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van Nispen C, Long B, Koyfman A. High risk and low prevalence diseases: Stevens Johnson syndrome and toxic epidermal necrolysis. Am J Emerg Med 2024; 81:16-22. [PMID: 38631147 DOI: 10.1016/j.ajem.2024.04.001] [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: 02/09/2024] [Revised: 03/04/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are serious conditions that carry a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of SJS/TEN, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION SJS/TEN is a rare, delayed hypersensitivity reaction resulting in de-epithelialization of the skin and mucous membranes. The majority of cases are associated with medication or infection. Clinicians should consider SJS/TEN in any patient presenting with a blistering mucocutaneous eruption. Evaluation of the skin, mucosal, pulmonary, renal, genital, and ocular systems are essential in the diagnosis of SJS/TEN, as well as in the identification of complications (e.g., sepsis). Laboratory and radiological testing cannot confirm the diagnosis in the ED setting, but they may assist in the identification of complications. ED management includes stabilization of airway and breathing, fluid resuscitation, and treatment of any superimposed infections with broad-spectrum antibiotic therapy. All patients with suspected SJS/TEN should be transferred and admitted to a center with burn surgery, critical care, dermatology, and broad specialist availability. CONCLUSIONS An understanding of SJS/TEN can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Christiaan van Nispen
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
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2
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Pabani UK, Khan Z, Ali L, Shah SK, Khan JA. Allopurinol-Induced Uncommon Dermatological Emergency of Toxic Epidermal Necrolysis (TEN). Cureus 2023; 15:e44812. [PMID: 37809172 PMCID: PMC10558959 DOI: 10.7759/cureus.44812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Toxic epidermal necrolysis (TEN) is a life-threatening, blistering dermatitis. It is characterized by fever and the development of mucocutaneous lesions, which lead to necrosis and sloughing of the epidermis. It is commonly triggered by medications and infections. We present the case of a 75-year-old male who presented to the hospital with a fever and widespread exfoliating skin rash involving 41% of his body surface area (BSA). He has a past medical history of gout, hypertension, asthma, and depression. He was recently started on allopurinol by his general practitioner (GP) for hyperuricemia. The condition also involved oral, eye, and pharynx mucosae. He was diagnosed with toxic epidermal necrolysis and was managed with intravenous (IV) hydrocortisone, steroid and antibiotic eye drops, and steroid and antibiotic topical creams. Due to the weak available evidence supporting the use of ciclosporin and intravenous immunoglobulins, this patient was managed with steroid use only. His rash initially worsened, but ultimately, he made a full recovery without any sequelae. The patient was reviewed in the dermatology clinic four weeks post-discharge, and he did not have any residual disease.
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Affiliation(s)
- Umesh Kumar Pabani
- Internal Medicine, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
| | - Zahid Khan
- Acute Medicine, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
- Cardiology, Barts Heart Centre, London, GBR
- Cardiology and General Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
- Cardiology, Royal Free Hospital, London, GBR
| | - Layla Ali
- Internal Medicine, Southend University Hospital, Southend-on-Sea, GBR
| | - Shuheda K Shah
- General Medicine, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
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3
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Wilkerson RG. Drug Hypersensitivity Reactions. Immunol Allergy Clin North Am 2023; 43:473-489. [PMID: 37394254 DOI: 10.1016/j.iac.2022.10.005] [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: 07/04/2023]
Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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4
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Ruiz S, Puebla B, Hernandez N, Rubio V, Young E, Mir H. Pemphigus Vulgaris: More Than Just a Skin Disease. Ann Plast Surg 2023; 91:62-63. [PMID: 37450862 DOI: 10.1097/sap.0000000000003589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Pemphigus is a group of autoimmune diseases of the skin and mucous membranes that is characterized by multiple bullae formation. It is caused by autoantibodies directed against the cell surface of keratinocytes, resulting in the loss of cell-cell adhesion of keratinocytes. This disease can be very debilitating and difficult to treat if large surface areas are involved. METHODS We performed a retrospective review of a complex case of pemphigus vulgaris in a 24-year-old man who develop partial-thickness skin lesions distributed throughout the entire body with a total body surface of 80% short after an episode of strep throat treated with amoxicillin. RESULTS The patient had a complicated hospital course in which the standard treatment of the disease led to adverse effects that were successfully managed at our busy burn center. CONCLUSIONS Pemphigus vulgaris is a complex skin disease in which treatment techniques carry their risk and must be tailored to the patient's specific needs. Treatment of this conditions at a burn center would be beneficial as demonstrated with conditions like Stevens-Johnson syndrome and toxic epidermal necrolysis.
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Affiliation(s)
- Samuel Ruiz
- From the Department of Surgery, Kendall Regional Medical Center
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Frezgi O, Russom M. Toxic Epidermal Necrolysis Associated with Misoprostol: A Case Report. Int Med Case Rep J 2023; 16:385-390. [PMID: 37388251 PMCID: PMC10305770 DOI: 10.2147/imcrj.s408342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/15/2023] [Indexed: 07/01/2023] Open
Abstract
Misoprostol, a synthetic prostaglandin E1 analog, is currently used for medical termination of pregnancy. In the summary of the product characteristics of different market authorization holders of misoprostol tablets, approved by major regulators, serious mucocutaneous reactions, including toxic epidermal necrolysis are not documented as adverse effects. We are now reporting an unusual case of toxic epidermal necrolysis following the use of misoprostol 200 mcg tablets prescribed for termination of a pregnancy. A 25-year-old grand multipara woman from the Gash-Barka region of Eritrea visited Tesseney hospital with a history of amenorrhea that lasted for four months. She was admitted as a case of missed abortion for medical termination of pregnancy. Following three doses of misoprostol 200 mcg tablet the patient developed toxic epidermal necrolysis. Except misoprostol, no other possible alternatives that could explain the condition were identified. Accordingly, the adverse effect was judged to be possibly related to misoprostol. The patient recovered after four weeks of treatment without sequelae. Toxic epidermal necrolysis could, therefore, be a possible adverse effect of misoprostol that needs to be further investigated with better epidemiological studies.
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Affiliation(s)
- Okbu Frezgi
- Gynecology and Obstetric Unit, Orotta College of Medicine and Health Sciences, Asmara, Eritrea
| | - Mulugeta Russom
- Eritrean Pharmacovigilance Centre, National Medicines and Food Administration, Ministry of Health, Asmara, Eritrea
- Department of Medical Informatics, Erasmus Medical Centre, Rotterdam, the Netherlands
- European Program for Pharmacovigilance and Pharmacoepidemiology, University of Bordeaux, Bordeaux, France
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Lee EY, Knox C, Phillips EJ. Worldwide Prevalence of Antibiotic-Associated Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Systematic Review and Meta-analysis. JAMA Dermatol 2023; 159:384-392. [PMID: 36790777 PMCID: PMC9932945 DOI: 10.1001/jamadermatol.2022.6378] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Importance Antibiotics are an important risk for Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN), which are the most severe types of drug hypersensitivity reaction with a mortality rate up to 50%. To our knowledge, no global systematic review has described antibiotic-associated SJS/TEN. Objective To evaluate the prevalence of antibiotics associated with SJS/TEN worldwide. Data Sources The MEDLINE and Embase databases were searched for experimental and observational studies that described SJS/TEN risks since database inception to February 22, 2022. Study Selection Included studies adequately described SJS/TEN origins and specified the antibiotics associated with SJS/TEN. Data Extraction and Synthesis Two reviewers (E.Y.L. and C.K.) independently selected the studies, extracted the data, and assessed the risk of bias. A meta-analysis using a random-effects model was performed in the studies that described patient-level associations. Subgroup analyses were performed to explore the heterogeneity. The risk of bias was assessed using the Joanna Briggs Institute checklist, and the certainty of evidence was rated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Main Outcomes and Measures Prevalence of antibiotic-associated SJS/TEN was presented as pooled proportions with 95% CIs. Results Among the 64 studies included in the systematic review, there were 38 studies that described patient-level associations; the meta-analysis included these 38 studies with 2917 patients to determine the prevalence of single antibiotics associated with SJS/TEN. The pooled proportion of antibiotics associated with SJS/TEN was 28% (95% CI, 24%-33%), with moderate certainty of evidence. Among antibiotic-associated SJS/TEN, the sulfonamide class was associated with 32% (95% CI, 22%-44%) of cases, followed by penicillins (22%; 95% CI, 17%-28%), cephalosporins (11%; 95% CI, 6%-17%), fluoroquinolones (4%; 95% CI, 1%-7%), and macrolides (2%; 95% CI, 1%-5%). There was a statistically significant heterogeneity in the meta-analysis, which could be partially explained in the subgroup analysis by continents. The overall risk of bias was low using the Joanna Briggs Institute checklist for case series. Conclusion and Relevance In this systematic review and meta-analysis of all case series, antibiotics were associated with more than one-quarter of SJS/TEN cases described worldwide, and sulfonamide antibiotics remained the most important association. These findings highlight the importance of antibiotic stewardship, clinician education and awareness, and weighing the risk-benefit assessment of antibiotic choice and duration.
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Affiliation(s)
- Erika Yue Lee
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, Eliot Phillipson Clinician-Scientist Training Program, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Knox
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Jane Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee,Centre for Clinical Pharmacology and Infectious Diseases, Murdoch University, Murdoch, Perth, Western Australia
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7
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Surowiecka A, Barańska-Rybak W, Strużyna J. Multidisciplinary Treatment in Toxic Epidermal Necrolysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2217. [PMID: 36767584 PMCID: PMC9916139 DOI: 10.3390/ijerph20032217] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
Toxic epidermal necrolysis, Leyll's syndrome (TEN), is a rare mucocutaneous blistering disease burdened with high mortality rates. The diagnosis of TEN is based on clinical symptoms and histopathological findings. In approximately 90% of cases, it is a severe adverse reaction to drugs. In TEN, not only is the skin affected, but also mucosa and organs' epithelium. There are no unequivocal recommendations in regard to systemic and topical treatment of the patients. The aim of this paper is to review available literature and propose unified protocols to be discussed. Early management and multidisciplinary treatment are necessary to improve patients' outcome. Treatment of patients with TEN suspicions should be initiated with early drug withdrawal. TEN patients, like patients with burns, require intensive care and multidisciplinary management. Each patient with TEN should be provided with adequate fluid resuscitation, respiratory support, nutritional treatment, pain control, infection prophylaxis, anticoagulant therapy, and gastric ulcer prophylaxis. The key to local treatment of patients with TEN is the use of nonadherent dressings that do not damage the epidermis during the change. The aim of the systemic treatment is purification of the blood stream from the causative agent. The most efficient way to clarify serum of TEN patients' is the combination of plasmapheresis and IVIG. Immunomodulatory therapy can reduce the mortality five times in comparison with the patients with immunosuppression or lack of full protocol.
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Affiliation(s)
- Agnieszka Surowiecka
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, 20-059 Lublin, Poland
| | - Wioletta Barańska-Rybak
- Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Jerzy Strużyna
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, 20-059 Lublin, Poland
- Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, 20-059 Lublin, Poland
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8
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Stewart S, Juang D, Aguayo P. Pediatric burn review. Semin Pediatr Surg 2022; 31:151217. [PMID: 36370620 DOI: 10.1016/j.sempedsurg.2022.151217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Shai Stewart
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA.
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9
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Sommerfelt H, Sandvik LF, Bachmann IM, Brekke RL, Svendsen HL, Guttormsen AB, Aziz S, Dillekås H, Straume O. Toxic epidermal necrolysis after immune checkpoint inhibition, case report, and review of the literature. Acta Oncol 2022; 61:1295-1299. [PMID: 36073292 DOI: 10.1080/0284186x.2022.2119099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Hanne Sommerfelt
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Lene F Sandvik
- Department of Dermatology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ingeborg M Bachmann
- Department of Dermatology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ragnvald Ljones Brekke
- Department of Plastic, Hand, and Reconstructive surgery, National Burn Centre, Haukeland University Hospital, Bergen, Norway
| | - Henrik Løvendahl Svendsen
- Department of Plastic, Hand, and Reconstructive surgery, National Burn Centre, Haukeland University Hospital, Bergen, Norway
| | - Anne Berit Guttormsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Sura Aziz
- Department of Pathology, Haukeland University Hospital Bergen, Bergen, Norway
| | - Hanna Dillekås
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Oddbjørn Straume
- Department of Oncology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway.,Centre for Cancer Biomarkers, University of Bergen, Bergen, Norway
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10
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Lian BSY, Lee HY. Managing the ADR of Stevens-Johnson syndrome/toxic epidermal necrolysis. Expert Opin Drug Saf 2022; 21:1039-1046. [PMID: 35878014 DOI: 10.1080/14740338.2022.2106367] [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: 11/04/2022]
Abstract
INTRODUCTION Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening adverse drug reactions that are collectively known as epidermal necrolysis. The abrupt detachment of the skin and mucositis results in systemic complications such as fluid and electrolyte disturbances, hypothermia, sepsis, organ failure, and death. Management is multidisciplinary and complex. AREAS COVERED This present article reviews the principles and best practices in the care of patients with epidermal necrolysis. These include having prompt admissions to optimal care facilities, coordinated specialized care during the acute phase, as well as long-term follow-up to manage chronic sequelae. EXPERT OPINION Patients with epidermal necrolysis should be managed in specialized/reference centers that are experienced with the management of the disease. Multi-disciplinary supportive care remains the cornerstone. Current evidence precludes definitive recommendation on any immunomodulatory agent as treatment. Long-term follow-up is required in order to diagnose and treat any chronic sequelae.
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Affiliation(s)
| | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital Singapore, Singapore.,Allergy Centre, Singapore General Hospital Singapore, Singapore.,Duke-NUS Medical School, Medicine Academic Clinical Programme, Singapore
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11
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Management of Drug-Induced Epidermal Necrolysis (DEN) in Pediatric Patients: Moving from Drug-Induced Stevens-Johnson Syndrome, Overlap and Toxic Epidermal Necrolysis to a Single Unifying Diagnosis of DEN. Paediatr Drugs 2022; 24:307-319. [PMID: 35676614 DOI: 10.1007/s40272-022-00515-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
Pediatric Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threating blistering diseases triggered by medications that affect the skin and mucosae. Drug-induced epidermal necrolysis is a better term for medication-triggered cases because there is a spectrum of disease severity that otherwise is divided into the separate entities of SJS, overlap SJS/TEN, and TEN. This manuscript reviews the management of drug-induced epidermal necrolysis (DEN), including diagnosis, investigations to exclude differential diagnoses, and treatment. Diagnosis of DEN relies on clinical features and a detailed medication history. The primary differential diagnosis is reactive infectious mucocutaneous eruption, which can be clinically distinguished by its disproportionate mucous membrane involvement relative to (sparse or absent) skin lesions. Identification and discontinuation of culprit medications is the mainstay of treatment of DEN. Early initiation of immunomodulatory therapy may prevent progression, reducing maximal disease severity and the risk of sequelae. A checklist approach to detailed management of DEN is proposed.
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Tempark T, John S, Rerknimitr P, Satapornpong P, Sukasem C. Drug-Induced Severe Cutaneous Adverse Reactions: Insights Into Clinical Presentation, Immunopathogenesis, Diagnostic Methods, Treatment, and Pharmacogenomics. Front Pharmacol 2022; 13:832048. [PMID: 35517811 PMCID: PMC9065683 DOI: 10.3389/fphar.2022.832048] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/01/2022] [Indexed: 12/19/2022] Open
Abstract
SCARs are rare and life-threatening hypersensitivity reactions. In general, the increased duration of hospital stays and the associated cost burden are common issues, and in the worst-case scenario, they can result in mortality. SCARs are delayed T cell-mediated hypersensitivity reactions. Recovery can take from 2 weeks to many months after dechallenging the culprit drugs. Genetic polymorphism of the HLA genes may change the selection and presentation of antigens, allowing toxic drug metabolites to initiate immunological reactions. However, each SCARs has a different onset latency period, clinical features, or morphological pattern. This explains that, other than HLA mutations, other immuno-pathogenesis may be involved in drug-induced severe cutaneous reactions. This review will discuss the clinical morphology of various SCARs, various immune pathogenesis models, diagnostic criteria, treatments, the association of various drug-induced reactions and susceptible alleles in different populations, and the successful implementation of pharmacogenomics in Thailand for the prevention of SCARs.
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Affiliation(s)
- Therdpong Tempark
- Division of Dermatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,The Pediatrics-Thai Severe Cutaneous Adverse Drug Reaction (Ped-Thai-SCAR) Research Group, Bangkok, Thailand
| | - Shobana John
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
| | - Pawinee Rerknimitr
- The Thai Severe Cutaneous Adverse Drug Reaction (Thai-SCAR) Research Group, Bangkok, Thailand.,Division of Dermatology, Department of Medicine, Faculty of Medicine, Skin, and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Patompong Satapornpong
- Division of General Pharmacy Practice, Department of Pharmaceutical Care, College of Pharmacy, Rangsit University, Pathum Thani, Thailand.,Excellence Pharmacogenomics and Precision Medicine Centre, College of Pharmacy, Rangsit University, Pathum Thani, Thailand
| | - Chonlaphat Sukasem
- The Pediatrics-Thai Severe Cutaneous Adverse Drug Reaction (Ped-Thai-SCAR) Research Group, Bangkok, Thailand.,Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand.,The Thai Severe Cutaneous Adverse Drug Reaction (Thai-SCAR) Research Group, Bangkok, Thailand.,Pharmacogenomics and Precision Medicine, The Preventive Genomics & Family Check-up Services Center, Bumrungrad International Hospital, Bangkok, Thailand.,MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
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13
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Shields BE, Wanat KA, Chiu YE. Undiagnosed and Rare Diseases in Critical Care. Crit Care Clin 2022; 38:243-269. [DOI: 10.1016/j.ccc.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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14
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Barrera-Ochoa C, Marioni-Manríquez S, Cortázar-Azuaje A, Quijada-Ucelo Z, Saba-Mussali A, Vega-Memije M. [Translated article] Use of Intravenous Immunoglobulins and Systemic Corticosteroids in Patients With Toxic Epidermal Necrolysis: Experience of a Hospital in Mexico City. ACTAS DERMO-SIFILIOGRAFICAS 2022. [DOI: 10.1016/j.ad.2022.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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15
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Barrera-Ochoa C, Marioni-Manríquez S, Cortázar-Azuaje A, Quijada-Ucelo Z, Saba-Mussali A, Vega-Memije M. Tratamiento con inmunoglobulina intravenosa y esteroides sistémicos en pacientes con necrólisis epidérmica tóxica: Experiencia en un hospital en Ciudad de México. ACTAS DERMO-SIFILIOGRAFICAS 2022; 113:294-299. [DOI: 10.1016/j.ad.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/29/2021] [Accepted: 08/31/2021] [Indexed: 10/19/2022] Open
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16
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Walton NT, Mohr NM. Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care? J Am Coll Emerg Physicians Open 2022; 3:e12631. [PMID: 35024689 PMCID: PMC8733842 DOI: 10.1002/emp2.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.
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Affiliation(s)
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia‐Critical Care Medicine, and EpidemiologyUniversity of Iowa–Carver College of MedicineIowa CityIowaUSA
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17
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Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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18
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Kloypan C, Koomdee N, Satapornpong P, Tempark T, Biswas M, Sukasem C. A Comprehensive Review of HLA and Severe Cutaneous Adverse Drug Reactions: Implication for Clinical Pharmacogenomics and Precision Medicine. Pharmaceuticals (Basel) 2021; 14:1077. [PMID: 34832859 PMCID: PMC8622011 DOI: 10.3390/ph14111077] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/13/2021] [Accepted: 10/18/2021] [Indexed: 12/19/2022] Open
Abstract
Human leukocyte antigen (HLA) encoded by the HLA gene is an important modulator for immune responses and drug hypersensitivity reactions as well. Genetic polymorphisms of HLA vary widely at population level and are responsible for developing severe cutaneous adverse drug reactions (SCARs) such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), maculopapular exanthema (MPE). The associations of different HLA alleles with the risk of drug induced SJS/TEN, DRESS and MPE are strongly supportive for clinical considerations. Prescribing guidelines generated by different national and international working groups for translation of HLA pharmacogenetics into clinical practice are underway and functional in many countries, including Thailand. Cutting edge genomic technologies may accelerate wider adoption of HLA screening in routine clinical settings. There are great opportunities and several challenges as well for effective implementation of HLA genotyping globally in routine clinical practice for the prevention of drug induced SCARs substantially, enforcing precision medicine initiatives.
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Affiliation(s)
- Chiraphat Kloypan
- Unit of Excellence in Integrative Molecular Biomedicine, School of Allied Health Sciences, University of Phayao, Phayao 56000, Thailand;
- Division of Clinical Immunology and Transfusion Science, Department of Medical Technology, School of Allied Health Sciences, University of Phayao, Phayao 56000, Thailand
| | - Napatrupron Koomdee
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (N.K.); (M.B.)
- Laboratory for Pharmacogenomics, Ramathibodi Hospital, Somdech Phra Debaratana Medical Center SDMC, Bangkok 10400, Thailand
| | - Patompong Satapornpong
- Division of General Pharmacy Practice, Department of Pharmaceutical Care, College of Pharmacy, Rangsit University, Pathum Thani 12000, Thailand;
- Excellence Pharmacogenomics and Precision Medicine Centre, College of Pharmacy, Rangsit University, Pathum Thani 12000, Thailand
| | - Therdpong Tempark
- Division of Dermatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand;
| | - Mohitosh Biswas
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (N.K.); (M.B.)
- Laboratory for Pharmacogenomics, Ramathibodi Hospital, Somdech Phra Debaratana Medical Center SDMC, Bangkok 10400, Thailand
- Department of Pharmacy, University of Rajshahi, Rajshahi 6205, Bangladesh
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (N.K.); (M.B.)
- Laboratory for Pharmacogenomics, Ramathibodi Hospital, Somdech Phra Debaratana Medical Center SDMC, Bangkok 10400, Thailand
- The Thai Severe Cutaneous Adverse Drug Reaction THAI-SCAR Research-Genomics Thailand, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
- The Preventive Genomics & Family Check-Up Services Center, Bumrungrad International Hospital, Pharmacogenomics and Precision Medicine Clinic, Bangkok 10110, Thailand
- MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L69 3GL, UK
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19
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Holtz M, Grimstad F, Higgins J, Denny G, Strickland J, Dowlut-McElroy T. Vulvovaginal Involvement in Pediatric Stevens-Johnson Syndrome: A Case Series. J Pediatr Adolesc Gynecol 2021; 34:745-748. [PMID: 33915265 PMCID: PMC8489310 DOI: 10.1016/j.jpag.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/03/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening spectra of mucocutaneous delayed hypersensitivity reactions. Prodromal viral-like symptoms are followed by a characteristic diffuse rash caused by keratinocyte apoptosis and epidermal detachment. CASES Three adolescents were admitted with SJS/TEN and vulvovaginal involvement following initiation of lamictal, bactrim, and phenobarbital. The patients received intravenous immunoglobulin and intravenous steroids. One patient received etanercept. Topical emollients and strict perineal hygiene were initiated. No permanent sequelae were noted following vaginoscopy. SUMMARY AND CONCLUSIONS Vulvovaginal involvement in SJS/TEN can occur and may result in permanent architectural changes. Basic management includes withdrawal of causative medication, intravenous steroids, intravenous immunoglobulin (IVIG), and supportive care. Early initiation of perineal hygiene, vaginal barrier creams, and menstrual suppression should be employed. Vaginoscopy may be used to document full recovery.
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Affiliation(s)
- Max Holtz
- Childrens' Mercy Hospital and University of Missouri Kansas City, Kansas City, Missouri, and Department of Obstetrics and Gynecology, University of Missouri Kansas City, Kansas City, Missouri; Department of Women's Health, Dell Medical School, The University of Texas, Austin, Texas.
| | - Frances Grimstad
- Division of Gynecology, Division of Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Jeannette Higgins
- Childrens' Mercy Hospital and University of Missouri Kansas City, Kansas City, Missouri, and Department of Obstetrics and Gynecology, University of Missouri Kansas City, Kansas City, Missouri
| | - George Denny
- Department of Dermatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Julie Strickland
- Childrens' Mercy Hospital and University of Missouri Kansas City, Kansas City, Missouri, and Department of Obstetrics and Gynecology, University of Missouri Kansas City, Kansas City, Missouri
| | - Tazim Dowlut-McElroy
- Eunice Kennedy Shriver National Institute of Health and Human Development, National Institutes of Health, Bethesda, Maryland
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20
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Frantz R, Huang S, Are A, Motaparthi K. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review of Diagnosis and Management. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:895. [PMID: 34577817 PMCID: PMC8472007 DOI: 10.3390/medicina57090895] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022]
Abstract
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare diseases that are characterized by widespread epidermal necrosis and sloughing of skin. They are associated with significant morbidity and mortality, and early diagnosis and treatment is critical in achieving favorable outcomes for patients. In this scoping review, Excerpta Medica dataBASE and PubMed were searched for publications that addressed recent advances in the diagnosis and management of the disease. Multiple proteins (galectin 7 and RIP3) were identified that are promising potential biomarkers for SJS/TEN, although both are still in early phases of research. Regarding treatment, cyclosporine is the most effective therapy for the treatment of SJS, and a combination of intravenous immunoglobulin (IVIg) and corticosteroids is most effective for SJS/TEN overlap and TEN. Due to the rare nature of the disease, there is a lack of prospective, randomized controlled trials and conducting these in the future would provide valuable insights into the management of this disease.
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Affiliation(s)
- Robert Frantz
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (R.F.); (A.A.)
| | - Simo Huang
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA;
| | - Abhirup Are
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (R.F.); (A.A.)
| | - Kiran Motaparthi
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (R.F.); (A.A.)
- Department of Dermatology, College of Medicine, University of Florida, Gainesville, FL 32606, USA
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21
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Haravu PN, Gottlieb LJ, Vrouwe SQ. Antishear therapy for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: a follow-up study. J Burn Care Res 2021; 42:1152-1161. [PMID: 34370855 DOI: 10.1093/jbcr/irab155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS/TEN) are life-threatening conditions best approached with multidisciplinary burn-equivalent care. There is a lack of consensus on wound management, in particular whether to debride detached epidermis. Our center instituted "antishear" wound therapy thirty-five years ago, where detached skin is left in situ as a biologic dressing and a standardized protocol avoids shear forces to prevent further desquamation. Our center's initial results showed outcomes comparable to SCORTEN predictions, but advancements in burn critical care necessitate a re-evaluation of the antishear approach. A retrospective chart review was conducted for all patients admitted between 06/2004 to 05/2020 with a dermatologist-confirmed diagnosis of SJS/TEN (N=51). All patients were treated with burn-equivalent critical care and antishear wound therapy. Standardized mortality ratios were calculated using the established SCORTEN, and newly developed ABCD-10, prediction models. Mean SCORTEN, ABCD-10, and %TBSA were 2.6, 2.0, and 28%. Overall mortality was 22%; SCORTEN score (p<0.001), ABCD-10 score (p<0.01), %TBSA involved (p=0.02), and development of multi-system organ failure (p<0.001) correlated with increased mortality. Cohort-wide standardized mortality based on ABCD-10 was 1.18 (p=0.79). Standardized mortality based on SCORTEN was 0.62 (p=0.20) and 0.77 (p=0.15) for patients with scores ≤3 and >3; across the cohort it was 0.71 (p=0.11), representing a 29% mortality reduction. Incorporating the antishear approach as part of burn-equivalent care for SJS/TENS led to outcomes comparable to those predicted for surgical debridement via SCORTEN. However, the antishear approach has the advantage of avoiding painful dressing changes, sedation, and general anesthesia required for surgical debridement.
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Affiliation(s)
- Pranav N Haravu
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Lawrence J Gottlieb
- Section of Plastic & Reconstructive Surgery, University of Chicago, Chicago, IL
| | - Sebastian Q Vrouwe
- Section of Plastic & Reconstructive Surgery, University of Chicago, Chicago, IL
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22
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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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23
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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: 21] [Impact Index Per Article: 7.0] [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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24
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Hanson LM, Bettencourt AP. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Guide for Nurses. AACN Adv Crit Care 2021; 31:281-295. [PMID: 32866260 DOI: 10.4037/aacnacc2020634] [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] [Indexed: 11/01/2022]
Abstract
Nurses are central to the care of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. Patients with these conditions present with nuanced symptoms and have complex nursing care needs. Although much of the exact pathophysiology of these diseases is not known, all nurses benefit from a fundamental understanding of the genesis of skin manifestations, associated pharmacology, and prognosis. The care of patients hospitalized with Stevens-Johnson syndrome and toxic epidermal necrolysis consists of wound care, infection prevention, comfort management, hydration and nutrition, psychosocial support, and the prevention of long-term complications. This article provides an overview of these diseases, including clinical diagnosis, history and physical assessment, related pharmacology, and nursing care priorities. A description of the current state of the science in clinical management for nurses at all levels is provided, with an emphasis on nursing's contribution to the best possible patient outcomes.
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Affiliation(s)
- Leah M Hanson
- Leah M. Hanson is Decentralized Nurse Educator, Burn Center, Regions Hospital, St Paul, Minnesota
| | - Amanda P Bettencourt
- Amanda P Bettencourt is Research Fellow, NCSP, and TACTICAL Scholar, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, North Campus Research Center, 2800 Plymouth Rd, B14, Suite G-100, Ann Arbor, MI 48109
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25
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Ahmed AF, Sukasem C, Sabbah MA, Musa NF, Mohamed Noor DA, Daud NAA. Genetic Determinants in HLA and Cytochrome P450 Genes in the Risk of Aromatic Antiepileptic-Induced Severe Cutaneous Adverse Reactions. J Pers Med 2021; 11:383. [PMID: 34067134 PMCID: PMC8150699 DOI: 10.3390/jpm11050383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/20/2021] [Accepted: 04/28/2021] [Indexed: 12/19/2022] Open
Abstract
Adverse drug reaction (ADR) is a pressing health problem, and one of the main reasons for treatment failure with antiepileptic drugs. This has become apparent in the event of severe cutaneous adverse reactions (SCARs), which can be life-threatening. In this review, four hypotheses were identified to describe how the immune system is triggered in the development of SCARs, which predominantly involve the human leukocyte antigen (HLA) proteins. Several genetic variations in HLA genes have been shown to be strongly associated with the susceptibility to developing SCARs when prescribed carbamazepine or phenytoin. These genetic variations were also shown to be prevalent in certain populations. Apart from the HLA genes, other genes proposed to affect the risk of SCARs are genes encoding for CYP450 drug-metabolising enzymes, which are involved in the pharmacokinetics of offending drugs. Genetic variants in CYP2C9 and CYPC19 enzymes were also suggested to modulate the risk of SCARs in some populations. This review summarizes the literature on the manifestation and aetiology of antiepileptic-induced SCARs, updates on pharmacogenetic markers associated with this reaction and the implementation of pre-emptive testing as a preventive strategy for SCARs.
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Affiliation(s)
- Ali Fadhel Ahmed
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang 11800, Malaysia or (A.F.A.); (D.A.M.N.)
| | - Chonlaphat Sukasem
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok 10400, Thailand
- The Thai Severe Cutaneous Adverse Drug Reaction (THAI-SCAR) Research Group, Chulalongkorn University, Bangkok 10330, Thailand
- Advanced Research and Development Laboratory, Bumrungrad International Hospital, Bangkok 10110, Thailand
| | - Majeed Arsheed Sabbah
- Forensic DNA for Research and Training Centre, Alnahrain University, Baghdad 64074, Iraq;
| | - Nur Fadhlina Musa
- Human Genome Center, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kota Bharu 16150, Malaysia;
| | - Dzul Azri Mohamed Noor
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang 11800, Malaysia or (A.F.A.); (D.A.M.N.)
| | - Nur Aizati Athirah Daud
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang 11800, Malaysia or (A.F.A.); (D.A.M.N.)
- Human Genome Center, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kota Bharu 16150, Malaysia;
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26
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Wong CY, Colven RM, Gibran NS, Stewart BT, Pham TN, Arbabi S, DeNiro KL. Accuracy and Cost-effectiveness of a Telemedicine Triage Initiative for Patients With Suspected Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. JAMA Dermatol 2021; 157:114-115. [PMID: 33237271 DOI: 10.1001/jamadermatol.2020.4490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Christine Y Wong
- Department of Dermatology, Stanford University School of Medicine, Stanford, California.,Department of Internal Medicine, Virginia Mason Hospital and Medical Center, Seattle, Washington
| | - Roy M Colven
- Harborview Medical Center, Dermatology Clinic, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Nicole S Gibran
- Harborview Medical Center, Department of Surgery, University of Washington School of Medicine, Seattle
| | - Barclay T Stewart
- Harborview Medical Center, Department of Surgery, University of Washington School of Medicine, Seattle
| | - Tam N Pham
- Harborview Medical Center, Department of Surgery, University of Washington School of Medicine, Seattle
| | - Saman Arbabi
- Harborview Medical Center, Department of Surgery, University of Washington School of Medicine, Seattle
| | - Katherine L DeNiro
- Harborview Medical Center, Dermatology Clinic, Department of Medicine, University of Washington School of Medicine, Seattle
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27
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Zhang Q, Shaikh AR, Yoon T, Shah S, Mahoney JW. The Reflection on the Management of Toxic Epidermal Necrolysis in the Community Setting: An Internist's Perspective. Cureus 2021; 13:e13042. [PMID: 33680588 PMCID: PMC7925054 DOI: 10.7759/cureus.13042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Toxic epidermal necrolysis (TEN) is a dermatological emergency that is often associated with high mortality. It is differentiated from Stevens-Johnson syndrome (SJS) based on the percentage of the total body surface area affected. There has been an established correlation with certain medications that could trigger the development of such a devastating disease. Despite numerous research studies conducted on aspects of this disease entity, TEN remains foreign to many general Internists situated in a community setting due to the extremely low disease prevalence that leads to a lack of overall experience and medical resources in dealing with this medical condition. Thus, we outlined several important management aspects of TEN/SJS that an Internist should be aware of in order to assist in prompt clinical decision making and prognosis forecasting as well as deliver effective family communication.
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Affiliation(s)
- Qian Zhang
- Internal Medicine, Abington Hospital- Jefferson Health, Abington, USA
| | - Ali Raza Shaikh
- Internal Medicine, Abington Hospital- Jefferson Health, Abington, USA
| | - Thomas Yoon
- Internal Medicine, Abington Hospital- Jefferson Health, Abington, USA
| | - Shreeja Shah
- Internal Medicine, Abington Hospital- Jefferson Health, Abington, USA
| | - James W Mahoney
- Internal Medicine, Abington Hospital- Jefferson Health, Abington, USA
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28
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Immune checkpoint inhibitor-related epidermal necrolysis: A rare condition with poor prognosis. Eur J Cancer 2021; 145:194-196. [PMID: 33493978 DOI: 10.1016/j.ejca.2020.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/13/2020] [Indexed: 11/23/2022]
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29
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Impact of Antibiotics Associated with the Development of Toxic Epidermal Necrolysis on Early and Late-Onset Infectious Complications. Microorganisms 2021; 9:microorganisms9010202. [PMID: 33477980 PMCID: PMC7835845 DOI: 10.3390/microorganisms9010202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 01/01/2023] Open
Abstract
Toxic epidermal necrolysis (TEN) is a rare disease, which predominantly manifests as damage to the skin and mucosa. Antibiotics count among the most common triggers of this hypersensitive reaction. Patients with TEN are highly susceptible to infectious complications due to the loss of protective barriers and immunosuppressant therapy. The aim of this study was to investigate the potential relationship between antibiotics used before the development of TEN and early and late-onset infectious complications in TEN patients. In this European multicentric retrospective study (Central European Lyell syndrome: therapeutic evaluation (CELESTE)), records showed that 18 patients with TEN used antibiotics (mostly aminopenicillins) before the disease development (group 1), while in 21 patients, TEN was triggered by another factor (group 2). The incidence of late-onset infectious complications (5 or more days after the transfer to the hospital) caused by Gram-positive bacteria (especially by Enterococcus faecalis/faecium) was significantly higher in group 1 than in group 2 (82.4% vs. 35.0%, p = 0.007/pcorr = 0.014) while no statistically significant difference was observed between groups of patients with infection caused by Gram-negative bacteria, yeasts, and filamentous fungi (p > 0.05). Patients with post-antibiotic development of TEN are critically predisposed to late-onset infectious complications caused by Gram-positive bacteria, which may result from the dissemination of these bacteria from the primary focus.
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Arora R, Pande RK, Panwar S, Gupta V. Drug-related Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review. Indian J Crit Care Med 2021; 25:575-579. [PMID: 34177178 PMCID: PMC8196388 DOI: 10.5005/jp-journals-10071-23826] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening, allergic reactions affecting the skin and mucous membranes. SJS is considered to be a milder form with less than 10% of body surface area (BSA) involvement. We report successful management of two cases of SJS and TEN. Firstly, a case of a 24-year-old female who presented with rashes over face, chest, and upper limbs after the oral intake of ciprofloxacin and local application of moxifloxacin eye drops. She developed high-grade fever and difficulty in breathing requiring intubation and lung-protective mechanical ventilation and was treated with high-dose methylprednisolone, azithromycin, soframycin skin dressings, and topical ocular antibiotics. Secondly, another case of a 16-year-old female who developed bullous eruptions over the trunk, arms, hands, face, and sole involving 60% of BSA, after oral intake of albendazole. She was diagnosed as TEN and successfully managed with sterile silver nitrate, soframycin dressings, and antibiotics. Key message Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening, allergic reactions affecting the skin and mucous membranes. Early identification, withdrawal of the suspected drug, and early transfer to a specialized center decrease mortality. How to cite this article Arora R, Pande RK, Panwar S, Gupta V. Drug-related Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review. Indian J Crit Care Med 2021;25(5):575-579.
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Affiliation(s)
- Rohini Arora
- Department of Critical Care, D BL Kapur Superspeciality Hospital, New Delhi, India
| | - Rajesh K Pande
- Department of Critical Care, D BL Kapur Superspeciality Hospital, New Delhi, India
| | - Shikha Panwar
- Department of Critical Care, D BL Kapur Superspeciality Hospital, New Delhi, India
| | - Vivek Gupta
- Department of Pharmacology, D BL Kapur Superspeciality Hospital, New Delhi, India
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Noe MH, Micheletti RG. Diagnosis and management of Stevens-Johnson syndrome/toxic epidermal necrolysis. Clin Dermatol 2020; 38:607-612. [DOI: 10.1016/j.clindermatol.2020.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Nygaard RM, Endorf FW. Differences in Treatment of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis at Burn Centers and Nonburn Centers. J Burn Care Res 2020; 41:945-950. [PMID: 32498082 DOI: 10.1093/jbcr/iraa082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and Stevens-Johnson/TEN overlap syndrome (SJS/TEN) are severe exfoliative skin disorders resulting primarily from allergic drug reactions and sometimes from viral causes. Because of the significant epidermal loss in many of these patients, many of them end up receiving treatment at a burn center for expertise in the care of large wounds. Previous work on the treatment of this disease focused only on the differences in care of the same patients treated at nonburn centers and then transferred to burn centers. We wanted to explore whether patients had any differences in care or outcomes when they received definitive treatment at burn centers and nonburn centers. We queried the National Inpatient Sample database from 2016 for patients with SJS, SJS/TEN, and TEN diagnoses. We considered burn centers as those with greater than 10 burn transfers to their center and fewer than 5 burn transfers out of their center in a year. Multivariable logistic regression assessed factors associated with treatment at a burn center and mortality. Using the National Inpatient Sample, a total of 1164 patients were identified. These were divided into two groups, nonburn centers vs burn centers, and those groups were compared for demographic characteristics as well as variables in their hospital course and outcome. Patients treated at nonburn centers were more likely to have SJS and patients treated at burn centers were more likely to have both SJS/TEN and TEN. Demographics were similar between treatment locations, though African-Americans were more likely to be treated at a burn center. Burn centers had higher rates of patients with extreme severity and mortality risks and a longer length of stay. However, burn centers had similar actual mortality compared to nonburn centers. Patients treated at burn centers had higher charges and were more likely to be transferred to long-term care after their hospital stay. The majority of patients with exfoliative skin disorders are still treated at nonburn centers. Patients with SJS/TEN and TEN were more likely to be treated at a burn center. Patients treated at burn centers appear to have more severe disease but similar mortality to those treated at nonburn centers. Further study is needed to determine whether patients with these disorders do indeed benefit from transfer to a burn center.
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Parperis K, Bhattarai B, Hadi M, Malla S, Barlingay G, Ramakuri M, Foster K. Burn center admissions of patients with autoimmune rheumatic diseases: clinical characteristics and outcomes. Rheumatol Int 2020; 40:1649-1656. [PMID: 32507914 DOI: 10.1007/s00296-020-04617-1] [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: 04/16/2020] [Accepted: 05/31/2020] [Indexed: 01/14/2023]
Abstract
The ojective of this study was to describe the reasons for admission to the burn center of patients with autoimmune rheumatic diseases (ARD), identify their clinical characteristics, and assess their outcomes relative to the non-ARD patients. We conducted a retrospective study of ARD patients admitted to a burn center from 2011 to 2018, and they were compared with a non-ARD group of patients. Medical records were reviewed for patients' clinical characteristics, including demographics, ARD diagnosis, laboratory studies, and APACHE II score. Additionally, we evaluate the reason for admission in the burn center, management during the burn center stay, complications, outcomes including length of stay, and mortality during the hospital stay. Among the 1094 adult patients admitted during the study period, 30 (2.7%) had a new or prior diagnosis of ARD. The most common ARD associated with admission in the burn center was rheumatoid arthritis (RA) (37%, n = 11) followed by systemic lupus erythematosus (SLE) (33%, n = 10). Burn injuries (47%, n = 14), and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) (30%, n = 9) were the most frequent admission reasons. Compared with the non-ARD group (n = 52), ARD patients were more likely to be females (60% vs. 24%, P = 0.004), to receive glucocorticoids (50% vs. 6.9%; P < 0.05), require renal replacement (20% vs. 5%, P < 0.05) and enteral nutrition (63% vs. 24%; P < 0.05) during their burn stay. The non-ARD group was more likely to be admitted for burn injuries (81% vs 46%, P < 0.01). RA and SLE were the most common ARD, and burn injuries, followed by SJS/TEN, the most frequent causes associated with burn admissions. ARD patients were more likely to be female, received glucocorticoids, require renal replacement, and enteral nutrition during the burn stay.
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Affiliation(s)
- Konstantinos Parperis
- Department of Medicine, Medical School, University of Cyprus, University of Arizona College of Medicine, 475 N 5th Street, Phoenix, AZ, USA.
| | - Bikash Bhattarai
- Valleywise Health, Biostatistician, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Mohanad Hadi
- Department of Medicine, Valleywise Health, Phoenix, AZ, USA
| | - Sawjanya Malla
- Department of Medicine, Valleywise Health, Phoenix, AZ, USA
| | | | | | - Kevin Foster
- Department of Surgery, Valleywise Health, Phoenix, AZ, USA
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Seminario-Vidal L, Kroshinsky D, Malachowski SJ, Sun J, Markova A, Beachkofsky TM, Kaffenberger BH, Ergen EN, Mauskar M, Bridges A, Calhoun C, Cardones AR, Chen ST, Chodosh J, Cotliar J, Davis MDP, DeNiro KL, Dominguez AR, Eljure-Téllez J, Femia A, Fox LP, Guda A, Mitchell C, Mostaghimi A, Ortega-Loayza AG, Owen C, Pasieka H, Rahnama-Moghadam S, Saeed HN, Saunderson RB, Shanbhag S, Sharon VR, Strowd L, Venkatesh S, Wanat KA, Wetter DA, Worswick S, Micheletti RG. Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. J Am Acad Dermatol 2020; 82:1553-1567. [PMID: 32151629 DOI: 10.1016/j.jaad.2020.02.066] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/04/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.
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Affiliation(s)
- Lucia Seminario-Vidal
- Department of Dermatology, University of South Florida, Morsani College of Medicine, Tampa, Florida; Cutaneous Oncology Program, H. Lee Moffitt Cancer Center, Tampa, Florida.
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen J Malachowski
- Department of Internal Medicine, Medical College of Wisconsin Affiliated Hospitals, St. Joseph's Hospital, Milwaukee, Wisconsin
| | - James Sun
- Cutaneous Oncology Program, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Alina Markova
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Elizabeth N Ergen
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melissa Mauskar
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alina Bridges
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Cody Calhoun
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Adela R Cardones
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Steven T Chen
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James Chodosh
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Cotliar
- Division of Dermatology, Harbor-University of California, Los Angeles Medical Center, Los Angeles, California
| | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | | | - Arturo R Dominguez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Juliana Eljure-Téllez
- Department of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - Alisa Femia
- Ronald O. Perelman Department of Dermatology, New York University Langone Health, New York, New York
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | - Anisha Guda
- University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas
| | - Caroline Mitchell
- Vincent Center for Reproductive Biology, Department of Obstetrics, Gynecology & Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Cindy Owen
- Division of Dermatology, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Helena Pasieka
- Department of Dermatology, MedStar Washington Hospital Center, Washington, DC
| | | | - Hajirah N Saeed
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Rebecca B Saunderson
- Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Swapna Shanbhag
- Tej Kohli Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, India
| | - Victoria R Sharon
- Department of Dermatology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Lindsay Strowd
- Department of Dermatology, Wake Forest University School of Medicine, Wake Forest, North Carolina
| | - Samantha Venkatesh
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Karolyn A Wanat
- Department of Dermatology, University of Southern California, Los Angeles, California
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Scott Worswick
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert G Micheletti
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
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Noe MH, Rosenbach M, Hubbard RA, Mostaghimi A, Cardones AR, Chen JK, Cotliar J, Davis MDP, Dominguez A, Fox LP, Hughey LC, Kaffenberger BH, Kroshinsky D, Kwong BY, Miller DD, Musiek A, Ortega-Loayza AG, Sharon VR, Shinkai K, Summers EM, Wanat KA, Wetter DA, Worswick S, Margolis DJ, Gelfand JM, Micheletti RG. Development and Validation of a Risk Prediction Model for In-Hospital Mortality Among Patients With Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis-ABCD-10. JAMA Dermatol 2020; 155:448-454. [PMID: 30840032 DOI: 10.1001/jamadermatol.2018.5605] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of severe mucocutaneous drug reaction associated with significant morbidity and mortality. A previously developed SJS/TEN-specific severity-of-illness model (Score of Toxic Epidermal Necrolysis [SCORTEN]) has been reported to overestimate and underestimate SJS/TEN-related in-hospital mortality in various populations. Objective To derive a risk prediction model for in-hospital mortality among patients with SJS/TEN and to compare prognostic accuracy with the SCORTEN model in a multi-institutional cohort of patients in the United States. Design, Setting, and Participants Data from a multicenter cohort of patients 18 years and older treated for SJS/TEN between January 1, 2000, and June 1, 2015, were obtained from inpatient consult databases and electronic medical record systems at 18 medical centers in the United States as part of the Society for Dermatology Hospitalists. A risk model was derived based on data from 370 of these patients. Model discrimination (calculated as area under the receiver operating characteristic curve [AUC]) and calibration (calculated as predicted vs observed mortality, and examined using the Hosmer-Lemeshow goodness-of-fit statistic) were assessed, and the predictive accuracy was compared with that of SCORTEN. All analysis took place between December 2016 and April 2018. Main Outcomes and Measures In-hospital mortality. Results Among 370 patients (mean [SD] age 49.0 [19.1] years; 195 [52.7%] women), 54 (15.14%) did not survive to hospital discharge. Five covariates, measured at the time of admission, were independent predictors of in-hospital mortality: age in years (odds ratio [OR], 1.05; 95% CI, 1.02-1.07), body surface area (BSA) in percentage of epidermal detachment (OR, 1.02; 95% CI, 1.01-1.04), serum bicarbonate level below 20 mmol/L (OR, 2.90; 95% CI, 1.43-5.88), active cancer (OR, 4.40; 95% CI, 1.82-10.61), and dialysis prior to admission (OR, 15.94; 95% CI, 3.38-66.30). A severity-of-illness score was calculated by taking the sum of 1 point each for age 50 years or older, epidermal detachment greater than 10% of BSA, and serum bicarbonate level below 20 mmol/L; 2 points for the presence of active cancer; and 3 points for dialysis prior to admission. The score was named ABCD-10 (age, bicarbonate, cancer, dialysis, 10% BSA). The ABCD-10 model showed good discrimination (AUC, 0.816; 95% CI, 0.759-0.872) and calibration (Hosmer-Lemeshow goodness of fit test, P = .30). For SCORTEN, on admission, the AUC was 0.827 (95% CI, 0.774-0.879) and was not significantly different from that of the ABCD-10 model (P = .72). Conclusions and Relevance In this cohort of patients with SJS/TEN, ABCD-10 accurately predicted in-hospital mortality, with discrimination that was not significantly different from SCORTEN. Additional research is needed to validate ABCD-10 in other populations. Future use of a new mortality prediction model may provide improved prognostic information for contemporary patients, including those enrolled in observational studies and therapeutic trials.
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Affiliation(s)
- Megan H Noe
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Misha Rosenbach
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Rebecca A Hubbard
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adela R Cardones
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Jennifer K Chen
- Department of Dermatology, Stanford Hospital and Clinics, Redwood City, California
| | | | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Arturo Dominguez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lindy P Fox
- Department of Dermatology, University of California San Francisco
| | - Lauren C Hughey
- Department of Dermatology, University of University of Alabama at Birmingham, Birmingham
| | | | | | - Bernice Y Kwong
- Department of Dermatology, Stanford Hospital and Clinics, Stanford, California
| | - Daniel D Miller
- Department of Dermatology, University of Minnesota, Rochester
| | - Amy Musiek
- Division of Dermatology, Washington University School of Medicine, St Louis, Missouri
| | | | - Victoria R Sharon
- Department of Dermatology, Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Kanade Shinkai
- Department of Dermatology, University of California San Francisco
| | - Erika M Summers
- Department of Dermatology, University of Utah School of Medicine, Salt Lake City
| | - Karolyn A Wanat
- Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Scott Worswick
- Division of Dermatology, University of California, Los Angeles
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Joel M Gelfand
- Department of Dermatology, University of Pennsylvania, Philadelphia
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IVIG and under Burn Unit Care Yield Favorable Outcomes in Pediatric Patients with Toxic Epidermal Necrolysis: A Case Report and Literature Review. Case Rep Dermatol Med 2020; 2020:6274053. [PMID: 32082644 PMCID: PMC7013329 DOI: 10.1155/2020/6274053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 12/31/2019] [Indexed: 11/20/2022] Open
Abstract
Body reactions to drugs can manifest as Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). TEN is the most severe form of cutaneous reactions with an incidence rate of 1-2 per million cases per year. Despite TEN being a critical and life-threatening condition, there is little to no evidence of clear management protocol. We reported a 5-year-old male child who presented with lamotrigine-induced TEN and was successfully treated with intravenous immune globulin (IVIG) with a burn unit care level, while TEN treatment with IVIG is an appropriate approach with predictable good outcomes, burn unit care is also effective in creating highly favorable effects. Upon reviewing the literature, several studies indicate that TEN patients treated with the combination of IVIG and burn unit care lead to decreased levels of morbidity and mortality than when treated with IVIG or burn unit care alone. Therefore, treatment involving both IVIG and burn unit care should be considered for TEN patients.
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Jaller JA, McLellan BN, Balagula Y. Wound Management in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00285-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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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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Kaide CG, San Miguel CE. Stevens Johnson Syndrome – “Steven Who? And Why I Should Care About His Johnson?”. CASE STUDIES IN EMERGENCY MEDICINE 2020. [PMCID: PMC7122494 DOI: 10.1007/978-3-030-22445-5_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Diagnosing rashes in the emergency department can be challenging. If the rash is extensive and targetoid, include Stevens-Johnson Syndrome (SJS) on your differential and be sure to obtain a thorough history to identify possible offending agents. Additionally, prioritize supportive care and obtaining a dermatology/burn consult to coordinate appropriate care.
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Affiliation(s)
- Colin G. Kaide
- Wexner Medical Center, Ohio State University, Columbus, OH USA
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Gelincik A, Cavkaytar O, Kuyucu S. An Update on the Management of Severe Cutaneous Drug Hypersensitivity Reactions. Curr Pharm Des 2019; 25:3881-3901. [DOI: 10.2174/1381612825666191106115556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/01/2019] [Indexed: 12/15/2022]
Abstract
Severe cutaneous drug hypersensitivity reactions involve of different mechanisms , some of which are
life-threatening, such as Stevens-Johnson syndrome/toxic epidermal necrolysis, drug reaction with eosinophilia
and systemic symptoms, acute generalized exanthematous pustulosis, generalized bullous fixed drug eruptions,
serum sickness and serum sickness-like reaction and drug-induced vasculitis. These reactions may have substantial
morbidity and mortality. In the past years, successive studies have provided new evidence regarding the
pathogenesis of some of these severe reactions and revealed that underlying mechanisms are highly variable.
Since these reactions have unique presentations and distinct pathomechanisms, the treatment methods and response
rates might be different among various entities. Although supportive and local therapies are sufficient in
some of these reactions, targeted immunosuppressive treatments and even mechanistic therapies such as plasmapheresis
may be required in severe ones. However, there is still insufficient evidence to support the best treatment
options for these patients since number of patients and large-scale studies are limited. In this review, conventional
and new treatment options for severe cutaneous drug hypersensitivity reactions are presented in detail in
order to provide the contemporary approaches to lessen the morbidity and mortality relevant to these severe iatrogenic
diseases.
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Affiliation(s)
- Aslı Gelincik
- Division of Immunology and Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University, Faculty of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Mersin University, Faculty of Medicine, Mersin, Turkey
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Management of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: a Review and Update. CURRENT DERMATOLOGY REPORTS 2019. [DOI: 10.1007/s13671-019-00275-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Richard EB, Hamer D, Musso MW, Short T, O'Neal HR. Variability in Management of Patients With SJS/TEN: A Survey of Burn Unit Directors. J Burn Care Res 2019; 39:585-592. [PMID: 29901804 DOI: 10.1093/jbcr/irx023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, type IV hypersensitivity reactions of the skin and mucosa. These reactions (SJS/TEN) are frequently managed in burn units; however, no standardized guidelines exist for the treatment and management of SJS/TEN. To gain insight into current SJS/TEN management practices, a survey on admission, diagnosis, and management, was conducted across accredited burn units in the United States. A 28-item question survey on SJS/TEN management, diagnosis, and treatment practices was distributed among medical directors and co-directors of American Burn Association-verified burn centers. Responses were collected over a 6-week period. In total, 31 (48% response rate) burn unit medical directors/co-directors participated in the survey. The majority of responders indicate that acceptance to their burn unit is based on clinical suspicion of SJS/TEN (74%), and biopsy or dermatological evaluation is not required (67 and 87%, respectively). More than half (61%) of the burn units have their own SJS/TEN protocol in place. No consensus was observed on different treatment aspects, such as infection control, systemic treatment, and wound care. Most directors reported their burn units to consult ophthalmology (77%) and dermatology (54%) for the management of patients with SJS/TEN. Large variability in procedures of admission, treatment, and management of SJS/TEN was identified across burn centers. This study demonstrates the urgent need for SJS/TEN standardized guidelines in the United States.
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Affiliation(s)
- Emily B Richard
- Internal Medicine Residency Program, Louisiana State University Health Sciences Center, New Orleans
| | - Diana Hamer
- Division of Academic Affairs, Our Lady of the Lake Regional Medical Center, Baton Rouge LA
| | - Mandi W Musso
- Division of Academic Affairs, Our Lady of the Lake Regional Medical Center, Baton Rouge LA
| | - Tracee Short
- Burn Unit, Baton Rouge General Medical Center, LA
| | - Hollis R O'Neal
- Internal Medicine Residency Program, Louisiana State University Health Sciences Center, New Orleans
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Krajewski A, Mazurek MJ, Mlynska-Krajewska E, Piorun K, Knakiewicz M, Markowska M. Toxic Epidermal Necrolysis Therapy with TPE and IVIG-10 Years of Experience of the Burns Treatment Center. J Burn Care Res 2019; 40:652-657. [PMID: 31032516 DOI: 10.1093/jbcr/irz073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a potentially life-threatening, exfoliative disease. It is described as idiosyncratic, severe, skin reaction to drugs. With Stevens-Johnson's Syndrome, it presents as a continuum of a disease being categorized relating to the percentage of affected skin. Without any multicenter trials comparing TEN treatment modalities, there is dearth of strong evidence-based guidelines of care. Total plasma exchange with intravenous immunoglobulin (IVIG) is one among plethora of possible treatment strategies. In our 10-year experience, we have observed 21 patients admitted to our burns center due to TEN. All of them were placed under intensive care with daily plasmapheresis (TPE) and IVIG. We have observed 52% mortality, with observed severe concomitant diseases in every patient in nonsurvivor group (average Acute Physiology and Chronic Health Evaluation II score at admission: 31.5%). We consider that TPE with IVIG might be of use in selected group of patients with TEN without any severe comorbidities. However, further multicenter trials are needed because in some cases it may raise mortality.
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Affiliation(s)
| | | | | | - Krzysztof Piorun
- West Pomeranian Burns and Plastic Surgery Center, Gryfice, Poland
| | | | - Marta Markowska
- West Pomeranian Burns and Plastic Surgery Center, Gryfice, Poland
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Trommel N, Hofland HW, van Komen RS, Dokter J, van Baar ME. Nursing problems in patients with toxic epidermal necrolysis and Stevens-Johnson syndrome in a Dutch burn centre: A 30-year retrospective study. Burns 2019; 45:1625-1633. [PMID: 31387802 DOI: 10.1016/j.burns.2019.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/12/2019] [Accepted: 07/02/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Multiple studies have been published on toxic epidermal necrolysis (TEN) and Stevens-Johnsen syndrome (SJS). Nursing care is an important part of the treatment of TEN patients. Unfortunately, limited information on nursing in TEN/SJS patients has been published in the current literature. Nursing research is needed to improve the complex nursing care required for these rare patients. Therefore, the objective was to assess nursing problems in TEN patients in a burn centre setting over a 30-year period. METHODS The data for this study were gathered retrospectively from nursing records of all patients with TEN/SJS admitted to Burn Centre Rotterdam between January 1987 and December 2016. Dutch burn centres were recently accepted as expertise centres for TEN patients. Nursing problems were classified using the classification of nursing problems of the Dutch Nursing Society. RESULTS A total of 69 patients were admitted with SJS/TEN. Fifty-nine patient files were available. The most frequently reported nursing problems (>20% of the patients) were wounds, threatened or disrupted vital functions, dehydration or fluid imbalance, pain, secretion problems and fever. Furthermore, TEN-specific nursing problems were documented, including oral mucosal lesions and ocular problems. The highest number of concomitant nursing problems occurred during the period between days three and 20 after onset of the disease and varied by nursing problem. CONCLUSIONS The most frequently reported nursing problems involved physical functions, especially on days three to 20 after onset of the disease. With this knowledge, we can start nursing interventions early in the treatment, address problems at the first sign and inform patients and their families or relatives of these issues early in the disease process. A next step to improve nursing care for TEN patients is to acquire knowledge on the optimal interventions for nursing problems.
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Affiliation(s)
- N Trommel
- Burn Centre, Maasstad Hospital, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands.
| | - H W Hofland
- Burn Centre, Maasstad Hospital, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands; Association of Dutch Burn Centres, P.O. Box 1015, 1940 EA Beverwijk, The Netherlands.
| | - R S van Komen
- Burn Centre, Maasstad Hospital, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands.
| | - J Dokter
- Burn Centre, Maasstad Hospital, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands.
| | - M E van Baar
- Burn Centre, Maasstad Hospital, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands; Association of Dutch Burn Centres, P.O. Box 1015, 1940 EA Beverwijk, The Netherlands.
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Abstract
Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are immunologic reactions to several stimuli, mostly medications, which present as a spectrum of primarily widespread mucocutaneous lesions, but also with other organ involvement. Pathology is characterized by full thickness necrosis of the epithelial layer of the involved organ due to immune-mediated apoptosis of the resident keratinocytes. High suspicion for early detection and quick withdrawal of the culprit medication are the most important steps in stopping this reaction. Aggressive supportive care is often necessary as the patient recovers. Steroids, other immunosuppressants, and plasmapheresis have all been studied as treatments, but high-quality evidence supporting their contributions, either together or separately, in decreasing length of hospital stay or prolonging survival have not been consistently demonstrated. Further studies of the mechanism of action and novel treatment modalities are still needed to improve outcomes in patients with this rare but often fatal condition.
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Affiliation(s)
- Joseph L. Nates
- Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Kristen J. Price
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX USA
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Zhang AJ, Nygaard RM, Endorf FW, Hylwa SA. Stevens‐Johnson syndrome and toxic epidermal necrolysis: retrospective review of 10‐year experience. Int J Dermatol 2019; 58:1069-1077. [DOI: 10.1111/ijd.14409] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/25/2018] [Accepted: 01/29/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Amy J. Zhang
- University of Minnesota Medical School Minneapolis MN USA
| | - Rachel M. Nygaard
- Department of Surgery Hennepin County Medical Center Minneapolis MN USA
| | | | - Sara A. Hylwa
- Department of Dermatology University of Minnesota Minneapolis MN USA
- Department of Dermatology Hennepin County Medical Center Minneapolis MN USA
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Jha AK, Suchismita A, Jha RK, Raj VK. Spectrum of gastrointestinal involvement in Stevens - Johnson syndrome. World J Gastrointest Endosc 2019; 11:115-123. [PMID: 30788030 PMCID: PMC6379748 DOI: 10.4253/wjge.v11.i2.115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 01/29/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
Stevens - Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) is a severe adverse drug reaction associated with involvement of skin and mucosal membranes, and carries significant risk of mortality and morbidity. Mucus membrane lesions usually involve the oral cavity, lips, bulbar conjunctiva and the anogenitalia. The oral/anal mucosa and liver are commonly involved in SJS or TEN. However, intestinal involvement is distinctly rare. We herein review the current literature regarding the gastrointestinal involvement in SJS or TEN. This review focuses mainly on the small bowel and colonic involvement in patients with SJS or TEN.
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Affiliation(s)
- Ashish Kumar Jha
- Department of Gastroenterology, Indira Gandhi Institute of Medical Science, Sheikhpura, Patna 800014, India
| | - Arya Suchismita
- Department of Pediatrics, Indira Gandhi Institute of Medical Science, Sheikhpura, Patna 800014, India
| | | | - Vikas Kumar Raj
- Health Center, National Institute of Technology, Patna 800014, India
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The Role of Biological Skin Substitutes in Stevens-Johnson Syndrome: Systematic Review. Plast Surg Nurs 2019; 38:121-127. [PMID: 30157125 DOI: 10.1097/psn.0000000000000234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Stevens-Johnson syndrome (SJS) is a disease that causes skin exfoliative lesions, characterized by fever, necrosis, and epidermal detachment. Biological skin substitutes may be considered interesting options for the treatment of this disease. This study aims at identifying in the literature the evidence on the current role of these biomaterials in the treatment of SJS and its related diseases. A systematic review with a search period between 2003 and 2017 was carried out, consulting the Lilacs, BVS, and PubMed databases. The quality of the included studies was evaluated by the Oxford Center for Evidence-Based Medicine Classification, for evaluating levels of evidence from the scientific publications. Ninety-five publications were found, and after applying inclusion and exclusion criteria, they resulted in 9 articles. In total, 20 patients with 73.87% average of body surface affected received SJS skin treatment with some biological substitutes, among them are cutaneous allograft, amnion, and xenograft. Mortality rate was 10%, and in these situations, literature indicates mortality rates ranging from 25% to 70%. Effectiveness of the use of biological dressings may be a possible explanation for this finding. Findings indicate the use of these biomaterials may favor reepithelialization, reduce water loss, decrease the chance of infection, and, consequently, improve the survival of patients with SJS and toxic epidermal necrolysis. Biological skin substitutes have characteristics that make them very promising in the topical treatment of these wounds, but their use remains very restricted in the treatment of SJS.
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Lee TH, Lee CC, Ng CY, Chang MY, Chang SW, Fan PC, Chung WH, Tian YC, Chen YC, Chang CH. The influence of acute kidney injury on the outcome of Stevens-Johnson syndrome and toxic epidermal necrolysis: The prognostic value of KDIGO staging. PLoS One 2018; 13:e0203642. [PMID: 30192870 PMCID: PMC6128626 DOI: 10.1371/journal.pone.0203642] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/26/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome are severe drug-induced cutaneous adverse reactions with high mortality. Acute kidney injury (AKI) was a common complication in an SJS/TEN group and noted as an independent risk factor for mortality in patients with SJS/TEN. To determine whether AKI staging can predict the outcome of patients with SJS/TEN, we compared the discriminative power of an AKI KDIGO staging system with that of SCROTEN, APACHE II, APACHE III, and SOFA. MATERIALS AND METHODS We retrospectively analyzed the data of 75 patients who were diagnosed with SJS, TEN, or SJS/TEN overlap syndrome at a tertiary care university hospital between January 1, 2011 and December 31, 2014. The baseline characteristics, biochemical analysis data, medication use, and outcomes of the patients were assessed, and the discriminative ability for predicting mortality was determined for each prognostic model. RESULTS Of the 75 patients, 23 (30.7%) had AKI, of whom 13 (56.5%) died during the index admission. Of the prognostic risk models analyzed, the KDIGO staging system showed similar discriminative ability in predicting in-hospital mortality as did the other models. In addition, combining KDIGO with other scoring systems yielded significantly more accurate risk prediction for in-hospital mortality compared with the other individual scores alone, as measured by net reclassification index. The patients with KDIGO stages 2 and 3 exhibited a significantly lower 1-year survival rate than did those with KDIGO stages 0 and 1. CONCLUSION AKI KDIGO staging has good discriminative ability and is easy to utilize for predicting mortality.
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Affiliation(s)
- Tao Han Lee
- Kidney Research Center, Department of Nephrology, Change Gung Memorial Hospital, Linkou branch, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Change Gung Memorial Hospital, Linkou branch, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chau-Yee Ng
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan
| | - Ming-Yang Chang
- Kidney Research Center, Department of Nephrology, Change Gung Memorial Hospital, Linkou branch, Taoyuan, Taiwan
| | - Su-Wei Chang
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Pei-Chun Fan
- Kidney Research Center, Department of Nephrology, Change Gung Memorial Hospital, Linkou branch, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan
| | - Ya-Chung Tian
- Kidney Research Center, Department of Nephrology, Change Gung Memorial Hospital, Linkou branch, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Kidney Research Center, Department of Nephrology, Change Gung Memorial Hospital, Linkou branch, Taoyuan, Taiwan
- Division of Nephrology, Department of Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Change Gung Memorial Hospital, Linkou branch, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- * E-mail: ,
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50
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Management and outcome of Stevens–Johnson syndrome and toxic epidermal necrolysis in patients admitted to Kenyatta National Hospital. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0512-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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