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Fabian IM, Maddox K, Robicheaux C, Islam RK, Anwar A, Dorius B, Robinson CL, Kaye AM, Varrassi G, Ahmadzadeh S, Shekoohi S, Kaye AD. Stevens-Johnson Syndrome From Combined Allopurinol and Angiotensin-Converting Enzyme Inhibitors: A Narrative Review. Cureus 2024; 16:e51899. [PMID: 38333456 PMCID: PMC10850002 DOI: 10.7759/cureus.51899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
Stevens-Johnson syndrome (SJS) is a severe and potentially debilitating skin reaction frequently related to medication use. Allopurinol and angiotensin-converting enzyme (ACE) inhibitors are commonly prescribed medications for prevalent health conditions worldwide, and their interaction associated with SJS warrants further investigation. A comprehensive literature search was performed to investigate cases as studies related to SJS occurring in patients with concomitant use of allopurinol and ACE inhibitors. We identified case reports and studies detailing hypersensitivity reactions, including SJS, attributed to a combination of allopurinol and ACE inhibitors. Despite the drug-drug interactions or lack thereof seen in patient populations, there is no definitive evidence of a pharmacokinetic interaction between allopurinol and ACE inhibitors. We were only able to find one case report specifically detailing SJS in a patient on combined ACE inhibitors and allopurinol. While the exact mechanism of the interaction is unclear, those reported cases of severe hypersensitivity reactions suggest a previous history of impaired renal function as a predisposing factor in the development of SJS. The potential risk of SJS with coadministration of ACE inhibitors and allopurinol is a drug-drug interaction that physicians should be aware of. This topic requires additional attention to determine if this drug combination should be avoided entirely in certain patients.
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Affiliation(s)
- Isabella M Fabian
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Kirsten Maddox
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Cameron Robicheaux
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Rahib K Islam
- School of Medicine, Louisiana State University Health Sciences Center (LSUHSC) New Orleans, New Orleans, USA
| | - Ahmed Anwar
- Department of Psychology, Quinnipiac University, Hamden, USA
| | - Bradley Dorius
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences University of the Pacific, Stockton, USA
| | | | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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DeNiro KL, Honari S, Hippe DS, Dai A, Pham TN, Caceres M, Mandell SP, Duong PQ, McMullen KA, Gibran NS. Physical and Psychological Recovery Following Toxic Epidermal Necrolysis: A Patient Survey. J Burn Care Res 2021; 42:1227-1231. [PMID: 34105730 DOI: 10.1093/jbcr/irab109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are acute, life-threatening diseases that cause sloughing of the skin and mucous membranes. Despite improved survival rates, few studies focus on long-term outcomes. We conducted a single-center review of all patients with SJS/TEN admitted from January 2008-2014. SJS/TEN survivors were invited to participate in the validated Veterans RAND 12 Item Health Survey (VR-12) to assess health related quality of life using a mental health composite score (MCS) and physical health component score (PCS). The sample was compared to US norms using one sample two tailed t-tests. A second questionnaire addressed potential long-term medical complications related to SJS/TEN. Of 81 treated subjects, 24 (30%) long-term survivors responded. Participants identified cutaneous sequelae most frequently (79%), followed by nail problems (70%), oral (62%) and ocular (58%) sequalae. Thirty-eight percent rated their quality of life to be "unchanged" to "much better" since their episode of SJS/TEN. The average PCS score was lower than US population norms (mean: 36 vs. 50, p=0.006), indicating persistent physical sequelae from SJS/TEN. These results suggest that SJS/TEN survivors continue to suffer from long-term complications that impair their quality of life and warrant ongoing follow-up by a multidisciplinary care team.
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Affiliation(s)
| | - Shari Honari
- Department of Surgery, University of Washington Medicine UW Medicine Regional Burn Center, Seattle, WA
| | - Dan S Hippe
- Department of Radiology, University of Washington, Seattle, WA
| | - Andrea Dai
- Department of Surgery, University of Washington Medicine UW Medicine Regional Burn Center, Seattle, WA
| | - Tam N Pham
- Department of Surgery, University of Washington Medicine UW Medicine Regional Burn Center, Seattle, WA
| | - Maria Caceres
- Department of Surgery, University of Washington Medicine UW Medicine Regional Burn Center, Seattle, WA.,Huntsville Hospital, Huntsville, AL
| | - Samuel P Mandell
- Department of Surgery, University of Washington Medicine UW Medicine Regional Burn Center, Seattle, WA
| | - Phi Q Duong
- Department of Surgery, University of Washington Medicine UW Medicine Regional Burn Center, Seattle, WA.,Seattle Children's Research Institute, Seattle, WA
| | - Kara A McMullen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Nicole S Gibran
- Department of Surgery, University of Washington Medicine UW Medicine Regional Burn Center, Seattle, WA
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Russo V, Klein T, Lim DJ, Solis N, Machado Y, Hiroyasu S, Nabai L, Shen Y, Zeglinski MR, Zhao H, Oram CP, Lennox PA, Van Laeken N, Carr NJ, Crawford RI, Franzke CW, Overall CM, Granville DJ. Granzyme B is elevated in autoimmune blistering diseases and cleaves key anchoring proteins of the dermal-epidermal junction. Sci Rep 2018; 8:9690. [PMID: 29946113 PMCID: PMC6018769 DOI: 10.1038/s41598-018-28070-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 06/15/2018] [Indexed: 01/23/2023] Open
Abstract
In healthy skin, epidermis and dermis are anchored together at the dermal-epidermal junction (DEJ), a specialized basement membrane pivotal for skin integrity and function. However, increased inflammation in the DEJ is associated with the disruption and separation of this junction and sub-epidermal blistering. Granzyme B (GzmB) is a serine protease secreted by immune cells. Dysregulated inflammation may lead to increased GzmB accumulation and proteolysis in the extracellular milieu. Although elevated GzmB is observed at the level of the DEJ in inflammatory and blistering skin conditions, the present study is the first to explore GzmB in the context of DEJ degradation in autoimmune sub-epidermal blistering. In the present study, GzmB induced separation of the DEJ in healthy human skin. Subsequently, α6/β4 integrin, collagen VII, and collagen XVII were identified as extracellular substrates for GzmB through western blot, and specific cleavage sites were identified by mass spectrometry. In human bullous pemphigoid, dermatitis herpetiformis, and epidermolysis bullosa acquisita, GzmB was elevated at the DEJ when compared to healthy samples, while α6/β4 integrin, collagen VII, and collagen XVII were reduced or absent in the area of blistering. In summary, our results suggest that regardless of the initial causation of sub-epidermal blistering, GzmB activity is a common final pathway that could be amenable to a single targeted treatment approach.
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Affiliation(s)
- Valerio Russo
- International Collaboration On Repair Discoveries (ICORD) Research Centre, Vancouver, BC, V5Z 1M9, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
- BC Professional Firefighters' Burn and Wound Healing Research Laboratory, Vancouver, BC, V5Z 1M9, Canada
| | - Theo Klein
- Centre for Blood Research, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Oral Biological and Medical Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Darielle J Lim
- International Collaboration On Repair Discoveries (ICORD) Research Centre, Vancouver, BC, V5Z 1M9, Canada
| | - Nestor Solis
- Centre for Blood Research, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Oral Biological and Medical Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Yoan Machado
- Centre for Blood Research, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Oral Biological and Medical Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Sho Hiroyasu
- International Collaboration On Repair Discoveries (ICORD) Research Centre, Vancouver, BC, V5Z 1M9, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
- BC Professional Firefighters' Burn and Wound Healing Research Laboratory, Vancouver, BC, V5Z 1M9, Canada
| | - Layla Nabai
- International Collaboration On Repair Discoveries (ICORD) Research Centre, Vancouver, BC, V5Z 1M9, Canada
- BC Professional Firefighters' Burn and Wound Healing Research Laboratory, Vancouver, BC, V5Z 1M9, Canada
| | - Yue Shen
- International Collaboration On Repair Discoveries (ICORD) Research Centre, Vancouver, BC, V5Z 1M9, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
- BC Professional Firefighters' Burn and Wound Healing Research Laboratory, Vancouver, BC, V5Z 1M9, Canada
| | - Matthew R Zeglinski
- International Collaboration On Repair Discoveries (ICORD) Research Centre, Vancouver, BC, V5Z 1M9, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
- BC Professional Firefighters' Burn and Wound Healing Research Laboratory, Vancouver, BC, V5Z 1M9, Canada
| | - Hongyan Zhao
- International Collaboration On Repair Discoveries (ICORD) Research Centre, Vancouver, BC, V5Z 1M9, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
- BC Professional Firefighters' Burn and Wound Healing Research Laboratory, Vancouver, BC, V5Z 1M9, Canada
| | - Cameron P Oram
- International Collaboration On Repair Discoveries (ICORD) Research Centre, Vancouver, BC, V5Z 1M9, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
- BC Professional Firefighters' Burn and Wound Healing Research Laboratory, Vancouver, BC, V5Z 1M9, Canada
| | - Peter A Lennox
- Department of Surgery, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
| | - Nancy Van Laeken
- Department of Surgery, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
| | - Nick J Carr
- Department of Surgery, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
| | - Richard I Crawford
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, V5Z 4E8, Canada
| | - Claus-Werner Franzke
- Department of Dermatology, Medical Center and Faculty of Medicine - University of Freiburg, 79104, Freiburg, Germany
| | - Christopher M Overall
- Centre for Blood Research, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Oral Biological and Medical Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - David J Granville
- International Collaboration On Repair Discoveries (ICORD) Research Centre, Vancouver, BC, V5Z 1M9, Canada.
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada.
- BC Professional Firefighters' Burn and Wound Healing Research Laboratory, Vancouver, BC, V5Z 1M9, Canada.
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Interleukin-15 Is Associated with Severity and Mortality in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. J Invest Dermatol 2016; 137:1065-1073. [PMID: 28011147 DOI: 10.1016/j.jid.2016.11.034] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/20/2016] [Accepted: 11/23/2016] [Indexed: 01/31/2023]
Abstract
Early diagnosis and prognosis monitoring for Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN) still remain a challenge. This study aims to explore any cytokine/chemokine with prognostic potential in Stevens-Johnson syndrome/TEN. Through screening a panel of 28 serological factors, IL-6, IL-8, IL-15, tumor necrosis factor-α, and granulysin were upregulated in patients with Stevens-Johnson syndrome/TEN and selected for the further validation in total 155 patients with Stevens-Johnson syndrome/TEN, including 77 from Taiwan and 78 from the Registry of Severe Cutaneous Adverse Reactions. Among these factors evaluated, the levels of IL-15 (r = 0.401; P < 0.001) and granulysin (r = 0.223; P = 0.026) were significantly correlated with the disease severity in 112 samples after excluding patients with insufficient data to calculate the score of TEN. In addition, IL-15 was also associated with mortality (P = 0.002; odds ratio, 1.09; 95% confidence interval, 1.03-1.14; P = 0.001; adjusted odds ratio, 1.10; 95% confidence interval, 1.04-1.16). Consistent results were obtained after the exclusion of Taiwanese patients with sepsis to rule out possible confounders. Moreover, IL-15 was shown to enhance cytotoxicity of cultured natural killer cells and blister cells from patients with TEN. Our findings highlight a usefulness of IL-15 in prognosis monitoring and therapeutic intervention of this devastating condition.
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Dao RL, Su SC, Chung WH. Recent advances of pharmacogenomics in severe cutaneous adverse reactions: immune and nonimmune mechanisms. Asia Pac Allergy 2015; 5:59-67. [PMID: 25938070 PMCID: PMC4415181 DOI: 10.5415/apallergy.2015.5.2.59] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 03/22/2015] [Indexed: 01/11/2023] Open
Abstract
Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) are severe cutaneous adverse reactions (SCAR) which are majorly caused by drugs. Though the incidence rate is low, SCAR sometimes can be life-threatening and leads to lifelong sequelae. Many pharmacogenomic associations in immune and nonimmune related genes with the development of SCAR have been discovered recently and the pharmacogenetic tests have been applied to prevent specific drug-induced SCAR. In this review, we discuss the recent advances of pharmacogenomics in SCAR.
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Affiliation(s)
- Ro-Lan Dao
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospitals, Taipei, Linkou, and Keelung, Taiwan. ; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shih-Chi Su
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospitals, Taipei, Linkou, and Keelung, Taiwan. ; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospitals, Taipei, Linkou, and Keelung, Taiwan. ; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
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Ben Salem C, Badreddine A, Belajouza O, Belajouza C, Ghariani N, Houssem H. Toxic epidermal necrolysis: a retrospective analysis of 17 cases from central Tunisia. Pan Afr Med J 2014; 19:269. [PMID: 25870724 PMCID: PMC4391892 DOI: 10.11604/pamj.2014.19.269.3987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 06/23/2014] [Indexed: 11/23/2022] Open
Abstract
Toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a rare, life-threatening and wide-spread exfoliative disease of the skin and mucous membrane that is most commonly drug-induced. We retrospectively reviewed the charts of 17 patients who suffered from TEN in Farhat Hached University Hospital, Sousse, Tunisia over a 19-year period from January 1994 to January 2013. Causality for suspected drugs was assessed by means of the Naranjo adverse drug reaction (ADR) probability scale. Antibiotics, mainly ß-lactams, were the most common implicated drugs, followed by nonsteroidal anti-inflammatory drugs, anticonvulsants, and allopurinol. The interval between drug intake and onset of the first symptom ranged between few hours and 19 days with a mean period of 6.11 days. There was extensive skin detachment, averaging 66.17% of total body surface area (range 40-95%). The most major complication was infection, occurring in 9 patients (53%). Seven patients died with a mortality rate of 41%.
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Affiliation(s)
- Chaker Ben Salem
- Department of Clinical Pharmacology, Faculty of Medicine of Sousse, Tunisia
| | - Atef Badreddine
- Department of Clinical Pharmacology, Faculty of Medicine of Sousse, Tunisia
| | - Omar Belajouza
- Dermatology Ward, Farhat Hached University Hospital, Sousse, Tunisia
| | | | - Najet Ghariani
- Dermatology Ward, Farhat Hached University Hospital, Sousse, Tunisia
| | - Hmouda Houssem
- Medical Intensive Care, Medical Intensive Care Unit, Sahloul University Hospital, Sousse, Tunisia
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7
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Amniotic Membrane Transplantation in Acute Toxic Epidermal Necrolysis: Histopathologic Changes and Ocular Surface Features after 1-Year follow-up. Eur J Ophthalmol 2014; 24:667-75. [DOI: 10.5301/ejo.5000434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2014] [Indexed: 11/20/2022]
Abstract
Purpose To evaluate ocular features and histopathologic changes in patients with toxic epidermal necrolysis (TEN) treated with amniotic membrane transplantation (AMT) in the acute phase. Methods A prospective study of 5 eyes (3 patients) with severe ocular involvement and 4 eyes (2 patients) with moderate involvement treated with AMT in the acute phase of TEN was performed. Patients underwent a complete ophthalmic assessment before the intervention and 3, 6, 9, and 12 months postoperatively. Tear film break-up time (BUT), Schirmer test, fluorescein_staining, corneal and conjunctival epithelial squamous metaplasia, ocular sequelae, and conjunctival retraction were measured. Results In patients with severe involvement, 2 eyes (40%) showed mild symblepharon and peripheral corneal neovascularization, and corneal epithelial defects, lid margin malposition, and trichiasis was found in 20% of the eyes; only 1 eye (20%) required surgery for structural defects. We did not find ocular sequelae after 1-year follow-up in the patients with moderate involvement. Only 1 eye (25%) developed mild symblepharon that did not require specific treatment. Amniotic membrane transplantation significantly improved the squamous metaplasia in corneal and conjunctival nonsecretory epithelial cells, and significantly improved the goblet cells density after 1-year follow-up. Conclusions Amniotic membrane transplantation performed for acute TEN reduced inflammation and ocular surface scarring, improved dry eye and squamous metaplasia. and decreased ocular sequelae in the chronic stage. Although further and prospective studies are needed, AMT may be the optimal treatment for acute TEN with severe or moderate ocular involvement.
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Mahar PD, Wasiak J, Hii B, Cleland H, Watters DA, Gin D, Spinks AB. A systematic review of the management and outcome of toxic epidermal necrolysis treated in burns centres. Burns 2014; 40:1245-54. [PMID: 24685065 DOI: 10.1016/j.burns.2014.02.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 12/20/2013] [Accepted: 02/11/2014] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Toxic epidermal necrolysis (TEN) is a rare condition characterised by mucocutaneous exfoliation of greater than 30% total body surface area (%TBSA), increasingly being treated in burns centres. The rate of mortality varies significantly in the literature, with recent prospective studies in non-burns centres reporting percentage mortality of approximately 45%. We undertook a systematic review of published studies that included TEN patients treated specifically in burns centres to determine a cumulative mortality rate. METHODS Electronic searches of MEDLINE, EMBASE and The Cochrane Library (Issue 4, 2010) databases from 1966 onwards were used to identify English articles related to the treatment of TEN in burns centres. RESULTS The systematic literature search identified 20 studies which specifically described patients with TEN grater than 30% %TBSA. Treatment regimens varied amongst studies, as did mortality. The overall percentage mortality of the combined populations was 30%. Risk factors commonly described as associated with mortality included age, %TBSA and delay to definitive treatment. CONCLUSION The review highlights the variation between principles of treatment and mortality amongst burns centres. It offers a standard that burns centre can use to internationally compare their mortality rates. The review supports the ongoing reporting of outcomes in TEN patients with epidermal detachment greater than 30%.
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Affiliation(s)
- Patrick D Mahar
- Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Dermatology, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, School of Medicine, Faculty of Health, Deakin University, Victoria, Australia.
| | - Jason Wasiak
- Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Belinda Hii
- Department of Plastic and Reconstructive Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Heather Cleland
- Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Central and Eastern Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - David A Watters
- Department of Surgery, School of Medicine, Faculty of Health, Deakin University, Victoria, Australia
| | - Douglas Gin
- Department of Dermatology, The Alfred Hospital, Melbourne, Victoria, Australia
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Mittal N, Gupta M, Singla M. Cutaneous adverse drug reactions notified by pharmacovigilance in a tertiary care hospital in north India. Cutan Ocul Toxicol 2014; 33:289-93. [PMID: 24517496 DOI: 10.3109/15569527.2013.857678] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Medication-related adverse events, apart from causing significant morbidity and mortality, increase the healthcare cost burden and lead to early treatment discontinuations. OBJECTIVES Knowing the fact that cutaneous adverse drug reactions (cADRs) are most frequent, this study was conducted with an aim to describe their clinical profiles and preventive strategies. METHODS All adverse drug reaction (ADR) forms filled from January 2012 to January 2013 were scrutinised and forms with cADRs analysed and assessed for causality, preventability and severity. RESULTS Of 400 ADR forms, 109 included cADRs. Sixty-eight percent patients were males and mean ± SD age was 35 ± 18 years. Rash, Steven-Johnson syndrome and toxic epidermal necrolysis were the most common presentations. Most frequent culprit drugs included antibiotics and anti-inflammatory agents. Causality was probable or possible in majority. Ninety percent cases were "not preventable". Majority of the patients had mild to moderate reactions and recovered completely after medical management. CONCLUSIONS Pharmacovigilance, with special attention to monitoring and reporting of cADRs must be encouraged. As major bulk of cADRs result from physician prescribed drugs, awareness on part of the physician can help in their timely detection and management, thereby restricting the associated damage.
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Affiliation(s)
- Niti Mittal
- Postgraduate Institute of Medical Sciences , Rohtak, Haryana , India
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11
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Naveen KN, Pai VV, Rai V, Athanikar SB. Retrospective analysis of Steven Johnson syndrome and toxic epidermal necrolysis over a period of 5 years from northern Karnataka, India. Indian J Pharmacol 2013; 45:80-2. [PMID: 23543919 PMCID: PMC3608301 DOI: 10.4103/0253-7613.106441] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 09/28/2012] [Accepted: 10/29/2012] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Cutaneous drug reactions are the most common type of adverse drug reactions. Adverse cutaneous drug reactions form 2-3% of the hospitalized patients. 2% of these are potentially serious. This study aims to detect the drugs commonly implicated in Steven Johnson Syndrome-Toxic Epidermal Necrosis (SJS-TEN). MATERIALS AND METHODS A retrospective analysis was done in all patients admitted in the last five years in SDM hospital with the diagnosis of SJS-TEN. RESULTS A total of 22 patients with SJS-TEN were studied. In 11 patients anti-epileptics was the causal drug and in 7, anti-microbials was the causal drug. Recovery was much faster in case of anti epileptics induced SJS-TEN as compared to that induced by ofloxacin. CONCLUSION SJS-TEN induced by ofloxacin has a higher morbidity and mortality compared to anti convulsants.
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Affiliation(s)
- Kikkeri Narayanasetty Naveen
- Department of Dermatology, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Dharwad, Karnataka, India
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Prabhasawat P, Tesavibul N, Karnchanachetanee C, Kasemson S. Efficacy of cyclosporine 0.05% eye drops in Stevens Johnson syndrome with chronic dry eye. J Ocul Pharmacol Ther 2013; 29:372-7. [PMID: 23289903 DOI: 10.1089/jop.2012.0009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of cyclosporine 0.05% (CsA) eye drops in patients with Stevens Johnson syndrome (SJS) who had chronic dry eye. DESIGN Prospective noncomparative interventional case series. METHODS Thirty cases of SJS patients who developed dry eye defined by symptoms and signs, including the Schirmer I test, the fluorescein clearance test (FCT), and corneal staining (fluorescein and Rose Bengal staining) were treated with CsA 0.05% eye drops twice daily for 6 months. Dry eye symptoms, eye injection, tear break up time (TBUT), and corneal staining were evaluated before and after the treatment at 0, 2, 4, and 6 months. The Shirmer I test and FCT were evaluated at 0 and 6 months. RESULTS Seventeen patients (56.67%) completed the study. Eight patients (26.67%) withdrew from the study as a result of intolerable side effects of CsA, which included pain, redness, and eyelid swelling. Five cases were lost in follow up. All 17 cases demonstrated significant improvement in dry eye symptoms, conjunctival injection, corneal staining, Schirmer I test, and FCT (P<0.05). CONCLUSIONS CsA 0.05% eye drops might be beneficial in the treatment of chronic dry eye associated with SJS.
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Affiliation(s)
- Pinnita Prabhasawat
- Department of Ophthalmology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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13
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Ang CC, Tay YK. Hematological abnormalities and the use of granulocyte-colony-stimulating factor in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. Int J Dermatol 2012; 50:1570-8. [PMID: 22098009 DOI: 10.1111/j.1365-4632.2011.05007.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Derangements in blood cell counts have been described in patients with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) but are not well characterized. We aim to describe the relationship between our patients' hematological results and the evolution of disease and hypothesize on the possible roles of granulocyte-colony-stimulating factor (G-CSF) in the management of these conditions. MATERIALS AND METHODS Clinical records of our patients with SJS and TEN from January 2005 to 2010 were analyzed. RESULTS Anemia and lymphopenia were most commonly seen, while thrombocytopenia was uncommon. Leukopenia and neutropenia were seen in patients with more severe disease, and the trend of leukopenia and neutropenia followed the evolution of disease. Two patients received G-CSF for febrile neutropenia and had a rapid recovery of their neutrophil counts as well as a shorter time to re-epithelialization. CONCLUSION Our patients tended to have leukopenia and neutropenia that followed a predictable trend of decline and subsequent improvement depending on the stage of disease. This may be of pathogenic significance, and G-CSF may be used in these cases to manage febrile neutropenia and aid re-epithelialization. Further basic science research is required to prove our hypotheses.
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Affiliation(s)
- Chia-Chun Ang
- Department of Dermatology, Changi General Hospital, Singapore.
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Abstract
OBJECTIVES The aims of this review are to summarize the definitions, causes, and clinical course as well as the current understanding of the genetic background, mechanism of disease, and therapy of toxic epidermal necrolysis and Stevens-Johnson syndrome. DATA SOURCES PubMed was searched using the terms toxic epidermal necrolysis, Stevens-Johnson syndrome, drug toxicity, drug interaction, and skin diseases. DATA SYNTHESIS Toxic epidermal necrolysis and Stevens-Johnson syndrome are acute inflammatory skin reactions. The onset is usually triggered by infections of the upper respiratory tract or by preceding medication, among which nonsteroidal anti-inflammatory agents, antibiotics, and anticonvulsants are the most common triggers. Initially the diseases present with unspecific symptoms, followed by more or less extensive blistering and shedding of the skin. Complete death of the epidermis leads to sloughing similar to that seen in large burns. Toxic epidermal necrolysis is the most severe form of drug-induced skin reaction and includes denudation of >30% of total body surface area. Stevens-Johnson syndrome affects <10%, whereas involvement of 10%-30% of body surface area is called Stevens-Johnson syndrome/toxic epidermal necrolysis overlap. Besides the skin, mucous membranes such as oral, genital, anal, nasal, and conjunctival mucosa are frequently involved in toxic epidermal necrolysis and Stevens-Johnson syndrome. Toxic epidermal necrolysis is associated with a significant mortality of 30%-50% and long-term sequelae. Treatment includes early admission to a burn unit, where treatment with precise fluid, electrolyte, protein, and energy supplementation, moderate mechanical ventilation, and expert wound care can be provided. Specific treatment with immunosuppressive drugs or immunoglobulins did not show an improved outcome in most studies and remains controversial. The mechanism of disease is not completely understood, but immunologic mechanisms, cytotoxic reactions, and delayed hypersensitivity seem to be involved. CONCLUSION Profound knowledge of exfoliative skin diseases is needed to improve therapy and outcome of these life-threatening illnesses.
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Sanmarkan AD, Sori T, Thappa DM, Jaisankar TJ. Retrospective analysis of stevens-johnson syndrome and toxic epidermal necrolysis over a period of 10 years. Indian J Dermatol 2011; 56:25-9. [PMID: 21572786 PMCID: PMC3088929 DOI: 10.4103/0019-5154.77546] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN), are the acute emergencies in dermatology practice. Prompt diagnosis and management may reduce the morbidity and mortality in SJS/TEN patients. Early identification of the offending drug is necessary for early withdrawal and to prevent the recurrences of such a devastating illness. Aims To study the demography, offending agents, clinical and laboratory features, treatment, complications, morbidity and mortality of SJS/TEN in our hospital. Materials and Methods: In this retrospective study, we reviewed the medical records of SJS, TEN, SJS/TEN overlap of inpatients over a period of 10 years Results: Maximum number of SJS/TEN cases were in the age group of 11-30 years. Males predominated in the SJS group with a ratio of 1.63:1, whereas females predominated the TEN group with a ratio of 1:2.57.Nonsteroidal anti-inflammatory drugs (NSAIDs) were the commonest group of drugs among the SJS group in 5/21 patients (23.8%). Antimicrobials were the commonest group of drugs causing TEN in 11/25 patients (44%). Mucosal lesions preceded the onset of skin lesions in nearly 50%. Our study had one patient each of SJS/TEN due to amlodipine and Phyllanthus amarus, an Indian herb. The most common morbidity noted in our study was due to ocular sequelae and sepsis leading to acute renal failure respectively. Kaposi's varicelliform eruption was found in three of our patients. Conclusion: Antimicrobials and NSAIDS are the common offending agents of SJS/TEN in our study.
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Affiliation(s)
- Abarna Devi Sanmarkan
- Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605 006, India
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Sofi FA, Koul PA, Mufti SA, Dhobi GN. Lamotrigine-induced toxic epidermal necrolysis in a young epileptic. BMJ Case Rep 2011; 2011:bcr.04.2011.4149. [PMID: 22693302 DOI: 10.1136/bcr.04.2011.4149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 20-year-old young female presented with extensive skin rashes with bullae and extensive epidermal necrolysis about 20 days after the addition of lamotrigine (LTG) to her anticonvulsant medication. The patient was managed by stopping LTG and supportive treatment. The seizures were controlled with increase in the doses of carbamazepine. The report emphasises exercising of caution once LTG is added to a regimen containing valproic acid.
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Affiliation(s)
- Fayaz A Sofi
- Department of Internal and Pulmonary Medicine, SheriKashmir Institute of Medical Sciences, Srinagar, India
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Abstract
The aim of this review was to describe the current evidence-based knowledge of the epidemiology, prevalence, incidence, risk factors and genetic associations of drug allergy. Articles published between 1966 and 2010 were identified in MEDLINE using the key words adult, adverse drug reaction reporting systems, age factors, anaphylactoid, anaphylaxis, anaesthetics, antibiotics, child, drug allergy, drug eruptions, ethnic groups, hypersensitivity, neuromuscular depolarizing agents, neuromuscular nondepolarizing agents, sex factors, Stevens Johnson syndrome and toxic epidermal necrolysis. Additional studies were identified from article reference lists. Relevant, peer-reviewed original research articles, case series and reviews were considered for review. Current epidemiological studies on adverse drug reactions (ADRs) have used different definitions for ADR-related terminology, often do not differentiate immunologically and non-immunologically mediated drug hypersensitivity, study different study populations (different ethnicities, inpatients or outpatients, adults or children), utilize different methodologies (spontaneous vs. non-spontaneous reporting, cohort vs. case-control studies), different methods of assessing drug imputability and different methods of data analyses. Potentially life-threatening severe cutaneous adverse reactions (SCAR) are associated with a high risk of morbidity and mortality. HLA associations for SCAR associated with allopurinol, carbamazepine and abacavir have been reported with the potential for clinical use in screening prior to prescription. Identification of risk factors for drug allergy and appropriate genetic screening of at-risk ethnic groups may improve the outcomes of drug-specific SCAR. Research and collaboration are necessary for the generation of clinically-relevant, translational pharmacoepidemiological and pharmacogenomic knowledge, and success of health outcomes research and policies on drug allergies.
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Affiliation(s)
- Bernard Y-H Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore.
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An update on diagnosis and treatment of toxic epidermal necrolysis / Novine u dijagnostici i lečenju toksične epidermalne nekrolize. SERBIAN JOURNAL OF DERMATOLOGY AND VENEREOLOGY 2011. [DOI: 10.2478/v10249-011-0037-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Toxic epidermal necrolysis is an idiosyncratic drug reaction which manifests with extensive epidermal detachment due to the massive keratinocyte apoptosis, mucous membrane involvement, and potentially lethal outcome. It is caused by adverse reactions to drugs, mostly idiosyncratic, unpredictable and independent of the applied dose, which develops 7-21 days after initiation of the drug, and is most commonly caused by the following drugs: sulfonamides, allopurinol, carbamazepine, phenobarbitone, phenytoin and oxycam group of nonsteroidal anti-inflammatory drugs. The treatment outcome depends on several factors, while older age, multiple drug use, late exclusion of the drug inducing toxic epidermal necrolysis, raised serum levels of urea, creatinine and cytopenia are poor prognostic indicators which are rated in SCORTEN scoring which proved to be of great help in the assessment of disease outcome. The basic approach to the treatment is early diagnosis, immediate suspension of the probable inducing drug, and emergency transport to the closest burn center, since treatment in burn units is associated with a lower risk of infection and mortality of these patients. Exclusion of the drug that induced toxic epidermal necrolysis, and supportive therapy, is the first and only therapy for which there is a consensus in different centers. Various forms of adjuvant therapy are also applied: in France, supportive therapy is a standard of care, in Germany it is short-term use of high-dose corticosteroids, while in USA, in the last decade high-dose intravenous immunoglobulins are the most widely accepted treatment modalities. Case reports and small patients’ series described therapeutic effects of plasmapheresis, cyclosporine and other immunosuppressants. In conclusion, elimination of the possible causal agent, rapid transport to the burn unit, and multidisciplinary approach to treatment are of utmost importance for favorable outcome of the disease with 20-30% mortality rate. An update on diagnosis and the treatment of toxic epidermal necrolysis is provided in this review.
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Palmon FE, Brilakis HS, Webster GF, Holland EJ. Erythema Multiforme, Stevens-Johnson Syndrome, and Toxic Epidermal Necrolysis. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00059-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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López-García JS, Rivas Jara L, García-Lozano CI, Conesa E, de Juan IE, Murube del Castillo J. Ocular features and histopathologic changes during follow-up of toxic epidermal necrolysis. Ophthalmology 2010; 118:265-71. [PMID: 20884054 DOI: 10.1016/j.ophtha.2010.06.035] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 06/25/2010] [Accepted: 06/28/2010] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To evaluate ocular surface histopathologic changes and ocular sequelae in the follow-up of patients with toxic epidermal necrolysis (TEN). DESIGN Prospective, consecutive, comparative, interventional case series. PARTICIPANTS Eleven patients (22 eyes) with TEN that developed after drug treatment and 33 normal subjects as the control group. METHODS Toxic epidermal necrolysis diagnosis was based on data obtained from medical records. Only patients with ocular involvement in the acute stage were included. Patients and controls underwent a complete ophthalmic assessment, including tear film evaluation and corneal and conjunctival impression cytology. These were performed at the beginning of the study (∼1 month after TEN) and 6 and 12 months later. Tear film production and stability were evaluated by break-up time, Schirmer's test with anesthesia, rose bengal, and fluorescein staining pattern. Conjunctival retraction was determined by studying the vanishing point in eye abduction of the lacunar folds. MAIN OUTCOME MEASURES Break-up time, Schirmer's test, fluorescein and rose bengal stain, corneal and conjunctival epithelial squamous metaplasia, conjunctival retraction, and ocular sequelae. RESULTS Mild or moderate ocular involvement was present in 73% of patients in the acute stage. Ocular involvement was not related to TEN severity, area of skin involvement, or drug etiology. One-year follow-up, ocular manifestations, slit-lamp findings, and epithelial cell squamous metaplasia were related to ocular involvement severity in the acute phase. We found pathologic conjunctival retraction in 86.4% of patients. Decreased levels of break-up time and Schirmer's test were found in patients with TEN. Conjunctival cytology showed a marked decrease in goblet cell density. No patients died, and there were no recurrences of TEN during the study. CONCLUSIONS Ocular involvement in the acute stage was not related to TEN severity or etiology. Ocular sequelae were related to ocular involvement severity in the acute phase. Early ophthalmic assessment and frequent follow-up are helpful because ocular involvement represents the first long-term complication in patients with TEN. Impression cytology and measurement of conjunctival retraction can be useful tools in the assessment of dynamic ocular changes in patients with TEN.
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Rajaratnam R, Mann C, Balasubramaniam P, Marsden JR, Taibjee SM, Shah F, Lim R, Papini R, Moiemen N, Lewis H. Toxic epidermal necrolysis: retrospective analysis of 21 consecutive cases managed at a tertiary centre. Clin Exp Dermatol 2010; 35:853-62. [DOI: 10.1111/j.1365-2230.2010.03826.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mamishi S, Fattahi F, Pourpak Z, Aghaee FM, Moinfar Z, Mohammadi M, Ashrafi M, Moin M. Severe cutaneous reactions caused by barbiturates in seven Iranian children. Int J Dermatol 2010; 48:1254-61. [PMID: 20064188 DOI: 10.1111/j.1365-4632.2007.03561.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The severe adverse cutaneous reactions of erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare mucocutaneous diseases associated with significant morbidity and mortality. The most common cause is antiepileptic drugs, particularly carbamazepine and lamotrigine, as well as the barbiturates group (phenobarbital and phenytoin). In this article, we present seven children with severe adverse cutaneous reactions caused by barbiturates. CASE REPORTS The age of the affected children was between 2 and 11 years and they all had a history of taking barbiturates. Their symptoms started 1-3 weeks after the initiation of barbiturates, including a prodrome characterized by 2-3 days of malaise, fever, cough and anorexia, after which the skin and mucosal lesions appeared and worsened. The skin lesions varied from rash to large bullae, plus different forms of mucous membrane involvement. The offending drugs (barbiturates) were stopped immediately and care was largely supportive. CONCLUSION As a result of the morbidity and/or mortality associated with EM, SJS and TEN, physicians should keep in mind their differential diagnosis when cutaneous reactions are observed in patients undergoing barbiturate therapy. Furthermore, although TEN and SJS are life-threatening diseases, early detection and appropriate care can lead to a decrease in the incidence of death. The strategies described here seem to be successful and safe because, despite the serious conditions, our patients responded well. All survived.
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Affiliation(s)
- Setareh Mamishi
- Department of Infectious Diseases, Immunology, Asthma and Allergy Research Institute, Children Medical Center, Medical Sciences/University of Tehran, Tehran, Iran
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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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Abstract
Toxic epidermal necrolysis, a unique rapidly developing mucocutaneous reaction pattern, characterized by sheets of erythema, necrosis and bullous detachment of the epidermis, closely resembling that of scalding of the skin and rapidly fatal, was described by Lyell, and is now recognized as toxic epidermal necrolysis (TEN) Lyell's syndrome. The condition is indistinguishable from staphylococcal scalded skin syndrome (SSSS), and generalized fixed drug eruption. Hence, there has always been controversy as regards terminology. It is well conceived that TEN is equivalent to Stevens-Johnson syndrome (SJS), at its greatest severity. TEN, therefore, is a great challenge and warrants instant attention based on a thorough knowledgeable background covering several related facets including the recent advances in pathogenesis and management strategies. The details contained in the following text should prove very useful in the comprehension of a largely intractable entity.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Centre, Sehgal Nursing Home, Panchwati, Azadpur, Skin Institute and School of Dermatology, Greater Kailash, New Delhi, India.
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Dalli RL, Kumar R, Kennedy P, Maitz P, Lee S, Johnson R. TOXIC EPIDERMAL NECROLYSIS/STEVENS?JOHNSON SYNDROME: CURRENT TRENDS IN MANAGEMENT. ANZ J Surg 2007; 77:671-6. [PMID: 17635282 DOI: 10.1111/j.1445-2197.2007.04184.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Toxic epidermal necrolysis (TEN) is an uncommon but potentially life-threatening condition that involves sloughing of the skin at the dermoepidermal junction. TEN is a well-recognized syndrome and is part of a range of severe mucocutaneous intolerance reactions, mostly elicited by drugs and/or their metabolites. Reported mortality rates vary widely from 20 to 75%. Several systemic treatment protocols for TEN have been published; however, none has been formally standardized in a randomized controlled trial. The present study documents the current management principles and trends seen in 16 patients admitted with TEN or Stevens-Johnson syndrome over a 5-year period at the Concord Repatriation General Hospital Burns Unit. METHOD Data were collected by retrospective chart review, and parameters included in the study were patient demographics, causative agents, percentage total body surface area and/or mucosal involvement, complications, treatment and outcome. In particular, dressing choice and documented healing of skin lesions were noted. RESULTS Sixteen patients were identified, with the beta-lactam antibiotics most commonly implicated as the cause. Complications tended to relate to degree of sepsis and/or mucous membrane involvement. Nanocrsytalline silver dressings, such as Acticoat (Smith & Nephew, Mount Waverley, Victoria, Australia), were used predominantly in more recent cases. CONCLUSION The shift in dressing choice from traditional Vaseline-impregnated gauze coincided with a general trend towards the use of nanocrystalline silver dressings for superficial burns after 2003. The nanocrystalline silver dressings have shown considerable advantage over previously used dressings, with no adverse reactions noted and good healing of the skin lesions for all patients.
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Affiliation(s)
- Rachel L Dalli
- Burns Unit, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.
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Al-Johani KA, Fedele S, Porter SR. Erythema multiforme and related disorders. ACTA ACUST UNITED AC 2007; 103:642-54. [PMID: 17344075 DOI: 10.1016/j.tripleo.2006.12.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2006] [Revised: 12/12/2006] [Accepted: 12/12/2006] [Indexed: 01/07/2023]
Abstract
Erythema multiforme (EM) and related disorders comprise a group of mucocutaneous disorders characterized by variable degrees of mucosal and cutaneous blistering and ulceration that occasionally can give rise to systemic upset and possibly compromise life. The clinical classification of these disorders has often been variable, thus making definitive diagnosis sometimes difficult. Despite being often caused by, or at least associated with, infection or drug therapy, the pathogenic mechanisms of these disorders remain unclear, and as a consequence, there are no evidence-based, reliably effective therapies. The present article reviews aspects of EM and related disorders of relevance to oral medicine clinical practice and highlights the associated potential etiologic agents, pathogenic mechanisms and therapies.
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Affiliation(s)
- Khalid A Al-Johani
- Division of Medical, Surgical and Diagnostic Sciences, Eastman Dental Institute for Oral Health Care Sciences, University College of London, London, England
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27
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Khan FD, Roychowdhury S, Gaspari AA, Svensson CK. Immune response to xenobiotics in the skin: from contact sensitivity to drug allergy. Expert Opin Drug Metab Toxicol 2006; 2:261-72. [PMID: 16866612 DOI: 10.1517/17425255.2.2.261] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Skin is the most frequent target of adverse drug reactions. These cutaneous drug reactions (CDRs) show varied clinical manifestations ranging from mildly discomforting rashes to life-threatening Stevens-Johnson syndrome or toxic epidermal necrolysis. Most CDRs appear to be immune mediated, although the mechanism by which they are initiated remains unclear. In this review, current knowledge of the mechanisms by which xenobiotics provoke immune responses in the skin after epicutaneous administration and how similar reactions may occur after systemic routes are summarised. This review also discusses a variety of genetic or environmental factors that may determine the susceptibility of individuals towards immune responses in skin following drug exposure.
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Affiliation(s)
- Farah D Khan
- University of Iowa, Division of Pharmaceutics, College of Pharmacy, 115 S. Grand Avenue, 201 PHAR, Iowa City, IA 52242, USA
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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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Sheridan RL, Liu V, Anupindi S. Case records of the Massachusetts General Hospital. Case 34-2005. A 10-year-old girl with a bullous skin eruption and acute respiratory failure. N Engl J Med 2005; 353:2057-66. [PMID: 16282181 DOI: 10.1056/nejmcpc059029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Arca E, Köse O, Erbil AH, Nişanci M, Akar A, Gür AR. A 2-year-old girl with Stevens--Johnson syndrome/toxic epidermal necrolysis treated with intravenous immunoglobulin. Pediatr Dermatol 2005; 22:317-20. [PMID: 16060867 DOI: 10.1111/j.1525-1470.2005.22407.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Toxic epidermal necrolysis and Stevens-Johnson syndrome are severe skin reactions, usually to drugs, associated with a widespread destruction of the epidermis. Widespread purpuric macules and epidermal detachment of less than 10% of the body surface is indicative of Stevens-Johnson syndrome, whereas epidermal detachment between 10% and 30% is called Stevens-Johnson-toxic epidermal necrolysis overlap. Epidermal detachment involving more than 30% of the total body surface is designated as toxic epidermal necrolysis. These generalized reactions are known to occur in association with various drugs. Treatment is primarily supportive care, and there are no specific therapy regimens. Therapeutic modalities such as corticosteroids, cyclosporin, thalidomide, cyclophosphamide, and plasmapheresis, usually based on a symptomatic approach, have been tried in single patients or in small series. Intravenous immunoglobulin has recently been shown to provide rapid improvement in all three of these skin reactions. We report a 2-year-old girl who developed Stevens-Johnson syndrome-toxic epidermal necrolysis overlap after receiving ampicillin-sulbactam for an upper respiratory tract infection. She was treated successfully with a 4-day course of intravenous immunoglobulin.
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Affiliation(s)
- Ercan Arca
- Department of Dermatology, Gülhane Military Medical Academy, School of Medicine, Etlik, Ankara, Turkey.
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McDonald MA, Favilla I. Visual loss in a patient with lamotrigine-induced cicatrizing conjunctivitis. Clin Exp Ophthalmol 2004; 31:541-3. [PMID: 14641167 DOI: 10.1046/j.1442-9071.2003.00717.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Paquet P, Jacob E, Damas P, Piérard GE. Recurrent fatal drug-induced toxic epidermal necrolysis (Lyell's syndrome) after putative beta-lactam cross-reactivity: Case report and scrutiny of antibiotic imputability. Crit Care Med 2002; 30:2580-3. [PMID: 12441773 DOI: 10.1097/00003246-200211000-00029] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A series of antibiotics may be responsible for toxic epidermal necrolysis. We report two successive episodes of toxic epidermal necrolysis in the same patient. Drug imputability criteria designate a cross-reactivity between two antibiotics of different chemical classes but sharing the beta-lactam ring in common. DESIGN Descriptive case report and review of the literature. SETTING Medical intensive care unit in a university medical center. PATIENT AND MAIN RESULTS: A 75-yr-old woman developed a first episode of toxic epidermal necrolysis (involving 40% of the body surface) after intake of cefotaxime, a third-generation cephalosporin. Perfusions of high-dose immunoglobulins rapidly improved the lesions, followed by partial reepithelialization in 5 days. Sepsis required the administration of meropenem, which is a carbapenem antibiotic. The epidermal destruction immediately recurred, with extension to previously uninvolved skin areas and fatal consequences. CONCLUSIONS The beta-lactam ring present in cephalosporins and carbapenems represents the putative chemical structure responsible for the presently reported cross-reactivity to two antibiotics of different classes. Drugs having any chemical similarity to the initial culprit compound should be strictly avoided when possible in the management of toxic epidermal necrolysis.
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Affiliation(s)
- Philippe Paquet
- Department of Dermatopathology, University Medical Center, University Medical Center, Sart Tilman, Belgium
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John T, Foulks GN, John ME, Cheng K, Hu D. Amniotic membrane in the surgical management of acute toxic epidermal necrolysis. Ophthalmology 2002; 109:351-60. [PMID: 11825823 DOI: 10.1016/s0161-6420(01)00900-9] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To report a new surgical technique to manage severe acute toxic epidermal necrolysis. DESIGN Two interventional case reports. PARTICIPANTS Two patients. Case 1: A 6-year-old boy had severe toxic epidermal necrolysis develop after being treated with trimethoprim and sulfamethoxazole for chronic otitis media. Both eyes and eyelids were affected. He underwent bilateral lysis of symblepharon and all adhesions and bilateral amniotic membrane transplantation to the entire ocular surface except the cornea. Loss of eyelid skin required transplantation of amniotic membrane to all four eyelids and strips of amniotic membrane at the eyelid margins. Case 2: An 8-year-old girl with severe toxic epidermal necrolysis associated with mycoplasma pneumonia had bilateral, diffuse keratoconjunctivitis, diffuse corneal epithelial defects, and bilateral symblepharon. Amniotic membrane transplantation was performed bilaterally, using a symblepharon ring in the left eye. INTERVENTION Amniotic membrane transplantation. MAIN OUTCOME MEASURES Preservation of normal ocular and eyelid surfaces and prevention of blindness. RESULTS Case 1: Thirty-six months after bilateral ocular surgery, there is no symblepharon, good ocular surface wetting, and an uncorrected bilateral vision of 20/20. Case 2: Amniotic membrane transplantation protected both ocular surfaces and prevented conjunctival contracture without adhesion of the eyelids to the ocular surface. The central vision was preserved. There was minimal peripheral corneal vascularization and mild conjunctival scarring of the tarsal conjunctival surface 34 months postoperatively. CONCLUSIONS These are the first cases of acute toxic epidermal necrolysis treated with amniotic membrane transplantation and the first use of the procedure on external eyelid surfaces with good healing of the eyelids. This new treatment for acute toxic epidermal necrolysis preserves normal ocular and eyelid surfaces and may prevent blindness.
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Affiliation(s)
- Thomas John
- Department of Ophthalmology, Loyola University at Chicago, Maywood, Illinois 60153, USA
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Honari S, Gibran NS, Heimbach DM, Gibbons J, Cain V, Engrav LH. Toxic epidermal necrolysis (TEN) in elderly patients. THE JOURNAL OF BURN CARE & REHABILITATION 2001; 22:132-5. [PMID: 11302601 DOI: 10.1097/00004630-200103000-00009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a severe exfoliative disease of the skin and mucous membranes that results in high mortality. As the elderly population increases, the number of elderly patients with TEN can also be expected to increase. Elderly patients with comparably sized burn wounds usually have a poor prognosis. Our purpose was to determine whether elderly TEN patients exhibit similarly high mortality. A retrospective review was conducted of 52 patients treated for TEN from October 1991 through September 1998. Eleven patients were older than 65 years. All patients were treated according to our TEN protocol. Eight of 11 patients recovered, and 3 died. The mean total body surface area (TBSA) involvement for the patients who recovered was 24%, compared with 66% for the nonsurvivors. The survival rate for elderly patients (73%) compares well with that for those younger than 65 years (89%). Therefore, we propose that we should be aggressive in treating elderly patients with TEN.
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Affiliation(s)
- S Honari
- Department of Surgery, University of Washington Burn Center, Harborview Medical Center, Seattle 98104, USA
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