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Moore A, Blumenthal KG, Chambers C, Namazy J, Nowak-Wegrzyn A, Phillips EJ, Rider NL. Improving Clinical Practice Through Patient Registries in Allergy and Immunology. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00470-7. [PMID: 38734373 DOI: 10.1016/j.jaip.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024]
Abstract
Patient registries are a mechanism for collecting data on allergic and immunologic diseases that provide important information on epidemiology and outcomes that can ultimately improve patient care. Key criteria for establishing effective registries include the use of a clearly defined purpose, identifying the target population and ensuring consistent data collection. Registries in allergic diseases include those for diseases such as inborn errors of immunity (IEI), food allergy, asthma and anaphylaxis, pharmacological interventions in vulnerable populations, and adverse effects of pharmacologic interventions including hypersensitivity reactions to drugs and vaccines. Important insights gained from patient registries in our field include contributions in phenotype and outcomes in IEI, the risk for adverse reactions in food-allergic patients in multiple settings, the benefits and risk of biologic medications for asthma during pregnancy, vaccine safety, and the categorization and genetic determination of risk for severe cutaneous adverse reactions to medications. Impediments to the development of clinically meaningful patient registries include the lack of funding resources for registry establishment and the quality, quantity, and consistency of available data. Despite these drawbacks, high-quality and successful registries are invaluable in informing clinical practice and improving outcomes in patients with allergic and immunological diseases.
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Affiliation(s)
- Andrew Moore
- ENTAA Care, Johns Hopkins Regional Physicians, Glen Burnie, Md.
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Christina Chambers
- Department of Pediatrics, University of California San Diego, La Jolla, Calif
| | - Jennifer Namazy
- Division of Allergy and Immunology, Scripps Clinic, La Jolla, Calif
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, Hassenfeld Children's Hospital, NYU Grossman School of Medicine, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Elizabeth J Phillips
- Department of Medicine, Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Nicholas L Rider
- Department of Health Systems and Implementation Science, Virginia Tech Carilion School of Medicine, Roanoke, Va; Carilion Clinic, Section of Allergy-Immunology, Roanoke, Va
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2
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Bataille P, Lebrun-Vignes B, Bettuzzi T, Ingen-Housz-Oro S, Hadj-Rabia S, Welfringer-Morin A, Bodemer C. Drugs associated with epidermal necrolysis in children: A World Health Organization pharmacovigilance database analysis. J Eur Acad Dermatol Venereol 2024. [PMID: 38682703 DOI: 10.1111/jdv.20054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening mucocutaneous reactions most often induced by drugs. To date, no large pharmacovigilance study has been conducted in the paediatric population. OBJECTIVES To describe the spectrum of drugs associated with SJS-TEN in children through the analysis of cases reported in the WHO pharmacovigilance database (VigiBase). METHODS Disproportionality study using data from VigiBase. All paediatric (age under 18 years) cases reported between January 1, 1967, and July 6, 2022, were included. For each molecule, a case-non-case study was performed to assess a potential pharmacovigilance signal by computing the lower end of the 95% credibility interval for the information component (IC025). We performed sensitivity analyses, (i) taking into account only cases reported by physicians and (ii) taking into account only cases reported in the last 10 years. RESULTS Among 31,376,783 adverse drug reactions reported in VigiBase, 2,248,727 were paediatric cases and 7342 were encoded as paediatric SJS-TEN. Significant statistical pharmacovigilance signals were observed for 165 drugs. The two most represented drug classes were antiepileptics and anti-infectious drugs. The five drugs with the highest IC025 were lamotrigine (IC025 4.99), carbamazepine (IC025 4.88), phenobarbital (IC025 4.67), phenytoin (IC025 4.52) and nimesulide (IC025 4.23). Acetaminophen was significantly associated with paediatric SJS-TEN (IC025 2.85) and we also described various new suspected drugs. Vaccines had no significant pharmacovigilance signal. These results were confirmed with the sensitivity analyses. CONCLUSIONS This study updates the spectrum of drugs potentially associated with paediatric SJS-TEN.
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Affiliation(s)
- Pauline Bataille
- Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades Hospital, APHP, Paris City University, Paris, France
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Paris City University, Imagine Institute, Data Science Platform, INSERM UMR 1163, Paris, France
| | - Benedicte Lebrun-Vignes
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
- Regional Pharmacovigilance Center, Department of Pharmacology, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
- Université Paris Est Créteil EpidermE, UPEC, Créteil, France
| | - Thomas Bettuzzi
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
- Regional Pharmacovigilance Center, Department of Pharmacology, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
- Université Paris Est Créteil EpidermE, UPEC, Créteil, France
- Dermatology Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Saskia Ingen-Housz-Oro
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
- Université Paris Est Créteil EpidermE, UPEC, Créteil, France
- Dermatology Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Smail Hadj-Rabia
- Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades Hospital, APHP, Paris City University, Paris, France
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
| | - Anne Welfringer-Morin
- Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades Hospital, APHP, Paris City University, Paris, France
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
| | - Christine Bodemer
- Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades Hospital, APHP, Paris City University, Paris, France
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
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3
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Gubernot D, Menis M, Whitaker B. Background rates for severe cutaneous reactions in the US: Contextual support for safety assessment of COVID-19 vaccines and novel biologics. Vaccine 2023; 41:6922-6929. [PMID: 37891051 DOI: 10.1016/j.vaccine.2023.10.025] [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: 04/19/2023] [Revised: 09/11/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
The global COVID-19 public health crisis has resulted in extraordinary collaboration to expeditiously develop vaccines and therapeutics. The safety of these biologics is closely monitored by the US Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC). Novel products may have limited safety data, and although serious medical outcomes associated with vaccination are rare, knowledge of background incidence rates of medical conditions in the US population puts reported adverse events (AEs) in perspective for further study. Although relatively minor vaccination skin reactions are common, rare instances of severe delayed hypersensitivity reactions such as erythema multiforme (EM), Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap syndrome may occur. To aid in the assessment of these events, we performed a literature search in PubMed and Web of Science on the background incidence of EM, SJS, SJS/TEN, and TEN in the US population and on published reports of these conditions occurring post-vaccination. The US background annual incidence rates per million individuals of all ages ranged from 5.3 to 63.0 for SJS, from 0.4 to 5.0 for TEN, and from 0.8 to 1.6 for SJS/TEN. Since these conditions may overlap, some studies reported rates for EM/SJS/TEN combined, however we did not find studies with exclusive EM incidence rates. The published literature, including studies of reports submitted to the FDA/CDC Vaccine Adverse Event Reporting System (VAERS), describes post-vaccination EM, SJS, SJS/TEN and/or TEN as rare occurrences. The vaccines most frequently associated with these conditions were measles, mumps, and rubella; diphtheria, tetanus, and pertussis; and varicella. The majority of VAERS reports of EM, SJS, SJS/TEN, or TEN occurred in children within 30 days of vaccination. This review summarizes background rates of these disorders in the general population and published AEs among vaccine recipients, to support safety surveillance of COVID-19 vaccines and other biologics.
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Affiliation(s)
- Diane Gubernot
- U.S. Food and Drug Administration, Center for Biologics Evaluation and Research, 10903 New Hampshire Avenue, Silver Spring, MD 20993, United States.
| | - Mikhail Menis
- U.S. Food and Drug Administration, Center for Biologics Evaluation and Research, 10903 New Hampshire Avenue, Silver Spring, MD 20993, United States.
| | - Barbee Whitaker
- U.S. Food and Drug Administration, Center for Biologics Evaluation and Research, 10903 New Hampshire Avenue, Silver Spring, MD 20993, United States.
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4
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Iriarte C, Karim SA, Nassim JS, Grenier PO, Massey KJ. Infantile Stevens Johnson syndrome and toxic epidermal necrolysis: A systematic review of clinical features and outcomes in children ages 12 months and under. Pediatr Dermatol 2022; 39:876-882. [PMID: 35676891 DOI: 10.1111/pde.15047] [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: 12/15/2021] [Accepted: 05/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND/OBJECTIVES Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening mucocutaneous hypersensitivity reactions that carry significant morbidity and mortality. While clinical features are well documented in adult and pediatric patients, infantile cases are rarely reported. Our objective was to synthesize clinical features and outcomes in this population. METHODS A literature search was performed from three large databases (PubMed, EMBASE, and Web of Science) to systematically identify reports of SJS/TEN in the infantile period (defined as less than 12 months of age) between 1962 and 2019. Cases determined to represent SJS/TEN based on defined criteria were included. Each case was scored based on Quality Rating Scheme for Studies and Other Evidence. The initial search yielded 4856 publications, of which 19 (n = 26) met final inclusion criteria. RESULTS All cases for which body surface area (BSA) involvement was available or able to be approximated (n = 18/26) met criteria for TEN. All cases (n = 26) had mucous membrane involvement, with the oral mucosa most commonly affected (85.7%). Mortality was high within our population with 39.1% of infants expiring, 77.8% secondary to bacterial sepsis. The most common triggers were medications (52.4%), infections (33.3%), and vaccinations (14.3%). CONCLUSIONS This review highlights several unique clinical findings amongst infants with SJS/TEN, including increased BSA involvement, higher rates of bacterial sepsis, and higher mortality rates compared to older children and adults. Infants are more likely to present as TEN over SJS. More research is needed to identify triggers, successful treatments, and specific outcomes in this population.
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Affiliation(s)
- Christopher Iriarte
- Dermatology Program, Department of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Sabrina A Karim
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Janelle S Nassim
- Dermatology Program, Department of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Dermatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Pierre-Olivier Grenier
- Dermatology Program, Department of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Krystal Jones Massey
- Dermatology Program, Department of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Cheyenne Skin Clinic, Cheyenne, Wyoming, USA
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5
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Carrera D, Ulloa JG. Iodinated contrast-induced Stevens-Johnson syndrome: A report of a rare complication for a common imaging agent. J Vasc Surg Cases Innov Tech 2022; 8:455-457. [PMID: 36016706 PMCID: PMC9395747 DOI: 10.1016/j.jvscit.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/29/2022] Open
Abstract
Steven-Johnson syndrome (SJS) is a rare condition commonly associated with exposure to antibiotics. We have presented the case of a 76-year-old man with end-stage renal disease who had developed SJS after endovascular thrombectomy of hemodialysis access. He had developed epithelial erosions of the mucosal membranes, hemorrhagic bullae to the palmar and plantar surfaces, and erosions of the genitalia. The findings from biopsies of the lip and palm were suggestive of a drug reaction. He developed SJS three times after exposure to iodinated contrast. The one time he did not develop SJS, he had undergone open thrombectomy with no contrast exposure.
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6
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Wang L, Varghese S, Bassir F, Lo YC, Ortega CA, Shah S, Blumenthal KG, Phillips EJ, Zhou L. Stevens-Johnson syndrome and toxic epidermal necrolysis: A systematic review of PubMed/MEDLINE case reports from 1980 to 2020. Front Med (Lausanne) 2022; 9:949520. [PMID: 36091694 PMCID: PMC9449801 DOI: 10.3389/fmed.2022.949520] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening immunologic reactions. Prior studies using electronic health records, registries or reporting databases are often limited in sample size or lack clinical details. We reviewed diverse detailed case reports published over four decades. Methods Stevens-Johnson syndrome and toxic epidermal necrolysis-related case reports were identified from the MEDLINE database between 1980 and 2020. Each report was classified by severity (i.e., SJS, TEN, or SJS-TEN overlap) after being considered a “probable” or “definite” SJS/TEN case. The demographics, preconditions, culprit agents, clinical course, and mortality of the cases were analyzed across the disease severity. Results Among 1,059 “probable” or “definite” cases, there were 381 (36.0%) SJS, 602 (56.8%) TEN, and 76 (7.2%) SJS-TEN overlap cases, with a mortality rate of 6.3%, 24.4%, and 21.1%, respectively. Over one-third of cases had immunocompromised conditions preceding onset, including cancer (n = 194,18.3%), autoimmune diseases (n = 97, 9.2%), and human immunodeficiency virus (HIV) (n = 52, 4.9%). During the acute phase of the reaction, 843 (79.5%) cases reported mucous membrane involvement and 210 (19.8%) involved visceral organs. Most cases were drug-induced (n = 957, 90.3%). A total of 379 drug culprits were reported; the most frequently reported drug were antibiotics (n = 285, 26.9%), followed by anticonvulsants (n = 196, 18.5%), analgesics/anesthetics (n = 126, 11.9%), and antineoplastics (n = 120, 11.3%). 127 (12.0%) cases reported non-drug culprits, including infections (n = 68, 6.4%), of which 44 were associated with a mycoplasma pneumoniae infection and radiotherapy (n = 27, 2.5%). Conclusion An expansive list of potential causative agents were identified from a large set of literature-reported SJS/TEN cases, which warrant future investigation to understand risk factors and clinical manifestations of SJS/TEN in different populations.
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Affiliation(s)
- Liqin Wang
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
- *Correspondence: Liqin Wang,
| | - Sheril Varghese
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
| | - Fatima Bassir
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
| | - Ying-Chin Lo
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
| | - Carlos A. Ortega
- School of Medicine, Vanderbilt University, Nashville, TN, United States
| | - Sonam Shah
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
- Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Elizabeth J. Phillips
- Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
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7
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Varol F, Can YY, Sahin E, Durak C, Kilic A, Sahin C, Gursoy F, Akin T. The role of treatment with plasma exchange therapy in two pediatric toxic epidermal necrolysis cases related to
COVID
‐19. J Clin Apher 2022; 37:516-521. [PMID: 35792366 PMCID: PMC9350357 DOI: 10.1002/jca.21997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/03/2022] [Accepted: 06/17/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Fatih Varol
- Department of Pediatric Intensive Care University of Health Sciences Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital Istanbul Turkey
| | - Yasar Yusuf Can
- Department of Pediatric Intensive Care University of Health Sciences Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital Istanbul Turkey
| | - Ebru Sahin
- Department of Pediatric Intensive Care University of Health Sciences Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital Istanbul Turkey
| | - Cansu Durak
- Department of Pediatric Intensive Care University of Health Sciences Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital Istanbul Turkey
| | - Aziz Kilic
- Department of Pediatrics Ankara University Faculty of Medicine Ankara Turkey
| | - Ceyhan Sahin
- Department of Pediatric Surgery University of Health Sciences Umraniye Training and Research Hospital Istanbul Turkey
| | - Fatima Gursoy
- Department of Pathology University of Health Sciences Umraniye Training and Research Hospital Istanbul Turkey
| | - Tugba Akin
- Department of Dermatology Konya Numune State Hospital Konya Turkey
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8
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Padniewski JJ, Jacobson‐Dunlop E, Albadri S, Hylwa S. Stevens–Johnson
syndrome precipitated by Moderna Inc.
COVID
‐19 vaccine: a case‐based review of literature comparing vaccine and drug‐induced
Stevens–Johnson
syndrome/toxic epidermal necrolysis. Int J Dermatol 2022; 61:923-929. [PMID: 35398905 PMCID: PMC9111554 DOI: 10.1111/ijd.16222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/05/2022] [Accepted: 03/22/2022] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Sam Albadri
- Department of Laboratory Medicine and Pathology Hennepin Healthcare Hennepin Minnesota USA
| | - Sara Hylwa
- Faculty Physician, Department of Dermatology Hennepin Healthcare Hennepin Minnesota USA
- Assistant Professor, Department of Dermatology University of Minnesota Minneapolis Minnesota USA
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9
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Mardani M, Mardani S, Asadi-Kani Z, Hakamifard A. An Extremely Rare Mucocutaneous Adverse Reaction Following COVID-19 Vaccination: Toxic Epidermal Necrolysis. Dermatol Ther 2022; 35:e15416. [PMID: 35238119 PMCID: PMC9111664 DOI: 10.1111/dth.15416] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/23/2022] [Accepted: 02/26/2022] [Indexed: 11/30/2022]
Abstract
Stevens‐Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), is a type of delayed hypersensitivity reaction that requires urgent medical intervention. In the COVID‐19 era, COVID‐19 vaccines are currently being widely administered and mucocutaneous adverse reactions following vaccination have been reported; however, severe cutaneous adverse reactions associated with COVID‐19 vaccines including SJS/TEN, are extremely rare. Herein, we describe a case of COVID‐19 vaccination induced TEN which developed 1 day after receiving the first dose of Sinopharm COVID‐19 vaccine with favorable clinical outcome.
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Affiliation(s)
- Masoud Mardani
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sayna Mardani
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Asadi-Kani
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atousa Hakamifard
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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10
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Calley BJ, Saleh J, Young K, Wanat KA. Stevens-Johnson Syndrome in a Pregnant Woman Who Received the Influenza Vaccine. JAAD Case Rep 2022; 23:35-37. [PMID: 35391912 PMCID: PMC8980270 DOI: 10.1016/j.jdcr.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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11
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Kumar R, Chatterjee M. TEN like lupus: A rare initial presentation of lupus erythematosus. Indian J Dermatol 2022; 67:96. [PMID: 35656270 PMCID: PMC9154130 DOI: 10.4103/ijd.ijd_411_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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12
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Bakir M, Almeshal H, Alturki R, Obaid S, Almazroo A. Toxic Epidermal Necrolysis Post COVID-19 Vaccination - First Reported Case. Cureus 2021; 13:e17215. [PMID: 34540442 PMCID: PMC8442571 DOI: 10.7759/cureus.17215] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 01/26/2023] Open
Abstract
Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of acute, delayed-type hypersensitivity reactions that affect the skin and the mucous membranes. Medications are the culprit cause of these disorders in addition to infections and in very rare instances vaccinations. We report a case of TEN in a 49-year-old woman with no previous medical history. The disorder developed one week after receiving the first dose of COVID-19 vaccine with no other identifiable causes. The patient received two doses of tumor necrosis factor-alpha inhibitor (etanercept) and she stopped developing new lesions after two days of the initial dose; complete healing was observed after 22 days and no side effects were observed in our patient. This case demonstrates an extremely rare complication to the COVID-19 vaccine. The benefits of receiving the COVID-19 outweigh the potential risk.
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Affiliation(s)
- Mohamad Bakir
- Department of Medicine and Surgery, College of Medicine, Alfaisal University, Riyadh, SAU
| | - Hanan Almeshal
- Department of Dermatology, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, SAU
| | - Rifah Alturki
- Department of Dermatology, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, SAU
| | - Sulaiman Obaid
- Department of Dermatology, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, SAU
| | - Areej Almazroo
- Department of Dermatology, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, SAU
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13
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Elboraey MO, Essa EESF. Stevens-Johnson syndrome post second dose of Pfizer COVID-19 vaccine: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 132:e139-e142. [PMID: 34384729 PMCID: PMC8288232 DOI: 10.1016/j.oooo.2021.06.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/26/2021] [Accepted: 06/30/2021] [Indexed: 11/17/2022]
Abstract
Coronavirus disease 2019 (COVID-19) began in December 2019 and has affected millions of people all over the world. Respiratory illness in the form of severe pneumonia, in addition to multiorgan failure and death, is the clinical spectrum of COVID-19. Although there are no specific therapeutic agents for COVID-19 infection, the COVID-19 vaccine reduces morbidity and mortality associated with COVID-19 infection and is generally well tolerated. We report one potential complication of the Pfizer COVID-19 vaccine: a known case of Stevens-Johnson syndrome (SJS) that occurred after the second dose of the Pfizer COVID-19 vaccine alone without exposure to any other drug. Despite the initial severe adverse reaction, the patient showed a full recovery. Although SJS can be associated with COVID-19 vaccination, it is rare, and the benefits of receiving the vaccination outweigh the potential harms.
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Affiliation(s)
- Mohamed Omar Elboraey
- Lecturer of Oral Medicine, Periodontology, Oral Diagnosis and Radiology Department, Faculty of Dentistry, Tanta University, Tanta, Egypt; Assistant Professor of Periodontology Department, College of Dentistry, Taibah University, Al Medinah, Kingdom of Saudi Arabia.
| | - Emad El Said Fahim Essa
- Assistant Professor of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tanta University, Tanta, Egypt; Associate Professor of Oral and Maxillofacial Surgery, College of Dentistry, Taibah University, Al Medinah, Kingdom of Saudi Arabia
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14
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Alpalhão M, Maia-Silva J, Filipe P. Severe Acute Respiratory Syndrome Coronavirus 2 Vaccines and Cutaneous Adverse Reactions: A Review. Dermatitis 2021; 32:133-139. [PMID: 33851937 DOI: 10.1097/der.0000000000000755] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We are entering a new stage of the severe acute respiratory syndrome coronavirus 2 pandemic with the initiation of large-scale vaccination programs globally. In these circumstances, even rare adverse effects of vaccines may be encountered more often, if millions of people are to be vaccinated in a short period. Vaccination has the potential for causing cutaneous adverse effects. Thus, it is paramount that dermatologists worldwide are acquainted with the possible skin reaction patterns to the coming vaccines. Herein, we conduct a review to discuss the most frequent cutaneous adverse effects of vaccines and their management, with a particular focus on the expected adverse reactions for the coming severe acute respiratory syndrome coronavirus 2 vaccines, such as local reactions, as well as immediate- and delayed-type hypersensitivity reactions, including erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrosis, serum sickness-like reactions, and vasculitides. We also discuss the yet unanswered questions on vaccines for which we may soon be asked to provide an expert opinion.
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Abstract
Influenza is a common virus that affects millions of people every year. The influenza vaccine decreases morbidity and mortality associated with influenza and is generally well tolerated. Stevens-Johnson syndrome (SJS) is a rare disorder of the skin and mucous membranes. We report the second known case of SJS occurring after an influenza vaccination alone without any other associated drug exposure. This corroborates the possibility of the influenza vaccine alone causing SJS. Despite the initial adverse reaction, the patient made a full recovery. Although the disease can be associated with vaccinations, the benefits of receiving the vaccinations outweigh the potential harms.
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Affiliation(s)
- Jonathan Tong
- Literature, Science, and the Arts, University of Michigan, Ann Arbor, USA
| | - June Chan
- Radiation Oncology, Ascension Providence Hospital, Novi, USA
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16
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Charlton OA, Harris V, Phan K, Mewton E, Jackson C, Cooper A. Toxic Epidermal Necrolysis and Steven-Johnson Syndrome: A Comprehensive Review. Adv Wound Care (New Rochelle) 2020; 9:426-439. [PMID: 32520664 PMCID: PMC7307670 DOI: 10.1089/wound.2019.0977] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 09/21/2019] [Indexed: 12/13/2022] Open
Abstract
Significance: Toxic epidermal necrolysis (TEN) and Steven-Johnson syndrome (SJS) are potentially fatal acute mucocutaneous vesiculobullous disorders. Evidence to date suggests that outcomes for patients with both TEN and SJS are largely dependent on stopping the causative agent, followed by supportive care and appropriate wound management in a specialized burns unit. These are life-threatening conditions characterized by widespread full-thickness cutaneous and mucosal necrosis. This article outlines the approach to holistic management of such patients, in a specialized unit, highlighting various practical aspects of wound care to prevent complications such as infection, mucosal and adhesions, and ocular scaring. Recent Advances: There is improved understanding of pain and morbidity with regard to the type and frequency of dressing changes. More modern dressings, such as nanocrystalline, are currently favored as they may be kept in situ for longer periods. The most recent evidence on systemic agents, such as corticosteroids and cyclosporine, and novel treatments, are also discussed. Critical Issues: Following cessation of the culprit trigger, management in a specialized burns unit is the most important management step. It is now understood that a multidisciplinary team is essential in the care of these patients. Following admission of such patients, dermatology, ear, nose, and throat surgery, ophthalmology, urology, colorectal surgery, and gynecology should all be consulted to prevent disease sequelae. Future Directions: Looking forward, research is aimed at achieving prospective data on the efficacy of systemic immunomodulating agents and dressing types. Tertiary centers with burns units should develop policies for such patients to ensure that the relevant teams are consulted promptly to avoid mucocutaneous complications.
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Affiliation(s)
- Olivia A. Charlton
- Department of Dermatology, Royal North Shore Hospital, Sydney, Australia
- Northern Clinical School, University of Sydney, Sydney, Australia
| | - Victoria Harris
- Department of Dermatology, Prince of Wales Hospital, Sydney, Australia
| | - Kevin Phan
- Department of Dermatology, Liverpool Hospital, Sydney, Australia
| | - Erin Mewton
- Department of Dermatology, Royal North Shore Hospital, Sydney, Australia
| | - Chris Jackson
- Northern Clinical School, University of Sydney, Sydney, Australia
- Kolling Institute of Medical Research, Sydney, Australia
| | - Alan Cooper
- Department of Dermatology, Royal North Shore Hospital, Sydney, Australia
- Northern Clinical School, University of Sydney, Sydney, Australia
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17
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Su JR, Haber P, Ng CS, Marquez PL, Dores GM, Perez-Vilar S, Cano MV. Erythema multiforme, Stevens Johnson syndrome, and toxic epidermal necrolysis reported after vaccination, 1999-2017. Vaccine 2019; 38:1746-1752. [PMID: 31870573 DOI: 10.1016/j.vaccine.2019.12.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/06/2019] [Accepted: 12/13/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Since the last review of vaccine safety surveillance data for erythema multiforme (EM), Stevens Johnson syndrome (SJS), SJS/TEN, and toxic epidermal necrolysis (TEN) (EM/SJS/TEN), over 37 new vaccines have been introduced in the United States. We sought to describe reported EM/SJS/TEN after vaccines during 1999-2017. METHODS We identified U.S. reports of EM/SJS/TEN received by the Vaccine Adverse Event Reporting System (VAERS) during 1999-2017. We stratified analysis by condition (EM, SJS, or TEN), and analyzed reports by serious or non-serious status, sex, age group, time from vaccination to symptom onset, exposure to known causes of EM/SJS/TEN, and vaccines administered. We used Empirical Bayesian data mining to detect vaccine-AE pairs reported more frequently than expected. RESULTS Of 466,027 reports to VAERS during 1999-2017, we identified 984 reports of EM, 89 reports of SJS, 6 reports of SJS/TEN, and 7 reports of TEN. Few reports of EM (9%), and most reports of SJS (52%), SJS/TEN (100%), and TEN (100%) were serious. Overall, 55% of reports described males, 48% described children aged < 4 years; 58% of EM/SJS/TEN occurred ≤ 7 days after vaccination. Few reports (≤5%) described exposure to known causes of EM/SJS/TEN. Overall, childhood vaccines (e.g., combined measles, mumps, and rubella vaccine) were most commonly reported. We identified 6 deaths; 4 were exposed to medications associated with EM/SJS/TEN. EM after smallpox vaccine was reported disproportionately among people aged 19-49 years. CONCLUSIONS EM/SJS/TEN were rarely reported after vaccination; data mining identified a known association between EM and smallpox vaccine.
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Affiliation(s)
- John R Su
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.
| | - Penina Haber
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Carmen S Ng
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Paige L Marquez
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Graça M Dores
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, United States
| | - Silvia Perez-Vilar
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, United States
| | - Maria V Cano
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
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18
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Estrella-Alonso A, Aramburu JA, González-Ruiz MY, Cachafeiro L, Sánchez MS, Lorente JA. Toxic epidermal necrolysis: a paradigm of critical illness. Rev Bras Ter Intensiva 2018; 29:499-508. [PMID: 29340540 PMCID: PMC5764563 DOI: 10.5935/0103-507x.20170075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 04/05/2017] [Indexed: 01/08/2023] Open
Abstract
Toxic epidermal necrolysis is an adverse immunological skin reaction secondary in
most cases to the administration of a drug. Toxic epidermal necrolysis,
Stevens-Johnson syndrome, and multiform exudative erythema are part of the same
disease spectrum. The mortality rate from toxic epidermal necrolysis is
approximately 30%. The pathophysiology of toxic epidermal necrolysis is similar
in many respects to that of superficial skin burns. Mucosal involvement of the
ocular and genital epithelium is associated with serious sequelae if the
condition is not treated early. It is generally accepted that patients with
toxic epidermal necrolysis are better treated in burn units, which are
experienced in the management of patients with extensive skin loss. Treatment
includes support, elimination, and coverage with biosynthetic derivatives of the
skin in affected areas, treatment of mucosal involvement, and specific
immunosuppressive treatment. Of the treatments tested, only immunoglobulin G and
cyclosporin A are currently used in most centers, even though there is no solid
evidence to recommend any specific treatment. The particular aspects of the
treatment of this disease include the prevention of sequelae related to the
formation of synechiae, eye care to prevent serious sequelae that can lead to
blindness, and specific immunosuppressive treatment. Better knowledge of the
management principles of toxic epidermal necrolysis will lead to better disease
management, higher survival rates, and lower prevalence of sequelae.
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Affiliation(s)
| | - José Antonio Aramburu
- Instituto de Investigación Sanitaria del Hospital Universitario de Getafe - Madrid, Spain.,Universidad Europea - Madrid, Spain
| | - Mercedes Yolanda González-Ruiz
- Instituto de Investigación Sanitaria del Hospital Universitario de Getafe - Madrid, Spain.,Universidad Europea - Madrid, Spain
| | - Lucía Cachafeiro
- Hospital Universitario La Paz-Cantoblanco-Carlos III, Instituto de investigación IdiPaz - Madrid, Spain
| | - Manuel Sánchez Sánchez
- Hospital Universitario La Paz-Cantoblanco-Carlos III, Instituto de investigación IdiPaz - Madrid, Spain
| | - José A Lorente
- Instituto de Investigación Sanitaria del Hospital Universitario de Getafe - Madrid, Spain.,Universidad Europea - Madrid, Spain.,CIBER de Enfermedades Respiratorias - Madrid, Spain
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19
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Tamez RL, Tan WV, O'Malley JT, Broder KR, Garzon MC, LaRussa P, Lauren CT. Influenza B virus infection and Stevens-Johnson syndrome. Pediatr Dermatol 2018; 35:e45-e48. [PMID: 29282756 PMCID: PMC6628912 DOI: 10.1111/pde.13370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 2-year-old boy with influenza B infection and rapidly worsening targetoid skin lesions with mucosal involvement was diagnosed with Stevens-Johnson syndrome (SJS) and treated with oseltamivir and intravenous immunoglobulin, with resolution of illness. Subsequent quadrivalent inactivated influenza vaccine was well tolerated. This case highlights the rarity of SJS in the setting of influenza B infection and addresses the safety of administering subsequent influenza vaccines to such individuals.
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Affiliation(s)
- Rebecca L Tamez
- Department of Dermatology, Northwell Health System, New Hyde Park, NY, USA
| | - Whitney V Tan
- Department of Dermatology, Columbia University Medical Center, New York, NY, USA
| | - John T O'Malley
- Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Karen R Broder
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Maria C Garzon
- Department of Dermatology, Columbia University Medical Center, New York, NY, USA.,Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Philip LaRussa
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Christine T Lauren
- Department of Dermatology, Columbia University Medical Center, New York, NY, USA.,Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
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20
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Dodiuk-Gad RP, Chung WH, Shear NH. Adverse Medication Reactions. CLINICAL AND BASIC IMMUNODERMATOLOGY 2017. [PMCID: PMC7123512 DOI: 10.1007/978-3-319-29785-9_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cutaneous adverse drug reactions (ADRs) are among the most frequent adverse reactions in patients receiving drug therapy. They have a broad spectrum of clinical manifestations, are caused by various drugs, and result from different pathophysiological mechanisms. Hence, their diagnosis and management is challenging. Severe cutaneous ADRs comprise a group of diseases with major morbidity and mortality, reaching 30 % mortality rate in cases of Toxic Epidermal Necrolysis. This chapter covers the terminology, epidemiology, pathogenesis and classification of cutaneous ADR, describes the severe cutaneous ADRs and the clinical and laboratory approach to the patient with cutaneous ADR and presents the translation of laboratory-based discoveries on the genetic predisposition and pathogenesis of cutaneous ADRs to clinical management guidelines.
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21
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Harris V, Jackson C, Cooper A. Review of Toxic Epidermal Necrolysis. Int J Mol Sci 2016; 17:ijms17122135. [PMID: 27999358 PMCID: PMC5187935 DOI: 10.3390/ijms17122135] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/09/2016] [Accepted: 12/12/2016] [Indexed: 12/13/2022] Open
Abstract
Toxic epidermal necrolysis (TEN) is a rare but life threatening mucocutaneous reaction to drugs or their metabolites. It is characterised by widespread keratinocyte apoptosis and sloughing of the skin, erosions of the mucous membranes, painful blistering, and severe systemic disturbance. The pathophysiology of TEN is incompletely understood. Historically, it has been regarded as a drug-induced immune reaction initiated by cytotoxic lymphocytes via a human leukocyte antigen (HLA)-restricted pathway. Several mediators have been identified as contributors to the cell death seen in TEN, including; granulysin, soluble Fas ligand, perforin/granzyme, tumour necrosis factor-α (TNF-α), and TNF-related apoptosis-inducing ligand. Currently, granulysin is accepted as the most important mediator of T cell proliferation. There is uncertainty around the accepted management of TEN. The lack of definitive management guidelines for TEN is explained in part by the rarity of the disease and its high mortality rate, which makes it difficult to conduct randomised control trials on emerging therapies. Developments have been made in pharmacogenomics, with numerous HLA alleles identified; however, these have largely been ethnically specific. These associations have translated into screening recommendations for Han Chinese.
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Affiliation(s)
- Victoria Harris
- Sydney Medical School-Northern, University of Sydney, 2065 Sydney, Australia.
| | - Christopher Jackson
- Sutton Arthritis Research Laboratory, Kolling Institute, University of Sydney, 2065 Sydney, Australia.
| | - Alan Cooper
- Dermatology Department, Royal North Shore Hospital, 2065 Sydney, Australia.
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22
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Dodiuk-Gad RP, Chung WH, Valeyrie-Allanore L, Shear NH. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: An Update. Am J Clin Dermatol 2015; 16:475-93. [PMID: 26481651 DOI: 10.1007/s40257-015-0158-0] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening mucocutaneous reactions, predominantly drug induced. The mortality rates for SJS and TEN are as high as 30 %, and short- and long-term morbidities are very common. SJS/TEN is one of the few dermatological diseases that constitute a true medical emergency. Early recognition and prompt and appropriate management can be lifesaving. In recent years, our understanding of the pathogenesis, clinical presentation, and management of SJS/TEN has improved. Nevertheless, in 2015, there are still no internationally accepted management guidelines. This review summarizes up-to-date insights on SJS/TEN and describes a protocol for assessment and treatment. We hope these suggested guidelines serve as a practical clinical tool in the management of SJS/TEN. The classic manifestation of SJS/TEN consists of initial "flu-like" symptoms (malaise, fever, anorexia) in the prodromal phase, followed by cutaneous and mucous membrane (ocular, oral, and genital) inflammation and pain, and other systemic involvement. Symptoms usually begin 4-28 days after the onset of drug intake. Treatment is multidisciplinary and includes identification and withdrawal of the culprit drug, transfer to a specialist unit, supportive care, medical treatment, communication, and provision of appropriate information and emotional support.
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23
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Kohanim S, Palioura S, Saeed HN, Akpek EK, Amescua G, Basu S, Blomquist PH, Bouchard CS, Dart JK, Gai X, Gomes JAP, Gregory DG, Iyer G, Jacobs DS, Johnson AJ, Kinoshita S, Mantagos IS, Mehta JS, Perez VL, Pflugfelder SC, Sangwan VS, Sippel KC, Sotozono C, Srinivasan B, Tan DTH, Tandon R, Tseng SCG, Ueta M, Chodosh J. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis--A Comprehensive Review and Guide to Therapy. I. Systemic Disease. Ocul Surf 2015; 14:2-19. [PMID: 26549248 DOI: 10.1016/j.jtos.2015.10.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 09/01/2015] [Accepted: 10/15/2015] [Indexed: 01/06/2023]
Abstract
The intent of this review is to comprehensively appraise the state of the art with regard to Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to the ocular surface complications and their management. SJS and TEN represent two ends of a spectrum of immune-mediated, dermatobullous disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. The widespread keratinocyte death seen in SJS/TEN is rapid and irreversible, and even with early and aggressive intervention, morbidity is severe and mortality not uncommon. We have divided this review into two parts. Part I summarizes the epidemiology and immunopathogenesis of SJS/TEN and discusses systemic therapy and its possible benefits. We hope this review will help the ophthalmologist better understand the mechanisms of disease in SJS/TEN and enhance their care of patients with this complex and often debilitating disease. Part II (April 2016 issue) will focus on ophthalmic manifestations.
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Affiliation(s)
- Sahar Kohanim
- Vanderbilt Eye Institute, Vanderbilt University School of Medicine, Nashville, TN
| | - Sotiria Palioura
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Hajirah N Saeed
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | - Esen K Akpek
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Guillermo Amescua
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Sayan Basu
- LV Prasad Eye Institute, Hyderabad, India
| | | | | | - John K Dart
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - Xiaowu Gai
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | | | - Darren G Gregory
- Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, Aurora, CO
| | - Geetha Iyer
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, India
| | - Deborah S Jacobs
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA; Boston Foundation for Sight, Boston, MA
| | | | | | | | - Jodhbir S Mehta
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
| | - Victor L Perez
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | - Chie Sotozono
- Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Bhaskar Srinivasan
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, India
| | - Donald T H Tan
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
| | - Radhika Tandon
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Delhi, India
| | - Scheffer C G Tseng
- Ocular Surface Center, Ocular Surface Research & Education Foundation, Miami, FL
| | - Mayumi Ueta
- Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - James Chodosh
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.
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24
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Banovic F, Olivry T, Bazzle L, Tobias JR, Atlee B, Zabel S, Hensel N, Linder KE. Clinical and Microscopic Characteristics of Canine Toxic Epidermal Necrolysis. Vet Pathol 2014; 52:321-30. [DOI: 10.1177/0300985814537530] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Canine toxic epidermal necrosis (TEN), a rare and life-threatening cutaneous drug reaction, traditionally has been described as full-thickness devitalization of the epidermis with minimal dermal inflammation; however, few reports detail the histologic findings. We characterize the clinical features and histologic variations of 3 canine TEN patients. Clinically, irregular erythematous and purpuric macules evolved into widespread and severely painful erosions. The number of eroded mucosae varied; however, periocular and perilabial mucocutaneous junctions frequently were affected. Thirteen of 17 biopsies were evaluated. Apoptosis at multiple epidermal levels was the most common pattern of epidermal necrosis (12/13 biopsies, 92%). In contrast, full-thickness coagulation necrosis was present less often (7/13 biopsies, 52%). Lymphocytic interface dermatitis was the predominant inflammatory pattern, and intraepidermal lymphocytes, along with fewer histiocytes, were present to some degree in all samples along with lymphocytic satellitosis of apoptotic keratinocytes. The sequence of changes points to lymphocyte-mediated keratinocyte apoptosis as an early step in lesion development with subsequent variation in progression to coagulation necrosis among patients. Histopathologic changes overlapped with those reported for erythema multiforme, in contrast to traditional histologic descriptions of canine TEN. A specific algorithm for assessment of drug causality in epidermal necrolysis (ALDEN) was applied for each patient; carprofen was associated with a probable score for causality in 1 dog. Clinicians should be encouraged to take multiple biopsies in TEN suspect cases as nearly 25% of all biopsies lacked epithelium and were not diagnostic.
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Affiliation(s)
- F. Banovic
- Department of Clinical Sciences, NC State University, College of Veterinary Medicine, Raleigh, NC, USA
- Center for Comparative Medicine and Translational Research, NC State University, College of Veterinary Medicine, Raleigh, NC, USA
| | - T. Olivry
- Department of Clinical Sciences, NC State University, College of Veterinary Medicine, Raleigh, NC, USA
- Center for Comparative Medicine and Translational Research, NC State University, College of Veterinary Medicine, Raleigh, NC, USA
| | - L. Bazzle
- Department of Clinical Sciences, NC State University, College of Veterinary Medicine, Raleigh, NC, USA
| | - J. R. Tobias
- Department of Population Health and Pathobiology, NC State University, College of Veterinary Medicine, Raleigh, NC, USA
| | - B. Atlee
- Animal Dermatology & Allergy Clinic, Raleigh, NC, USA
| | - S. Zabel
- Department of Small Animal Medicine & Surgery, The University of Georgia, College of Veterinary Medicine, Athens, GA, USA
| | - N. Hensel
- Department of Small Animal Medicine & Surgery, The University of Georgia, College of Veterinary Medicine, Athens, GA, USA
| | - K. E. Linder
- Center for Comparative Medicine and Translational Research, NC State University, College of Veterinary Medicine, Raleigh, NC, USA
- Department of Population Health and Pathobiology, NC State University, College of Veterinary Medicine, Raleigh, NC, USA
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25
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Ellenburg JT, Josey D. An atypical presentation of pulmonary air-leak syndrome and multisystem toxic epidermal necrolysis. Pediatr Pulmonol 2014; 49:E130-4. [PMID: 24668933 DOI: 10.1002/ppul.22908] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 08/13/2013] [Indexed: 11/12/2022]
Abstract
Toxic epidermal necrolysis (TEN) is a rare and potentially fatal mucocutaneous condition that may affect both children and adults. TEN mortality rates vary greatly between both patient populations, but multisystem involvement is common. Management presents many challenges as there is no specific therapy for TEN, and patients often require the expertise of burn units. We report a child who survived TEN with multisystem involvement including the rare but life threatening occurrence of a pulmonary air-leak syndrome while also reviewing controversies surrounding TEN's pathophysiology, sequelae, and multidisciplinary approach to management.
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Affiliation(s)
- Joseph T Ellenburg
- Department of Pediatric Pulmonology, University of Mississippi Medical Center, Jackson, Mississippi
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26
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Daley MF, Yih WK, Glanz JM, Hambidge SJ, Narwaney KJ, Yin R, Li L, Nelson JC, Nordin JD, Klein NP, Jacobsen SJ, Weintraub E. Safety of diphtheria, tetanus, acellular pertussis and inactivated poliovirus (DTaP-IPV) vaccine. Vaccine 2014; 32:3019-24. [PMID: 24699471 DOI: 10.1016/j.vaccine.2014.03.063] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/14/2014] [Accepted: 03/17/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND In 2008, a diphtheria, tetanus, acellular pertussis, and inactivated poliovirus combined vaccine (DTaP-IPV) was licensed for use in children 4 through 6 years of age. While pre-licensure studies did not demonstrate significant safety concerns, the number vaccinated in these studies was not sufficient to examine the risk of uncommon but serious adverse events. OBJECTIVE To assess the risk of serious adverse events following DTaP-IPV vaccination. METHODS The study was conducted from January 2009 through September 2012 in the Vaccine Safety Datalink (VSD) project. In the VSD, electronic vaccination and encounter data are updated and aggregated weekly as part of ongoing surveillance activities. Based on previous reports and biologic plausibility, eight potential adverse events were monitored: meningitis/encephalitis; seizures; stroke; Guillain-Barré syndrome; Stevens-Johnson syndrome; anaphylaxis; serious allergic reactions other than anaphylaxis; and serious local reactions. Adverse event rates in DTaP-IPV recipients were compared to historical incidence rates in the VSD population prior to 2009. Sequential probability ratio testing was used to analyze the data on a weekly basis. RESULTS During the study period, 201,116 children received DTaP-IPV vaccine. Ninety-seven percent of DTaP-IPV recipients also received other vaccines on the same day, typically measles-mumps-rubella and varicella vaccines. There was no statistically significant increased risk of any of the eight pre-specified adverse events among DTaP-IPV recipients when compared to historical incidence rates. CONCLUSIONS In this safety surveillance study of more than 200,000 DTaP-IPV vaccine recipients, there was no evidence of increased risk for any of the pre-specified adverse events monitored. Continued surveillance of DTaP-IPV vaccine safety may be warranted to monitor for rare adverse events, such as Guillain-Barré syndrome.
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Affiliation(s)
- Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Avenue, Denver, CO 80231, United States; Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 065, Aurora, CO 80045, United States.
| | - W Katherine Yih
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215, United States.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Avenue, Denver, CO 80231, United States.
| | - Simon J Hambidge
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Avenue, Denver, CO 80231, United States; Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 065, Aurora, CO 80045, United States; Community Health Services, Denver Health, 777 Bannock Street, Denver, CO 80204, United States.
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Avenue, Denver, CO 80231, United States.
| | - Ruihua Yin
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215, United States.
| | - Lingling Li
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215, United States.
| | - Jennifer C Nelson
- Biostatistics Unit, Group Health Research Institute, 1730 Minor Ave #1600, Seattle, WA 98101, United States; Department of Biostatistics, University of Washington, 5th Floor, 1107 NE 45th St., Seattle, 98105, United States.
| | - James D Nordin
- HealthPartners Institute for Education and Research, Mail stop 21111R, PO Box 1524, Minneapolis, MN 55440-1524, United States.
| | - Nicola P Klein
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, United States.
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles Avenue, 2nd Floor, Pasadena, CA 91101, United States.
| | - Eric Weintraub
- Immunization Safety Office, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333, United States.
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Schwartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis. J Am Acad Dermatol 2013; 69:173.e1-13; quiz 185-6. [DOI: 10.1016/j.jaad.2013.05.003] [Citation(s) in RCA: 187] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/06/2013] [Accepted: 05/10/2013] [Indexed: 11/16/2022]
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Evans G, Levine EM, Jacobs AL. Legal issues. Vaccines (Basel) 2013. [DOI: 10.1016/b978-1-4557-0090-5.00077-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hwang YH, Kang MS, Lim KO, Lee SM. Toxic epidermal necrolysis with ocular involvement following vaccination for hemorrhagic fever with renal syndrome. Yonsei Med J 2012; 53:228-30. [PMID: 22187258 PMCID: PMC3250336 DOI: 10.3349/ymj.2012.53.1.228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We report a case of toxic epidermal necrolysis with ocular involvement following vaccination for hemorrhagic fever with renal syndrome. A healthy 20-year-old male soldier presented with confluent purpuric and erythematous dusky red macules evolving to flaccid blister and epidermal detachment on the whole body with conjunctival injection. The patient had no antecedent medical or surgical conditions except for two doses of hemorrhagic fever with renal syndrome vaccination. With supportive care, skin lesions were improved. Ophthalmic examinations revealed conjunctival injection with epithelial defects in both eyes. Ocular complications were resolved after amniotic membrane transplantation. Toxic epidermal necrolysis may be considered as a possible complication of hemorrhagic fever with renal syndrome vaccination.
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Affiliation(s)
- Young Hoon Hwang
- Department of Ophthalmology, Armed Forces Capital Hospital, Seongnam, Korea
| | - Myung Seung Kang
- Department of Dermatology, Armed Forces Capital Hospital, Seongnam, Korea
| | - Kyung O Lim
- Department of Ophthalmology, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sang Mok Lee
- Department of Ophthalmology, Armed Forces Capital Hospital, Seongnam, Korea
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Cruz MJ, Mota A, Baudrier T, Gil-da-Costa MJ, Azevedo F. Stevens-Johnson syndrome associated with cytomegalovirus infection in a child with ependymoma. J Dermatol Case Rep 2011; 4:11-4. [PMID: 21886739 DOI: 10.3315/jdcr.2010.1043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Accepted: 03/22/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Stevens-Johnson syndrome is an uncommon, acute life-threatening disease characterized by extensive epidermal sloughing and mucositis. In childhood, as in adulthood, this condition is mostly related to drugs, in particular antibiotics. Only a few cases reported were firmly attributed to infectious agents, mainly Mycoplasma pneumonia but the causative role of infectious microorganisms seems particularly relevant in pediatric patients. The seriousness of this condition imposes a prompt recognition and the early withdrawal of the potential causative drugs or the institution of directed measures against infectious agents (depending on the suspected etiology), as well as a supportive and more specific therapy. Some treatments claim to halt the progression of skin detachment, but remain of unproven benefit due to the lack of prospective, well controlled, randomized clinical trials. MAIN OBSERVATIONS We report a case of a 2-year-old boy admitted in our hospital for the treatment of an ependymoma of the posterior fossa, who developed a Stevens-Johnson syndrome associated most probably with a cytomegalovirus infection. He was successfully treated with high dose intravenous immunoglobulin and gancyclovir. CONCLUSION To the best of our knowledge, this is the first case of SJS associated with CMV infection.
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Affiliation(s)
- Maria João Cruz
- Department of Dermatology and Venereology, Hospital de São João, Porto, Portugal
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Harr T, French LE. Toxic epidermal necrolysis and Stevens-Johnson syndrome. Orphanet J Rare Dis 2010; 5:39. [PMID: 21162721 PMCID: PMC3018455 DOI: 10.1186/1750-1172-5-39] [Citation(s) in RCA: 304] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 12/16/2010] [Indexed: 12/14/2022] Open
Abstract
Toxic epidermal necrolysis (TEN) and Stevens Johnson Syndrome (SJS) are severe adverse cutaneous drug reactions that predominantly involve the skin and mucous membranes. Both are rare, with TEN and SJS affecting approximately 1or 2/1,000,000 annually, and are considered medical emergencies as they are potentially fatal. They are characterized by mucocutaneous tenderness and typically hemorrhagic erosions, erythema and more or less severe epidermal detachment presenting as blisters and areas of denuded skin. Currently, TEN and SJS are considered to be two ends of a spectrum of severe epidermolytic adverse cutaneous drug reactions, differing only by their extent of skin detachment. Drugs are assumed or identified as the main cause of SJS/TEN in most cases, but Mycoplasma pneumoniae and Herpes simplex virus infections are well documented causes alongside rare cases in which the aetiology remains unknown. Several drugs are at "high" risk of inducing TEN/SJS including: Allopurinol, Trimethoprim-sulfamethoxazole and other sulfonamide-antibiotics, aminopenicillins, cephalosporins, quinolones, carbamazepine, phenytoin, phenobarbital and NSAID's of the oxicam-type. Genetic susceptibility to SJS and TEN is likely as exemplified by the strong association observed in Han Chinese between a genetic marker, the human leukocyte antigen HLA-B*1502, and SJS induced by carbamazepine. Diagnosis relies mainly on clinical signs together with the histological analysis of a skin biopsy showing typical full-thickness epidermal necrolysis due to extensive keratinocyte apoptosis. Differential diagnosis includes linear IgA dermatosis and paraneoplastic pemphigus, pemphigus vulgaris and bullous pemphigoid, acute generalized exanthematous pustulosis (AGEP), disseminated fixed bullous drug eruption and staphyloccocal scalded skin syndrome (SSSS). Due to the high risk of mortality, management of patients with SJS/TEN requires rapid diagnosis, evaluation of the prognosis using SCORTEN, identification and interruption of the culprit drug, specialized supportive care ideally in an intensive care unit, and consideration of immunomodulating agents such as high-dose intravenous immunoglobulin therapy. SJS and TEN are severe and life-threatening. The average reported mortality rate of SJS is 1-5%, and of TEN is 25-35%; it can be even higher in elderly patients and those with a large surface area of epidermal detachment. More than 50% of patients surviving TEN suffer from long-term sequelae of the disease.
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Affiliation(s)
- Thomas Harr
- Department of Dermatology, University Hospital Zurich, Switzerland.
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Lee HY, Tey HL, Pang SM, Thirumoorthy T. Systemic lupus erythematosus presenting as Stevens-Johnson syndrome and toxic epidermal necrolysis: a report of three cases. Lupus 2010; 20:647-52. [PMID: 21148602 DOI: 10.1177/0961203310385162] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening dermatological conditions that are characterized by mucositis, epidermal detachment and erosions. The underlying etiology in SJS and TEN is almost invariably secondary to drugs. Rarely, other causes such as systemic lupus erythematosus (SLE), infections and vaccinations have been implicated. This report describes three patients with SLE who presented with manifestations of SJS/TEN without a clear drug causality. All three patients presented with photodistributed macular exanthema, which evolved to target lesions, bullae, erosions or sheet-like detachment. This was associated with oral mucositis and conjunctivitis. The onset of the rash was insidious with a protracted clinical course. Ultraviolet exposure and steroid tapering appear to be precipitating factors. In two of the patients, SJS and TEN were the initial presentation of lupus. Although SJS and TEN are almost invariably due to medications, they may, rarely, be an initial presentation of lupus, particularly when associated with an initial photodistribution, absence of genital involvement and a prolonged clinical course.
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Affiliation(s)
- H Y Lee
- Dermatology Unit, Singapore General Hospital, Singapore.
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Harr T, French LE. Severe cutaneous adverse reactions: acute generalized exanthematous pustulosis, toxic epidermal necrolysis and Stevens-Johnson syndrome. Med Clin North Am 2010; 94:727-42, x. [PMID: 20609860 DOI: 10.1016/j.mcna.2010.04.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Most drug hypersensitivity reactions show skin symptoms. The most severe cutaneous manifestations include pustular and bullous skin eruptions. These 2 manifestations can lead to acute generalized exanthematous pustulosis or Stevens-Johnson syndrome and toxic epidermal necrolysis. These complications are rare, but should be known to any doctor prescribing drugs because they are life threatening and early stoppage of treatment is mandatory.
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Affiliation(s)
- Thomas Harr
- Department of Dermatology, University Hospital Zurich, Gloriastrasse 31, Zurich 8031, Switzerland.
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Underexpression and overexpression of Fas and Fas ligand: a double-edged sword. Ann Allergy Asthma Immunol 2010; 104:286-92. [PMID: 20408337 DOI: 10.1016/j.anai.2010.01.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare autoimmune lymphoproliferative syndrome (ALPS) and Stevens-Johnson syndrome (SJS) with respect to the defects in Fas- and Fas ligand (FasL)-mediated apoptosis. DATA SOURCES Selected reviews, case reports, and original studies were searched in PubMed and MEDLINE for the keywords ALPS, SJS, Fas, FasL, and apoptosis. STUDY SELECTION Case reports of ALPS and SJS were selected as examples of Fas- and FasL-mediated diseases. In addition, we selected articles that examined the pathophysiology of apoptosis in the context of Fas-FasL interaction. RESULTS Failure to initiate apoptosis of abnormal T lymphocytes occurs in such diseases as ALPS, leading to the accumulation of double negative T cells with an increase in autoimmunity. In contrast to apoptotic failure, SJS is associated with a pathological increase in programmed keratinocyte cell death. CONCLUSION The consequences of dysregulated Fas- and FasL-mediated apoptosis leads to self-reactivity, malignant transformation, and immune dysfunction. An understanding of underlying mechanisms and qualitative assessment of Fas and FasL may have clinical benefits when control of these homeostatic mechanisms is in question.
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Paquet P, Piérard GE. New insights in toxic epidermal necrolysis (Lyell's syndrome): clinical considerations, pathobiology and targeted treatments revisited. Drug Saf 2010; 33:189-212. [PMID: 20158284 DOI: 10.2165/11532540-000000000-00000] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Drug-induced toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a life-threatening drug reaction characterized by extensive destruction of the epidermis and mucosal epithelia. The eyes are typically involved in TEN. At present, the disease has a high mortality rate. Conceptually, TEN and the Stevens-Johnson syndrome are closely related, although their severity and outcome are different. Distinguishing TEN from severe forms of erythema multiforme relies on consideration of aetiological, clinical and histological characteristics. The current understanding of the pathomechanism of TEN suggests that keratinocytes are key initiator cells. It is probable that the combined deleterious effects on keratinocytes of both the cytokine tumour necrosis factor (TNF)-alpha and oxidative stress induce a combination of apoptotic and necrotic events. As yet, there is no evidence indicating the superiority of monotherapy with corticosteroids, ciclosporin (cyclosporine) or intravenous immunoglobulins over supportive care only for patients with TEN. However, the current theory of TEN pathogenesis supports the administration of a combination of antiapoptotic/antinecrotic drugs (e.g. anti-TNF-alpha antibodies plus N-acetylcysteine) targeting different levels of the keratinocyte failure machinery.
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Affiliation(s)
- Philippe Paquet
- Department of Dermatopathology, University Hospital of Liège, CHU Sart Tilman, Liège, Belgium.
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37
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Wetter DA, Camilleri MJ. Clinical, etiologic, and histopathologic features of Stevens-Johnson syndrome during an 8-year period at Mayo Clinic. Mayo Clin Proc 2010; 85:131-8. [PMID: 20118388 PMCID: PMC2813820 DOI: 10.4065/mcp.2009.0379] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine clinical, etiologic, and histologic features of Stevens-Johnson syndrome and to identify possible correlates of clinical disease severity related to etiologic and histopathologic findings. PATIENTS AND METHODS This is a retrospective review of patients seen at Mayo Clinic between January 1, 2000, and December 31, 2007. RESULTS Of 27 patients (mean age, 28.1 years), 22 (81%) had involvement of 2 or more mucous membranes, and 19 (70%) had ocular involvement. Medications, most commonly antibiotics and anticonvulsants, were causative in 20 patients. Mycoplasma pneumoniae infection caused 6 of the 27 cases. Corticosteroids were the most common systemic therapy. No patients with mycoplasma-induced Stevens-Johnson syndrome had internal organ involvement or required treatment in the intensive care unit, in contrast to 4 patients each in the drug-induced group. Three patients had chronic ocular sequelae, and 1 died of complications. Biopsy specimens from 13 patients (48%) showed epidermal necrosis (8 patients), basal vacuolar change (10 patients), and subepidermal bullae (10 patients). Biopsy specimens from 11 patients displayed moderate or dense dermal infiltrate. Histologic features in drug-induced cases included individual necrotic keratinocytes, dense dermal infiltrate, red blood cell extravasation, pigment incontinence, parakeratosis, and substantial eosinophils or neutrophils. CONCLUSION Our clinical and etiologic findings corroborate those in previous reports. M pneumoniae-induced Stevens-Johnson syndrome manifested less severely than its drug-induced counterpart. The limited number of biopsies precludes unequivocal demonstration of histopathologic differences between drug-induced and M pneumoniae-induced Stevens-Johnson syndrome.
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Affiliation(s)
| | - Michael J. Camilleri
- Individual reprints of this article are not available. Address correspondence to Michael J. Camilleri, MD, Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Shahverdian DE, Anastassiades CP, Charles JC. 60-year-old man with rash. Mayo Clin Proc 2009; 84:838-41. [PMID: 19720782 PMCID: PMC2735434 DOI: 10.4065/84.9.838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
| | | | - Joseph C. Charles
- Advisor to residents and Consultant in Hospital Internal Medicine, Mayo Clinic Arizona, Scottsdale, AZ
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Abstract
Toxic epidermal necrolysis, a unique rapidly developing mucocutaneous reaction pattern, characterized by sheets of erythema, necrosis and bullous detachment of the epidermis, closely resembling that of scalding of the skin and rapidly fatal, was described by Lyell, and is now recognized as toxic epidermal necrolysis (TEN) Lyell's syndrome. The condition is indistinguishable from staphylococcal scalded skin syndrome (SSSS), and generalized fixed drug eruption. Hence, there has always been controversy as regards terminology. It is well conceived that TEN is equivalent to Stevens-Johnson syndrome (SJS), at its greatest severity. TEN, therefore, is a great challenge and warrants instant attention based on a thorough knowledgeable background covering several related facets including the recent advances in pathogenesis and management strategies. The details contained in the following text should prove very useful in the comprehension of a largely intractable entity.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Centre, Sehgal Nursing Home, Panchwati, Azadpur, Skin Institute and School of Dermatology, Greater Kailash, New Delhi, India.
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40
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Vellozzi C, Burwen DR, Dobardzic A, Ball R, Walton K, Haber P. Safety of trivalent inactivated influenza vaccines in adults: background for pandemic influenza vaccine safety monitoring. Vaccine 2009; 27:2114-20. [PMID: 19356614 DOI: 10.1016/j.vaccine.2009.01.125] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Revised: 01/22/2009] [Accepted: 01/29/2009] [Indexed: 11/16/2022]
Abstract
In preparation for pandemic vaccine safety monitoring, we assessed adverse events reported to the Vaccine Adverse Event Reporting System following receipt of trivalent inactivated influenza vaccines among adults from 1990 through 2005. We calculated reporting rates for nonserious, serious, and neurological adverse events. We reviewed reports of recurrent events and deaths, as well as reports identified through advanced signal detection. The most frequently reported events were local reactions and systemic symptoms. Guillain-Barré syndrome was the most frequently reported serious event (0.70 reports per million vaccinations). Adverse event reporting rates have been reasonably constant over time. No new safety concerns emerged after our review of 15 years of post-licensure surveillance data. These findings provide useful information if pandemic vaccine is rapidly distributed and pre-licensure data are limited.
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Affiliation(s)
- Claudia Vellozzi
- Immunization Safety Office (ISO), Office of the Chief Science Officer (OCSO), Centers for Disease Control and Prevention, Atlanta, GA, United States.
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Levi N, Bastuji-Garin S, Mockenhaupt M, Roujeau JC, Flahault A, Kelly JP, Martin E, Kaufman DW, Maison P. Medications as risk factors of Stevens-Johnson syndrome and toxic epidermal necrolysis in children: a pooled analysis. Pediatrics 2009; 123:e297-304. [PMID: 19153164 DOI: 10.1542/peds.2008-1923] [Citation(s) in RCA: 141] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the relation of medications to the risk of Stevens-Johnson syndrome and toxic epidermal necrolysis in children <15 years of age. METHODS We conducted a pooled analysis by using data from 2 multicenter international case-control studies: the severe cutaneous adverse reaction (SCAR) study and the multinational severe cutaneous adverse reaction (EuroSCAR) study conducted in France, Germany, Italy, Portugal, the Netherlands, Austria, and Israel. We selected case subjects aged <15 years, hospitalized for Stevens-Johnson syndrome, Stevens-Johnson syndrome/toxic epidermal necrolysis-overlap, or toxic epidermal necrolysis, and age-, gender-, and country-matched hospital controls. Pooled crude odds ratios were estimated and adjusted for confounding by multivariate methods when numbers permitted. RESULTS Our study included 80 cases and 216 matched controls. Antiinfective sulfonamides, phenobarbital, carbamazepine, and lamotrigine were strongly associated with the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. Significant associations were highlighted in univariate analysis for valproic acid and nonsteroidal antiinflammatory drugs as a group and for acetaminophen (paracetamol) in multivariate analysis. CONCLUSIONS We confirmed 4 previously highly suspected drug risk factors for Stevens-Johnson syndrome/toxic epidermal necrolysis in children: antiinfective sulfonamides, phenobarbital, carbamazepine, and lamotrigine. Among more unexpected risk factors, we suspect that acetaminophen (paracetamol) use increases the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis.
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Affiliation(s)
- Natacha Levi
- Service de Pharmacologie Clinique, Hôpital Henri Mondor Albert-Chenevier, Créteil, France
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Pereira FA, Mudgil AV, Rosmarin DM. Toxic epidermal necrolysis. J Am Acad Dermatol 2007; 56:181-200. [PMID: 17224365 DOI: 10.1016/j.jaad.2006.04.048] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 03/10/2006] [Accepted: 04/11/2006] [Indexed: 10/23/2022]
Abstract
UNLABELLED Toxic epidermal necrolysis (TEN) is an unpredictable, life-threatening drug reaction associated with a 30% mortality. Massive keratinocyte apoptosis is the hallmark of TEN. Cytotoxic T lymphocytes appear to be the main effector cells and there is experimental evidence for involvement of both the Fas-Fas ligand and perforin/granzyme pathways. Optimal treatment for these patients remains to be clarified. Discontinuation of the offending drug and prompt referral to a burn unit are generally agreed upon steps. Beyond that, however, considerable controversy exists. Evidence both pro and con exists for the use of IVIG, systemic corticosteroid, and other measures. There is also evidence suggesting that combination therapies may be of value. All the clinical data, however, is anecdotal or based on observational or retrospective studies. Definitive answers are not yet available. Given the rarity of TEN and the large number of patients required for a study to be statistically meaningful, placebo controlled trials are logistically difficult to accomplish. The absence of an animal model further hampers research into this condition. This article reviews recent data concerning clinical presentation, pathogenesis and treatment of TEN. LEARNING OBJECTIVES At the conclusion of this learning activity, participants should have acquired a more comprehensive knowledge of our current understanding of the classification, clinical presentation, etiology, pathophysiology, prognosis, and treatment of TEN.
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Affiliation(s)
- Frederick A Pereira
- Department of Dermatology, Mount Sinai School of Medicine, New York, New York, USA.
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45
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Hynes AY, Kafkala C, Daoud YJ, Foster CS. Controversy in the use of high-dose systemic steroids in the acute care of patients with Stevens-Johnson syndrome. Int Ophthalmol Clin 2005; 45:25-48. [PMID: 16199965 DOI: 10.1097/01.iio.0000177430.89645.6d] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Alla Y Hynes
- MERSI, 100 Charles River Plaza, 3rd Floor, Suite 301, 165 Cambridge Street, Boston, MA 02114, USA
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46
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Allix M, Barbarot S, Hery B, Chenebaux A, Stalder J. Syndrome de Lyell du nourrisson et vaccination. Ann Dermatol Venereol 2004. [DOI: 10.1016/s0151-9638(04)93692-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hehn J, Hartmann K, Bröcker EB, Goebeler M. Influenza-Schutzimpfung und Dermatosen - Koinzidenz oder kausale Assoziation? Influenza vaccination and skin disease - coincidence or causal association? J Dtsch Dermatol Ges 2003; 1:99-104. [PMID: 16285177 DOI: 10.1046/j.1610-0387.2003.02026.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Influenza remains an important cause of morbidity and mortality worldwide; therefore, vaccination of risk groups is recommended by health authorities in many countries of the world. Vaccination against influenza has been implicated occasionally induce or trigger skin diseases. We review the literature and present data from the German registry for vaccination-associated adverse effects at the Paul-Ehrlich-Institut. In addition to local reactions at the injection site, exanthema, urticaria and anaphylactic reactions to vaccine components, vasculitis has been documented to be likely induced or triggered by influenza vaccination. Other skin diseases do not appear to be associated with vaccination to influenza. Overall, the risk of vaccination-associated skin disease is very low and is not a reason to avoid of influenza vaccination.
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Affiliation(s)
- Jennifer Hehn
- Klinik und Poliklinik für Hautkrankheiten der Universität Würzburg, Würzburg
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48
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Abstract
With a decreasing disease burden from vaccine-preventable diseases in developed countries, ensuring the safety of vaccines is critically important for maintaining public confidence in vaccination programs and continuing low levels of disease. This will require investment in resources to identify true adverse effects, understand their pathophysiology, and design and manufacture safer vaccines.
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Affiliation(s)
- Robert Ball
- Vaccine Safety Branch, Division of Epidemiology, Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, MD, USA.
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Ball R, Halsey N, Braun MM, Moulton LH, Gale AD, Rammohan K, Wiznitzer M, Johnson R, Salive ME. Development of case definitions for acute encephalopathy, encephalitis, and multiple sclerosis reports to the vaccine: Adverse Event Reporting System. J Clin Epidemiol 2002; 55:819-24. [PMID: 12384197 DOI: 10.1016/s0895-4356(01)00500-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The Vaccine Adverse Event Reporting System (VAERS), administered by the FDA and CDC, is the U.S. system for surveillance of vaccine adverse events (AE). Acute encephalopathy age <18 months (EO < 18), age > or =18 months (EO > or = 18), encephalitis (EI), and multiple sclerosis (MS) after vaccination have been reported to VAERS, but reports often contain insufficient information to validate diagnoses. Standardized case definitions would enhance the utility of VAERS reports for AE surveillance. We developed practical case definitions for classification of VAERS reports, and three neurologists independently applied the definitions to reports submitted in 1993. Inter-observer agreement was assessed, and non-concordant classifications were reviewed in a follow-up conference call. Reports of EO < 18 (n = 8), EO > or = 18 (n = 20), EI (n = 15), and MS (n = 16) were classified as "definite" in 7% to 30% of the cases, while 26% to 51% of reports were thought to have insufficient information to make a classification. Agreement among reviewers was good to excellent, (kappa: 0.65 to 0.85) except for EO < 18 m for which it was marginal (kappa: 0.37). It is possible to develop reproducible case definitions for acute encephalopathy, encephalitis, and multiple sclerosis using a standardized approach. Application of standardized case definitions to VAERS reports documents the limited information in many reports, specifies data for supplemental collection, and indicates that VAERS reports should be cautiously interpreted. Development and application of case definitions for other adverse events reported after vaccination should enhance the value of vaccine safety databases. Published by Elsevier Science Inc.
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Affiliation(s)
- Robert Ball
- Division of Epidemiology, Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, MD 20852, USA.
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Abstract
Rubella is still a public health concern in this country. With the great numbers of immigrants welcomed in the United States also comes the risk of diseases that are little known or thought to be of little concern. Obviously, there is a need for continued vaccination of citizens, not only at approximately 1 year of age and school age but also in terms of continued screening for and immunization of susceptible women of childbearing age. Policies need to be developed to address the issue of rubella infection and susceptibility in areas where there is a high population density of people from countries that may not have such strict immunization practices. Vaccination at workplaces that employ high numbers of foreign-born workers or that involve a close working environment, education of workers and health care professionals in the recognition of rubella and its potentially devastating effects, and continued surveillance for and reporting of cases in high-risk areas may be of benefit.
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Affiliation(s)
- Melody R Vander Straten
- Departments of Dermatology and Microbiology/Immunology, University of Texas Medical Branch, Galveston, TX 77555-1070, USA
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