Stevens-Johnson syndrome and toxic epidermal necrolysis: consequence of treatment of an emerging pathogen

Treatment of Skin and Soft Tissue Infections

Group A streptococcus and Staphylococcus aureus are the most common bacterial etiologies of skin and soft tissue infections that range in virulence from very mild to limb/life threatening. Antibiotic coverage recommendations are varying and subject to controversy. Antibiotic resistance patterns are evolving with many different biochemical mechanisms. Rapid bacterial identification using mass spectrometry is on the horizon. Therapeutic considerations should include cost and adherence issues.

Oral lesions associated with Nevirapine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis: A report of 10 cases

Stevens–Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are closely related severe, acute mucocutaneous reactions usually caused by drugs. They are acute life-threatening conditions and cause widespread necrosis of the epithelium. There is persistence of a high risk of SJS or TEN in relation to human immunodeficiency virus (HIV) infection associated with exposure to nevirapine (NVP). In this article, we present nine cases of SJS and one case of TEN in HIV-seropositive individuals who developed cutaneous, oral, ocular and genital lesions while being treated with NVP.

Drug-induced severe adverse reaction enhanced by human herpes virus-6 reactivation

Reactivation of certain latent viruses has been linked with a more severe course of drug-induced hypersensitivity reaction (HSR). For example, reactivation of human herpes virus (HHV)-6 is associated with severe organ involvement and a prolonged course of disease. The present study discusses an HSR developed in a previously healthy male exposed to ceftriaxone, doxycycline, vancomycin, and trimethoprim/sulfamethoxazole (co-trimoxazole; TMP/SMX). Initially, the patient presented clinical manifestations of HSR, as well as clinical and laboratory measurements compatible with liver and renal failure. Moreover, the patient presented skin desquamation compatible with Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis. During the reaction, it was observed HHV-6 reactivation. The severity of clinical symptoms is correlated with HHV-6 titer, as well as with results of the in vitro lymphocyte toxicity assay (LTA). Serum levels of a large panel of cytokines are compared between the patient, a large population of SJS patients, and a cohort of healthy controls, using data collected by our laboratory over the years. HHV-6 was measured in the cell culture media from lymphocytes incubated with each of the 4 drugs. Moreover, we describe a new assay using cytokines released by patient lymphocytes following in vitro exposure to the incriminated drugs as biomarkers of HSR. Based on LTA results, HHV-6 reactivation and cytokine measurements, we establish that only doxycycline and TMP/SMX were involved in the HSR. As result of this analysis, the patient could continue to use the other 2 antibiotics safely.

Stevens–Johnson syndrome in a juvenile systemic lupus erythematosus patient

Stevens-Johnson syndrome (SJS) is a severe and rare immune-mediated cutaneous reaction usually induced by drugs or infections. Few case reports have demonstrated SJS associated with adult systemic lupus erythematosus (SLE), and rarely in juvenile SLE (JSLE) patients. However, to the best of our knowledge the prevalence of this life-threatening cutaneous disease in the pediatric lupus population has not been studied. Therefore, from January 1983 to December 2010, 5508 patients were followed-up at the Pediatric Rheumatology Unit of our University Hospital and 279 (5%) of them met the American College of Rheumatology (ACR) classification criteria for SLE. Only one (0.4%) of our JSLE patients had SJS and was described. This female patient was diagnosed with JSLE at 14 years old. After four years of follow-up, she was hospitalized due to congestive heart failure and renal insufficiency. During hospitalization, the patient developed sepsis with positive blood culture for Stenotrophomonas maltophilia and was treated with vancomycin and meropenem. One week later, she developed septic shock and chest x-ray showed acute widespread pulmonary infiltrate. Antimicrobials were changed to linezolid and trimethoprim-sulfamethoxazole. After four days, the blood culture isolated Staphylococcus aureus resistant to vancomycin, and she presented with erythematous cutaneous lesions involving her face, trunk, and limbs, with evolution in a few hours to diffuse hemorrhagic vesicles and blisters. Epidermal detachment was observed on 5% of the body surface area. Concomitantly, she had conjunctivitis, cheilitis, oral erosions, and hemorrhagic crust on the nasal mucosa. Vulva, vagina, and perianal erosions were also evidenced. The diagnosis of SJS was established and intravenous immunoglobulin was promptly administered. Three days later, she died of pulmonary hemorrhage. The autopsy findings demonstrated generalized infection and widespread subepidermal detachment with necrotic keratinocytes. In conclusion, SJS is a rare and severe vesiculobullous disease in a pediatric lupus population and is probably associated with infections and drug therapy.