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Strużyna J, Surowiecka A, Korzeniowski T, Piszczek J, Korulczyk P, Drozd L, Stachura A, Torres K, Krajewski A. Immunomodulatory treatment of Lyell's syndrome - a simultaneous plasmapheresis and IVIGs therapy. J Burn Care Res 2022; 43:1394-1398. [PMID: 35396849 DOI: 10.1093/jbcr/irac046] [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: 11/14/2022]
Abstract
Lyell's syndrome, or toxic epidermal necrolysis (TEN) is a rare but life-threatening condition. It manifests with blistering of skin and mucous due to subepidermal bullae and keratinocyte necrosis. In most cases it is an immune response to drugs or their metabolites. The mortality in TEN is high despite optimal infection and wound control. There are no unequivocal treatment guidelines in TEN. Immunosuppressive treatment may increase the wound infection risk and mortality. The aim of the study was to evaluate a 10-year experience with immunomodulatory therapy in TEN. We perform a combination of plasmapheresis and IVIGs to control the disease. There were 35 patients in the group and we performed a post hoc evaluation. 28 patients received the full protocol and there were 7 patients who did not complete the treatment (single therapy group). The mortality in the test group was 14,29%, and the difference reached statistical significance in comparison with the single therapy group (p<0.05). Our protocol reduced the mortality risk 5 times. Our study proved that simultaneous plasmaphereses with IVIGs administration was safe and improved patients' outcome in TEN.
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Affiliation(s)
- Jerzy Strużyna
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Poland
| | - Agnieszka Surowiecka
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland
| | - Tomasz Korzeniowski
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,West Pomeranian Burns and Plastic Surgery Center, Gryfice, Poland
| | - Joanna Piszczek
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Poland
| | - Patrycja Korulczyk
- Chair and Department of Didactics and Medical Simulation, Medical University of Lublin, Poland
| | - Lukasz Drozd
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland
| | - Aldona Stachura
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland
| | - Kamil Torres
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,Chair and Department of Didactics and Medical Simulation, Medical University of Lublin, Poland
| | - Andrzej Krajewski
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,West Pomeranian Burns and Plastic Surgery Center, Gryfice, Poland
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2
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Houschyar KS, Tapking C, Borrelli MR, Nietzschmann I, Puladi B, Ooms M, Rein S, Houschyar M, Duscher D, Maan ZN, Reumuth G, Branski LK, Modabber A, Kluwig D, Schmitt L, Philipp-Dormston WG, Yazdi AS, Siemers F. Stevens-Johnson syndrome and toxic epidermal necrolysis: a 10-year experience in a burns unit. J Wound Care 2021; 30:492-496. [PMID: 34121430 DOI: 10.12968/jowc.2021.30.6.492] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Stevens-Johnson syndrome (SJS) and its more severe counterpart, toxic epidermal necrolysis (TEN), are skin hypersensitivity reactions defined by epidermal blistering and necrosis. The exact pathophysiology of SJS/TEN is yet to be deciphered, but a number of risk factors have been identified including adverse drug reactions. The diagnosis of SJS/TEN is made on a clinical basis, and treatment consists of supportive care and occasionally immunosuppressants, such as cyclosporin, high-dose intravenous immunoglobulins and/or corticosteroids. Mortality rates can reach 20-25% in adults but are reduced with early intervention. To identify optimal treatment regimens, to better understand the patient cohort affected, and to help identify key risk factors for mortality, we report our experience with the treatment and management of SJS/TEN patients. METHODS A retrospective review of consecutive patients with SJS and/or TEN admitted to a single burns centre in Germany, between 2008 and 2018, was conducted. The primary outcomes of demographics, clinical course, treatment and patient-reported outcomes were recorded and compared with a control group of patients with burns without a diagnosis of SJS/TEN. RESULTS A total of 23 patients with SJS/TEN met the inclusion criteria: 17 (74%) with TEN; four (17%) with SJS/TEN overlap; and two (9%) with SJS. Of the patients, 14 (61%) were female and nine (39%) were male. Patient age ranged from 32-78 years (mean: 52 years). A matched cohort of 23 patients with burns served as the control group. All patients received standard of care with a multidisciplinary team. Compared with the control group, SJS/TEN patients had higher mortality rates (n=6, 26% versus n=8, 35%, respectively). The average age of death was 69 years in SJS/TEN patients versus 63 years in control group patients. Age and SCORTEN scores were significant predictors of mortality. CONCLUSIONS SJS and TEN are rare but extreme reactions of the skin and mucosa, associated with high disease mortality rates. This 10-year single-centre retrospective review contributes to the bank of information for reviews evaluating the management of SJS/TEN patients.
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Affiliation(s)
- Khosrow S Houschyar
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Germany.,Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost Halle, Halle, Germany
| | - Christian Tapking
- Department of Surgery, Shriners Hospital for Children-Galveston, University of Texas Medical Branch, Galveston, US.,Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Mimi R Borrelli
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford School of Medicine, Stanford, US
| | - Ina Nietzschmann
- Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost Halle, Halle, Germany
| | - Behrus Puladi
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH, Aachen, Germany
| | - Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH, Aachen, Germany
| | - Susanne Rein
- Department of Plastic and Hand Surgery-Burn Center-Clinic St. Georg, Leipzig, Germany
| | - Madeline Houschyar
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Germany
| | - Dominik Duscher
- Department of Plastic Surgery and Hand Surgery, Technical University Munich, Munich, Germany
| | - Zeshaan N Maan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford School of Medicine, Stanford, US
| | - Georg Reumuth
- Department of Plastic Surgery and Hand Surgery, Evangelische Elisabeth Klinik, Berlin, Germany
| | - Ludwik K Branski
- Department of Surgery, Shriners Hospital for Children-Galveston, University of Texas Medical Branch, Galveston, US
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH, Aachen, Germany
| | - David Kluwig
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Germany
| | - Laurenz Schmitt
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Germany
| | | | - Amir S Yazdi
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Germany
| | - Frank Siemers
- Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost Halle, Halle, Germany
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Gomes ESR, Marques ML, Regateiro FS. Epidemiology and Risk Factors for Severe Delayed Drug Hypersensitivity Reactions. Curr Pharm Des 2020; 25:3799-3812. [PMID: 31694518 DOI: 10.2174/1381612825666191105115346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/31/2019] [Indexed: 02/07/2023]
Abstract
Severe delayed drug hypersensitivity reactions comprise different clinical entities and can involve different immune-mediated mechanisms. Common examples are severe cutaneous adverse reactions and druginduced internal organ injuries. The incidence of such reactions is overall low but seems to be on the rise reaching numbers as high as 9 per million individuals-years in the case of SJS/TEN and DRESS. Such conditions carry an important associated morbidity, and mortality can attain 40% in SJS/TEN patients, making these hypersensitivity reactions important targets when implementing preventive measures. Several risk factors have been identified for reaction severity; some are transverse, such as older age and underlying chronic diseases. The recent advances in pharmacogenetics allowed the identification of specific populations with higher risk and permitted strategic avoidance of certain drugs being HLA-B*57:01 screening in patients initiating abacavir the best successful example. In this work, we reviewed the epidemiology of SCARs and liver/kidney/lung drug-induced immune-mediated reactions. We focus on particular aspects such as prevalence and incidence, drugs involved, mortality and risk factors.
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Affiliation(s)
- Eva S R Gomes
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitario do Porto, Porto, Portugal
| | - Maria L Marques
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitario do Porto, Porto, Portugal
| | - Frederico S Regateiro
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal.,Institute of Immunology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Reseach (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Torres‐Navarro I, Briz‐Redón Á, Botella‐Estrada R. Accuracy of SCORTEN to predict the prognosis of Stevens‐Johnson syndrome/toxic epidermal necrolysis: a systematic review and meta‐analysis. J Eur Acad Dermatol Venereol 2020; 34:2066-2077. [DOI: 10.1111/jdv.16137] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/21/2019] [Indexed: 12/13/2022]
Affiliation(s)
- I. Torres‐Navarro
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
| | - Á. Briz‐Redón
- Department of Statistics and Operations Research Universitat de València València Spain
| | - R. Botella‐Estrada
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
- Department of Medicine Universitat de València València Spain
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Bhullar HK, Aung AK, Graudins L, Ihle J, Gin D, Cleland H, Mei Teh B. Upper airway involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis. Burns 2019; 46:682-686. [PMID: 31591001 DOI: 10.1016/j.burns.2019.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/27/2019] [Accepted: 09/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening hypersensitivity conditions associated with epidermal detachment and mucositis. The indication for flexible nasoendoscopy (FNE) and overall predictive factors for early intubation are unclear. OBJECTIVES To describe the incidence of airway involvement and the key indicators for intubation in our SJS or TEN patient cohort. To determine the association between FNE findings and early intubation. METHODS A retrospective review of 45 patients with biopsy proven SJS or TEN admitted to an Australian tertiary burns centre from 2010 to 2017. RESULTS Thirty-five patients were diagnosed with TEN (77.8%), followed by overlap syndrome (SJS-TEN) (n = 6, 13.3%) and SJS (n = 4, 8.9%). Twenty (44.4%) patients were intubated; and all 20 had a diagnosis of TEN (100.0%) (p < 0.05). Intubated patients had a higher increase in total body surface area percentage(%) from day 1-3 [10.0% (IQR 0.0-23.8%)] and a longer length of stay [26.0 days (IQR 12.5-34.0)], compared to non-intubated patients [0.0% (IQR 0.0-4.0%)], [10.0 days (IQR 6.0-14.0)] (p < 0.05) respectively. The main indications for intubation were to facilitate operative and dressing management (47.4%) followed by airway involvement (26.3%). FNE was performed on 32 patients (71.1%), however FNE findings did not significantly influence intubation rates. CONCLUSION More than half (n = 20, 57.1%) of the 35 patients diagnosed with TEN underwent intubation, mainly to facilitate operative and dressing management. FNE was performed on most patients, however there was no clear association between FNE findings and early intubation.
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Affiliation(s)
- Harmeet K Bhullar
- Ear, Nose and Throat Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; Central Clinical School, Monash University, Victoria, Australia.
| | - Ar Kar Aung
- Department of General Medicine, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; School of Public Health and Preventative Medicine, Monash University, Victoria, Australia.
| | - Linda Graudins
- Pharmacy Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Josh Ihle
- School of Public Health and Preventative Medicine, Monash University, Victoria, Australia; Intensive Care Unit, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Douglas Gin
- Department of Dermatology, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Heather Cleland
- Central Clinical School, Monash University, Victoria, Australia; Victorian Adult Burns Services, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Bing Mei Teh
- Ear, Nose and Throat Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; Department of Surgery, Monash University, Victoria, Australia.
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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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Chowdhury S, Podder I, Saha A, Bandyopadhyay D. Inpatient Mortality Resulting from Dermatological Disorders at a Tertiary Care Center in Eastern India: A Record-based Observational Study. Indian J Dermatol 2017; 62:626-629. [PMID: 29263537 PMCID: PMC5724311 DOI: 10.4103/ijd.ijd_284_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Contrary to popular perception, several dermatological conditions may be associated with lethal outcome in the absence of timely intervention or due to complications. Aims The aim was to estimate the number of deaths and analyze their causes due to skin disorders at a tertiary level inpatient dermatology ward. Materials and Methods We conducted a retrospective, record-based observational study involving 538 patients spanning over 4 years (2013-2016) at our dermatology indoor setup. Results There were 45 deaths (male:female = 1.5:1), accounting for 8.4% or total admissions, occurring mostly in patients in their 7th decade. Vesiculobullous disorders were the most frequent cause of mortality (57.8%), followed by drug reactions accounting for 17.8% of cases. In the former group pemphigus vulgaris accounted for most deaths (31.1%) followed by bullous pemphigoid (17.8%) and pemphigus foliaceus (8.9%), whereas toxic epidermal necrolysis was the most frequent cause of death from drug reactions (8.9%). Almost half of all deaths (48.9%) occurred due to septicemia followed by cardiopulmonary complications (40%). Most of the cases presented to us at an advanced state of the disease previously being treated inappropriately. Conclusion Prompt diagnosis and treatment of such dermatological conditions are mandated, preferably in an intensive care set-up, to reduce mortality rates. Advanced age, the area of skin involvement, mucosal involvement, and septicemia were adverse prognostic factors in these patients.
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Affiliation(s)
- Satyendranath Chowdhury
- Department of Dermatology, Venereology, and Leprosy, Medical College, Kolkata, West Bengal, India
| | - Indrashis Podder
- Department of Dermatology, Venereology, and Leprosy, Medical College, Kolkata, West Bengal, India
| | - Abanti Saha
- Department of Dermatology, Venereology, and Leprosy, Medical College, Kolkata, West Bengal, India
| | - Debabrata Bandyopadhyay
- Department of Dermatology, Venereology, and Leprosy, Medical College, Kolkata, West Bengal, India
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Balakirski G, Merk HF. Cutaneous allergic drug reactions: update on pathophysiology, diagnostic procedures and differential diagnosic. Cutan Ocul Toxicol 2017; 36:307-316. [DOI: 10.1080/15569527.2017.1319379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Galina Balakirski
- Department of Dermatology and Allergology, RWTH Aachen University, Aachen, Germany
| | - Hans F. Merk
- Department of Dermatology and Allergology, RWTH Aachen University, Aachen, Germany
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