Effect of older age on complications and mortality in inpatients with Stevens-Johnson syndrome or toxic epidermal necrolysis

Risk of Cardiovascular Morbidity and Mortality in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Survivors

Importance

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) cause diffuse epidermal detachment and necrosis. Patients who survive the initial SJS/TEN episodes are affected by various sequelae.

Objective

To investigate the risks of cardiovascular morbidity and mortality in SJS/TEN survivors.

Design, Setting, and Participants

This was a nationwide population-based cohort study using data from Taiwan's National Health Research Institute Database linked to the National Register of Death databases for 1998 to 2021. Survivors of SJS/TEN were identified and matched with non-SJS/TEN participants by age, sex, and Charlson Comorbidity Index. Data analysis was performed from November 2023 to June 2024.

Exposure

Cerebrovascular accidents (CVA) or ischemic heart disease (IHD) after SJS/TEN survival.

Main Outcomes and Measures

Cox proportional hazards models were used to estimate the hazard ratios (HRs) of CVA and IHD morbidity and mortality after SJS/TEN survival.

Results

The CVA cohort included 10 571 SJS/TEN survivors (mean [SD] age, 56.1 [18.5] years; 5358 females [50.7%] and 5213 males [49.3%]). The IHD cohort included 11 084 SJS/TEN survivors (mean [SD] age, 56.6 [18.6] years; 5561 females [50.2%] and 5523 males [49.8%]). The Cox proportional hazards model and competing risk regression model showed that compared with non-SJS/TEN participants, patients with SJS/TEN had higher risks of cardiovascular morbidity (CVA: HR, 1.65 [95% CI, 1.57-1.72] and subdistribution HR [sHR], 1.40 [95% CI, 1.33-1.46]; IHD: HR, 1.58 [95% CI, 1.51-1.65] and sHR, 1.32 [95% CI, 1.26-1.38]) and death due to cardiovascular disease (CVA: HR, 1.69; 95% CI, 1.46-1.96; IHD: HR, 1.55; 95% CI, 1.32-1.82). The increased cardiovascular mortality risks peaked at 1 year after SJS/TEN and persisted for 4 to 7 years. Older survivors and survivors admitted to an intensive care unit at SJS/TEN diagnosis had significantly higher cardiovascular mortality risk.

Conclusions and Relevance

In this cohort study, SJS/TEN had a lasting association with cardiovascular function after the acute phase. This suggests a need to mitigate the elevated cardiovascular morbidity and mortality risks among survivors. Further research using databases or registries with more comprehensive clinical data are needed to validate these results.

Toxic epidermal necrolysis with thrombocytopenia induced by intravenous immunoglobulin: a case report and mini review

BACKGROUND

Toxic epidermal necrolysis (TEN), a severe cutaneous hypersensitivity reaction induced particularly by drugs, is diagnosed when there is a fever of ≥ 38 °C, mucocutaneous symptoms, a rash with multiple erythema, and skin peeling of ≥ 30% of the body surface area. The mortality rate of TEN is high, and thrombocytopenia during treatment can lead to severe outcomes. Intravenous immunoglobulin (IVIg) is used when steroids are ineffective in TEN and may improve mortality; however, thrombocytopenia is a rare adverse event associated with IVIg use. We report the case of thrombocytopenia during IVIg therapy for TEN. We also reviewed previous reports to learn more about the clinical course and mechanism of IVIg-induced thrombocytopenia.

CASE PRESENTATION

An 83-year-old man with end-stage renal failure on hemodialysis was diagnosed with TEN. After an inadequate response to pulse methylprednisolone therapy, IVIg (400 mg/kg/day) was administered for 5 days. He developed thrombocytopenia after IVIg administration, leading to the diagnosis of thrombocytopenia due to IVIg after excluding other diseases. The platelet count began to increase approximately 10 days after IVIg administration.

CONCLUSIONS

When IVIg is administered for TEN, the risk of thrombocytopenia should be recognized and the platelet count should be carefully monitored.