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Abstract
Systemic autoimmune diseases are reportedly associated with a high frequency of drug allergies. In particular, systemic lupus erythematosus (SLE), Sjögren's syndrome (SS), and adult-onset Still's disease (AOSD) have recently drawn attention. Based on previous reports, drug allergies have been reported in 17.1-63%, 7-40.1%, and 17.6-54% of patients with SS, SLE, and AOSD patients, respectively. Antimicrobial agents, including sulfa drugs and nonsteroidal anti-inflammatory drugs, are the most common causative agents of drug allergies. However, few studies have examined in detail the relationship between drug eruptions, a major symptom of drug allergy, and systemic autoimmune diseases, and their actual status remains unclear. These autoimmune diseases commonly exhibit a diverse range of skin manifestations in the course of these diseases, rendering it may be difficult to determine whether it is a true drug eruption. Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), a fatal, severe drug eruption, has also been associated with autoimmune diseases. The development of SS-like symptoms after SJS/TEN onset and high prevalence of anti-SS-A antibodies in SJS/TEN are intriguing observations. Although the presence of SLE is known to be a risk factor for SJS/TEN, common pathological conditions, such as excessive immune status, abnormal function of regulatory T cells, and neutrophil extracellular traps in autoimmune diseases such as SS and SLE, are potentially involved in the development of drug eruptions.
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Affiliation(s)
- Yuko Watanabe
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Yukie Yamaguchi
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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2
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Wang YP, Su JZ, Sun ZP, Park K, Lee SW, Cai ZG, Liu XJ, Gao Y, Zhang L, Yu GY. Clinical and histopathologic characteristics of submandibular gland in Stevens-Johnson syndrome: A comparative study. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 133:326-332. [PMID: 34753700 DOI: 10.1016/j.oooo.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/05/2021] [Accepted: 09/12/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the clinical manifestations and pathologic appearances of the submandibular gland (SMG) in Stevens-Johnson syndrome (SJS). STUDY DESIGN Patients with autologous transplantation of SMG for treatment of severe dry eye between March 1998 and May 2018 were divided into the SJS group (70 cases) and non-SJS group (50 cases) according to the history of SJS. The SMG weight and computed tomography volume and salivary flow rate were measured. The concentration index and secretion index were estimated using scintigraphy with technetium-99m-pertechnetate. Histopathology studies of SMG tissues were conducted, and the acini parameters were measured using a digital image analyzer. RESULTS A decreased computed tomography volume and weight was observed in 48.57% the SJS group and 2% in the non-SJS group (P < .01). The rest whole, acid-stimulated whole, and SMG rest salivary flow rates decreased in the SJS group (P < .05). The normal SMG concentration index (37.5% vs 96.67%, P < .001) and secretion index (35% vs 96.67%, P < .001) rates were lower in the SJS group than in the non-SJS group. The glandular parenchyma was reduced, the acinar space was widened, and the fat content was increased in the SJS group. CONCLUSION SMG atrophic and degenerative changes occurred in the SJS group, with a decrease in salivary secretion function in more than half of the patients.
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Affiliation(s)
- Yi-Ping Wang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China
| | - Jia-Zeng Su
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China
| | - Zhi-Peng Sun
- Department of Oral Radiology, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China
| | - Kyungpyo Park
- Department of Physiology, School of Dentistry, Seoul National University, Oromaxillofacial Dysfunction Research Center for the Elderly(ODRCE), Seoul, Korea
| | - Sang-Woo Lee
- Department of Physiology, School of Dentistry, Seoul National University, Oromaxillofacial Dysfunction Research Center for the Elderly(ODRCE), Seoul, Korea
| | - Zhi-Gang Cai
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China
| | - Xiao-Jing Liu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China
| | - Yan Gao
- Department of Oral Pathology, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China
| | - Lei Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China.
| | - Guang-Yan Yu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, National Clinical Research Center for Oral Diseases, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing, China.
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Abstract
The 2017 consensus report of the Asia Dry Eye Society (ADES) on the definition and diagnosis of dry eyes described dry eye disease as "Dry eye is a multifactorial disease characterized by unstable tear film causing a variety of symptoms and/or visual impairment, potentially accompanied by ocular surface damage." The report emphasized the instability of tear film and the importance of visual dysfunction in association with dry eyes, highlighting the importance of the evaluation of tear film stability. This report also discussed the concept of tear film-oriented therapy, which stemmed from the definition, and which is centered on provision of insufficient components in each tear film layer and ocular surface epithelium. The current ADES report proposes a simple classification of dry eyes based on the concept of tear film-oriented diagnosis and suggests that there are three types of dry eye: aqueous-deficient, decreased wettability, and increased evaporation. It is suggested that these three types respectively coincide with the problems of each layer: aqueous, membrane-associated mucins, and lipid/secretory mucin. Although each component cannot be quantitatively evaluated with the current technology, a practical diagnosis based on the patterns of fluorescein breakup is recommended. The Asia Dry Eye Society classification report suggests that for a practical use of the definition, diagnostic criteria and classification system should be integrated and be simple to use. The classification system proposed by ADES is a straightforward tool and simple to use, only through use of fluorescein, which is available even to non-dry eye specialists, and which is believed to contribute to an effective diagnosis and treatment of dry eyes.
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Shanbhag SS, Chodosh J, Fathy C, Goverman J, Mitchell C, Saeed HN. Multidisciplinary care in Stevens-Johnson syndrome. Ther Adv Chronic Dis 2020; 11:2040622319894469. [PMID: 32523661 PMCID: PMC7236394 DOI: 10.1177/2040622319894469] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/12/2019] [Indexed: 12/17/2022] Open
Abstract
Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are potentially fatal mucocutaneous diseases that can involve many organ systems. Manifestations of SJS/TEN outside of the skin, eyes, and oral mucosa are not well defined or well recognized, and, therefore, are often not addressed clinically. As supportive care improves and mortality from SJS/TEN decreases, chronic complications in affected organ systems are becoming more prevalent. Recognition of the manifestations of SJS/TEN in the acute phase is critical to optimal care. In this review, we review the organ systems that may be involved in SJS/TEN, provide an overview of their management, and propose a list of items that should be communicated to the patient and family upon discharge. The organ systems discussed include the pulmonary, gastrointestinal/hepatic, oral, otorhinolaryngologic, gynecologic, genitourinary, and renal systems. In addition, the significant psychosocial, nutritional, and pain consequences and management of SJS/TEN are discussed.
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Affiliation(s)
- Swapna S Shanbhag
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Cherie Fathy
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeremy Goverman
- Department of Surgery, Massachusetts General Hospital, Sumner Redstone Burn Center, Boston, MA, USA
| | - Caroline Mitchell
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - Hajirah N Saeed
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114, USA
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5
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Seminario-Vidal L, Kroshinsky D, Malachowski SJ, Sun J, Markova A, Beachkofsky TM, Kaffenberger BH, Ergen EN, Mauskar M, Bridges A, Calhoun C, Cardones AR, Chen ST, Chodosh J, Cotliar J, Davis MDP, DeNiro KL, Dominguez AR, Eljure-Téllez J, Femia A, Fox LP, Guda A, Mitchell C, Mostaghimi A, Ortega-Loayza AG, Owen C, Pasieka H, Rahnama-Moghadam S, Saeed HN, Saunderson RB, Shanbhag S, Sharon VR, Strowd L, Venkatesh S, Wanat KA, Wetter DA, Worswick S, Micheletti RG. Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. J Am Acad Dermatol 2020; 82:1553-1567. [PMID: 32151629 DOI: 10.1016/j.jaad.2020.02.066] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/04/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.
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Affiliation(s)
- Lucia Seminario-Vidal
- Department of Dermatology, University of South Florida, Morsani College of Medicine, Tampa, Florida; Cutaneous Oncology Program, H. Lee Moffitt Cancer Center, Tampa, Florida.
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen J Malachowski
- Department of Internal Medicine, Medical College of Wisconsin Affiliated Hospitals, St. Joseph's Hospital, Milwaukee, Wisconsin
| | - James Sun
- Cutaneous Oncology Program, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Alina Markova
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Elizabeth N Ergen
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melissa Mauskar
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alina Bridges
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Cody Calhoun
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Adela R Cardones
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Steven T Chen
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James Chodosh
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Cotliar
- Division of Dermatology, Harbor-University of California, Los Angeles Medical Center, Los Angeles, California
| | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | | | - Arturo R Dominguez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Juliana Eljure-Téllez
- Department of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - Alisa Femia
- Ronald O. Perelman Department of Dermatology, New York University Langone Health, New York, New York
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | - Anisha Guda
- University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas
| | - Caroline Mitchell
- Vincent Center for Reproductive Biology, Department of Obstetrics, Gynecology & Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Cindy Owen
- Division of Dermatology, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Helena Pasieka
- Department of Dermatology, MedStar Washington Hospital Center, Washington, DC
| | | | - Hajirah N Saeed
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Rebecca B Saunderson
- Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Swapna Shanbhag
- Tej Kohli Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, India
| | - Victoria R Sharon
- Department of Dermatology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Lindsay Strowd
- Department of Dermatology, Wake Forest University School of Medicine, Wake Forest, North Carolina
| | - Samantha Venkatesh
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Karolyn A Wanat
- Department of Dermatology, University of Southern California, Los Angeles, California
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Scott Worswick
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert G Micheletti
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
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6
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Sakellariou G, Koukoudis P, Karpouzas J, Alexopoulos E, Papadopoulou D, Chrisomalis F, Skenteris N, Tsakaris D, Papadimitriou M. Plasma Exchange (Pe) Treatment in Drug-Induced Toxic Epidermal Necrolysis (Ten). Int J Artif Organs 2018. [DOI: 10.1177/039139889101401006] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- G. Sakellariou
- Department of Nephrology, Hippokration General Hospital, Aristotelian University of Thessaloniki, Thessaloniki - Greece
| | - P. Koukoudis
- Department of Nephrology, Hippokration General Hospital, Aristotelian University of Thessaloniki, Thessaloniki - Greece
| | - J. Karpouzas
- Department of Nephrology, Hippokration General Hospital, Aristotelian University of Thessaloniki, Thessaloniki - Greece
| | - E. Alexopoulos
- Department of Nephrology, Hippokration General Hospital, Aristotelian University of Thessaloniki, Thessaloniki - Greece
| | - D. Papadopoulou
- Department of Nephrology, Hippokration General Hospital, Aristotelian University of Thessaloniki, Thessaloniki - Greece
| | - F. Chrisomalis
- Department of Nephrology, Hippokration General Hospital, Aristotelian University of Thessaloniki, Thessaloniki - Greece
| | - N. Skenteris
- Department of Nephrology, Hippokration General Hospital, Aristotelian University of Thessaloniki, Thessaloniki - Greece
| | - D. Tsakaris
- Department of Nephrology, Hippokration General Hospital, Aristotelian University of Thessaloniki, Thessaloniki - Greece
| | - M. Papadimitriou
- Department of Nephrology, Hippokration General Hospital, Aristotelian University of Thessaloniki, Thessaloniki - Greece
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Lee H, Walsh S, Creamer D. Long-term complications of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN): the spectrum of chronic problems in patients who survive an episode of SJS/TEN necessitates multidisciplinary follow-up. Br J Dermatol 2017; 177:924-935. [DOI: 10.1111/bjd.15360] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2017] [Indexed: 12/14/2022]
Affiliation(s)
- H.Y. Lee
- Department of Dermatology; Singapore General Hospital; Singapore
| | - S.A. Walsh
- Department of Dermatology; King's College Hospital; London U.K
| | - D. Creamer
- Department of Dermatology; King's College Hospital; London U.K
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Creamer D, Walsh SA, Dziewulski P, Exton LS, Lee HY, Dart JKG, Setterfield J, Bunker CB, Ardern-Jones MR, Watson KMT, Wong GAE, Philippidou M, Vercueil A, Martin RV, Williams G, Shah M, Brown D, Williams P, Mohd Mustapa MF, Smith CH. U.K. guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016. Br J Dermatol 2017; 174:1194-227. [PMID: 27317286 DOI: 10.1111/bjd.14530] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 12/11/2022]
Affiliation(s)
- D Creamer
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - S A Walsh
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - P Dziewulski
- St Andrews Centre for Plastic Surgery and Burns, Mid Essex Hospital Services NHS Trust, Chelmsford, CM1 7ET, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - H Y Lee
- Dermatology Unit, Singapore General Hospital, Singapore
| | - J K G Dart
- Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, U.K
| | - J Setterfield
- Mucosa and Salivary Biology, Dental Institute, King's College London, Guy's Campus, Great Maze Pond, London, SE1 9RT, U.K
| | - C B Bunker
- University College Hospital, London, NW1 2BU, U.K
| | - M R Ardern-Jones
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, U.K
| | - K M T Watson
- Department of Dermatology, Orpington Hospital, Orpington, Kent, BR6 9JU, U.K
| | - G A E Wong
- Department of Dermatology, University Hospital of South Manchester NHS Foundation Trust, Manchester, M23 9LT, U.K
| | - M Philippidou
- Department of Histopathology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - A Vercueil
- Intensive Care Medicine, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - R V Martin
- St Andrews Centre for Plastic Surgery and Burns, Mid Essex Hospital Services NHS Trust, Chelmsford, CM1 7ET, U.K
| | - G Williams
- Late of the Burns Centre, Chelsea and Westminster NHS Foundation Trust, London, SW10 9NH, U.K
| | - M Shah
- Department of Burns and Plastic Surgery, University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, M23 9LT, U.K
| | - D Brown
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
| | - P Williams
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - C H Smith
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
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UK guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults 2016. J Plast Reconstr Aesthet Surg 2016; 69:e119-e153. [DOI: 10.1016/j.bjps.2016.01.034] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/14/2016] [Indexed: 12/13/2022]
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Kohanim S, Palioura S, Saeed HN, Akpek EK, Amescua G, Basu S, Blomquist PH, Bouchard CS, Dart JK, Gai X, Gomes JAP, Gregory DG, Iyer G, Jacobs DS, Johnson AJ, Kinoshita S, Mantagos IS, Mehta JS, Perez VL, Pflugfelder SC, Sangwan VS, Sippel KC, Sotozono C, Srinivasan B, Tan DTH, Tandon R, Tseng SCG, Ueta M, Chodosh J. Acute and Chronic Ophthalmic Involvement in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis - A Comprehensive Review and Guide to Therapy. II. Ophthalmic Disease. Ocul Surf 2016; 14:168-88. [PMID: 26882981 DOI: 10.1016/j.jtos.2016.02.001] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 02/07/2023]
Abstract
Our purpose is to comprehensively review the state of the art with regard to Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to improving the management of associated ocular surface complications. SJS and TEN are two ends of a spectrum of immune-mediated disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. Part I of this review focused on the systemic aspects of SJS/TEN and was published in the January 2016 issue of this journal. The purpose of Part II is to summarize the ocular manifestations and their management through all phases of SJS/TEN, from acute to chronic. We hope this effort will assist ophthalmologists in their management of SJS/TEN, so that patients with this complex and debilitating disease receive the best possible care and experience the most optimal outcomes in their vision and quality of life.
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Affiliation(s)
- Sahar Kohanim
- Vanderbilt Eye Institute, Vanderbilt University School of Medicine, USA
| | - Sotiria Palioura
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, USA
| | - Hajirah N Saeed
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, USA
| | - Esen K Akpek
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, USA
| | - Guillermo Amescua
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, USA
| | | | | | | | - John K Dart
- Moorfields Eye Hospital, NHS Foundation Trust, UK
| | - Xiaowu Gai
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, USA
| | | | - Darren G Gregory
- Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, USA
| | - Geetha Iyer
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, India
| | - Deborah S Jacobs
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, USA; Boston Foundation for Sight, USA
| | | | | | | | - Jodhbir S Mehta
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
| | - Victor L Perez
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, USA
| | | | | | | | | | - Bhaskar Srinivasan
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, India
| | - Donald T H Tan
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
| | - Radhika Tandon
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, India
| | - Scheffer C G Tseng
- Ocular Surface Center, Ocular Surface Research & Education Foundation, USA
| | - Mayumi Ueta
- Kyoto Prefectural University of Medicine, Japan
| | - James Chodosh
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, USA.
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11
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Kaku Y, Kodama S, Higuchi M, Nakamura A, Nakamura M, Kaieda T, Takahama S, Minami R, Miyamura T, Suematsu E, Yamamoto M. Corticoid therapy for overlapping syndromes in an HIV-positive patient. Intern Med 2015; 54:223-30. [PMID: 25743017 DOI: 10.2169/internalmedicine.54.3094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Human immunodeficiency virus (HIV) infection disturbs the host's immune function and often coexists with various autoimmune and/or systemic rheumatic diseases with manifestations that sometimes overlap with each other. We herein present the case of a 43-year-old Japanese man infected with HIV who exhibited elevated serum creatine kinase and transaminases levels without any symptoms. He was diagnosed with autoimmune hepatitis, polymyositis and Sjögren's syndrome and received combined antiretroviral therapy (cART); however, the laboratory abnormalities persisted. We successfully administered cART with the addition of oral prednisolone, and the patient's condition recovered without side effects related to the metabolic or immunosuppressive effects of these drugs.
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Affiliation(s)
- Yu Kaku
- Department of Internal Medicine, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan
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12
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Sotozono C, Yamauchi N, Maeda S, Kinoshita S. Tear exchangeable limbal rigid contact lens for ocular sequelae resulting from Stevens-Johnson syndrome or toxic epidermal necrolysis. Am J Ophthalmol 2014; 158:983-93. [PMID: 25036881 DOI: 10.1016/j.ajo.2014.07.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 07/11/2014] [Accepted: 07/11/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the therapeutic benefits of tear-exchangeable, limbal, rigid contact lenses (limbal CLs) in patients with Stevens-Johnson syndrome- or toxic epidermal necrolysis-associated ocular sequelae. DESIGN Noncomparative, retrospective, interventional case series. METHODS We enrolled 53 eyes of 42 patients (mean age, 51.8 ± 13.9 years; mean follow-up, 25.7 ± 15.7 months) with Stevens-Johnson syndrome- or toxic epidermal necrolysis-associated ocular sequelae and divided them into 3 groups according to the best-corrected visual acuity (BCVA) before limbal CL fitting: (1) BCVA worse than 20/2000 (11 eyes), (2) BCVA ranging from 20/200 to 20/2000 (31 eyes), and (3) BCVA of 20/200 or better (11 eyes). The BCVA and the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) composite score before fitting and after 3 months of limbal CL use were evaluated. The change in BCVA (in logarithm of the minimal angle of resolution [logMAR] units) and 25-item National Eye Institute Visual Function Questionnaire composite score change were compared among the 3 groups. RESULTS Best-corrected visual acuity improved from 1.61 to 0.86 logMAR at 3 months after fitting CL use. Improvement in BCVA in groups 1, 2, and 3 was 0.95 logMAR, 0.82 logMAR, and 0.37 logMAR, respectively. The mean 25-item National Eye Institute Visual Function Questionnaire composite score for the 11 subscales improved from 37.6 ± 16.0 to 58.4 ± 17.4 (P = .000001). All 11 subscores, except that for driving ability, improved significantly. The general vision subscore improved most in group 3, yet the general health subscore improved most in group 1. No serious adverse events attributable to limbal CL use occurred. CONCLUSIONS The tear-exchangeable limbal CL is safe and effective for the improvement of vision and quality of life in Stevens-Johnson syndrome or toxic epidermal necrolysis patients with severe ocular sequelae.
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Fellahi A, Zouhair K, Amraoui A, Benchikhi H. Séquelles cutanéomuqueuses et oculaires des SJS et de Lyell. Ann Dermatol Venereol 2011; 138:88-92. [DOI: 10.1016/j.annder.2010.10.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 09/28/2010] [Accepted: 10/20/2010] [Indexed: 10/18/2022]
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Paquet P, Piérard GE. New insights in toxic epidermal necrolysis (Lyell's syndrome): clinical considerations, pathobiology and targeted treatments revisited. Drug Saf 2010; 33:189-212. [PMID: 20158284 DOI: 10.2165/11532540-000000000-00000] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Drug-induced toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a life-threatening drug reaction characterized by extensive destruction of the epidermis and mucosal epithelia. The eyes are typically involved in TEN. At present, the disease has a high mortality rate. Conceptually, TEN and the Stevens-Johnson syndrome are closely related, although their severity and outcome are different. Distinguishing TEN from severe forms of erythema multiforme relies on consideration of aetiological, clinical and histological characteristics. The current understanding of the pathomechanism of TEN suggests that keratinocytes are key initiator cells. It is probable that the combined deleterious effects on keratinocytes of both the cytokine tumour necrosis factor (TNF)-alpha and oxidative stress induce a combination of apoptotic and necrotic events. As yet, there is no evidence indicating the superiority of monotherapy with corticosteroids, ciclosporin (cyclosporine) or intravenous immunoglobulins over supportive care only for patients with TEN. However, the current theory of TEN pathogenesis supports the administration of a combination of antiapoptotic/antinecrotic drugs (e.g. anti-TNF-alpha antibodies plus N-acetylcysteine) targeting different levels of the keratinocyte failure machinery.
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Affiliation(s)
- Philippe Paquet
- Department of Dermatopathology, University Hospital of Liège, CHU Sart Tilman, Liège, Belgium.
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Lissia M, Mulas P, Bulla A, Rubino C. Toxic epidermal necrolysis (Lyell's disease). Burns 2010; 36:152-63. [DOI: 10.1016/j.burns.2009.06.213] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2008] [Revised: 04/21/2009] [Accepted: 06/03/2009] [Indexed: 10/20/2022]
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Tougeron-Brousseau B, Delcampe A, Gueudry J, Vera L, Doan S, Hoang-Xuan T, Muraine M. Vision-related function after scleral lens fitting in ocular complications of Stevens-Johnson syndrome and toxic epidermal necrolysis. Am J Ophthalmol 2009; 148:852-9.e2. [PMID: 19837383 DOI: 10.1016/j.ajo.2009.07.006] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Revised: 06/20/2009] [Accepted: 07/11/2009] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the therapeutic benefits of scleral lenses in the management of severe ocular surface disease attributable to toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS). DESIGN Retrospective study. METHODS Clinical records of 39 patients (67 eyes) fitted with scleral lenses for refractory ocular surface disease attributable to SJS or TEN were reviewed. To assess vision-specific quality of life, each patient completed the Ocular Surface Disease Index (OSDI) questionnaire and the National Eye Institute Visual Function Questionnaire (NEI VFQ-25). Slit-lamp examination was performed at regular intervals to detect side effects. Main outcome measures were best-corrected visual acuity (VA) and OSDI and NEI VFQ-25 composite score before and 6 months after scleral lens fitting. RESULTS The mean age was 35.8 +/- 13.9 years. Scleral lens fitting failed in 3 patients. The mean follow-up was 33.3 +/- 17.6 months. Among fitted patients, VA in the better eye (36 patients, 36 eyes) progressed from 0.73 to 0.50 logarithm of the minimum angle of resolution (P = .0001) 6 months after scleral lens placement. The mean OSDI improved from 76.9 +/- 22.8 to 37.1 +/- 26.7 (P = .0001). Thirty-two NEI VFQ-25 composite scores were available. The mean NEI VFQ-25 composite score improved from 25.1 +/- 16.8 to 67.4 +/- 22.1 (P = .0001). No serious adverse events attributable to the scleral lenses occurred. CONCLUSIONS Scleral lens use appears to be efficient and safe for visual rehabilitation of refractory ocular surface disease attributable to TEN and SJS.
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Chuang JY, Tzeng NS. Sjögren's syndrome precipitated by lamotrigine treatment. Prog Neuropsychopharmacol Biol Psychiatry 2009; 33:1075-6. [PMID: 19446598 DOI: 10.1016/j.pnpbp.2009.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Revised: 05/02/2009] [Accepted: 05/09/2009] [Indexed: 11/18/2022]
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Palmares J, Correia O, Delgado L, Vazsilva M, Mesquita-Guimaraes J, Castro-Correia J. Ocular involvement in toxic epidermal necrolysis. Ocul Immunol Inflamm 2009; 1:171-8. [DOI: 10.3109/09273949309086556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pereira FA, Mudgil AV, Rosmarin DM. Toxic epidermal necrolysis. J Am Acad Dermatol 2007; 56:181-200. [PMID: 17224365 DOI: 10.1016/j.jaad.2006.04.048] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 03/10/2006] [Accepted: 04/11/2006] [Indexed: 10/23/2022]
Abstract
UNLABELLED Toxic epidermal necrolysis (TEN) is an unpredictable, life-threatening drug reaction associated with a 30% mortality. Massive keratinocyte apoptosis is the hallmark of TEN. Cytotoxic T lymphocytes appear to be the main effector cells and there is experimental evidence for involvement of both the Fas-Fas ligand and perforin/granzyme pathways. Optimal treatment for these patients remains to be clarified. Discontinuation of the offending drug and prompt referral to a burn unit are generally agreed upon steps. Beyond that, however, considerable controversy exists. Evidence both pro and con exists for the use of IVIG, systemic corticosteroid, and other measures. There is also evidence suggesting that combination therapies may be of value. All the clinical data, however, is anecdotal or based on observational or retrospective studies. Definitive answers are not yet available. Given the rarity of TEN and the large number of patients required for a study to be statistically meaningful, placebo controlled trials are logistically difficult to accomplish. The absence of an animal model further hampers research into this condition. This article reviews recent data concerning clinical presentation, pathogenesis and treatment of TEN. LEARNING OBJECTIVES At the conclusion of this learning activity, participants should have acquired a more comprehensive knowledge of our current understanding of the classification, clinical presentation, etiology, pathophysiology, prognosis, and treatment of TEN.
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Affiliation(s)
- Frederick A Pereira
- Department of Dermatology, Mount Sinai School of Medicine, New York, New York, USA.
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Kamada N, Kinoshita K, Togawa Y, Kobayashi T, Matsubara H, Kohno M, Igari H, Kuriyama T, Nakamura M, Hirasawa H, Shinkai H. Chronic pulmonary complications associated with toxic epidermal necrolysis: report of a severe case with anti-Ro/SS-A and a review of the published work. J Dermatol 2006; 33:616-22. [PMID: 16958806 DOI: 10.1111/j.1346-8138.2006.00142.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with toxic epidermal necrolysis (TEN) have been known to have various complications. Though pulmonary complications are often observed, they usually show an acute form; however, chronic complications are quite rare and little is known about either their incidences or clinical manifestations. We herein report a 33-year-old man who presented with chronic pulmonary complications after a recovery from TEN. At the onset of TEN, he had severe respiratory failure and artificial ventilation was instituted. Despite being extubated successfully, respiratory failure reappeared 1 month later. A diagnosis of chronic bronchitis with severe obstructive ventilatory impairment and bronchiectasis was made and he was treated with steroids, bronchodilators and antibiotics, however, he died 1.5 years after the onset of TEN. There have been 13 reported cases of chronic pulmonary complications with TEN or Stevens-Johnson syndrome (SJS) in the English published work. Such cases are usually classified into chronic bronchitis/bronchiolitis with obstructive change (including bronchiolitis obliterans and bronchiolitis obliterans organizing pneumonia), respiratory tract obstruction and bronchiectasis. Approximately 40% of all such patients die while the surviving continue to suffer from these complications because no curative therapy yet exists. As a result, the prognosis seems to be poor. The relationship between TEN and these chronic pulmonary complications remains to be elucidated. Interestingly, our patient was asymptomatically anti-Ro/SS-A positive at the onset of TEN. In addition, eccrine gland involvement and an extremely high level of serum salivary amylase were observed at the onset of TEN, furthermore, Sjögren-like symptoms occurred after recovery from TEN. These findings suggested that the Sjögren-like autoimmune abnormalities induced by anti-Ro/SS-A correlated with the development of chronic pulmonary complications in our patient.
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Affiliation(s)
- Noriaki Kamada
- Department of Dermatology, Graduate School of Medicine, Chiba University, Japan.
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Yip LW, Thong BY, Tan AW, Khin LW, Chng HH, Heng WJ. High-dose intravenous immunoglobulin in the treatment of toxic epidermal necrolysis: a study of ocular benefits. Eye (Lond) 2006; 19:846-53. [PMID: 15389280 DOI: 10.1038/sj.eye.6701653] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To compare acute ocular complications of toxic epidermal necrolysis (TEN) following treatment with high-dose human intravenous immunoglobulin (IVIG) with a historical cohort not treated with IVIG. METHODS Retrospective, historically controlled study. In all, 10 consecutive patients with TEN (treatment cohort) presenting between 1 July 2001 and 30 June 2002. Totally, 18 consecutive patients with TEN (historical cohort). SettingTan Tock Seng Hospital, Singapore. The treatment cohort received high-dose IVIG (2 g/kg body weight over 2 days). Patients' records were retrospectively reviewed for their demographic characteristics, causative drug, treatment, ocular involvement (if any, as assessed by an ophthamologist), and its severity. The historical cohort comprised patients coded with a diagnosis of TEN (ICD Code 695.1) between 1 July 1995 and 30 June 2001. RESULTS Nine (90%) of 10 patients treated with IVIG had ocular involvement. Phenytoin was the implicated drug in three (37.5%) patients. Of the nine patients, 1 died of septic shock. Of the eight survivors, IVIG was initiated immediately upon onset of TEN as all the patients were hospitalized by the time of onset of an exanthema. Acute ocular complications were mild in two (25%) (lid oedema or mild conjunctival injection), moderate in four (50%) (pseudomembranes) and severe in two (25%) (nonhealing epithelial defect with visual loss and symblepharon). In total, 10 (55.6%) of 18 patients in the historical cohort with TEN had acute ocular involvement. Two patients died. Ocular involvement in survivors was mild in five (62.5%) cases and moderate in three (37.5%), with no severe cases. CONCLUSIONS IVIG did not appear to reduce the severity of visually significant ocular complications. Larger studies are needed to confirm this finding.
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Affiliation(s)
- L W Yip
- The Eye Institute at Tan Tock Seng Hospital, National Healthcare Group, Singapore.
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Paquet P, Jacob E, Piérard GE. Cystic lesion of the parotid following drug-induced toxic epidermal necrolysis (Lyell's syndrome). J Oral Pathol Med 2005; 34:380-2. [PMID: 15946188 DOI: 10.1111/j.1600-0714.2005.00315.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 32-year-old woman developed a unilateral cyst of the duct of parotid gland 4 months after severe oral involvement of drug-induced toxic epidermal necrolysis (TEN). The pathomechanism leading to the TEN epidermal destruction had presumably involved the salivary epithelium as well, leading to the development of the cystic lesion. The patient had low serum lipase levels, but high serum amylase levels at the time of TEN. These serological markers could represent a clue for the risk of developing cystic lesions of the large salivary glands following TEN.
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Affiliation(s)
- P Paquet
- Department of Dermatopathology University Hospital Sart Tilman, Liège, Belgium.
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Letko E, Papaliodis DN, Papaliodis GN, Daoud YJ, Ahmed AR, Foster CS. Stevens-Johnson syndrome and toxic epidermal necrolysis: a review of the literature. Ann Allergy Asthma Immunol 2005; 94:419-36; quiz 436-8, 456. [PMID: 15875523 DOI: 10.1016/s1081-1206(10)61112-x] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To perform a comprehensive review of Stevens-Johnson syndrome and toxic epidermal necrolysis. DATA SOURCES A MEDLINE search was performed for the years 1975 to 2003 using the keywords Stevens-Johnson syndrome and toxic epidermal necrolysis to identify relevant articles published in English in peer-reviewed journals. STUDY SELECTION All clinical studies that reported on 4 or more patients, review articles, and experimental studies that concerned disease mechanisms were selected and further analyzed. Clinical reports that included fewer than 4 patients were selected only if they were believed to carry a significant message about disease mechanism or therapy. RESULTS Stevens-Johnson syndrome and toxic epidermal necrolysis seem to be variants of the same disease with differing severities. A widely accepted consensus regarding diagnostic criteria and therapy does not exist at present. Despite the recent experimental studies, the pathogenic mechanisms of these diseases remain unknown. Although progress in survival through early hospitalization in specialized burn units has been made, the prevalence of life-long disability from the ocular morbidity of Stevens-Johnson syndrome and toxic epidermal necrolysis has remained unchanged for the past 35 years. Further progress depends on modification of the acute phase of the disease rather than continuation of supportive care. The available published evidence indicates that a principal problem in the pathogenesis is immunologic and that immunomodulatory intervention with short-term, high-dose intravenous steroids or intravenous immunoglobulin holds the most promise for effective change in survival and long-term morbidity. CONCLUSIONS The results of this review call for a widely accepted consensus on diagnostic criteria for Stevens-Johnson and toxic epidermal necrolysis and multicenter collaboration in experimental studies and clinical trials that investigate disease mechanisms and novel therapeutic interventions, respectively.
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Affiliation(s)
- Erik Letko
- Department of Ophthalmology, Uveitis and Immunology Service, The Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts 02114, USA
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Affiliation(s)
- R Solans
- Servei de Medicina Interna, Hospital General Vall d'Hebron, Barcelona, Spain
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García Fernández D, García-Patos Briones V, Castells Rodellas A. Síndrome de Stevens-Johnson/necrólisis epidérmica tóxica. ACTA ACUST UNITED AC 2001. [DOI: 10.1016/s0213-9251(01)72498-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Toxic epidermal necrolysis (TEN) is a rare but life-threatening adverse drug reaction. Implicated drugs are sulfonamides, anticonvulsants, allopurinol, and pyrazolone derivatives. Recently, advances in pathogenesis have been made in two directions. It is now known that (1) most patients with TEN have an abnormal metabolism to the culprit drug; and (2) the mechanism leading to epidermal necrolysis seems to be a cell-mediated cytotoxic reaction. The treatment remains symptomatic.
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Affiliation(s)
- P Wolkenstein
- Department of Dermatology, Paris XII University, Henri-Mondor Hospital, Créteil, France
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Wong KC, Kennedy PJ, Lee S. Clinical manifestations and outcomes in 17 cases of Stevens-Johnson syndrome and toxic epidermal necrolysis. Australas J Dermatol 1999; 40:131-4. [PMID: 10439522 DOI: 10.1046/j.1440-0960.1999.00342.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The clinical features and outcomes of 17 patients with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) were retrospectively reviewed. There were 11 males and six females with an average age of 61.5 years. Ten patients with SJS (seven males, three females) and seven patients with TEN (four males, three females) were identified. Antibiotics, mainly beta-lactams, were the most common cause of SJS/TEN in this series. The mean skin loss in TEN was 45.7% total body surface area in contrast to the lesser skin loss (< 10%) observed in three patients with SJS. Complications included septicaemia, pneumonia and multi-organ failure, mainly in the TEN group. Two patients died from TEN-related complications and one patient with SJS died from unrelated causes. Ocular involvement and skin pigmentary changes represented the most significant long-term sequelae.
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Affiliation(s)
- K C Wong
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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Wolkenstein P, Revuz J. Allergic emergencies encountered by the dermatologist. Severe cutaneous adverse drug reactions. Clin Rev Allergy Immunol 1999; 17:497-511. [PMID: 10829817 DOI: 10.1007/bf02737652] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- P Wolkenstein
- Department of Dermatology, Hôpital Henri-Mondor, Créteil, France
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Affiliation(s)
- P E Wolkenstein
- Department of Dermatology, Hôpital Henri-Mondor, Créteil, France
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Coetzer M, van der Merwe AE, Warren BL. Toxic epidermal necrolysis in a burn patient complicated by acute pancreatitis. Burns 1998; 24:181-3. [PMID: 9625248 DOI: 10.1016/s0305-4179(97)00107-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This report concerns a previously healthy patient who presented with 8% total body surface area burn wounds to his face and neck. Even though his burn wounds healed quickly, his course was complicated by the development of toxic epidermal necrolysis affecting 60% total body surface area due to a drug reaction. During the recovery period he subsequently developed jaundice and pancreatitis -- a rare and interesting course that is not well described in the literature.
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Affiliation(s)
- M Coetzer
- Department of Surgery, University of Stellenbosch, Tygerberg Hospital, Republic of South Africa
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Revuz JE, Roujeau JC. Advances in toxic epidermal necrolysis. SEMINARS IN CUTANEOUS MEDICINE AND SURGERY 1996; 15:258-66. [PMID: 9069594 DOI: 10.1016/s1085-5629(96)80039-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
On the basis of the clinicopathologic and causative characteristics, one can separate an erythema multiformis spectrum from a toxic epidermal necrolysis (TEN)-Stevens Johnson syndrome which is a drug induced disease. Despite a well-known clinical aspect, several cutaneous diseases may be mistaken for TEN. Responsible drugs are sulfonamides anticonvulsants, and nonsteroidal antiinflammatory drugs--patients infected with HIV are at a higher risk of developing TEN. Pathogenesis includes abnormal drug metabolism and cell mediated immune keratinocyte apoptosis. Treatment relies on symptomatic management and so-called specific treatments including steroids are probably harmful.
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Affiliation(s)
- J E Revuz
- Service de Dermatologie, Hôpital Henri Mondor, Université Paris XII, Créteil, France
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Abstract
Toxic epidermal necrolysis (TEN) is a rare, drug-induced, life-threatening syndrome with widespread epidermal loss and mucosal erosions. The classification, pathophysiology, clinical features and treatment are discussed in this review. Prognosis has improved as admission to a burns unit and early treatment of infection has become standard management. The role of corticosteroids in treatment is still controversial.
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Affiliation(s)
- W Weightman
- Department of Dermatology, Queen Elizabeth Hospital, Woodville, Australia
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Abstract
Severe skin adverse drug reactions can result in death, but the rate of such events is fortunately low. The incidences of Stevens-Johnson syndrome and toxic epidermal necrolysis range from 1.2 to 6 per million per year and 0.4 to 1.2 per million per year, respectively. Stevens-Johnson syndrome is fatal in about 5% and toxic epidermal necrolysis in 30% of cases. Drugs implicated in these diseases are the sulphonamides, anticonvulsants, allopurinol, pyrazolone derivatives, oxicams and chlormezanone. The principles of symptomatic treatment are the same as for burns, and patients with extensive skin detachment should be transferred to an intensive care unit or a burn centre. Hypersensitivity syndrome is characterised by mucocutaneous eruption and fever with frequent lymphadenopathy, hepatitis and eosinophilia. Drugs implicated are mainly anticonvulsants and sulphonamides. The mortality rate of such a reaction has been estimated to be about 8%. Corticosteroid therapy has been widely used in hypersensitivity syndrome, despite the lack of controlled studies. Drug-induced vasculitis and serum sickness may also be life-threatening when the kidney, liver, gastrointestinal tract or nervous system are involved. In angioedema, congestion may involve mucous membranes and therefore impair swallowing and ventilation. Drugs associated with angioedema include penicillins, radiographic contrast agents and ACE inhibitors. Severe forms of angioedema necessitate epinephrine (adrenaline) subcutaneous injection and possibly resuscitative efforts. Corticosteroids and/or antihistamines are used to block or reduce prolonged or late phase reactions. Prompt recognition and withdrawal of the suspected drug is essential in severe drug-induced skin reactions.
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Affiliation(s)
- P Wolkenstein
- Department of Dermatology, Henri-Mondor Hospital and University, Paris, France
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Affiliation(s)
- J C Roujeau
- Dermatology Service, Henri Mondor Hospital, University of Paris XII, France
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Wilkins J, Morrison L, White CR. Oculocutaneous Manifestations of the Erythema Multiforme/Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Spectrum. Dermatol Clin 1992. [DOI: 10.1016/s0733-8635(18)30324-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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de la Cotera FJ, Kuo PC. Toxic epidermal necrolysis: report of a case. J Oral Maxillofac Surg 1992; 50:638-42. [PMID: 1593330 DOI: 10.1016/0278-2391(92)90450-e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Affiliation(s)
- T E Rohrer
- Department of Internal Medicine, Yale University, School of Medicine, New Haven, Connecticut
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Sabán J, Pais JR, Rodríguez JL, Boixeda D. Sjögren-like pluriglandular exocrine insufficiency after drug-induced toxic epidermal necrolysis. Postgrad Med J 1991; 67:195-7. [PMID: 2041854 PMCID: PMC2398994 DOI: 10.1136/pgmj.67.784.195] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We present the case of a patient that progressively developed xerophthalmia, xerostomia, cutaneous xerosis and exocrine pancreatic insufficiency 3 months after metamizole-induced toxic epidermal necrolysis. Though the association of Sjögren's syndrome and exocrine pancreatic impairment is well established, the Sjögren-like syndrome after drug-induced toxic epidermal necrolysis in association with such a wide exocrine glandular insufficiency has not been previously described, to our knowledge.
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Affiliation(s)
- J Sabán
- Department of Medicine, Hospital Ramón y Cajal, University of Alcalá de Henares, Madrid, Spain
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Abstract
Toxic epidermal necrolysis is perhaps the most formidable disease encountered by dermatologists. Uncommon but not rare, toxic epidermal necrolysis occurs in 60 to 70 persons per year in France. It remains as puzzling a disorder as it was 34 years ago, when described by Lyell. Whether or not toxic epidermal necrolysis is the most severe form of erythema multiforme is still the subject of discussion. The physiopathologic events that lead to this rapidly extensive necrosis of the epidermis are not understood. Indirect evidence suggests a hypersensitivity reaction, but the search for potential immunologic mechanisms has resulted in little data to support this hypothesis. Accumulated clinical evidence points to drugs as the most important, if not the only, cause of toxic epidermal necrolysis. Sulfonamides, especially long-acting forms, anticonvulsants, nonsteroidal anti-inflammatory agents, and certain antibiotics are associated with most cases of toxic epidermal necrolysis. Many other drugs have been implicated in isolated case reports. All organs may be involved either by the same process of destruction of the epithelium as observed in the epidermis or by the same systemic consequences of "acute skin failure" as seen in patients with widespread burns. Sepsis is the most important complication and cause of death. Approximately 20% to 30% of all patients with toxic epidermal necrolysis die. Elderly patients and patients with extensive lesions have a higher mortality rate. Surviving patients completely heal in 3 to 4 weeks, but up to 50% will have residual, potentially disabling ocular lesions. The prognosis is improved by adequate therapy, as provided in burn units, that is, aggressive fluid replacement, nutritional support, and a coherent antibacterial policy. Corticosteroids, advocated by some in high doses to halt the "hypersensitivity" process, have been shown in several studies to be detrimental and should be avoided.
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Affiliation(s)
- J C Roujeau
- Department of Dermatology, Hôpital Henri Mondor, Université Paris XII
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Abstract
Toxic epidermal necrolysis (TEN) is a life-threatening condition in which the epidermis blisters and peels in large sheets. The clinical syndrome and diagnosis are reviewed. Current treatment and prevention of complications are discussed. The key to low morbidity and mortality in TEN is early intervention. Physicians should be knowledgeable about TEN and the appearance of the skin in its initial presentation.
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Affiliation(s)
- P A Dolan
- Department of Medicine, Medical College of Georgia, Augusta
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Abstract
Toxic epidermal necrolysis is a potentially fatal dermatological disease. Large bullae covering extensive areas of the body cause continuous exfoliation of skin, which requires immediate medical attention. Intraoral manifestations may precede cutaneous lesions. Two cases with different treatment protocols are presented.
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Scully C. Sjögren's syndrome: clinical and laboratory features, immunopathogenesis, and management. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1986; 62:510-23. [PMID: 3537893 DOI: 10.1016/0030-4220(86)90313-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Sjögren's syndrome may be accompanied by local oral problems such as dry mouth, rampant caries, candidosis, or sialadenitis, but it is a systemic autoimmune disorder with wide repercussions, including a small premalignant potential. This article reviews the clinical and immunopathogenic features, as well as the etiology, of Sjögren's syndrome and discusses the diagnosis and management of oral complications.
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