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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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Liu TJ, Lin LL, McMeniman E, Wu J, Kao YC, Kumari S, Boyle GM, Wells JW, Soyer HP, Gonzalez-Cruz JL. Cytokine/Chemokine assessment as a complementary diagnostic tool for inflammatory skin diseases. Front Immunol 2022; 13:1028435. [PMID: 36466878 PMCID: PMC9709404 DOI: 10.3389/fimmu.2022.1028435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/26/2022] [Indexed: 10/14/2023] Open
Abstract
Inflammatory skin conditions are the 4th leading cause of non-fatal health burden in the general population worldwide. The diagnosis of skin lesions due to systemic drug reactions, viral or bacterial exanthems, or in patients with psoriasis, atopic dermatitis or contact dermatitis is often difficult and relies heavily upon conventional histopathologic examination. Conversely, it is widely accepted that the cutaneous profile of inflammatory markers, or 'inflammatory signature', is differentially expressed in various skin conditions. In this pilot study, we investigated the possibility of inflammatory skin disease diagnosis from an immunological perspective in small punch biopsies. We collected lesional and perilesional punch biopsies from 139 patients suffering from a variety of inflammatory skin conditions and attending the Dermatology Department at the Princess Alexandra Hospital in Brisbane, Australia. Using bead-based immunoassays we were able to measure 13 out of 17 inflammatory markers from a pre-selected multi-analyte panel and to detect significant differences between lesional and perilesional biopsies from each individual patient. Hierarchical and unbiased clustering methods based on inflammatory signatures grouped psoriasis and atopic dermatitis lesions into individual clusters in contrast to other skin conditions, highlighting the potential of inflammatory signatures to be used as diagnostic differentiators and to inform alternative targets in anti-inflammatory treatment strategies.
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Affiliation(s)
- Timothy J. Liu
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia
- Department of Dermatology, Princess Alexandra Hospital, Metro South Health, Brisbane, QLD, Australia
| | - Lynlee L. Lin
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Erin McMeniman
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia
- Department of Dermatology, Princess Alexandra Hospital, Metro South Health, Brisbane, QLD, Australia
| | - Jason Wu
- Department of Dermatology, Princess Alexandra Hospital, Metro South Health, Brisbane, QLD, Australia
| | - Yung-Ching Kao
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Snehlata Kumari
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Glen M. Boyle
- Department of Cell and Molecular Biology, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - James W. Wells
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia
| | - H. Peter Soyer
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia
- Department of Dermatology, Princess Alexandra Hospital, Metro South Health, Brisbane, QLD, Australia
| | - Jazmina L. Gonzalez-Cruz
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia
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Drug-Induced vs. Viral Maculopapular Exanthem—Resolving the Dilemma. Dermatopathology (Basel) 2022; 9:164-171. [PMID: 35645232 PMCID: PMC9149972 DOI: 10.3390/dermatopathology9020021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 02/04/2023] Open
Abstract
Maculopapular exanthem is a commonly encountered presentation in routine clinical practice, and differentiation between its two most common etiologies, i.e., viral- and drug-induced, often poses a diagnostic dilemma. Clinical, hematological and biochemical investigations are seldom reliable in distinguishing between a drug reaction and a viral exanthem. Certain key histopathological features such as the presence of a moderate degree of spongiosis, extensive basal cell damage with multiple necrotic keratinocytes and dermal infiltrate rich in eosinophils or lymphocytes and histiocytes may favor a drug exanthem, while distinctive epidermal cytopathic changes and lymphocytic vasculitis point towards a viral etiology. Similarly, notable immunohistochemical markers such as IL-5, eotaxin and FAS ligand may support a diagnosis of a drug-induced maculopapular eruption. Histopathological and immunohistochemical evaluations may help in distinguishing between the two etiologies when faced with a clinical overlap, especially in patients on multiple essential drugs when drug withdrawal and rechallenge is not feasible.
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Che J, Dai X, Gao J, Sheng H, Zhan W, Lu Y, Li D, Gao Z, Jin Z, Chen B, Luo P, Yang B, Hu Y, He Q, Weng Q, Dong X. Discovery of N-((3 S,4 S)-4-(3,4-Difluorophenyl)piperidin-3-yl)-2-fluoro-4-(1-methyl-1 H-pyrazol-5-yl)benzamide (Hu7691), a Potent and Selective Akt Inhibitor That Enables Decrease of Cutaneous Toxicity. J Med Chem 2021; 64:12163-12180. [PMID: 34375113 DOI: 10.1021/acs.jmedchem.1c00815] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rash is one of the primary dose-limiting toxicities of Akt (protein kinase B) inhibitors in clinical trials. Here, we demonstrate the inhibition of Akt2 isozyme may be a driver for keratinocyte apoptosis, which promotes us to search for new selective Akt inhibitors with an improved cutaneous safety property. According to our previous research, compound 2 is selected for further optimization for overcoming the disadvantages of compound 1, including high Akt2 inhibition and high toxicity against HaCaT keratinocytes. The dihedral angle-based design and molecular dynamics simulation lead to the identification of Hu7691 (B5) that achieves a 24-fold selectivity between Akt1 and Akt2. Hu7691 exhibits low activity in inducing HaCaT apoptosis, promising kinase selectivity, and excellent anticancer cell proliferation potencies. Based on the superior results of safety property, pharmacokinetic profile, and in vivo efficacy, the National Medical Products Administration (NMPA) approved the investigational new drug (IND) application of Hu7691.
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Affiliation(s)
- Jinxin Che
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Xiaoyang Dai
- Center for Drug Safety Evaluation and Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Jian Gao
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Haichao Sheng
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Wenhu Zhan
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Yang Lu
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Dan Li
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Zizheng Gao
- Institute of Pharmacology & Toxicology, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Zegao Jin
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Binhui Chen
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Peihua Luo
- Institute of Pharmacology & Toxicology, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Bo Yang
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
- Institute of Pharmacology & Toxicology, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Yongzhou Hu
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
| | - Qiaojun He
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
- Center for Drug Safety Evaluation and Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
- Institute of Pharmacology & Toxicology, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou 310018, P. R. China
- Cancer Center, Zhejiang University, Hangzhou 310058, P. R. China
| | - Qinjie Weng
- Center for Drug Safety Evaluation and Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
- Institute of Pharmacology & Toxicology, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou 310018, P. R. China
| | - Xiaowu Dong
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, P. R. China
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou 310018, P. R. China
- Cancer Center, Zhejiang University, Hangzhou 310058, P. R. China
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5
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Zhang J, Lei Z, Xu C, Zhao J, Kang X. Current Perspectives on Severe Drug Eruption. Clin Rev Allergy Immunol 2021; 61:282-298. [PMID: 34273058 PMCID: PMC8286049 DOI: 10.1007/s12016-021-08859-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/16/2022]
Abstract
Adverse drug reactions involving the skin are commonly known as drug eruptions. Severe drug eruption may cause severe cutaneous adverse drug reactions (SCARs), which are considered to be fatal and life-threatening, including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), acute generalized exanthematous pustulosis (AGEP), and drug reaction with eosinophilia and systemic symptoms (DRESS). Although cases are relatively rare, approximately 2% of hospitalized patients are affected by SCARs. There is an incidence of 2 to 7 cases/million per year of SJS/TEN and 1/1000 to 1/10,000 exposures to offending agents result in DRESS. However, the mortality rate of severe drug eruptions can reach up to 50%. SCARs represent a real medical emergency, and early identification and proper management are critical to survival. The common pathogenesis of severe drug eruptions includes genetic linkage with HLA- and non-HLA-genes, drug-specific T cell-mediated cytotoxicity, T cell receptor restriction, and cytotoxicity mechanisms. A multidisciplinary approach is required for acute management. Immediate withdrawal of potentially causative drugs and specific supportive treatment is of great importance. Immunoglobulins, systemic corticosteroids, and cyclosporine A are the most frequently used treatments for SCARs; additionally, new biologics and plasma exchange are reasonable strategies to reduce mortality. Although there are many treatment methods for severe drug eruption, controversies remain regarding the timing and dosage of drug eruption. Types, dosages, and indications of new biological agents, such as tumor necrosis factor antagonists, mepolizumab, and omalizumab, are still under exploration. This review summarizes the clinical characteristics, risk factors, pathogenesis, and treatment strategies of severe drug eruption to guide clinical management.
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Affiliation(s)
- Jingzhan Zhang
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Zixian Lei
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Chen Xu
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Juan Zhao
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Xiaojing Kang
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China. .,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China.
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6
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Sadek M, Iqbal O, Siddiqui F, Till S, Mazariegos M, Campbell E, Mudaliar K, Speiser J, Bontekoe E, Kouta A, Farooqui A, Daravath B, Qneibi D, Sadek R, Hoppensteadt D, Fareed J, Bouchard C. The Role of IL-13, IL-15 and Granulysin in the Pathogenesis of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. Clin Appl Thromb Hemost 2021; 27:1076029620950831. [PMID: 33560872 PMCID: PMC7876748 DOI: 10.1177/1076029620950831] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are Severe
Cutaneous Adverse Reactions (SCARS) characterized by fever and mucocutaneous
lesions leading to necrosis and sloughing of the epidermis. Conjunctival lesions
are reported in 85% of patients. The pathogenesis of SJS/TEN/SCARS is not
completely understood. It is hypothesized that IL-13, IL-15 and Granulysin
expressed in plasma and skin may play a role. We measured the circulating levels
of these cytokines in the plasma using ELISA and their expression in the skin
using immunofluorescence microscopy. A total of 12 SJS/TEN skin biopsy samples
(8 SJS, 2 SJS/TEN overlap and 2 TEN) were analyzed. Biopsy samples from patients
with Lichen Planus (an inflammatory condition of the skin and mucous membranes)
served as controls. Studies were also performed in human corneal epithelial
cells where expression of these cytokines were measured following a challenge
with TNF-α (0, 1, 10 and 100 ng/ml). The intensity of immunofluorescence was
measured Using Imaris® software. The results showed significantly increased
expression of these cytokines in the skin biopsy samples as measured by the
average intensities of IL-13 (6.1 x 133.0 ± 4.231 x 10^8), and Granulysin (4.2 x
123.0 ± 4.231 x 10^8) compared to Lichen planus control (3.0 x 123.0 ±1.62 x
10^5). Increased expression of IL-13 and IL-15 were noted in cell culture
studies and in the plasma samples when compared to Normal Human Plasma as
controls. It is concluded that IL-13, IL-15 and Granulysin play a role in the
pathogenesis of SJS/TEN.
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Affiliation(s)
- Michael Sadek
- Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Omer Iqbal
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Divisions, Maywood, IL, USA
| | - Fakiha Siddiqui
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Divisions, Maywood, IL, USA
| | - Sean Till
- Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Melissa Mazariegos
- Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Edward Campbell
- Department of Microbiology and Immunology, Loyola University Medical Center, Maywood, IL, USA
| | - Kumaran Mudaliar
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
| | - Jodi Speiser
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
| | - Emily Bontekoe
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Divisions, Maywood, IL, USA
| | - Ahmed Kouta
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Divisions, Maywood, IL, USA
| | - Ambar Farooqui
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Divisions, Maywood, IL, USA
| | - Bharathi Daravath
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Divisions, Maywood, IL, USA
| | - Dalia Qneibi
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Divisions, Maywood, IL, USA
| | - Ramy Sadek
- Department of Medicine, University of California Los Angles, Olive View, Maywood, IL, USA
| | - Debra Hoppensteadt
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Divisions, Maywood, IL, USA
| | - Jawed Fareed
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Divisions, Maywood, IL, USA
| | - Charles Bouchard
- Department of Ophthalmology, Loyola University Medical Center, Maywood, IL, USA
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7
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Yazicioglu M, Gokmirza Ozdemir P, Turgut B, Sut N. Serum soluble Fas ligand levels and peripheral blood lymphocyte subsets in patients with drug-induced maculopapular rashes, dress, and viral exanthemas. Allergol Immunopathol (Madr) 2020; 48:339-347. [PMID: 31375337 DOI: 10.1016/j.aller.2019.02.003] [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: 06/13/2018] [Revised: 02/03/2019] [Accepted: 02/14/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fatty acid synthetase (Fas)/Fas ligand (FasL)-dependent apoptotic pathways have been reported as being involved in the pathogenesis of drug-induced maculopapular rashes. OBJECTIVE We investigated serum soluble FasL (sFasL) levels and peripheral blood lymphocyte subtypes to discriminate maculopapular drug eruptions (MPDE) from viral exanthema (VE). PATIENTS/METHODS Children with confirmed MPDE (group I), VE (group II), and drug rashes with eosinophilia and systemic symptoms (DRESS) or drug-induced hypersensitivity syndrome (DIHS) (group III) were included. Serum sFasL levels and peripheral blood lymphocyte subtypes were analyzed in groups I-III on admission, and repeated twice (only once for group IV - controls). RESULTS There were no significant serum soluble FasL level differences among the groups for all the samples. In the initial samples, CD19+ cell numbers in group II were significantly higher than in group IV, and the CD4+/CD8+ ratio was higher than groups I and IV. In the second samples, CD4+ and CD19+ cell numbers were significantly higher in group II than group I. In the final samples, CD4+ cell numbers in group II were significantly higher than group I and group III. CD19+ cells numbers in group III were significantly lower than the other groups for all samples. CONCLUSION Serum sFasL levels were not found to be useful in discriminating viral exanthemas from other drug rashes. The significant differences between MPDE, VE, and DRESS were high CD4+ and CD19+ cell-count numbers in VE but low B-cell numbers in DRESS. This might be important for discriminating VE from DRESS, and the low B-cell count in early symptoms might be a useful predictor of DRESS development.
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Hasegawa A, Abe R. Recent advances in managing and understanding Stevens-Johnson syndrome and toxic epidermal necrolysis. F1000Res 2020; 9. [PMID: 32595945 PMCID: PMC7308994 DOI: 10.12688/f1000research.24748.1] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 12/15/2022] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening diseases characterized by detachment of the epidermis and mucous membrane. SJS/TEN are considered to be on the same spectrum of diseases with different severities. They are classified by the percentage of skin detachment area. SJS/TEN can also cause several complications in the liver, kidneys, and respiratory tract. The pathogenesis of SJS/TEN is still unclear. Although it is difficult to diagnose early stage SJS/TEN, biomarkers for diagnosis or severity prediction have not been well established. Furthermore, optimal therapeutic options for SJS/TEN are still controversial. Several drugs, such as carbamazepine and allopurinol, are reported to have a strong relationship with a specific human leukocyte antigen (HLA) type. This relationship differs between different ethnicities. Recently, the usefulness of HLA screening before administering specific drugs to decrease the incidence of SJS/TEN has been investigated. Skin detachment in SJS/TEN skin lesions is caused by extensive epidermal cell death, which has been considered to be apoptosis via the Fas-FasL pathway or perforin/granzyme pathway. We reported that necroptosis, i.e. programmed necrosis, also contributes to epidermal cell death. Annexin A1, released from monocytes, and its interaction with the formyl peptide receptor 1 induce necroptosis. Several diagnostic or prognostic biomarkers for SJS/TEN have been reported, such as CCL-27, IL-15, galectin-7, and RIP3. Supportive care is recommended for the treatment of SJS/TEN. However, optimal therapeutic options such as systemic corticosteroids, intravenous immunoglobulin, cyclosporine, and TNF-α antagonists are still controversial. Recently, the beneficial effects of cyclosporine and TNF-α antagonists have been explored. In this review, we discuss recent advances in the pathophysiology and management of SJS/TEN.
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Affiliation(s)
- Akito Hasegawa
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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9
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Lin CC, Chen CB, Wang CW, Hung SI, Chung WH. Stevens-Johnson syndrome and toxic epidermal necrolysis: risk factors, causality assessment and potential prevention strategies. Expert Rev Clin Immunol 2020; 16:373-387. [DOI: 10.1080/1744666x.2020.1740591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Chu-Chi Lin
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Bing Chen
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
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10
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a delayed-type hypersensitivity reaction to drugs. They represent true medical emergencies and an early recognition and appropriate management is decisive for the survival. SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms. The difference between SJS, SJS/TEN overlap, and TEN is defined by the degree of skin detachment: SJS is defined as skin involvement of < 10%, TEN is defined as skin involvement of > 30%, and SJS/TEN overlap as 10-30% skin involvement. The diagnosis of different degrees of epidermal necrolysis is based on the clinical assessment in conjunction with the corresponding histopathology. The mortality rates for SJS and TEN have decreased in the last decades. Today, the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is available for SJS/TEN severity assessment. Drugs with a high risk of causing SJS/TEN are anti-infective sulfonamides, anti-epileptic drugs, non-steroidal anti-inflammatory drugs of the oxicam type, allopurinol, nevirapine, and chlormezanone. Besides conventional drugs, herbal remedies and new biologicals should be considered as causative agents. The increased risk of hypersensitivity reactions to certain drugs may be linked to specific HLA antigens. Our understanding of the pathogenesis of SJS/TEN has improved: drug-specific T cell-mediated cytotoxicity, genetic linkage with HLA- and non-HLA-genes, TCR restriction, and cytotoxicity mechanisms were clarified. However, many factors contributing to epidermal necrolysis still have to be identified, especially in virus-induced and autoimmune forms of epidermal necrolysis not related to drugs. In SJS/TEN, the most common complications are ocular, cutaneous, or renal. Nasopharyngeal, esophageal, and genital mucosal involvement with blisters, erosions as well as secondary development of strictures also play a role. However, in the acute phase, septicemia is a leading cause of morbidity and fatality. Pulmonary and hepatic involvement is frequent. The acute management of SJS/TEN requires a multidisciplinary approach. Immediate withdrawal of potentially causative drugs is mandatory. Prompt referral to an appropriate medical center for specific supportive treatment is of utmost importance. The most frequently used treatments for SJS/TEN are systemic corticosteroids, immunoglobulins, and cyclosporine A.
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Singh S, Khandpur S, Arava S, Rath R, Ramam M, Singh M, Sharma VK, Kabra SK. Assessment of histopathological features of maculopapular viral exanthem and drug-induced exanthem. J Cutan Pathol 2017; 44:1038-1048. [DOI: 10.1111/cup.13047] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 09/10/2017] [Accepted: 09/11/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Sanjay Singh
- Department of Dermatology and Venereology; All India Institute of Medical Sciences; New Delhi India
| | - Sujay Khandpur
- Department of Dermatology and Venereology; All India Institute of Medical Sciences; New Delhi India
| | - Sudheer Arava
- Department of Pathology; All India Institute of Medical Sciences; New Delhi India
| | - Ramashankar Rath
- Department of Centre for Community Medicine; All India Institute of Medical Sciences; New Delhi India
| | - M. Ramam
- Department of Dermatology and Venereology; All India Institute of Medical Sciences; New Delhi India
| | - Manoj Singh
- Department of Pathology; All India Institute of Medical Sciences; New Delhi India
| | - Vinod K. Sharma
- Department of Dermatology and Venereology; All India Institute of Medical Sciences; New Delhi India
| | - Sushil Kumar Kabra
- Department of Paediatrics; All India Institute of Medical Sciences; New Delhi India
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are a spectrum of T-cell mediated immune disorders. While the contributory mechanisms leading to the apoptosis of epidermal cells in SJS/TEN remain unproven, the keratinocyte apoptosis seen in SJS/TEN is thought to occur through the T-cell mediated Fas-Fas ligand (FasL), perforin/granzyme B, and other immune mediators. Most recently, emphasis has been placed on the granulysin pathway as being the primary mediator of apoptosis and widespread epidermal necrosis in SJS/TEN. This article aims to review the proposed mechanisms by which these pathways work and the immunomodulatory therapies that have been developed in an attempt to target them.
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Affiliation(s)
- Hajirah N Saeed
- a Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School , Boston , Massachusetts , USA
| | - James Chodosh
- a Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School , Boston , Massachusetts , USA
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Monitoring the acute response in severe hypersensitivity reactions to drugs. Curr Opin Allergy Clin Immunol 2015; 15:294-9. [DOI: 10.1097/aci.0000000000000180] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abe R. Immunological response in Stevens-Johnson syndrome and toxic epidermal necrolysis. J Dermatol 2014; 42:42-8. [PMID: 25355273 DOI: 10.1111/1346-8138.12674] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 09/17/2014] [Indexed: 11/30/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening cutaneous adverse drug reactions that induce widespread epidermal necrosis. Recent advances in pharmacogenomic studies have provided evidence of genetic predispositions to SJS/TEN. Several concepts have been proposed to explain the pathogenesis of severe cutaneous adverse drug reactions. In the hapten concept, small molecules called haptens elicit an immune response only when attached to proteins. The "p-i" concept postulates that the causative drugs can stimulate cells by binding directly and reversibly to immune receptors. In addition, there is the idea that drugs alter the antigen by binding to the human leukocyte antigen pocket. With regard to keratinocyte death, several cell death mediators, such as FasL, granulysin and annexin A1, have been proposed as playing a role in SJS/TEN pathogenesis. A subset of T lymphocytes, including regulatory T cells, also may play a role in SJS/TEN.
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Affiliation(s)
- Riichiro Abe
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Perkins JR, Ariza A, Blanca M, Fernández TD. Tests for evaluating non-immediate allergic drug reactions. Expert Rev Clin Immunol 2014; 10:1475-86. [DOI: 10.1586/1744666x.2014.966691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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17
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Aurelian L, Burnett JW. Current understanding of herpes simplex virus-associated erythema multiforme. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.3.4.491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ferastraoaru DE, Dickler MN, Patel S, Fischer EA, Pulitzer MP, Myskowski PL, Jerschow E. Nonimmediate Hypersensitivity Reaction After Trastuzumab Infusion: A Suspected Drug-Virus Interaction. J Clin Oncol 2013; 31:e407-9. [DOI: 10.1200/jco.2012.45.9958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Maura N. Dickler
- Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, New York, NY
| | - Sima Patel
- Touro College of Ostheopatic Medicine, New York, NY
| | | | - Melissa P. Pulitzer
- Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, New York, NY
| | - Patricia L. Myskowski
- Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, New York, NY
| | - Elina Jerschow
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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20
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Schwartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis. J Am Acad Dermatol 2013; 69:173.e1-13; quiz 185-6. [DOI: 10.1016/j.jaad.2013.05.003] [Citation(s) in RCA: 187] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/06/2013] [Accepted: 05/10/2013] [Indexed: 11/16/2022]
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Immunological mechanisms of epidermal damage in toxic epidermal necrolysis. Curr Opin Allergy Clin Immunol 2012; 12:376-82. [PMID: 22688730 DOI: 10.1097/aci.0b013e328355b865] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of the present review is to introduce recent findings on the pathomechanisms of toxic epidermal necrolysis (TEN), which is characterized by widespread epidermal detachment due to keratinocyte apoptosis. RECENT FINDINGS In the mechanism of epidermal damage, the roles of drug metabolites, cytotoxic lymphocytes, and apoptosis-inducing factors have been noted. In addition, recent studies have focused on monocytes/macrophages, which may participate in epidermal damage through the production of apoptosis-inducing factors and the expression of costimulatory factors with the ability to activate CD8 T cells. SUMMARY Epidermal keratinocyte death is a hallmark of TEN. In a very high proportion of cases, drugs are responsible for TEN. It has been suggested that toxic drug metabolites produced by keratinocytes act like electrophilic agents to induce apoptosis and inflammation. Next, cytotoxic lymphocytes and monocytes function in the development of widespread epidermal damage through direct or indirect cytotoxic pathways. In addition, T-cell activation may be strengthened by the impairment of regulatory T-cell function and activated monocytes. The development of epidermal damage in TEN may require the coordinated action of these factors.
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Viard-Leveugle I, Gaide O, Jankovic D, Feldmeyer L, Kerl K, Pickard C, Roques S, Friedmann PS, Contassot E, French LE. TNF-α and IFN-γ are potential inducers of Fas-mediated keratinocyte apoptosis through activation of inducible nitric oxide synthase in toxic epidermal necrolysis. J Invest Dermatol 2012; 133:489-98. [PMID: 22992806 DOI: 10.1038/jid.2012.330] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a severe immune-mediated adverse cutaneous drug eruption characterized by rapid and extensive epithelial cell death in the epidermis and mucosae. The molecular events leading to this often fatal condition are only partially understood, but evidence suggests a dual mechanism implicating a "drug"-specific immune response on one side and the onset of target cell death by proapoptotic molecules including FasL on the other side. Herein, we describe a potential molecular bridge between these two events that involves inducible nitric oxide synthase (iNOS), which is highly upregulated in the skin of TEN patients. We show that activated T cells secrete high amounts of tumor necrosis factor-α (TNF-α) and IFN-γ, and that both cytokines lead to increased expression and activity of keratinocyte iNOS. A similar observation has been made with drug-specific T lymphocytes from a TEN patient exposed to the culprit drug. The resulting increase in nitric oxide significantly upregulates keratinocyte FasL expression, resulting in Fas- and caspase-8-mediated keratinocyte cell death. Taken together, our data suggest that T-lymphocyte activation by drugs in TEN patients may indirectly lead to FasL-mediated keratinocyte apoptosis, via a molecular bridge involving TNF-α, IFN-γ, and iNOS.
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Toxic epidermal necrolysis: Review of pathogenesis and management. J Am Acad Dermatol 2012; 66:995-1003. [DOI: 10.1016/j.jaad.2011.09.029] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 09/17/2011] [Accepted: 09/24/2011] [Indexed: 12/29/2022]
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Abstract
Many cutaneous conditions can mimic infection. If these lesions are not accurately recognized, they may be treated with antimicrobial agents, which adds cost, potential risk, and inconvenience to the patient and the healthcare system. The presenting signs and symptoms of many ulcerating, pustular, morbilliform, bullous, neoplastic, granulomatous, autoimmune, and neutrophilic conditions, as well as clinical vasculitis, cellulitis, folliculitis, and panniculitis, have been mistaken for infection. This review emphasizes the clinical presentation, physical exam, and diagnostic workup of many of these conditions to assist the clinician in ascertaining the correct diagnosis. In addition, general treatment options are provided for each disease category.
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Affiliation(s)
- Janelle R Ricketts
- Dermatology Department, University of CT Health Center, Farmington, CT 06030, USA.
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Schlapbach C, Zawodniak A, Irla N, Adam J, Hunger RE, Yerly D, Pichler WJ, Yawalkar N. NKp46+ cells express granulysin in multiple cutaneous adverse drug reactions. Allergy 2011; 66:1469-76. [PMID: 21819408 DOI: 10.1111/j.1398-9995.2011.02677.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The spectrum of cutaneous adverse drug reactions (cADRs) ranges from benign presentations to severe life-threatening forms such as toxic epidermal necrolysis (TEN). In TEN, granulysin has been shown to be the key cytotoxic molecule. Still, little is known about the expression of granulysin in other cADRs. As an important source of granulysin, natural killer (NK) cells are of major interest in cADRs. Recently, NKp46 has been identified as the most selective NK-cell marker. However, the role of NKp46(+) cells in cADRs and their contribution to granulysin expression remain to be elucidated. METHODS Immunohistochemical and immunofluorescence staining of tissue sections from multiple cADRs were quantitatively and qualitatively evaluated. Further, in vivo and in vitro drug-stimulation tests were performed. RESULTS Granulysin is expressed at different levels in multiple cADRs both by NKp46(+) cells and by CD8(+) T cells. Even in mild forms of cADRs, granulysin can be induced in vivo and in vitro in a drug-specific manner. NKp46(+) cells were found to infiltrate the dermal/epidermal junction particularly in TEN. CONCLUSION The impressive clinical differences of cADRs may not be uniquely explained by the expression of granulysin. Additional factors such as drug-specific activation and recruitment of NKp46(+) cells to the epidermis may play a role in determining the severity of cADRs. Therefore, unraveling the effects of drugs on NK-cell activation and trafficking may help to better understand the cytotoxic mechanisms behind cADRs.
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Affiliation(s)
- C Schlapbach
- Department of Dermatology, Inselspital, University of Bern, Switzerland
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Abstract
Once administered, a drug can activate the immune system by various mechanisms and lead to a large range of clinical manifestations closely related to the type of immune reaction elicited. Administration of the drug can classically result in an immunoglobulin E (IgE)-type sensitization, but can also result in more complex activation of the immune system potentially resulting in severe syndromes, such as the drug-induced hypersensitivity syndrome (DIHS). Although there has been a major increase in our knowledge over the last years, the exact mechanisms of drug allergy are not well understood for most clinical manifestations. A complex interaction between individual characteristics, environmental factors, and the drug itself is usually responsible for adverse reactions to drugs. In this educational review series, we described three cases of drug allergy: first, a child with a typical IgE-mediated drug allergy, second, a child with a non-immediate reaction to penicillin, and in the third patient, we will discuss the drug-induced hypersensitivity syndrome, which is rare but potentially fatal. These cases are correlated to the immune mechanism potentially involved.
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Affiliation(s)
- Jean-Christoph Caubet
- Department of Child and Adolescent, University Hospitals of Geneva and Medical School of the University of Geneva, Geneva, Switzerland
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de Araujo E, Dessirier V, Laprée G, Valeyrie-Allanore L, Ortonne N, Stathopoulos EN, Bagot M, Bensussan A, Mockenhaupt M, Roujeau JC, Tsapis A. Death ligand TRAIL, secreted by CD1a+ and CD14+ cells in blister fluids, is involved in killing keratinocytes in toxic epidermal necrolysis. Exp Dermatol 2011; 20:107-12. [PMID: 21255088 DOI: 10.1111/j.1600-0625.2010.01176.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Toxic epidermal necrolysis (TEN) is characterized by an acute detachment and destruction of keratinocytes, affecting large areas of the skin. It is often related to adverse drug reactions. Previous studies have shown that effector CD8+ T cells, which accumulate in the blister fluid, are functionally cytotoxic and act through a classical perforin/granzyme B pathway. It has recently been shown that these cytotoxic T cells also secrete granulysin peptide, which is lethal to keratinocytes. These cytotoxic T cells exert their killer activity against autologous keratinocytes in the presence of the drug. However, they are unlikely to be the only effectors of TEN. We therefore searched for soluble death factors in the blister fluids that might kill keratinocytes. We found that the amounts of interferon-γ, TRAIL and TNF-α proteins were significantly greater in TEN blister fluids than in all controls (normal sera, TEN sera, burns and Eosinophilic pustular folliculitis blister fluids) and TNF-like weak inducer of apoptosis (TWEAK) amounts are also greater in all controls except burns. We showed that these proteins acted in synergy to induce the death of keratinocytes in vitro. We also found that TRAIL and TWEAK were secreted by CD1a+ and CD14+ cells present in the blister fluids. Thus, in addition to MHC class I-restricted cytotoxic T lymphocytes (CTLs), which lyse keratinocytes, ligands secreted by non-lymphoid cells capable of inducing keratinocyte death in an MHC class I-independent manner, also seem to be present in the blister fluids of patients with TEN.
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The role of penicillin in benign skin rashes in childhood: a prospective study based on drug rechallenge. J Allergy Clin Immunol 2010; 127:218-22. [PMID: 21035175 PMCID: PMC7126001 DOI: 10.1016/j.jaci.2010.08.025] [Citation(s) in RCA: 228] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 07/16/2010] [Accepted: 08/09/2010] [Indexed: 11/27/2022]
Abstract
Background Delayed-onset urticarial or maculopapular rashes are frequently observed in children treated with β-lactams. Many are labeled “allergic” without reliable testing. Objective Determine the etiology of these rashes by exploring both infectious and allergic causes. Methods Children presenting to the emergency department with delayed-onset urticarial or maculopapular rashes were enrolled. Acute and convalescent sera were obtained for viral screening along with a throat swab. Subjects underwent intradermal and patch skin testing for β-lactams 2 months after presentation. Anti–β-lactam blood allergy tests were also obtained. All subjects underwent an oral challenge test (OCT) with the culprit antibiotic. Results Eighty-eight children were enrolled between 2006 and 2008. There were 11 (12.5%) positive intradermal and no positive patch tests. There were 2 (2.3%) positive blood allergy tests. There were 6 (6.8%) subjects with a positive OCT, 2 were intradermal-negative, and 4 were intradermal-positive. No OCT reactions were more severe than the index event. Most subjects had at least 1 positive viral study, 54 (65.9%) in the OCT negative group. Conclusion In this situation, β-lactam allergy is clearly overdiagnosed because the skin rash is only rarely reproducible (6.8%) by a subsequent challenge. Viral infections may be an important factor in many of these rashes. OCTs were positive in a minority of intradermal skin test–positive subjects. Patch testing and blood allergy testing provided no useful information. OCTs should be considered in all children who develop a delayed-onset urticarial or maculopapular rash during treatment with a β-lactam.
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Wang ECE, Lee JSS, Tan AWH, Tang MBY. Fas-ligand staining in non-drug- and drug-induced maculopapular rashes. J Cutan Pathol 2010; 38:196-201. [DOI: 10.1111/j.1600-0560.2010.01611.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nagy N, McGrath JA. Blistering skin diseases: a bridge between dermatopathology and molecular biology. Histopathology 2010; 56:91-9. [PMID: 20055907 DOI: 10.1111/j.1365-2559.2009.03442.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although dermatopathology and molecular biology are often considered to be separate laboratory disciplines, the respective approaches are far from mutually exclusive. This is certainly the case for understanding the pathology of blistering skin diseases, both acquired and inherited. For example, in toxic epidermal necrolysis, dermatopathology in isolation may provide few clues to disease pathogenesis. There is widespread keratinocyte apoptosis and a variable infiltrate of cytotoxic T cells, but morphology alone offers little insight into what causes the epidermal destruction. In contrast, molecular biology studies have revealed several key processes that help explain the keratinocyte death, including increased expression of death receptors and their ligands on keratinocyte cell membranes as well as the presence of local or systemic immunocyte-derived cytolytic granules. For some inherited blistering diseases, however, such as epidermolysis bullosa, the molecular pathology is complex and difficult to unravel in isolation, yet the addition of dermatopathology is helpful in focusing molecular investigations. Notably, immunolabelling of cell adhesion proteins using specific antibody probes can identify reduced or absent immunoreactivity for candidate genes/proteins. Bridging dermatopathology and molecular biology investigations facilitates a greater understanding of disease processes, improves diagnostic accuracy, and provides a basis for the development and appraisal of new treatments.
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Affiliation(s)
- Nikoletta Nagy
- St John's Institute of Dermatology, King's College London, Guy's Campus, London, UK
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Rieder MJ. Immune mediation of hypersensitivity adverse drug reactions: implications for therapy. Expert Opin Drug Saf 2010; 8:331-43. [PMID: 19505265 DOI: 10.1517/14740330902933736] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Adverse drug reactions are among the top causes of death in the developed world, and among the spectrum of adverse drug reactions, drug hypersensitivity is a principal contributor to serious adverse drug events. The pathophysiology of drug hypersensitivity remains incompletely understood, but seems to involve the initial recognition of a drug or metabolite by the immune system followed by an immune response that determines the clinical manifestations. At present, there are two competing theories for how immune recognition occurs: the Hapten Hypothesis in which drug hapten-carrier association is the key driver for immune recognition and the Pharmacological Interference Concept that postulates direct recognition of drugs by low affinity association with the T cell receptor. The Danger Hypothesis provides a potentially important addition to the Hapten Hypothesis. Therapy for drug hypersensitivity has traditionally involved excellent supportive care. Although corticosteroids and intravenous immunoglobulin have both been used as immunomodulatory therapy, there is no robust evidence supporting the efficacy of their therapy for drug hypersensitivity. Recent advances in molecular biology and genomic pharmacology offer previously unappreciated opportunities to clarify the controversies surrounding drug hypersensitivity and to better diagnose, treat and, it is hoped, prevent drug hypersensitivity in the future.
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Affiliation(s)
- Michael J Rieder
- University of Western Ontario, Children's Health Research Institute, Schulich School of Medicine & Dentistry, Ontario, Canada.
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Fernando SL, Broadfoot AJ. Prevention of severe cutaneous adverse drug reactions: the emerging value of pharmacogenetic screening. CMAJ 2009; 182:476-80. [PMID: 19933789 DOI: 10.1503/cmaj.090401] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Suran L Fernando
- PaLMS Immunorheumatology Laboratory, Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Reserve Rd, St. Leonards, Sydney, NSW 2065, Australia.
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Yamamoto M, Ikeda M, Kodama H, Sano S. Transition of psoriasiform drug eruption to psoriasis de novo evidenced by histopathology. J Dermatol 2009; 35:732-6. [PMID: 19120769 DOI: 10.1111/j.1346-8138.2008.00558.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Drug reaction can be one of the triggering factors either for exacerbation of pre-existing psoriasis or precipitation of psoriasis de novo. Herein, we report a case with psoriasiform drug eruption due to pravastatin, but it relapsed after discontinuance of the drug. Serial investigation of the histopathology and immunohistochemistry with anti-signal transducer and activator of transcription 3 (STAT3) revealed drug reaction-associated lesions intermingled with psoriasiform changes, which later predominated, suggesting a conversion into psoriasis de novo.
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Affiliation(s)
- Mayuko Yamamoto
- Department of Dermatology, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
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Chung WH, Hung SI, Yang JY, Su SC, Huang SP, Wei CY, Chin SW, Chiou CC, Chu SC, Ho HC, Yang CH, Lu CF, Wu JY, Liao YD, Chen YT. Granulysin is a key mediator for disseminated keratinocyte death in Stevens-Johnson syndrome and toxic epidermal necrolysis. Nat Med 2008; 14:1343-50. [PMID: 19029983 DOI: 10.1038/nm.1884] [Citation(s) in RCA: 491] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Accepted: 09/30/2008] [Indexed: 12/22/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening adverse drug reactions characterized by massive epidermal necrosis, in which the specific danger signals involved remain unclear. Here we show that blister cells from skin lesions of SJS-TEN primarily consist of cytotoxic T lymphocytes (CTLs) and natural killer (NK) cells, and both blister fluids and cells were cytotoxic. Gene expression profiling identified granulysin as the most highly expressed cytotoxic molecule, confirmed by quantitative PCR and immunohistochemistry. Granulysin concentrations in the blister fluids were two to four orders of magnitude higher than perforin, granzyme B or soluble Fas ligand concentrations, and depleting granulysin reduced the cytotoxicity. Granulysin in the blister fluids was a 15-kDa secretory form, and injection of it into mouse skin resulted in features mimicking SJS-TEN. Our findings demonstrate that secretory granulysin is a key molecule responsible for the disseminated keratinocyte death in SJS-TEN and highlight a mechanism for CTL- or NK cell--mediated cytotoxicity that does not require direct cellular contact.
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Tohyama M, Shirakata Y, Sayama K, Hashimoto K. A marked increase in serum soluble Fas ligand in drug-induced hypersensitivity syndrome. Br J Dermatol 2008; 159:981-4. [DOI: 10.1111/j.1365-2133.2008.08750.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lam A, Randhawa I, Klaustermeyer W. Cephalosporin induced toxic epidermal necrolysis and subsequent penicillin drug exanthem. Allergol Int 2008; 57:281-4. [PMID: 18566552 DOI: 10.2332/allergolint.c-07-55] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2007] [Accepted: 01/10/2008] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Drug hypersensitivity is classically divided into IgE mediated and non-IgE mediated disease. We report a rare case of consequent IgE mediated and non-IgE mediated reactions within the beta lactam class of antibiotics. CASE SUMMARY An 84-year-old man developed toxic epidermal necrolysis (TEN) due to ceftriaxone, a third generation cephalosporin, involving 72% of the body surface area. The patient recovered but within weeks subsequently developed an acute IgE mediated allergic reaction to piperacillin/tazobactam, an extended spectrum penicillin. Further IgE RAST revealed positive results to penicillin major determinant. DISCUSSION This case demonstrates the complexity of drug hypersensitivity reactions. While it is accepted that IgE mediated penicillin allergy is a predisposition to cephalosporin allergy, this case displays an unusual correlation between drug hypersensitivity and drug class. There have been few studies that evaluate the cross reactivity with penicillin or other beta-lactams in subjects with primary hypersensitivity to cephalosporins. This clinical scenario emphasizes the need of more studies on cephalosporin allergy in particular as shown by this case of sequential non-IgE mediated cephalosporin induced TEN reaction pursuant by an IgE mediated penicillin allergy.
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Affiliation(s)
- Amanda Lam
- UCLA West Los Angeles VA Medical Center 90073, USA.
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40
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Murata J, Abe R, Shimizu H. Increased soluble Fas ligand levels in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis preceding skin detachment. J Allergy Clin Immunol 2008; 122:992-1000. [PMID: 18692887 DOI: 10.1016/j.jaci.2008.06.013] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 06/06/2008] [Accepted: 06/12/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND It is difficult to distinguish the early phase of Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) from other ordinary types of drug-induced skin reactions (ODSRs). Levels of several serum soluble factors, including soluble Fas ligand (sFasL), have been reported to be increased in patients with SJS/TEN; however, the marker to predict the onset of SJS/TEN before the development of skin detachment or mucosal lesions has not been identified. OBJECTIVE We sought to determine whether sFasL might be a useful marker in the early stages of SJS/TEN. METHODS Sera of 19 patients with SJS and 16 patients with TEN at 1 or multiple time points were obtained from Japanese multiple hospitals. The disease onset (day 1) was defined when erosion/ulceration of the mucocutaneous or ocular lesion first developed. For the investigation of soluble factors, including sFasL, TNF-alpha, IFN-gamma, IL-6, and sCD40 ligand, we used ELISAs and Cytometric Bead Arrays. RESULTS Before disease onset (day -4 to approximately -2), 7 samples were available, and we detected the highest concentrations of sFasL in 5 (71.4%) of 7 patients. Increased sFasL levels decreased rapidly within 5 days of disease onset. In all 32 patients with ODSRs and 33 healthy control subjects, no increase of sFasL levels was detected. Other soluble factor concentrations did not show significant difference with those seen in patients with SJS/TEN before disease onset and ODSRs. CONCLUSION The sFasL levels of sera in patients with SJS/TEN are significantly increased before development of skin detachment, mucosal lesions, or both.
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Affiliation(s)
- Junko Murata
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Borchers AT, Lee JL, Naguwa SM, Cheema GS, Gershwin ME. Stevens-Johnson syndrome and toxic epidermal necrolysis. Autoimmun Rev 2008; 7:598-605. [PMID: 18603022 DOI: 10.1016/j.autrev.2008.06.004] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, but potentially life threatening, diseases characterized by widespread epidermal necrosis, and are predominantly medication-induced. Unfortunately, though they are often associated with long-term debilitating sequelae, there are currently no efficacious pharmaceutical interventions proven through large clinical trials. It has been well established that the epidermal damage in these diseases is due to keratinocyte apoptosis. Although drug-specific T cells are implicated in this process, our understanding of the immunopathology is far from complete. The scenario suggested by today's literature points towards drug-specific CD8+ cytotoxic T cells utilizing perforin/granzyme B trigger keratinocyte apoptosis. Subsequently, there may be an expansion of apoptosis involving the interaction of either membrane-bound or soluble Fas ligand (sFasL) with its receptor Fas. The cellular source of sFasL remains controversial, with both peripheral lymphocytes and keratinocytes themselves as potential candidates. Cytokines produced by T lymphocytes, macrophages or keratinocytes may participate by activating keratinocytes and enhancing their expression of Fas and FasL, or by promoting the skin recruitment of lymphocytes by upregulating adhesion molecules. A better understanding of the underlying immunological mechanisms is required to identify appropriate therapeutic interventions. Finally, clinicians must remain vigilant about drug hypersensitivity to prevent SJS/TEN.
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Affiliation(s)
- Andrea T Borchers
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Suite 6510, Davis, CA 95616, United States
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Abstract
Interface dermatitis can be classified based upon the cell type that dominates the infiltrate (ie, neutrophilic, lymphocytic, or lymphohistiocytic) or by the intensity of the interface inflammation. Regarding lymphocytic interface dermatitis, there are 2 broad categories: cell-poor interface dermatitis, when only a sparse infiltrate of inflammatory cells is present along the dermoepidermal junction, or cell rich, which typically occurs as a heavy bandlike infiltrate that obscures the basal layers of the epidermis. In the case of lymphocytic interface dermatitis, the latter is often termed a lichenoid interface dermatitis. This review focuses upon the mononuclear cell-predominant forms of interface dermatitis.
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Affiliation(s)
- A Neil Crowson
- Department of Dermatology, University of Oklahoma and Regional Medical Laboratories, St John Medical Center, 1923 S Utica Ave, Tulsa, OK 74104, USA.
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Farley SM, Purdy DE, Ryabinina OP, Schneider P, Magun BE, Iordanov MS. Fas ligand-induced proinflammatory transcriptional responses in reconstructed human epidermis. Recruitment of the epidermal growth factor receptor and activation of MAP kinases. J Biol Chem 2007; 283:919-28. [PMID: 17977827 DOI: 10.1074/jbc.m705852200] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Fas ligand (FasL) exerts potent proapoptotic and proinflammatory actions on epidermal keratinocytes and has been implicated in the pathogenesis of eczema, toxic epidermal necrolysis, and drug-induced skin eruptions. We used reconstructed human epidermis to investigate the mechanisms of FasL-induced inflammatory responses and their relationships with FasL-triggered caspase activity. Caspase activity was a potent antagonist of the pro-inflammatory gene expression triggered by FasL prior to the onset of cell death. Furthermore, we found that FasL-stimulated autocrine production of epidermal growth factor receptor (EGFR) ligands, and the subsequent activation of EGFR and ERK1 and ERK2 mitogen-activated protein kinases, were obligatory extracellular steps for the FasL-induced expression of a subset of inflammatory mediators, including CXCL8/interleukin (IL)-8, ICAM-1, IL-1alpha, IL-1beta, CCL20/MIP-3alpha, and thymic stromal lymphopoietin. These results expand the known physiological role of EGFR and its ligands from promoting keratinocyte mitogenesis and survival to mediating FasL-induced epidermal inflammation.
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Affiliation(s)
- Sherry M Farley
- Department of Cell and Developmental Biology, Oregon Health & Science University, Portland, Oregon 97239, USA
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Murata J, Abe R. Soluble Fas ligand: is it a critical mediator of toxic epidermal necrolysis and Stevens-Johnson syndrome? J Invest Dermatol 2007; 127:744-5. [PMID: 17363955 DOI: 10.1038/sj.jid.5700693] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although soluble Fas ligand (sFasL) is an important candidate in toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS), Stur and colleagues report that elevated sFasL has been detected in maculopapular rashes. In addition to sFasL, other factors, including predisposing genetic factors, should also be investigated to determine their precise pathogenesis in TEN and SJS.
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Affiliation(s)
- Junko Murata
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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