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Ferdause J, Momtahena SJ, Karim R, Chowdhury AP, Hossain NT, Islam MA, Habib MB, Kadir AKMS, Haque MA. Trastuzumab-induced toxic epidermal necrolysis in a Her-2-positive metastatic breast cancer patient-A rare case report. Clin Case Rep 2024; 12:e9103. [PMID: 38915931 PMCID: PMC11194292 DOI: 10.1002/ccr3.9103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 06/26/2024] Open
Abstract
Toxic Epidermal Necrolysis (TEN) is a rare, but potentially fatal mucocutaneous reaction, that may occur due to an immunologic response to certain medications. However, TEN triggered by Trastuzumab is extremely rare. Early diagnosis, recognition, and prompt cessation of the offending drugs and initiation of steroid therapy with supportive management are the most important actions for managing TEN. Although rare, it is important to be vigilant about this potential adverse reactions associated with trastuzumab to ensure patient safety and contribute to better outcomes.
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Affiliation(s)
| | | | - Rubama Karim
- Ahsania Mission Cancer and General HospitalDhakaBangladesh
| | | | | | | | - Maruf Bin Habib
- Department of MedicineAhsania Mission Medical CollegeDhakaBangladesh
| | | | - Md Ariful Haque
- Department of Public HealthAtish Dipankar University of Science and TechnologyDhakaBangladesh
- Voice of Doctors Research SchoolDhakaBangladesh
- Department of Orthopaedic SurgeryYan'an Hospital Affiliated to Kunming Medical UniversityKunmingYunnanChina
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2
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Dean C, Ongchuan S, Munjal S. Not All Mucosal Rashes After Lamotrigine Are Stevens-Johnson Syndrome: Case of Mycoplasma pneumoniae -Induced Rash and Mucositis and Review of Differential Diagnosis. J Clin Psychopharmacol 2024; 44:314-316. [PMID: 38526521 DOI: 10.1097/jcp.0000000000001857] [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: 03/26/2024]
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Neagu TP, Tiglis M, Peride I, Niculae A. Toxic Epidermal Necrolysis, A Serious Side Effect of Tenoxicam Use: A Case Report. Healthcare (Basel) 2023; 11:2195. [PMID: 37570435 PMCID: PMC10418430 DOI: 10.3390/healthcare11152195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
Tenoxicam, a selective cyclooxygenase (COX)-2 inhibitor, has potent analgesic and anti-inflammatory effects and is frequently used for out-of-hospital pain control. Even though other non-steroidal anti-inflammatory drugs were incriminated in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) appearance, the literature is scarce regarding this agent. We report a case of tenoxicam-induced toxic epidermal necrolysis, detailing the multidisciplinary approach in a patient presenting skin detachment of 90% of the total body surface area, with concomitant ocular, oral, nasal, and vaginal mucosae involvement. A skin biopsy confirmed the diagnosis. The immediate cessation of the incriminated drug and rapid initiation of systemic steroids, along with topical therapies, and isolation into a specific environmental condition to limit skin infection were the cornerstones of therapeutic management. The patient was discharged with skin hyperpigmentation area and mild anxiety as long-term sequels. This report emphasized that severe or complicated cases should be transferred to a specialized burn center to reduce mortality risk and long-term morbidity.
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Affiliation(s)
- Tiberiu Paul Neagu
- Clinical Department No. 11, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Mirela Tiglis
- Department of Anesthesia and Intensive Care, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
| | - Ileana Peride
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Andrei Niculae
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
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Cao J, Zhang X, Xing X, Fan J. Biologic TNF-α Inhibitors for Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, and TEN-SJS Overlap: A Study-Level and Patient-Level Meta-Analysis. Dermatol Ther (Heidelb) 2023:10.1007/s13555-023-00928-w. [PMID: 37178320 DOI: 10.1007/s13555-023-00928-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/13/2023] [Indexed: 05/15/2023] Open
Abstract
INTRODUCTION Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions with high morbidity and mortality and not clearly established treatment protocol. This meta-analysis aimed to evaluate the efficacy and safety of three biologic TNF-α inhibitors (infliximab, etanercept, adalimumab) in the treatment of SJS, SJS-TEN overlap, and TEN. METHODS Electronic databases were searched for original studies containing human participants diagnosed with SJS/TEN and treated with biologic TNF-α inhibitors. Individual patient data were collected and summarized to provide a comprehensive overview on therapeutic efficacy of different biologic TNF-α inhibitors for SJS, SJS-TEN overlap, and TEN, respectively. Meta-analyses on aggregated study data were conducted using random-effects model. RESULTS Overall, 55 studies with 125 sets of individual patient data were included. Infliximab was used to treat 3 patients with SJS-TEN overlap and 28 patients with TEN, and the actual mortality rate was 33.3% and 17%, respectively. Etanercept was administered to 17 patients with SJS, 9 patients with SJS-TEN overlap, and 64 patients with TEN, and mortality rate was reported to be 0%, 0%, and 12.5%, respectively. For participants with TEN, no significant difference was found in time of reepithelialization, hospitalization time, and mortality rate comparing etanercept with infliximab. More sequelae were reported in patients receiving infliximab than in patients treated with etanercept (39.3% versus 6.4%). Adalimumab was administered to four patients with TEN, and mortality rate was 25%. Meta-analyses on aggregated study data revealed significantly shortened hospitalization time in etanercept compared with non-etanercept groups [weighted mean differences (WMD) -5.30; 95% confidence interval (CI) -8.65 to -1.96]. Etanercept was associated with a survival benefit for patients when compared with non-etanercept treatment, however, the analysis was not statistically significant (odds ratio 0.55; 95% CI 0.23-1.33). CONCLUSIONS On the basis of the current findings, etanercept is currently the most promising biologic therapy for SJS/TEN. Further evaluation in prospective studies is required to confirm its efficacy and safety.
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Affiliation(s)
- Jiali Cao
- Department of Dermatology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, Beijing, 100020, China.
| | - Xuan Zhang
- Department of Dermatology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Xinzhu Xing
- Department of Dermatology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Jie Fan
- Medical Department, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, 101300, China
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Surowiecka A, Barańska-Rybak W, Strużyna J. Multidisciplinary Treatment in Toxic Epidermal Necrolysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2217. [PMID: 36767584 PMCID: PMC9916139 DOI: 10.3390/ijerph20032217] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
Toxic epidermal necrolysis, Leyll's syndrome (TEN), is a rare mucocutaneous blistering disease burdened with high mortality rates. The diagnosis of TEN is based on clinical symptoms and histopathological findings. In approximately 90% of cases, it is a severe adverse reaction to drugs. In TEN, not only is the skin affected, but also mucosa and organs' epithelium. There are no unequivocal recommendations in regard to systemic and topical treatment of the patients. The aim of this paper is to review available literature and propose unified protocols to be discussed. Early management and multidisciplinary treatment are necessary to improve patients' outcome. Treatment of patients with TEN suspicions should be initiated with early drug withdrawal. TEN patients, like patients with burns, require intensive care and multidisciplinary management. Each patient with TEN should be provided with adequate fluid resuscitation, respiratory support, nutritional treatment, pain control, infection prophylaxis, anticoagulant therapy, and gastric ulcer prophylaxis. The key to local treatment of patients with TEN is the use of nonadherent dressings that do not damage the epidermis during the change. The aim of the systemic treatment is purification of the blood stream from the causative agent. The most efficient way to clarify serum of TEN patients' is the combination of plasmapheresis and IVIG. Immunomodulatory therapy can reduce the mortality five times in comparison with the patients with immunosuppression or lack of full protocol.
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Affiliation(s)
- Agnieszka Surowiecka
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, 20-059 Lublin, Poland
| | - Wioletta Barańska-Rybak
- Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Jerzy Strużyna
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, 20-059 Lublin, Poland
- Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, 20-059 Lublin, Poland
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Accuracy of SCORTEN in predicting mortality in toxic epidermal necrolysis. BMC Med Inform Decis Mak 2022; 22:273. [PMID: 36261833 PMCID: PMC9583545 DOI: 10.1186/s12911-022-02013-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 09/16/2022] [Accepted: 10/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Toxic epidermal necrolysis (TEN) patients require multi-directional and multi-disciplinary treatment. In most cases, they are hospitalised at intensive care units and require multi-directional, burn-complication preventive care. Choosing the most appropriate treatment option might be troublesome even when predicting scores are used. SCORTEN is the most renowned prognostic score for TEN patients, however, there are some data indicating that the accuracy of this test may be limited. The credibility of not just the predicted mortality risk, but also componential laboratory results and clinical features subject to debate. The aim of this study was to evaluate the efficacy and credibility of SCORTEN in clinical practice, on proprietary material. METHODS A retrospective analysis of 35 patients with diagnosed in histopathology TEN was performed. The inclusion criteria were as follows: day of submission before 5th day from the onset of the symptoms, full protocol of plasmaphereses and IVIGs according to our scheme. Our protocol includes cycle of plasmapheresis with frozen fresh plasma twice daily for the first 2 days following admission, and once daily for the subsequent 5 to 7 days. IVIGs were administered after the first two sessions of plasmapheresis, for 4 to 7 days. The dosage was calculated according to body weight, at 0.4 to 0.5 g/kg per dose. RESULTS The sensitivity of SCORTEN for the analysed cohort was 100%, with a specificity of 24%. The estimated death was 41,9%, while the actual death rates were 12,5%. Our protocol improved the survival, OR = 26,57, RR = 6,34, p = 0,022. Decrease in mortality was caused by a combined treatment protocol we use- plasmaphereses with IVIGs. No independent risk factor was significant in death evaluation. CONCLUSION Our data suggest that the scoring system for predicting death among TEN patients are reliable when they are high. New prognostic factors should be found to improve the evaluation of patients with low SCORTEN.
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Khan AA, Rashid F, Khan FU, Tahmina T, Amin S, Anand A. Diagnosis and treatment of flurbiprofen-induced Stevens-Johnson syndrome: A rare case report. Clin Case Rep 2022; 10:e6365. [PMID: 36188027 PMCID: PMC9500423 DOI: 10.1002/ccr3.6365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/29/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Our case highlights the occurrence of severe cutaneous adverse reactions with flurbiprofen use and alerts physicians to its odds with safer drugs.
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Affiliation(s)
- Asad Ali Khan
- Department of Internal MedicineHayatabad Medical ComplexPeshawarPakistan
| | - Farhana Rashid
- Department of DermatologyKhyber Medical CollegePeshawarPakistan
| | - Farhat Ullah Khan
- Department of Internal MedicineHayatabad Medical ComplexPeshawarPakistan
| | - Tahmina Tahmina
- Department of Internal MedicineKhyber Medical CollegePeshawarPakistan
| | - Said Amin
- Department of Internal MedicineHayatabad Medical ComplexPeshawarPakistan
| | - Ayush Anand
- BP Koirala Institute of Health SciencesDharanNepal
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Strużyna J, Surowiecka A, Korzeniowski T, Piszczek J, Korulczyk P, Drozd L, Stachura A, Torres K, Krajewski A. Immunomodulatory treatment of Lyell's syndrome - a simultaneous plasmapheresis and IVIGs therapy. J Burn Care Res 2022; 43:1394-1398. [PMID: 35396849 DOI: 10.1093/jbcr/irac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Lyell's syndrome, or toxic epidermal necrolysis (TEN) is a rare but life-threatening condition. It manifests with blistering of skin and mucous due to subepidermal bullae and keratinocyte necrosis. In most cases it is an immune response to drugs or their metabolites. The mortality in TEN is high despite optimal infection and wound control. There are no unequivocal treatment guidelines in TEN. Immunosuppressive treatment may increase the wound infection risk and mortality. The aim of the study was to evaluate a 10-year experience with immunomodulatory therapy in TEN. We perform a combination of plasmapheresis and IVIGs to control the disease. There were 35 patients in the group and we performed a post hoc evaluation. 28 patients received the full protocol and there were 7 patients who did not complete the treatment (single therapy group). The mortality in the test group was 14,29%, and the difference reached statistical significance in comparison with the single therapy group (p<0.05). Our protocol reduced the mortality risk 5 times. Our study proved that simultaneous plasmaphereses with IVIGs administration was safe and improved patients' outcome in TEN.
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Affiliation(s)
- Jerzy Strużyna
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Poland
| | - Agnieszka Surowiecka
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland
| | - Tomasz Korzeniowski
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,West Pomeranian Burns and Plastic Surgery Center, Gryfice, Poland
| | - Joanna Piszczek
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Poland
| | - Patrycja Korulczyk
- Chair and Department of Didactics and Medical Simulation, Medical University of Lublin, Poland
| | - Lukasz Drozd
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland
| | - Aldona Stachura
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland
| | - Kamil Torres
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,Chair and Department of Didactics and Medical Simulation, Medical University of Lublin, Poland
| | - Andrzej Krajewski
- East Center of Burns Treatment and Reconstructive Surgery, Medical University of Lublin, Łęczna, Poland.,West Pomeranian Burns and Plastic Surgery Center, Gryfice, Poland
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9
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Lee KCH, Ko JP, Oh CC, Sewa DW. Managing respiratory complications in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Int J Dermatol 2021; 61:660-666. [PMID: 34494255 DOI: 10.1111/ijd.15888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 07/29/2021] [Accepted: 08/13/2021] [Indexed: 11/28/2022]
Abstract
In the recently published guidelines by the Society of Dermatology Hospitalists on the management of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), a brief section was included on airway management. These recommendations provide an easy reference on how to manage respiratory complications of the disease. Understanding the evidence that underlies these recommendations would offer physicians greater clarity on the considerations behind every decision and treatment offered. We present a review of the literature on respiratory manifestations associated with SJS and TEN. In addition, we aim to address specific concerns regarding the respiratory management of these patients. These include issues such as the indications and optimal timing of intubation, tracheostomy, role of flexible nasoendoscopy, bronchoscopy, ventilation strategies, and management of chronic respiratory complications.
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Affiliation(s)
- Ken Cheah Hooi Lee
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Joanna Phone Ko
- Nursing Division (Specialty Nursing), Singapore General Hospital, Singapore, Singapore
| | - Choon Chiat Oh
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
| | - Duu Wen Sewa
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
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10
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Haravu PN, Gottlieb LJ, Vrouwe SQ. Antishear therapy for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: a follow-up study. J Burn Care Res 2021; 42:1152-1161. [PMID: 34370855 DOI: 10.1093/jbcr/irab155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS/TEN) are life-threatening conditions best approached with multidisciplinary burn-equivalent care. There is a lack of consensus on wound management, in particular whether to debride detached epidermis. Our center instituted "antishear" wound therapy thirty-five years ago, where detached skin is left in situ as a biologic dressing and a standardized protocol avoids shear forces to prevent further desquamation. Our center's initial results showed outcomes comparable to SCORTEN predictions, but advancements in burn critical care necessitate a re-evaluation of the antishear approach. A retrospective chart review was conducted for all patients admitted between 06/2004 to 05/2020 with a dermatologist-confirmed diagnosis of SJS/TEN (N=51). All patients were treated with burn-equivalent critical care and antishear wound therapy. Standardized mortality ratios were calculated using the established SCORTEN, and newly developed ABCD-10, prediction models. Mean SCORTEN, ABCD-10, and %TBSA were 2.6, 2.0, and 28%. Overall mortality was 22%; SCORTEN score (p<0.001), ABCD-10 score (p<0.01), %TBSA involved (p=0.02), and development of multi-system organ failure (p<0.001) correlated with increased mortality. Cohort-wide standardized mortality based on ABCD-10 was 1.18 (p=0.79). Standardized mortality based on SCORTEN was 0.62 (p=0.20) and 0.77 (p=0.15) for patients with scores ≤3 and >3; across the cohort it was 0.71 (p=0.11), representing a 29% mortality reduction. Incorporating the antishear approach as part of burn-equivalent care for SJS/TENS led to outcomes comparable to those predicted for surgical debridement via SCORTEN. However, the antishear approach has the advantage of avoiding painful dressing changes, sedation, and general anesthesia required for surgical debridement.
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Affiliation(s)
- Pranav N Haravu
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Lawrence J Gottlieb
- Section of Plastic & Reconstructive Surgery, University of Chicago, Chicago, IL
| | - Sebastian Q Vrouwe
- Section of Plastic & Reconstructive Surgery, University of Chicago, Chicago, IL
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11
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Hanson LM, Bettencourt AP. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Guide for Nurses. AACN Adv Crit Care 2021; 31:281-295. [PMID: 32866260 DOI: 10.4037/aacnacc2020634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Nurses are central to the care of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. Patients with these conditions present with nuanced symptoms and have complex nursing care needs. Although much of the exact pathophysiology of these diseases is not known, all nurses benefit from a fundamental understanding of the genesis of skin manifestations, associated pharmacology, and prognosis. The care of patients hospitalized with Stevens-Johnson syndrome and toxic epidermal necrolysis consists of wound care, infection prevention, comfort management, hydration and nutrition, psychosocial support, and the prevention of long-term complications. This article provides an overview of these diseases, including clinical diagnosis, history and physical assessment, related pharmacology, and nursing care priorities. A description of the current state of the science in clinical management for nurses at all levels is provided, with an emphasis on nursing's contribution to the best possible patient outcomes.
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Affiliation(s)
- Leah M Hanson
- Leah M. Hanson is Decentralized Nurse Educator, Burn Center, Regions Hospital, St Paul, Minnesota
| | - Amanda P Bettencourt
- Amanda P Bettencourt is Research Fellow, NCSP, and TACTICAL Scholar, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, North Campus Research Center, 2800 Plymouth Rd, B14, Suite G-100, Ann Arbor, MI 48109
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12
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Shegaonkar SH. Bilateral panophthalmitis following toxic epidermal necrolysis: A case report. Indian J Ophthalmol 2020; 68:538-540. [PMID: 32057029 PMCID: PMC7043163 DOI: 10.4103/ijo.ijo_1208_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 70 year old man presented with systemic signs of toxic epidermal necrolysis (TEN) following consumption of diclofenac tablets for a prodromal illness a week back. Ophthalmic evaluation showed no perception of light in both eyes along with lid edema, total corneal sloughing, and pus-filled anterior chamber. An amniotic membrane transplant was planned but within a few hours, both eyes developed panophthalmitis with restricted extraocular movements and mild proptosis and had to be eviscerated. This is perhaps the first case showing such devastating sequelae of TEN.
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13
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Guvenir H, Arikoglu T, Vezir E, Misirlioglu ED. Clinical Phenotypes of Severe Cutaneous Drug Hypersensitivity Reactions. Curr Pharm Des 2019; 25:3840-3854. [PMID: 31696807 DOI: 10.2174/1381612825666191107162921] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/06/2019] [Indexed: 12/17/2022]
Abstract
Drug hypersensitivity reactions are clinically heterogenous ranging from mild to severe. Most drug hypersensitivity reactions are accompanied by cutaneous manifestations. Fever, mucous membrane involvement, large blisters, facial oedema, pustulosis and visceral involvement are clinical features that lead to suspicion of severe adverse drug reactions. Severe cutaneous adverse drug reactions (SCARs) include Stevens-Johnson syndrome, toxic epidermal necrolysis, drug rash eosinophilia and systemic symptoms, acute generalized exanthematous pustulosis. Serum sickness like reactions, drug induced vasculitis and generalized bullous fixed drug eruptions are less severe clinical entities. SCARs are uncommon but associated with significant morbidity and mortality. Physician should be aware of specific red flags and danger signs to immediately identify these reactions. Immediate drug withdrawal is mandatory. Early diagnosis and appropriate treatment significantly affect the prognosis of the disease. The purpose of our review is to discuss clinical phenotypes of severe cutaneous drug hypersensitivity reactions.
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Affiliation(s)
- Hakan Guvenir
- Department of Pediatric Allergy and Immunology, Malatya Training and Research Hospital, Malatya, Turkey
| | - Tugba Arikoglu
- Department of Pediatric Allergy and Immunology, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Emine Vezir
- Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Training and Research Hospital, Ankara, Turkey
| | - Emine Dibek Misirlioglu
- Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
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14
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Wang H, Mustafa A, Liu S, Liu J, Lv D, Yang H, Zou J. Immune Checkpoint Inhibitor Toxicity in Head and Neck Cancer: From Identification to Management. Front Pharmacol 2019; 10:1254. [PMID: 31708780 PMCID: PMC6819434 DOI: 10.3389/fphar.2019.01254] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 09/27/2019] [Indexed: 02/05/2023] Open
Abstract
Benefiting from the continuously clarifying underlying biology of immune checkpoints and ligand–receptor interactions, the emergence of new anticancer treatment strategy, immunotherapy has shown substantial benefits on several liquid and solid tumors. Immune checkpoint inhibitors (ICIs) can block the negative regulatory components and enhance the T cell function, thus leading to prominent anticancer activity. On account of their promising effect on various malignancies shown in clinical trials, ICIs have been considered to be the most potent anticancer agents in the near future. Head and neck cancer is the seventh most common neoplasm worldwide, and the gross 5-year survival rate was only 60%. Managing locoregionally advanced, recurrent, or metastatic head and neck tumors is still a challenging problem for both oncologists and surgeons. Recent clinical trials employing the immune-modulating antibodies that target cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) and programmed cell death 1 (PD-1) herald a new era of anticancer therapy. However, like all other anticancer drugs, ICIs also have side effects while upregulating the immune system to enhance antitumor response, which were known as immune-related adverse events (irAEs). Generally, most irAEs were transient, but sometimes they can cause serious organ dysfunction, even fatal. In addition, due to the distinct anatomical feature, advanced head and neck tumors often affect the upper aerodigestive tract and cause serious dyspnea or dysphagia. Toxicities of ICIs may be more lethal for such patients. Thus, with the increasing application of anti-checkpoint agents in head and neck cancer, there is urgent need to ascertain the safety of this novel treatment strategy. Here, we compile this review of existing clinical trials on the toxicity of ICIs during cancer treatment. The particular clinical manifestation, characteristics of complication development in fatal cases, and the management strategies were discussed. This may provide vital information for future oncology trials and clinical practice.
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Affiliation(s)
- Haiyang Wang
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Abdulkadir Mustafa
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Shixi Liu
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Liu
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Dan Lv
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hui Yang
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Zou
- Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
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Bhullar HK, Aung AK, Graudins L, Ihle J, Gin D, Cleland H, Mei Teh B. Upper airway involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis. Burns 2019; 46:682-686. [PMID: 31591001 DOI: 10.1016/j.burns.2019.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/27/2019] [Accepted: 09/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening hypersensitivity conditions associated with epidermal detachment and mucositis. The indication for flexible nasoendoscopy (FNE) and overall predictive factors for early intubation are unclear. OBJECTIVES To describe the incidence of airway involvement and the key indicators for intubation in our SJS or TEN patient cohort. To determine the association between FNE findings and early intubation. METHODS A retrospective review of 45 patients with biopsy proven SJS or TEN admitted to an Australian tertiary burns centre from 2010 to 2017. RESULTS Thirty-five patients were diagnosed with TEN (77.8%), followed by overlap syndrome (SJS-TEN) (n = 6, 13.3%) and SJS (n = 4, 8.9%). Twenty (44.4%) patients were intubated; and all 20 had a diagnosis of TEN (100.0%) (p < 0.05). Intubated patients had a higher increase in total body surface area percentage(%) from day 1-3 [10.0% (IQR 0.0-23.8%)] and a longer length of stay [26.0 days (IQR 12.5-34.0)], compared to non-intubated patients [0.0% (IQR 0.0-4.0%)], [10.0 days (IQR 6.0-14.0)] (p < 0.05) respectively. The main indications for intubation were to facilitate operative and dressing management (47.4%) followed by airway involvement (26.3%). FNE was performed on 32 patients (71.1%), however FNE findings did not significantly influence intubation rates. CONCLUSION More than half (n = 20, 57.1%) of the 35 patients diagnosed with TEN underwent intubation, mainly to facilitate operative and dressing management. FNE was performed on most patients, however there was no clear association between FNE findings and early intubation.
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Affiliation(s)
- Harmeet K Bhullar
- Ear, Nose and Throat Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; Central Clinical School, Monash University, Victoria, Australia.
| | - Ar Kar Aung
- Department of General Medicine, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; School of Public Health and Preventative Medicine, Monash University, Victoria, Australia.
| | - Linda Graudins
- Pharmacy Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Josh Ihle
- School of Public Health and Preventative Medicine, Monash University, Victoria, Australia; Intensive Care Unit, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Douglas Gin
- Department of Dermatology, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Heather Cleland
- Central Clinical School, Monash University, Victoria, Australia; Victorian Adult Burns Services, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Bing Mei Teh
- Ear, Nose and Throat Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; Department of Surgery, Monash University, Victoria, Australia.
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