytotoxic CD8+ cells react against keratinocytes, resulting in widespread apoptosis and cell necrosis. About 90% of these cases are attributed to drug reactions, while 10% are idiopathic. The disease is classified according to body surface area (BSA) involvement and the thickness of epidermal loss. We report a case of a female with borderline personality disorder on antipsychotic medication, who developed SJS/TEN overlap after taking ciprofloxacin for her urinary tract infection (UTI). Her condition improved with meticulous management, but after switching her antibiotic from intravenous clarithromycin to oral linezolid, she developed SJS/TEN again, this time with more severe involvement. She received active management involving a multidisciplinary approach. Her condition improved slowly and, after one month, her lesions began to heal, and she was discharged with advice not to use both antimicrobial drugs in the future.
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Affiliation(s)
- Shafia Memon
- Dermatology, Bahria University Medical and Dental College/PNS Shifa Hospital, Karachi, PAK
| | - Najia Ahmed
- Dermatology, Bahria University Medical and Dental College/PNS Shifa Hospital, Karachi, PAK
| | | | - Fatima Zahoor
- Dermatology, Bahria University Medical and Dental College/PNS Shifa Hospital, Karachi, PAK
| | - Ghazal Afzal
- Dermatology, Bahria University Medical and Dental College/PNS Shifa Hospital, Karachi, PAK
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Ceylan A, Mergen B, Aydin FO, Avci E, Yildirim Y. Sutureless Amniotic Membrane Transplantation Using Pediatric Nasogastric Tube for Patients With Acute Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. Eye Contact Lens 2023; 49:199-203. [PMID: 36943174 DOI: 10.1097/icl.0000000000000986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
PURPOSE Evaluation of the results of sutureless amniotic membrane transplantation (AMT) using a pediatric nasogastric tube (NGT) for patients with acute Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) was aimed. METHODS Twenty-six eyes of 13 patients with SJS/TEN with ocular involvement at a single tertiary care hospital between May 2020 and January 2022 were included in the study. An amniotic membrane was implanted to the ocular surface and conjunctival fornix using a modified symblepharon ring (MR) created by inserting NGT end-to-end. Patients were followed for at least 6 months. The mean duration of the surgery was recorded. The presence of corneal epithelial defect and vascularization, meibomian gland dysfunction (MGD) grade, conjunctival scarring, eyelid margin keratinization, symblepharon, and trichiasis were recorded. RESULTS The mean age of the patients was 38.4±17.6 years. Amniotic membrane transplantation was performed only once for eight patients and twice for five patients. The mean duration of the surgery was 3.2±0.4 min. The modified symblepharon ring was removed 28 days after its application. At the first examination, 20 eyes (76.9%) had a corneal epithelial defect and 6 (23.1%) had early symblepharon. At the postoperative 6 months, although seven eyes (26.9%) had conjunctival scarring and 5 (19.2%) had eyelid margin keratinization, all patients were without any corneal defect, corneal vascularization, or symblepharon. Only 11 eyes (42.3%) showed MGD, and 1 eye (3.8%) showed trichiasis. CONCLUSIONS This study showed that sutureless AMT using pediatric NGT could be a potentially fast and inexpensive treatment option for the treatment of SJS/TEN with ocular involvement at the bedside without the need for general anesthesia.
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Affiliation(s)
- Ali Ceylan
- Department of Ophthalmology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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Shamloul G, Desai M, Laslett N. An Unusual Case of Stevens-Johnson/Toxic Epidermal Necrolysis Overlap Syndrome in HER2 (Human Epidermal Growth Factor Receptor 2)-Positive Breast Cancer Patient Treated With Docetaxel. Cureus 2023; 15:e37590. [PMID: 37193463 PMCID: PMC10183237 DOI: 10.7759/cureus.37590] [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: 01/10/2023] [Accepted: 04/02/2023] [Indexed: 05/18/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening drug-induced hypersensitivity reactions existing as a disease continuum based on the area of skin detachment. Following three cycles of treatment with docetaxel, a 60-year-old female with early-stage human epidermal growth factor receptor 2 (HER2)-positive breast cancer presented to the hospital with a flu-like illness and black crusting of the bilateral orbits, navel, and perianal region. Nikolsky sign was positive, and the patient was subsequently transferred to a specialized burn center for treatment of SJS/TEN overlap syndrome. There are a small number of cases documenting SJS/TEN following docetaxel administration in cancer patients.
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Affiliation(s)
- Gelan Shamloul
- Oncology, Philadelphia College of Osteopathic Medicine, Philadelphia, USA
| | - Mehir Desai
- Internal Medicine, Christiana Care Health System, Newark, USA
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39
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Lantz R. Toxic Epidermal Necrolysis in a Critically Ill African American Woman: A Case Report Written With ChatGPT Assistance. Cureus 2023; 15:e35742. [PMID: 37025739 PMCID: PMC10072179 DOI: 10.7759/cureus.35742] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 03/06/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening spectrum diseases in which a medication triggers a mucocutaneous reaction associated with severe necrosis and loss of epidermal integrity. The disease has a high mortality rate that can be assessed by dermatology scoring scales based on an affected total body surface area (TBSA). Sloughing of <10% TBSA is considered SJS, with a mortality of 10%. Sloughing of >30% TBSA is termed TEN, with an increased mortality rate of 25% to 35%. We present a case and management of TEN that involved >30% TBSA in a critically ill African American woman. Identification of the offending agent was difficult due to complicated medication exposure throughout her multi-facility care management. This case conveys the importance of close monitoring of a critically ill patient during a clinical course involving SJS-/TEN-inducing drugs. We also discuss the potential increased risks for SJS/TEN in the African American population due to genetic or epigenetic predispositions to skin conditions. This case report also contributes to increasing skin of color representation in the current literature. Additionally, we discuss the use of Chat Generative Pre-trained Transformer (ChatGPT, OpenAI LP, OpenAI Inc., San Francisco, CA, USA) and list its benefits and errors.
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Sljivic S, Nam J, Matthews R, Agala CB, Hollowell J, Nizamani R, King B, Williams FN. Does A History of Malignancy Lead to Worse Outcomes in a Single-center Burn Unit? J Burn Care Res 2023; 44:274-279. [PMID: 36617221 DOI: 10.1093/jbcr/irad002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Indexed: 01/09/2023]
Abstract
A history of malignancy is associated with worse outcomes in cardiac disease and trauma. Our objective was to determine if a past medical history or comorbid condition of cancer portends an increased morbidity or mortality in burns or skin-sloughing disorders at our institution. Patients were identified using our Institutional Burn Center registry and linked to the clinical and administrative data. All patients admitted between January 1, 2014 and June 30, 2021 were eligible for inclusion. Demographics, length of stay, comorbid conditions and mortality were evaluated. Statistical analysis was performed with Kruskal-Wallis, chi-square, and Fisher's exact tests. Seven thousand three hundred seventy-two patients were admitted during this time period. Three hundred eighty-six patients had a history of cancer (5%). Patients with a history of cancer were older (56 vs 44 years, P < .0001). They had a significantly longer length of stay (16 vs 10 days, P < .0001). They also had larger burns and higher hospital costs ($147,021 versus $83,788, P < .0001), were more likely to be male and more likely to have a skin-sloughing disorder. A history of cancer was not associated with increased odds of burn mortality. Thus, a history of cancer is associated with increased lengths of stay and costs in patients admitted for burn injury or skin-sloughing disorders, but not associated with increased mortality. Further study is warranted to investigate and mitigate what aspects of their care could be adjusted to improve outcomes.
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Affiliation(s)
- Sanja Sljivic
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA.,North Carolina Jaycee Burn Center, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Jason Nam
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, 2301 Erwin Road Durham, North Carolina 27710, USA
| | - Robert Matthews
- Department of Anesthesiology, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Chris B Agala
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Jamie Hollowell
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA.,North Carolina Jaycee Burn Center, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Rabia Nizamani
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA.,North Carolina Jaycee Burn Center, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Booker King
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA.,North Carolina Jaycee Burn Center, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
| | - Felicia N Williams
- Department of Surgery, University of North Carolina School of Medicine, 101 Manning Drive Chapel Hill, North Carolina 27599, USA.,North Carolina Jaycee Burn Center, 101 Manning Drive Chapel Hill, North Carolina 27599, USA
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41
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Allopurinol induced severe cutaneous adverse reactions: Vigilance of prescription (31 cases). REVUE FRANÇAISE D'ALLERGOLOGIE 2023. [DOI: 10.1016/j.reval.2022.103275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Next-generation sequencing-based HLA typing reveals the association of HLA-B*46:01:01 and HLA-DRB1*09:01:02 alleles with carbamazepine-induced hypersensitivity reactions in Vietnamese patients with epilepsy. Hum Immunol 2023; 84:186-195. [PMID: 36725456 DOI: 10.1016/j.humimm.2023.01.005] [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: 06/15/2022] [Revised: 11/03/2022] [Accepted: 01/17/2023] [Indexed: 02/02/2023]
Abstract
Several studies have reported an association between certain human leukocyte antigen (HLA) alleles and carbamazepine (CBZ)-induced hypersensitivity reactions in patients with epilepsy. Here, the relationship between the clinical spectrum and the HLA allele profiles in patients with CBZ-induced hypersensitivity reactions was investigated using next-generation sequence (NGS) data obtained from 65 Vietnamese patients with epilepsy, including 33 with CBZ-tolerance and 32 patients with CBZ-hypersensitivity, in which only 8 with severe cutaneous adverse drug reactions and 24 were mild-hypersensitive patients. Three loci of HLA class I (HLA-A, -B, and -C) and two loci of HLA class II (HLA-DQA1 and -DRB1) were included in our analysis. We observed a higher prevalence of three alleles, HLA-B*46:01:01, HLA-DQA1*03:02:01, and HLA-DRB1*09:01:02, in the CBZ hypersensitivity group compared to that in the CBZ tolerant group. Notably, all hypersensitive patients with HLA-DQA1*03:02:01 also harbored HLA-DRB1*09:01:02. We also used molecular modeling to gain mechanistic insight into the interactions of HLA-B*46:01 and HLA-DRB1*09:01 with CBZ. Our findings proposed the direct interaction of CBZ with peptide-binding pockets of these HLA proteins. The sensitivity and specificity of HLA-B*46:01:01 in considering with the appearance of HLA-DRB1*09:01:02 were 46.88% and 84.85%, respectively. Our data suggest that the presence of HLA-B*46:01:01/HLA-DRB1*09:01:02 is a potential marker of CBZ-induced hypersensitivity reactions in Vietnamese patients.
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Li Y, Bian LF, Li CY, Shi XL. Serious toxic epidermal necrolysis occurred during comprehensive treatment in a patient with advanced cholangiocarcinoma: A case report. Asian J Surg 2023; 46:1975-1976. [PMID: 36739182 DOI: 10.1016/j.asjsur.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/04/2023] [Indexed: 02/05/2023] Open
Affiliation(s)
- Yan Li
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
| | - Li-Fang Bian
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China.
| | - Chun-Yan Li
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
| | - Xiao-Lan Shi
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
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Li J, Huang Y. Marsupialization of conjunctival inclusion cyst in Stevens-Johnson syndrome. ADVANCES IN OPHTHALMOLOGY PRACTICE AND RESEARCH 2023; 3:1-5. [PMID: 37846432 PMCID: PMC10577827 DOI: 10.1016/j.aopr.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/25/2022] [Accepted: 10/17/2022] [Indexed: 10/18/2023]
Affiliation(s)
- Jinglan Li
- Medical School of Chinese PLA, Beijing, China
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
| | - Yifei Huang
- Department of Ophthalmology, Chinese PLA General Hospital, Beijing, China
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45
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Green EA, Fogarty K, Ishmael FT. Penicillin Allergy. Prim Care 2023; 50:221-235. [PMID: 37105603 DOI: 10.1016/j.pop.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.
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Affiliation(s)
- Estelle A Green
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Kelan Fogarty
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Faoud T Ishmael
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA; Mount Nittany Health, 1850 East Park Avenue, State College, PA 16803, USA.
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Surowiecka A, Barańska-Rybak W, Strużyna J. Multidisciplinary Treatment in Toxic Epidermal Necrolysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2217. [PMID: 36767584 PMCID: PMC9916139 DOI: 10.3390/ijerph20032217] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
Toxic epidermal necrolysis, Leyll's syndrome (TEN), is a rare mucocutaneous blistering disease burdened with high mortality rates. The diagnosis of TEN is based on clinical symptoms and histopathological findings. In approximately 90% of cases, it is a severe adverse reaction to drugs. In TEN, not only is the skin affected, but also mucosa and organs' epithelium. There are no unequivocal recommendations in regard to systemic and topical treatment of the patients. The aim of this paper is to review available literature and propose unified protocols to be discussed. Early management and multidisciplinary treatment are necessary to improve patients' outcome. Treatment of patients with TEN suspicions should be initiated with early drug withdrawal. TEN patients, like patients with burns, require intensive care and multidisciplinary management. Each patient with TEN should be provided with adequate fluid resuscitation, respiratory support, nutritional treatment, pain control, infection prophylaxis, anticoagulant therapy, and gastric ulcer prophylaxis. The key to local treatment of patients with TEN is the use of nonadherent dressings that do not damage the epidermis during the change. The aim of the systemic treatment is purification of the blood stream from the causative agent. The most efficient way to clarify serum of TEN patients' is the combination of plasmapheresis and IVIG. Immunomodulatory therapy can reduce the mortality five times in comparison with the patients with immunosuppression or lack of full protocol.
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Affiliation(s)
- Agnieszka Surowiecka
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, 20-059 Lublin, Poland
| | - Wioletta Barańska-Rybak
- Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Jerzy Strużyna
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, 20-059 Lublin, Poland
- Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, 20-059 Lublin, Poland
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Sun B, Wen YF, Culhane-Pera KA, Lo M, Straka RJ. Pharmacogenomic variabilities in geo-ancestral subpopulations and their clinical implications: Results of collaborations with Hmong in the United States. Front Genet 2023; 13:1070236. [PMID: 36685861 PMCID: PMC9845584 DOI: 10.3389/fgene.2022.1070236] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/07/2022] [Indexed: 01/06/2023] Open
Abstract
Underrepresentation of subpopulations within geo-ancestral groups engaged in research can exacerbate health disparities and impair progress toward personalized medicine. This is particularly important when implementing pharmacogenomics which uses genomic-based sources of variability to guide medication selection and dosing. This mini-review focuses on pharmacogenomic findings with Hmong in the United States and their potential clinical implications. By actively engaging Hmong community in pharmacogenomic-based research, several clinically relevant differences in allele frequencies were observed within key pharmacogenes such as CYP2C9 and CYP2C19 in Hmong compared to those in either East Asians or Europeans. Additionally, using state-of-the-art genome sequencing approaches, Hmong appear to possess novel genetic variants within CYP2D6, a critical pharmacogene affecting pharmacokinetics of a broad range of medications. The allele frequency differences and novel alleles in Hmong have translational impact and real-world clinical consequences. For example, Hmong patients exhibited a lower warfarin stable dose requirement compared to East Asian patients. This was predicted based on Hmong's unique genetic and non-genetic factors and confirmed using real-world data from clinical practice settings. By presenting evidence of the genetic uniqueness and its translational impact within subpopulations, such as the Hmong, we hope to inspire greater inclusion of other geo-ancestrally underrepresented subpopulations in pharmacogenomic-based research.
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Affiliation(s)
- Boguang Sun
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Ya-Feng Wen
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | | | - Muaj Lo
- Minnesota Community Care, St. Paul, MN, United States
| | - Robert J. Straka
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
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Liu J, Yan H, Yang C, Li Y. Bronchiolitis obliterans associated with toxic epidermal necrolysis induced by infection: A case report and literature review. Front Pediatr 2023; 11:1116166. [PMID: 36937984 PMCID: PMC10018143 DOI: 10.3389/fped.2023.1116166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/08/2023] [Indexed: 03/06/2023] Open
Abstract
Background Stevens-Johnson syndrome/toxic epidermal necrolysis has a severe impact on patients' eyes, genital mucosa, and many other organs. Bronchiolitis obliterans is a rare complication of Stevens-Johnson syndrome/toxic epidermal necrolysis. Data sources We report a case of bronchiolitis obliterans associated with toxic epidermal necrolysis in our department. Furthermore, we examined the patients with bronchiolitis obliterans induced by Stevens-Johnson syndrome/toxic epidermal necrolysis and summarized the clinical characteristics, treatment, and prognosis. Databases available online in English including PubMed, Medline, and Web of Science were consulted. Results We report one case and review 23 published case reports. Of the 24 patients, 13 were female, the oldest patient was 59 years old and the youngest was 5 years old. The time of bronchiolitis obliterans onset after Stevens-Johnson syndrome/toxic epidermal necrolysis varied from 5 days to 5 months. Bronchoscopy examination showed ulceration, exudative lesions, occlusion, and inflammation. The CT of lung manifestation included mosaic perfusion, bronchiectasis, consolidation, air trapping, pneumatocele, pleural thickening, lung collapse, larger central airway dilatation, lung overinflation, oligemia, and pneumomediastinum. Most cases indicated pulmonary function tests with obstructive ventilation dysfunction. The prognosis was poor; six of the patients died. Conclusions Patients with Stevens-Johnson syndrome/toxic epidermal necrolysis may develop bronchitis obliterans at different stages, so all patients with Stevens-Johnson syndrome/toxic epidermal necrolysis should be followed up for possible respiratory complications.
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Gao L, Liu X, Zhao W, Li C, Wang F, Gao J, Liao X, Wei L, Wu H, Zheng Y, Wang L. Extracellular-matrix-mimicked 3D nanofiber and hydrogel interpenetrated wound dressing with a dynamic autoimmune-derived healing regulation ability based on wound exudate. Biofabrication 2022; 15. [PMID: 36579621 DOI: 10.1088/1758-5090/acaa01] [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: 07/21/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
Dynamic regulation of wound physiological signals is the basis of wound healing. Conventional biomaterials delivering growth factors to drive wound healing leads to the passive repair of soft tissues because of the mismatch of wound healing stages. Meanwhile, the bioactivity of wound exudate is often restricted by oxidation and bacterial contamination. Herein, an extracellular matrix mimicked nanofiber/hydrogel interpenetrated network (NFHIN) was constructed with a 3D nanofibrous framework for cell immigration, and interfiled aerogel containing cross-linked hyaluronic acid and hyperbranched polyamidoamine to balance the wound microenvironment. The aerogel can collect wound exudate and transform into a polycationic hydrogel with contact-killing effects even against intracellular pathogens (bactericidal rate > 99.9% in 30 min) and real-time scavenging property of reactive oxygen species. After co-culturing with the NFHIN, the bioactivity of fibroblast in theex vivoblister fluid was improved by 389.69%. The NFHIN showed sustainable exudate management with moisture-vapor transferring rate (6000 g m-2×24 h), equilibrium liquid content (75.3%), Young's modulus (115.1 ± 7 kPa), and anti-tearing behavior similar to human skin. The NFHIN can collect and activate wound exudate, turning it from a clinical problem to an autoimmune-derived wound regulation system, showing potential for wound care in critical skin diseases.
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Affiliation(s)
- Liheng Gao
- Key Laboratory of Textile Science and Technology, Ministry of Education, College of Textiles, Donghua University, Shanghai 201620, People's Republic of China
| | - Xingxing Liu
- Key Laboratory of Textile Science and Technology, Ministry of Education, College of Textiles, Donghua University, Shanghai 201620, People's Republic of China
| | - Wenshuo Zhao
- Key Laboratory of Textile Science and Technology, Ministry of Education, College of Textiles, Donghua University, Shanghai 201620, People's Republic of China
| | - Chaojin Li
- Key Laboratory of Textile Science and Technology, Ministry of Education, College of Textiles, Donghua University, Shanghai 201620, People's Republic of China
| | - Fujun Wang
- Key Laboratory of Textile Science and Technology, Ministry of Education, College of Textiles, Donghua University, Shanghai 201620, People's Republic of China
| | - Jing Gao
- Key Laboratory of Textile Science and Technology, Ministry of Education, College of Textiles, Donghua University, Shanghai 201620, People's Republic of China
| | - Xinqin Liao
- School of Electrical and Electronic Engineering, Nanyang Technological University, 50 Nanyang Avenue, Singapore 639798, Singapore
| | - Lei Wei
- School of Electrical and Electronic Engineering, Nanyang Technological University, 50 Nanyang Avenue, Singapore 639798, Singapore
| | - Hao Wu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai 200040, People's Republic of China
| | - Yuanjin Zheng
- School of Electrical and Electronic Engineering, Nanyang Technological University, 50 Nanyang Avenue, Singapore 639798, Singapore
| | - Lu Wang
- Key Laboratory of Textile Science and Technology, Ministry of Education, College of Textiles, Donghua University, Shanghai 201620, People's Republic of China
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Qiumei G, Zhengju C, Xuefei H, Qu C. Association of HLA-C*01:02 with methazolamide-induced toxic epidermal necrolysis. BMJ Case Rep 2022; 15:e250048. [PMID: 36572447 PMCID: PMC9806075 DOI: 10.1136/bcr-2022-250048] [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: 12/27/2022] Open
Abstract
We identified a Yi Chinese female patient from an ethnic minority group with methazolamide-induced toxic epidermal necrolysis. Genotyping revealed that she and her immediate family members carried the HLA-C*01:02 haplotypes, known to be associated with methazolamide-induced toxic epidermal necrolysis.
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Affiliation(s)
- Gu Qiumei
- The Department of Optometry and Visual Sciences, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Chen Zhengju
- The Department of Optometry and Visual Sciences, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - He Xuefei
- The Department of Optometry and Visual Sciences, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Chao Qu
- Department of Ophthalmology, Sichuan Academy of Medical Sciences and Sichuan People's Hospital, Chengdu, Sichuan, China
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