1
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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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2
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Fabian IM, Maddox K, Robicheaux C, Islam RK, Anwar A, Dorius B, Robinson CL, Kaye AM, Varrassi G, Ahmadzadeh S, Shekoohi S, Kaye AD. Stevens-Johnson Syndrome From Combined Allopurinol and Angiotensin-Converting Enzyme Inhibitors: A Narrative Review. Cureus 2024; 16:e51899. [PMID: 38333456 PMCID: PMC10850002 DOI: 10.7759/cureus.51899] [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: 12/07/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
Stevens-Johnson syndrome (SJS) is a severe and potentially debilitating skin reaction frequently related to medication use. Allopurinol and angiotensin-converting enzyme (ACE) inhibitors are commonly prescribed medications for prevalent health conditions worldwide, and their interaction associated with SJS warrants further investigation. A comprehensive literature search was performed to investigate cases as studies related to SJS occurring in patients with concomitant use of allopurinol and ACE inhibitors. We identified case reports and studies detailing hypersensitivity reactions, including SJS, attributed to a combination of allopurinol and ACE inhibitors. Despite the drug-drug interactions or lack thereof seen in patient populations, there is no definitive evidence of a pharmacokinetic interaction between allopurinol and ACE inhibitors. We were only able to find one case report specifically detailing SJS in a patient on combined ACE inhibitors and allopurinol. While the exact mechanism of the interaction is unclear, those reported cases of severe hypersensitivity reactions suggest a previous history of impaired renal function as a predisposing factor in the development of SJS. The potential risk of SJS with coadministration of ACE inhibitors and allopurinol is a drug-drug interaction that physicians should be aware of. This topic requires additional attention to determine if this drug combination should be avoided entirely in certain patients.
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Affiliation(s)
- Isabella M Fabian
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Kirsten Maddox
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Cameron Robicheaux
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Rahib K Islam
- School of Medicine, Louisiana State University Health Sciences Center (LSUHSC) New Orleans, New Orleans, USA
| | - Ahmed Anwar
- Department of Psychology, Quinnipiac University, Hamden, USA
| | - Bradley Dorius
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences University of the Pacific, Stockton, USA
| | | | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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3
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Lee KCH, Ko JP, Oh CC, Sewa DW. Managing respiratory complications in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Int J Dermatol 2021; 61:660-666. [PMID: 34494255 DOI: 10.1111/ijd.15888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 07/29/2021] [Accepted: 08/13/2021] [Indexed: 11/28/2022]
Abstract
In the recently published guidelines by the Society of Dermatology Hospitalists on the management of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), a brief section was included on airway management. These recommendations provide an easy reference on how to manage respiratory complications of the disease. Understanding the evidence that underlies these recommendations would offer physicians greater clarity on the considerations behind every decision and treatment offered. We present a review of the literature on respiratory manifestations associated with SJS and TEN. In addition, we aim to address specific concerns regarding the respiratory management of these patients. These include issues such as the indications and optimal timing of intubation, tracheostomy, role of flexible nasoendoscopy, bronchoscopy, ventilation strategies, and management of chronic respiratory complications.
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Affiliation(s)
- Ken Cheah Hooi Lee
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Joanna Phone Ko
- Nursing Division (Specialty Nursing), Singapore General Hospital, Singapore, Singapore
| | - Choon Chiat Oh
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
| | - Duu Wen Sewa
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
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4
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King D, Roberts K, Stenton S, Jenkins A. Stevens-Johnson syndrome associated with Hodgkin's lymphoma. Pediatr Dermatol 2021; 38:1347-1348. [PMID: 34272763 DOI: 10.1111/pde.14716] [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] [Indexed: 11/29/2022]
Abstract
Hodgkin's lymphoma accounts for approximately 40% of all lymphomas presenting in childhood and can be associated with a variety of dermatologic manifestations. Here, we describe a case of Hodgkin's lymphoma presenting with Stevens-Johnson syndrome. Clinicians should be aware of this association, especially if no alterative trigger for Stevens-Johnson syndrome can be identified.
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Affiliation(s)
- David King
- Department of Paediatric Oncology, Sheffield Children's Hospital NHS Foundation Trust, Western Bank, Sheffield, UK
| | - Kristen Roberts
- Department of Paediatric Oncology, Sheffield Children's Hospital NHS Foundation Trust, Western Bank, Sheffield, UK
| | - Sophie Stenton
- Department of Histopathology, Sheffield Children's Hospital NHS Foundation Trust, Western Bank, Sheffield, UK
| | - Anna Jenkins
- Department of Paediatric Oncology, Sheffield Children's Hospital NHS Foundation Trust, Western Bank, Sheffield, UK
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5
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Hanson LM, Bettencourt AP. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Guide for Nurses. AACN Adv Crit Care 2021; 31:281-295. [PMID: 32866260 DOI: 10.4037/aacnacc2020634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Nurses are central to the care of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. Patients with these conditions present with nuanced symptoms and have complex nursing care needs. Although much of the exact pathophysiology of these diseases is not known, all nurses benefit from a fundamental understanding of the genesis of skin manifestations, associated pharmacology, and prognosis. The care of patients hospitalized with Stevens-Johnson syndrome and toxic epidermal necrolysis consists of wound care, infection prevention, comfort management, hydration and nutrition, psychosocial support, and the prevention of long-term complications. This article provides an overview of these diseases, including clinical diagnosis, history and physical assessment, related pharmacology, and nursing care priorities. A description of the current state of the science in clinical management for nurses at all levels is provided, with an emphasis on nursing's contribution to the best possible patient outcomes.
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Affiliation(s)
- Leah M Hanson
- Leah M. Hanson is Decentralized Nurse Educator, Burn Center, Regions Hospital, St Paul, Minnesota
| | - Amanda P Bettencourt
- Amanda P Bettencourt is Research Fellow, NCSP, and TACTICAL Scholar, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, North Campus Research Center, 2800 Plymouth Rd, B14, Suite G-100, Ann Arbor, MI 48109
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6
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Wong CSM, Yeung CK, Chan CY, Yap DYH, Tang SCW, Cheung BMY, Kwok JSY, Chan HHL. HLA-B*58:01 screening to prevent allopurinol-induced severe cutaneous adverse reactions in Chinese patients with chronic kidney disease. Arch Dermatol Res 2021; 314:651-659. [PMID: 34213582 DOI: 10.1007/s00403-021-02258-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 12/17/2022]
Abstract
Human leukocyte antigen (HLA)-B*58:01 allele is a significant risk factor for allopurinol-induced severe cutaneous adverse reactions (SCARs) which is potentially fatal. In some studies, chronic kidney disease (CKD) was also implicated to compound the risk of SCARs. We aim to investigate if pre-treatment HLA-B*58:01 screening can prevent allopurinol-induced SCARs in Chinese patients with CKD and its cost-effectiveness. We prospectively recruited Chinese CKD patients who required allopurinol during 2011-2015 and performed pre-treatment HLA testing (HLA screening group). Patients tested positive for HLA-B*58:01 were refrained from allopurinol while those tested negative were prescribed allopurinol. The incidence of SCARs in the HLA screening group was compared with the historical control in previous 5 years and the cost-effectiveness of HLA testing was analyzed. In the historical control (2006-2010), 3605 patients on allopurinol were screened, 22 out of 1027 (2.14%) CKD Chinese patients newly started on allopurinol developed SCARs, including 6 SJS/TEN. In the HLA screening group, 28 out of 192 patients (14.6%) tested HLA-B*58:01 positive were advised to avoid allopurinol; 156 out of 164 HLA-B*58:01-negative patients received allopurinol and none developed SCARs. The incidence rate of SCARs was significantly lower in the HLA screening group compared with controls (0% vs 2.14% respectively, p = 0.037*). The targeted HLA screening approach was associated with lower healthcare costs compared with no HLA screening (US$ 92,430 vs US$ 281,226). Pre-treatment HLA-B*58:01 screening is cost-effective to target on patients with CKD in Chinese to prevent allopurinol-induced SCARs.
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Affiliation(s)
- Christina Sze-Man Wong
- Division of Dermatology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Chi-Keung Yeung
- Division of Dermatology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Chun-Yin Chan
- Division of Dermatology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Desmond Yat-Hin Yap
- Division of Nephrology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Sydney Chi-Wai Tang
- Division of Nephrology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Bernard Man-Yung Cheung
- Division of Clinical Pharmacology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Janette Siu-Yin Kwok
- Division of Transplantation and Immunogenetics, Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
| | - Henry Hin-Lee Chan
- Division of Dermatology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China. .,Dermatology and Laser Centre, 1 Wellington Street, Central, Hong Kong SAR, China.
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7
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Hoyos-Samboní DF, Munar JV, López D, Vásquez-Arteaga LR. Síndrome de Stevens-Johnson con reactivación de herpes simple asociado a la ingestión de paracetamol. Reporte de caso. REVISTA DE LA FACULTAD DE MEDICINA 2021. [DOI: 10.15446/revfacmed.v69n4.85264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. El síndrome de Stevens-Johnson (SJS) es una enfermedad poco común que afecta la piel y las mucosas oral, ocular y urogenital; además, en más del 50% de los casos es producida por reacciones a medicamentos.
Presentación del caso. Hombre de 20 años quien asistió al servicio de urgencias de hospital de tercer nivel de Popayán por un cuadro clínico de 10 días de evolución consistente en astenia, adinamia, fiebre no cuantificada, tos con escasa expectoración blanquecina y cefalea, sintomatología que mejoraba con el uso de paracetamol; sin embargo, la condición del paciente empeoró en los últimos dos días, presentando hiporexia, prurito en faringe, vesículas y ampollas en comisuras labiales, mucosa oral, tronco y extremidades, y dificultad respiratoria y odinofagia, razón por la cual acudió al servicio. En principio de sospechó de herpes simple diseminado, lupus eritematoso sistémico, y SJS; sin embargo, con base en los hallazgos clínicos y de laboratorio se confirmó el diagnóstico de SJS con reactivación de herpes simple asociado a la ingesta de paracetamol, por lo que se suspendió este medicamento y se inició manejo con aciclovir y metilprednisolona. El paciente tuvo una evolución satisfactoria y fue dado de alta a los 10 días del inicio del nuevo tratamiento y en las citas de control su condición general era óptima.
Conclusión. El desarrollo de SJS puede estar asociado al consumo de paracetamol; sin embargo, su uso no se desaconseja gracias a sus grandes bondades y beneficios generales. En este sentido, dado que el paracetamol es un medicamento venta libre y uso extenso en Colombia, es indispensable reconocer las manifestaciones clínicas del SJS para poder dar un manejo adecuado y evitar complicaciones en casos como el aquí reportado.
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8
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Rathinam KK, Sabarathinam S, Nuthalapati P, Mahalingam VT. Phenytoin Induced Stevens Johnson Syndrome- Toxic Epidermal Necrolysis Overlap Exacerbated by Cephalexin in a 65-Year-Old Neurosurgical Patient: A Rare Case Report. Curr Drug Res Rev 2021; 14:80-83. [PMID: 34225642 DOI: 10.2174/2589977513666210322160009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/28/2020] [Accepted: 02/12/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To report a rare case of drug induced overlap of Stevens-Johnson syndrome and Toxic Epidermal Necrosis Syndrome exacerbated by cephalexin. CASE SUMMARY In this case report we present a 65-year-old female who had come to the hospital with complaints of Sloughing of the skin and redness all over the body with raised body temperature. She was on therapeutic Phenytoin to prevent the post-surgical complications of Communicating Hydrocephalus. After a detailed examination it was found that the patient had misemployed with an overdose of Phenytoin. The patient was found with nikolsky sign and diagnosed as Stevens-Johnson syndrome and Toxic Epidermal Necrosis overlap. This case report emphasizes phenytoin induced Stevens-Johnson syndrome and Toxic Epidermal Necrosis syndrome exacerbated by cephalexin. PRACTICE IMPLICATIONS By witnessing this phenomenon, we could figure out the association between cephalexin and Stevens-Johnson syndrome- Toxic Epidermal Necrosis syndrome overlap. The Immediate dismissal of the offending agent and commencement of supportive care was found to be effective.
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Affiliation(s)
- Kiran Kumar Rathinam
- Department of Pharmacy Practice, SRM College of Pharmacy, SRM IST, Kattankulathur-603203, kancheepuram, Tamil Nadu, India
| | - Sarvesh Sabarathinam
- Department of Pharmacy Practice, SRM College of Pharmacy, SRM IST, Kattankulathur-603203, kancheepuram, Tamil Nadu, India
| | - Poojith Nuthalapati
- Department of Pharmacy Practice, SRM College of Pharmacy, SRM IST, Kattankulathur-603203, kancheepuram, Tamil Nadu, India
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9
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Masuka JT, Muzopambwa G, Khoza S, Chibanda D. An Interesting Case of Carbamazepine-Induced Stevens-Johnson Syndrome. DRUG SAFETY - CASE REPORTS 2018; 6:1. [PMID: 30535610 PMCID: PMC6288101 DOI: 10.1007/s40800-018-0095-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A 29-year-old Black female patient was admitted to a psychiatric ward with symptoms of major depressive disorder with psychosis. The patient was started on amitriptyline 50 mg/day and haloperidol 10 mg/day. On day 4 post-admission, the preferred first-line antidepressant, fluoxetine, became available and the patient was switched from amitriptyline to fluoxetine 20 mg/day. On the same day, the dose of haloperidol was reduced to 5 mg/day. Thirteen days post-initiation of these medications the patient became talkative, associated with emotional lability, an expansive mood, irritability and restlessness. The working diagnosis was changed to bipolar affective disorder in the manic phase. Fluoxetine was discontinued and carbamazepine 600 mg/day was added to the patient's treatment regimen. Her manic symptoms started to resolve; however, 14 days post-initiation of carbamazepine, the patient had a fever; itchy, discharging eyes; respiratory distress; generalised symmetrical erythematosus rash; buccal ulceration; and conjunctival injection with difficulty opening her eyes. Carbamazepine was immediately discontinued and the patient received intravenous fluid resuscitation. The patient recovered considerably after 12 days of symptomatic and supportive management, and was transferred back to the psychiatric ward for the continuation of bipolar disorder management. Lithium therapy was instituted and the patient was subsequently discharged. Using the Algorithm of Drug causality for Epidermal Necrolysis (ALDEN) Stevens-Johnson Syndrome/toxic epidermal necrolysis (SJS/TEN) drug causality scoring system, carbamazepine and fluoxetine were evaluated as 'very probable' and 'possible' causes of SJS, respectively, in this patient. Fluoxetine-induced SJS was considered on account of previous case reports, however no evidence of causality was found in this patient. Consecutive administration with a potential increase in carbamazepine due to inhibition of cytochrome P450 (CYP) 3A4 metabolism by fluoxetine was also not ruled out. A diagnosis of carbamazepine-induced SJS was made and was considered an idiosyncratic adverse drug reaction.
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Affiliation(s)
- Josiah Tatenda Masuka
- Division of Psychiatry, Harare Central Hospital, PO Box ST 14, Southerton, Harare, Zimbabwe.
| | - Garikai Muzopambwa
- Division of Psychiatry, Harare Central Hospital, PO Box ST 14, Southerton, Harare, Zimbabwe
| | - Star Khoza
- Department of Clinical Pharmacology, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe.,Discipline of Pharmacology and Clinical Pharmacy, School of Pharmacy, Faculty of Natural Sciences, University of the Western Cape, Private Bag X17, Bellville, 7535, South Africa
| | - Dixon Chibanda
- Division of Psychiatry, Harare Central Hospital, PO Box ST 14, Southerton, Harare, Zimbabwe.,Department of Psychiatry, College of Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe
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10
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Su SC, Chen CB, Chang WC, Wang CW, Fan WL, Lu LY, Nakamura R, Saito Y, Ueta M, Kinoshita S, Sukasem C, Yampayon K, Kijsanayotin P, Nakkam N, Saksit N, Tassaneeyakul W, Aihara M, Lin YJ, Chang CJ, Wu T, Hung SI, Chung WH. HLA Alleles and CYP2C9*3 as Predictors of Phenytoin Hypersensitivity in East Asians. Clin Pharmacol Ther 2018; 105:476-485. [PMID: 30270535 DOI: 10.1002/cpt.1190] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/30/2018] [Indexed: 12/14/2022]
Abstract
To develop a pre-emptive genetic test that comprises multiple predisposing alleles for the prevention of phenytoin-related severe cutaneous adverse reactions (SCARs), three sets of patients with phenytoin-SCAR and drug-tolerant controls from Taiwan, Thailand, and Japan, were enrolled for this study. In addition to cytochrome P450 (CYP)2C9*3, we found that HLA-B*13:01, HLA-B*15:02, and HLA-B*51:01 were significantly associated with phenytoin hypersensitivity with distinct phenotypic specificities. Strikingly, we showed an increase in predictive sensitivity of concurrently testing CYP2C9*3/HLA-B*13:01/HLA-B*15:02/HLA-B*51:01 from 30.5-71.9% for selecting the individuals with the risk of developing phenytoin-SCAR in Taiwanese cohorts, accompanied by a specificity of 77.7% (combined sensitivity, 64.7%; specificity, 71.9% for three Asian populations). Meta-analysis of the four combined risk alleles showed significant associations with phenytoin-SCAR in three Asian populations. In conclusion, combining the assessment of risk alleles of HLA and CYP2C9 potentiated the usefulness of predictive genetic tests to prevent phenytoin hypersensitivity in Asians.
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Affiliation(s)
- Shih-Chi Su
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan.,Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan
| | - Chun-Bing Chen
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan.,Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Dermatology, Chang Gung Memorial Hospital, Xiamen, China
| | - Wan-Chun Chang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan.,Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Dermatology, Chang Gung Memorial Hospital, Xiamen, China
| | - Wen-Lang Fan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Lai-Ying Lu
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ryosuke Nakamura
- Division of Medicinal Safety Science, National Institute of Health Sciences, Kawasaki, Japan
| | - Yoshiro Saito
- Division of Medicinal Safety Science, National Institute of Health Sciences, Kawasaki, Japan
| | - Mayumi Ueta
- Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shigeru Kinoshita
- Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Chonlaphat Sukasem
- Division of Pharmacogenetics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
| | - Kittika Yampayon
- Adverse Drug Reaction (ADR) Unit, Pharmacy Department, Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Department of Pharmacology and Physiology, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Pornpimol Kijsanayotin
- Department of Pharmacology and Physiology, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Nontaya Nakkam
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Niwat Saksit
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.,School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | | | - Michiko Aihara
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yu-Jr Lin
- Research Services Center for Health Information, Chang Gung University, Taoyuan, Taiwan
| | - Chee-Jen Chang
- Graduate Institute of Clinical Medical Science, Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Tony Wu
- Department of Neurology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Shuen-Iu Hung
- Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taiwan
| | - Wen-Hung Chung
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan.,Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Dermatology, Chang Gung Memorial Hospital, Xiamen, China
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11
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Sukasem C, Katsila T, Tempark T, Patrinos GP, Chantratita W. Drug-Induced Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Call for Optimum Patient Stratification and Theranostics via Pharmacogenomics. Annu Rev Genomics Hum Genet 2018; 19:329-353. [PMID: 29652519 DOI: 10.1146/annurev-genom-083115-022324] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Global Genomic Medicine Collaborative, a multinational coalition of genomic and policy experts working to implement genomics in clinical care, considers pharmacogenomics to be among the first areas in genomic medicine that can provide guidance in routine clinical practice, by linking genetic variation and drug response. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe life-threatening reactions to medications with a high incidence worldwide. Genomic screening prior to drug administration is a key opportunity and potential paradigm for using genomic medicine to reduce morbidity and mortality and ultimately eliminate one of the most devastating adverse drug reactions. This review focuses on the current understanding of the surveillance, pathogenesis, and treatment of SJS/TEN, including the role of genomics and pharmacogenomics in the etiology, treatment, and eradication of preventable causes of drug-induced SJS/TEN. Gaps, unmet needs, and priorities for future research have been identified for the optimal management of drug-induced SJS/TEN in various ethnic populations. Pharmacogenomics holds great promise for optimal patient stratification and theranostics, yet its clinical implementation needs to be cost-effective and sustainable.
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Affiliation(s)
- Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.,Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.,South East Asian Pharmacogenomics Research Network (SEAPHARM)
| | - Theodora Katsila
- Department of Pharmacy, School of Health Sciences, University of Patras, GR-26504 Patras, Greece
| | - Therdpong Tempark
- Department of Pediatrics, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok 10330, Thailand
| | - George P Patrinos
- Department of Pharmacy, School of Health Sciences, University of Patras, GR-26504 Patras, Greece.,Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Wasun Chantratita
- South East Asian Pharmacogenomics Research Network (SEAPHARM).,Excellence Center for Medical Genomics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
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12
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Interleukin-15 Is Associated with Severity and Mortality in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. J Invest Dermatol 2016; 137:1065-1073. [PMID: 28011147 DOI: 10.1016/j.jid.2016.11.034] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/20/2016] [Accepted: 11/23/2016] [Indexed: 01/31/2023]
Abstract
Early diagnosis and prognosis monitoring for Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN) still remain a challenge. This study aims to explore any cytokine/chemokine with prognostic potential in Stevens-Johnson syndrome/TEN. Through screening a panel of 28 serological factors, IL-6, IL-8, IL-15, tumor necrosis factor-α, and granulysin were upregulated in patients with Stevens-Johnson syndrome/TEN and selected for the further validation in total 155 patients with Stevens-Johnson syndrome/TEN, including 77 from Taiwan and 78 from the Registry of Severe Cutaneous Adverse Reactions. Among these factors evaluated, the levels of IL-15 (r = 0.401; P < 0.001) and granulysin (r = 0.223; P = 0.026) were significantly correlated with the disease severity in 112 samples after excluding patients with insufficient data to calculate the score of TEN. In addition, IL-15 was also associated with mortality (P = 0.002; odds ratio, 1.09; 95% confidence interval, 1.03-1.14; P = 0.001; adjusted odds ratio, 1.10; 95% confidence interval, 1.04-1.16). Consistent results were obtained after the exclusion of Taiwanese patients with sepsis to rule out possible confounders. Moreover, IL-15 was shown to enhance cytotoxicity of cultured natural killer cells and blister cells from patients with TEN. Our findings highlight a usefulness of IL-15 in prognosis monitoring and therapeutic intervention of this devastating condition.
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13
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Su SC, Hung SI, Fan WL, Dao RL, Chung WH. Severe Cutaneous Adverse Reactions: The Pharmacogenomics from Research to Clinical Implementation. Int J Mol Sci 2016; 17:ijms17111890. [PMID: 27854302 PMCID: PMC5133889 DOI: 10.3390/ijms17111890] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/07/2016] [Accepted: 11/07/2016] [Indexed: 01/11/2023] Open
Abstract
Severe cutaneous adverse reactions (SCARs), previously thought to be idiosyncratic or unpredictable, are a deadly form of adverse drug reactions with skin manifestations. Current pharmacogenomic studies of SCARs have made important strides, as the prevention of SCARs, to some extent, appears attainable with the identification of genetic variants for genes encoding drug-metabolizing enzymes and human leukocyte antigens (HLAs). Despite the improvement of incidence, a treatment guideline for this devastating condition is still unavailable, highlighting the inadequacy of contemporary accepted therapeutic interventions. As such, prompt withdrawal of causative drugs is believed to be a priority of patient management. In this review, we discuss recent cutting-edge findings concerning the discovery of biomarkers for SCARs and their clinical utilities in the better prediction and early diagnosis of this disease. The knowledge compiled herein provides clues for future investigations on deciphering additional genetic markers for SCARs and the design of clinical trials for the prospective identification of subjects at genetic risk for this condition, ultimately personalizing the medicine.
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Affiliation(s)
- Shih-Chi Su
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung 204, Taiwan.
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung 105, Taiwan.
| | - Shuen-Iu Hung
- Institute of Pharmacology, School of Medicine, Infection and Immunity Research Center, National Yang-Ming University, Taipei 112, Taiwan.
| | - Wen-Lang Fan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung 204, Taiwan.
| | - Ro-Lan Dao
- Institute of Pharmacology, School of Medicine, Infection and Immunity Research Center, National Yang-Ming University, Taipei 112, Taiwan.
| | - Wen-Hung Chung
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung 204, Taiwan.
- Institute of Pharmacology, School of Medicine, Infection and Immunity Research Center, National Yang-Ming University, Taipei 112, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
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14
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Monteiro D, Egipto P, Barbosa J, Horta R, Amarante J, Silva P, Silva A. Nine years of a single referral center management of Stevens-Johnson syndrome and toxic epidermal necrolysis (Lyell's syndrome). Cutan Ocul Toxicol 2016; 36:163-168. [PMID: 27487073 DOI: 10.1080/15569527.2016.1218501] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
CONTEXT Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) corresponds to a rare and acute life-threatening mucocutaneous reactions characterized by extensive necrosis and epidermal detachment. There are no efficacious pharmaceutical interventions proven through large clinical trials. OBJECTIVE We sought to study clinical cases admitted in our institution in order to determine which drugs and medical comorbidities or treatments impacted the mortality. MATERIAL AND METHODS In a retrospective study over 9 years we evaluated all patients presenting biopsy-proven SJS or TEN for age, gender, total body surface area involved, causing agents, SCORTEN score, blood transfusion, steroid administration, intubation, length of intensive care stay and death rate. Statistical analysis was done using SPSS statistical software. RESULTS The highest incidence of SJS and TEN was in age group of 71-80 years. Of the 30 patients, 30% died from SJS/TEN, mainly due sepsis. For each subgroup SJS/TEN overlap had the highest mortality. The highest mortality was from antibiotic treatment as causing agent. Step-wise regression analysis identified mechanical ventilation requirement and age over 65 years as mortality high-risk factors. DISCUSSION The most crucial interventions are discontinuation of the offending drug and prompt referral to a burn unit, which helps in early diagnosis and decrease mortality in these diseases. CONCLUSION When SJS/TEN is caused by antibiotics suspicion of developing fatal sepsis should be high, independently of patients' medical condition.
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Affiliation(s)
| | - Paula Egipto
- a Centro Hospitalar de Sao Joao , Porto , Portugal
| | | | | | | | - Pedro Silva
- a Centro Hospitalar de Sao Joao , Porto , Portugal
| | - Alvaro Silva
- a Centro Hospitalar de Sao Joao , Porto , Portugal
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15
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Paulmann M, Mockenhaupt M. Severe drug-induced skin reactions: clinical features, diagnosis, etiology, and therapy. J Dtsch Dermatol Ges 2016; 13:625-45. [PMID: 26110722 DOI: 10.1111/ddg.12747] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Drugs can induce severe skin reactions that differ in clinical presentation, prognosis, and therapy. The spectrum of these reactions not only includes bullous reactions such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and generalized bullous fixed drug eruption (GBFDE) but also acute generalized exanthematous pustulosis (AGEP) and drug reaction with eosinophilia and systemic symptoms (DRESS). If AGEP or DRESS is suspected, the diagnosis should be confirmed by thorough clinical examination, a skin biopsy, and specific laboratory tests. Crucial for the patient's prognosis, the causative agent should be rapidly identified and discontinued. It is therefore important to know the most frequent triggers of severe drug reactions, some of which may induce various reaction patterns. Depending on the clinical diagnosis, symptomatic and adequate supportive therapy, as well as systemic immunomodulatory treatments are used. The prognosis in SJS/TEN is often poor and depends on the patient's age and underlying conditions as well as the extent of skin detachment. The prognosis of GBFDE is somewhat better, but recurrences may lead to more severe disease manifestations. In DRESS, protracted and recurrent courses have been described, whereas AGEP usually resolves without problems.
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16
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Wu J, Lee YY, Su SC, Wu TS, Kao KC, Huang CC, Chang WC, Yang CH, Chung WH. Stevens-Johnson syndrome and toxic epidermal necrolysis in patients with malignancies. Br J Dermatol 2015. [PMID: 26218033 DOI: 10.1111/bjd.14052] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Malignancy is known to be associated with an increased mortality rate in patients with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, risk factors contributing to the poor prognosis of patients with SJS/TEN with malignancies remain undefined. OBJECTIVES To explore the potential involvement of malignancy and its related factors contributing to the poor outcome of SJS/TEN, in a retrospective study. METHODS In total 517 patients with SJS/TEN were enrolled. Forty-seven who sustained various types of malignancies were analysed for numerous malignancy-related factors, including cancer types, clinical stages and chemotherapies given or not before the onset of SJS/TEN. RESULTS We found that the mortality rate of patients with SJS/TEN with malignancies was higher than that of patients without malignancies (32%, 15/47 vs. 8·5%, 40/470, respectively) (P < 0·001). The use of phenytoin was significantly higher in the malignancy group. The presence of hepatocellular carcinoma (80%, four of five; P < 0·001; odds ratio 43) and colorectal cancer (67%, two of three; P = 0·022; odds ratio 21·5) significantly increased the death rate of patients with SJS/TEN, whereas lung cancer and urothelial carcinoma did not. Patients who had received ongoing or recent chemotherapy showed higher mortality than those without chemotherapy (P = 0·022; odds ratio 4·95). Furthermore, among the 47 patients with SJS/TEN with malignancies, lower serum albumin, haemoglobin and platelet count were detected in the deceased patients than in the surviving patients before the onset of SJS/TEN. CONCLUSIONS Our results suggest that several factors related to malignancies, such as specific cancer types, chemotherapy and malnutrition, may contribute to poor prognosis in patients with malignancies developing SJS/TEN.
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Affiliation(s)
- J Wu
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Y Y Lee
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - S C Su
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - T S Wu
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Infectious Disease, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan
| | - K C Kao
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Thoracic Medicine, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan
| | - C C Huang
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Thoracic Medicine, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan
| | - W C Chang
- College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan.,Department of Hematology-Oncology, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan
| | - C H Yang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - W H Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taipei and Linkou, 33305, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
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17
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Paulmann M, Mockenhaupt M. Schwere arzneimittelinduzierte Hautreaktionen: Klinik, Diagnostik, Ätiologie und Therapie. J Dtsch Dermatol Ges 2015. [DOI: 10.1111/ddg.130_12747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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18
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HLA associations and clinical implications in T-cell mediated drug hypersensitivity reactions: an updated review. J Immunol Res 2014; 2014:565320. [PMID: 24901010 PMCID: PMC4034438 DOI: 10.1155/2014/565320] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 03/28/2014] [Indexed: 01/11/2023] Open
Abstract
T-cell mediated drug hypersensitivity reactions may range from mild rash to severe fatal reactions. Among them, drug reaction with eosinophilia and systemic symptoms (DRESS) or drug-induced hypersensitivity syndrome (DIHS), Stevens-Johnson syndrome/ toxic epidermal necrolysis (SJS/TEN), are some of the most life-threatening severe cutaneous adverse reactions (SCARs). Recent advances in pharmacogenetic studies show strong genetic associations between human leukocyte antigen (HLA) alleles and susceptibility to drug hypersensitivity. This review summarizes the literature on recent progresses in pharmacogenetic studies and clinical application of pharmacogenetic screening based on associations between SCARs and specific HLA alleles to avoid serious conditions associated with drug hypersensitivity.
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19
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Su SC, Chung WH. Cytotoxic proteins and therapeutic targets in severe cutaneous adverse reactions. Toxins (Basel) 2014; 6:194-210. [PMID: 24394640 PMCID: PMC3920257 DOI: 10.3390/toxins6010194] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 12/20/2013] [Accepted: 12/27/2013] [Indexed: 11/16/2022] Open
Abstract
Severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN), are rare but life-threatening conditions induced mainly by a variety of drugs. Until now, an effective treatment for SJS/TEN still remains unavailable. Current studies have suggested that the pathobiology of drug-mediated SJS and TEN involves major histocompatibility class (MHC) I-restricted activation of cytotoxic T lymphocytes (CTLs) response. This CTLs response requires several cytotoxic signals or mediators, including granulysin, perforin/granzyme B, and Fas/Fas ligand, to trigger extensive keratinocyte death. In this article, we will discuss the cytotoxic mechanisms of severe cutaneous adverse reactions and their potential applications on therapeutics for this disease.
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Affiliation(s)
- Shih-Chi Su
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospitals, Taipei, Linkou, and Keelung, 33305, Taiwan.
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospitals, Taipei, Linkou, and Keelung, 33305, Taiwan.
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