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Salah E. TEN mimics: Classification and practical approach to toxic epidermal necrolysis-like dermatoses. Indian J Dermatol Venereol Leprol 2022; 89:337-346. [PMID: 36688885 DOI: 10.25259/ijdvl_244_2022] [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: 03/01/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
Toxic epidermal necrolysis (TEN) is an acute life-threatening dermatologic emergency. However, many dermatoses can present with a TEN-like eruption. Those "TEN-mimics" are a true diagnostic challenge and an alarming differential diagnosis to such a serious condition. Herein, we will expose and classify the landscape of TEN-mimics. Also, the key differentiating clinical and/or laboratory points will be highlighted to help an accurate diagnosis of either a TEN or a TEN-like presentation.
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Affiliation(s)
- Eman Salah
- Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Zagazig University, Egypt
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2
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Michalak-Micka K, Rütsche D, Johner L, Moehrlen U, Biedermann T, Klar AS. Expression Profile of CD157 Reveals Functional Heterogeneity of Capillaries in Human Dermal Skin. Biomedicines 2022; 10:biomedicines10030676. [PMID: 35327478 PMCID: PMC8945771 DOI: 10.3390/biomedicines10030676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/08/2022] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Abstract
CD157 acts as a receptor, regulating leukocyte trafficking and the binding of extracellular matrix components. However, the expression pattern and the role of CD157 in human blood (BEC) and the lymphatic endothelial cells (LEC) of human dermal microvascular cells (HDMEC), remain elusive. We demonstrated constitutive expression of CD157 on BEC and LEC, in fetal and juvenile/adult skin, in situ, as well as in isolated HDMEC. Interestingly, CD157 epitopes were mostly localized on BEC, co-expressing high levels of CD31 (CD31High), as compared to CD31Low BEC, whereas the podoplanin expression level on LEC did not affect CD157. Cultured HDMEC exhibited significantly higher numbers of CD157-positive LEC, as compared to BEC. Interestingly, separated CD157− and CD157+ HDMEC demonstrated no significant differences in clonal expansion in vitro, but they showed distinct expression levels of cell adhesion molecules, before and after cytokine stimulation in vitro. In particular, we proved the enhanced and specific adherence of CD11b-expressing human blood myeloid cells to CD157+ HDMEC fraction, using an in vitro immune-binding assay. Indeed, CD157 was also involved in chemotaxis and adhesion of CD11b/c monocytes/neutrophils in prevascularized dermo–epidermal skin substitutes (vascDESS) in vivo. Thus, our data attribute specific roles to endothelial CD157, in the regulation of innate immunity during inflammation.
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Affiliation(s)
- Katarzyna Michalak-Micka
- Tissue Biology Research Unit, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland; (K.M.-M.); (D.R.); (L.J.); (U.M.); (T.B.)
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
| | - Dominic Rütsche
- Tissue Biology Research Unit, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland; (K.M.-M.); (D.R.); (L.J.); (U.M.); (T.B.)
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
| | - Lukas Johner
- Tissue Biology Research Unit, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland; (K.M.-M.); (D.R.); (L.J.); (U.M.); (T.B.)
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
| | - Ueli Moehrlen
- Tissue Biology Research Unit, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland; (K.M.-M.); (D.R.); (L.J.); (U.M.); (T.B.)
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
- Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Thomas Biedermann
- Tissue Biology Research Unit, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland; (K.M.-M.); (D.R.); (L.J.); (U.M.); (T.B.)
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
| | - Agnes S. Klar
- Tissue Biology Research Unit, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland; (K.M.-M.); (D.R.); (L.J.); (U.M.); (T.B.)
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- University of Zurich, 8006 Zurich, Switzerland
- Correspondence:
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3
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Cravero K, Chakrala T, Shychuk A. Multisystem organ failure secondary to acute generalised exanthematous pustulosis (AGEP) with atypical presentation resembling septic shock. BMJ Case Rep 2022; 15:15/3/e247040. [PMID: 35232738 PMCID: PMC8889165 DOI: 10.1136/bcr-2021-247040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A woman was admitted for sepsis secondary to cellulitis. After clinical improvement of sepsis, non-follicular small pustules were observed on the trunk, limbs and face while vesicles/bullae and skin exfoliation were noted on upper extremities. Larger systemic manifestations included fever, hypertension and tachycardia. Laboratory results revealed neutrophilic leukocytosis, eosinophilia, mild transaminitis and acute renal failure. Despite treatment for potential sepsis and discontinuation of offending agents, her condition worsened leading to haemodynamic instability and renal failure requiring vasopressor support, intubation and continuous veno-venous haemodialysis. Skin biopsy revealed a diagnosis of acute generalised exanthematous pustulosis (AGEP), a rare condition usually caused by antibiotic treatment. The suspected offending drug was clindamycin, with possible combined effects by metronidazole and/or vancomycin. Improvement of skin manifestations were seen within 48 hours of starting systemic steroids. Here, we present an uncharacteristic case of AGEP clinically presenting with atypical skin lesions, severe systemic involvement mimicking septic shock, which culminated in multisystem organ failure.
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Affiliation(s)
- Karen Cravero
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Teja Chakrala
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Andrew Shychuk
- Internal Medicine, University of Florida College of Medicine, Gainesville, Florida, USA .,University of Florida, Gainesville, Florida, USA
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4
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de Groot AC. Results of patch testing in Acute generalized exanthematous pustulosis (AGEP): a literature review. Contact Dermatitis 2022; 87:119-141. [PMID: 35187690 DOI: 10.1111/cod.14075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 11/29/2022]
Abstract
The literature on positive patch test results in acute generalized exanthematous pustulosis (AGEP) is reviewed. 93 drugs were identified that have together caused 259 positive patch tests in 248 patients suffering from AGEP. The drug classes causing the highest number of reactions are beta-lactam antibiotics (25.9%), other antibiotics (20.8%), iodinated contrast media (7.3%) and corticosteroids (5.4%), together accounting for nearly 60% of all reactions. The highest number of reactions to individual drugs was to amoxicillin (n=36), followed by pristinamycin (n=25), diltiazem (n=14), amoxicillin-clavulanic acid (n=13), clindamycin (n=11) and iomeprol (n=8); 59 of the 93 drugs each caused a single case only. The "Top-10" drugs together caused over 50% of all reactions. The sensitivity of patch testing (percentage of positive reactions) in patients with AGEP is largely unknown, but may generally be around 50%, which also applies to pristinamycin. Patch testing in AGEP appears to be safe, although mild recurrence of AGEP skin symptoms or other rashes may occur occasionally. Clinical aspects of AGEP, including epidemiology, etiology and pathophysiology, clinical features, histology, treatment, and prognosis are briefly presented, as are diagnosing the disease and identifying the culprit drugs with patch tests, intradermal tests, in vitro tests, and challenge tests. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anton C de Groot
- dermatologist np, Schipslootweg 5, 8351 HV Wapserveen, The Netherlands
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5
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O’Brian M, Carr CL, Thomas C, Dominguez AR, Mauskar M. Clinical characteristics and management of acute generalized exanthematous pustulosis with haemodynamic instability. SKIN HEALTH AND DISEASE 2021; 1:e74. [PMID: 35663770 PMCID: PMC9060138 DOI: 10.1002/ski2.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/15/2021] [Accepted: 10/30/2021] [Indexed: 11/12/2022]
Abstract
Background Acute generalized exanthematous pustulosis (AGEP) is a severe pustular drug eruption with rare reports of haemodynamic instability. Objective To describe the clinical characteristics, management, and outcomes of patients with AGEP‐associated haemodynamic instability. Methods This retrospective case series identified adult patients diagnosed with AGEP who had haemodynamic instability from November 2012 to February 2020 that were seen at two academic teaching hospitals with roles as a burn centre and tertiary referral centre at the University of Texas Southwestern Medical Center in Dallas, TX USA. Patients with a discharge diagnosis of AGEP that had haemodynamic instability during their eruption were included. Patients with a history of psoriasis, presentations thought to be a flare of generalized pustular psoriasis, or concurrent infection during eruption were excluded. AGEP with haemodynamic instability was characterized by degree of hypotension, dermatologic phenotype at time of dermatologic consultation, and management approach. Results This study included 19 patients with AGEP‐associated haemodynamic instability (mean age, 52 years; age range, 29–76 years; 11 (58%) female). Patients were classified on a spectrum of haemodynamic instability; three had sustained hypotension, 10 had hypotension with organ dysfunction, and six had shock. Patients with AGEP‐associated haemodynamic instability had a range of dermatologic phenotypes at initial consultation: subtle exanthematous eruption with minimal pustules, typical eruption with pustules and flexural predominance, and severe eruption with features of Stevens–Johnson syndrome. Both topical and systemic corticosteroids were used for treatment of several patients. Of the patients that required vasopressors and received systemic steroids, the majority were off vasopressors within 24 h of steroid initiation. Conclusion Approximately 22% of patients presenting with AGEP to a tertiary referral center had haemodynamic instability. Clinicians should be aware that dermatologic phenotype of AGEP at presentation does not correlate with development of haemodynamic instability.
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Affiliation(s)
- M. O’Brian
- University of Texas Southwestern Medical Center University of Texas Southwestern Medical School Dallas Texas USA
| | - C. L. Carr
- University of Texas Southwestern Medical Center University of Texas Southwestern Medical School Dallas Texas USA
| | - C. Thomas
- Department of Dermatology University of Texas Southwestern Medical Center Dallas Texas USA
- Department of Internal Medicine University of Texas Southwestern Medical Center Dallas Texas USA
| | - A. R. Dominguez
- Department of Dermatology University of Texas Southwestern Medical Center Dallas Texas USA
- Department of Internal Medicine University of Texas Southwestern Medical Center Dallas Texas USA
| | - M. Mauskar
- Department of Dermatology University of Texas Southwestern Medical Center Dallas Texas USA
- Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center Dallas Texas USA
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6
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O'Brian M, Kolitz E, Jeong HS, Cao L, Vandergriff T, Glass DA, Dominguez AR. A severe presentation of acute generalized exanthematous pustulosis with non-infectious circulatory shock in an adolescent. Pediatr Dermatol 2021; 38:1267-1271. [PMID: 34272752 DOI: 10.1111/pde.14704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We present a severe case of acute generalized exanthematous pustulosis (AGEP) secondary to trimethoprim-sulfamethoxazole complicated by non-infectious circulatory shock in a 16-year-old boy. Hemodynamic instability has been reported as a complication of AGEP in adults, but is rarely observed in pediatric patients. The patient we present demonstrated characteristic cutaneous findings of AGEP including isolated non-follicular, sterile pustules on a background of erythema with involvement at intertriginous areas and subsequently developed non-infectious circulatory shock. This case expands the spectrum of possible clinical presentations for AGEP in pediatric patients.
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Affiliation(s)
- Madeleine O'Brian
- University of Texas Southwestern Medical School, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Elysha Kolitz
- University of Texas Southwestern Medical School, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Haneol S Jeong
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Lauren Cao
- Department of Dermatology, Kaiser Permanente, Woodland Hills Medical Center, Woodland Hills, CA, USA
| | - Travis Vandergriff
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donald A Glass
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Arturo R Dominguez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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7
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Kinoshita M, Ogawa Y, Hama N, Ujiie I, Hasegawa A, Nakajima S, Nomura T, Adachi J, Sato T, Koizumi S, Shimada S, Fujita Y, Takahashi H, Mizukawa Y, Tomonaga T, Nagao K, Abe R, Kawamura T. Neutrophils initiate and exacerbate Stevens-Johnson syndrome and toxic epidermal necrolysis. Sci Transl Med 2021; 13:13/600/eaax2398. [PMID: 34193610 DOI: 10.1126/scitranslmed.aax2398] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 12/13/2020] [Accepted: 06/10/2021] [Indexed: 12/14/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening mucocutaneous adverse drug reactions characterized by massive epidermal detachment. Cytotoxic T cells and associated effector molecules are known to drive SJS/TEN pathophysiology, but the contribution of innate immune responses is not well understood. We describe a mechanism by which neutrophils triggered inflammation during early phases of SJS/TEN. Skin-infiltrating CD8+ T cells produced lipocalin-2 in a drug-specific manner, which triggered the formation of neutrophil extracellular traps (NETs) in early lesional skin. Neutrophils undergoing NETosis released LL-37, an antimicrobial peptide, which induced formyl peptide receptor 1 (FPR1) expression by keratinocytes. FPR1 expression caused keratinocytes to be vulnerable to necroptosis that caused further release of LL-37 by necroptotic keratinocytes and induced FPR1 expression on surrounding keratinocytes, which likely amplified the necroptotic response. The NETs-necroptosis axis was not observed in less severe cutaneous adverse drug reactions, autoimmune diseases, or neutrophil-associated disorders, suggesting that this was a process specific to SJS/TEN. Initiation and progression of SJS/TEN keratinocyte necroptosis appear to involve a cascade of events mediated by innate and adaptive immune responses, and understanding these responses may contribute to the identification of diagnostic markers or therapeutic targets for these adverse drug reactions.
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Affiliation(s)
- Manao Kinoshita
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Youichi Ogawa
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan.
| | - Natsumi Hama
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Inkin Ujiie
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Akito Hasegawa
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Saeko Nakajima
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takashi Nomura
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Jun Adachi
- Laboratory of Proteome Research, National Institute of Biomedical Innovation, Health and Nutrition, Osaka, Japan.,Laboratory of Proteomics for Drug Discovery, Center for Drug Design Research, National Institute of Biomedical Innovation, Health and Nutrition, Osaka, Japan
| | - Takuya Sato
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Schuichi Koizumi
- Department of Neuropharmacology, Interdisciplinary Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Shinji Shimada
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Yasuyuki Fujita
- Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hayato Takahashi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiko Mizukawa
- Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Takeshi Tomonaga
- Laboratory of Proteome Research, National Institute of Biomedical Innovation, Health and Nutrition, Osaka, Japan.,Laboratory of Proteomics for Drug Discovery, Center for Drug Design Research, National Institute of Biomedical Innovation, Health and Nutrition, Osaka, Japan
| | - Keisuke Nagao
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health, Bethesda, MD, USA
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tatsuyoshi Kawamura
- Department of Dermatology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
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8
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Chowdhury TA, Talib KA, Patricia J, Nye KD, Moosa SA. Rare and Complicated Overlap of Stevens-Johnson Syndrome and Acute Generalized Exanthematous Pustulosis. Cureus 2021; 13:e15921. [PMID: 34336425 PMCID: PMC8310679 DOI: 10.7759/cureus.15921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 12/28/2022] Open
Abstract
Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) and acute generalized exanthematous pustulosis (AGEP) are two separate pathological entities of severe cutaneous adverse reactions (SCARs) with different etiologies and treatment strategies. Diagnosis is, however, complicated by the similarity in their clinical presentation. Although there are few claims of AGEP-SJS/TEN overlap, a simultaneous true overlap of SJS/TEN and AGEP has rarely been described in the literature. Here, we report a case study of a 61-year-old female with a known allergy to sulfa drugs presenting with altered mental status, generalized weakness, and erythematous and excoriated purulent wounds. Based on initial workup and extensive consultation, the patient was diagnosed with severe sepsis secondary to diffuse purulent cellulitis, community-acquired pneumonia, and acute renal failure due to prerenal azotemia from dehydration. She was treated with several antibiotics, starting with vancomycin, piperacillin/tazobactam. Six days later, antibiotics were de-escalated to ceftriaxone and metronidazole because of the patient's improved status. The medications were withheld when the patient started developing extensive blistering on day 8. Blood cultures ruled out any bacterial etiology. Skin biopsy confirmed overlapping features of AGEP and SJS/TEN. Due to the uncontrolled progression of her rash, she was transferred to the burn unit of a higher care center. This is potentially the first histologically confirmed case of AGEP-SJS/TEN overlap in the United States. In this case study, a conclusive diagnosis would have never been made without a biopsy, especially because the condition presented clinically as SJS/TEN. We, therefore, recommend considering a potential overlap of multiple pathologies at each presentation or suspicion of a SCAR and performing an early skin biopsy in order to provide definitive diagnosis and treatment.
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Affiliation(s)
- Towfiqul A Chowdhury
- Internal Medicine, United Health Services Wilson Medical Center, Johnson City, USA
| | - Khandokar A Talib
- Internal Medicine, United Health Services Wilson Medical Center, Johnson City, USA
| | - Justin Patricia
- Internal Medicine, Upstate University Hospital, Syracuse, USA
| | | | - Syed Ahmad Moosa
- Research, Bangladesh Medical Association of North America, New York, USA.,Internal Medicine, St. John's Episcopal Hospital, Queens Village, USA
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9
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Ralph J, Maguire M, Malone V, Fabre A, Foley CC. A generalized unexpected eruption. Clin Exp Dermatol 2020; 46:383-386. [PMID: 33080076 DOI: 10.1111/ced.14474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 09/12/2020] [Accepted: 09/16/2020] [Indexed: 11/26/2022]
Affiliation(s)
- J Ralph
- Departments of, Department of, Dermatology, St Vincent's University Hospital, Dublin, Ireland
| | - M Maguire
- Departments of, Department of, Dermatology, St Vincent's University Hospital, Dublin, Ireland
| | - V Malone
- Department of, Histopatology, St Vincent's University Hospital, Dublin, Ireland
| | - A Fabre
- Department of, Histopatology, St Vincent's University Hospital, Dublin, Ireland
| | - C C Foley
- Departments of, Department of, Dermatology, St Vincent's University Hospital, Dublin, Ireland
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10
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Copaescu AM, Bouffard D, Masse MS. Acute generalized exanthematous pustulosis simulating toxic epidermal necrolysis: case presentation and literature review. Allergy Asthma Clin Immunol 2020; 16:9. [PMID: 32042284 PMCID: PMC7001236 DOI: 10.1186/s13223-020-0407-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 01/22/2020] [Indexed: 12/18/2022] Open
Abstract
Background Acute generalized exanthematous pustulosis (AGEP) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions. These rare conditions differ in clinical presentation, pathological features, treatment and prognosis, but overlap has been described implying a challenging clinical management. Case presentation We describe a case of overlap between TEN and AGEP probably secondary to beta-lactams in a 77-year-old patient treated for a complicated cholangitis. We review the diagnosis and the management of these two conditions. The diagnosis of TEN was suggested by the initial clinical presentation with severe hemodynamic instability, skin detachment, positive Nikolsky sign and mucosal involvement. However, the skin biopsy as well as the rapid improvement of the skin lesions were discriminative for AGEP. This indicated an overlap presentation. Unfortunately, the patient refused allergy investigations in order to find the culprit drug. Medical photographs, proper physical examination and histopathological results are integrated. Conclusion Despite clinical features indicating a diagnosis of TEN, histopathology was conclusive for AGEP thus indicating a possible clinical-pathological overlap between the two conditions, a scarcely described situation in the medical literature. To our knowledge, this is one of the few cases that portrays a TEN–AGEP overlap probably secondary to Piperacillin Tazobactam. Understanding the immunological implications of these conditions can help us better distinguish and manage these severe reactions.
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Affiliation(s)
- Ana-Maria Copaescu
- 1Allergy and Immunology Department, Centre Hospitalier de l'Université de Montréal (CHUM), 264 Boulevard René-Lévesque E, Montréal, QC H2X 1P1 Canada
| | - Danielle Bouffard
- 2Pathology Department, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | - Marie-Soleil Masse
- 1Allergy and Immunology Department, Centre Hospitalier de l'Université de Montréal (CHUM), 264 Boulevard René-Lévesque E, Montréal, QC H2X 1P1 Canada
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11
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Gelincik A, Cavkaytar O, Kuyucu S. An Update on the Management of Severe Cutaneous Drug Hypersensitivity Reactions. Curr Pharm Des 2019; 25:3881-3901. [DOI: 10.2174/1381612825666191106115556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/01/2019] [Indexed: 12/15/2022]
Abstract
Severe cutaneous drug hypersensitivity reactions involve of different mechanisms , some of which are
life-threatening, such as Stevens-Johnson syndrome/toxic epidermal necrolysis, drug reaction with eosinophilia
and systemic symptoms, acute generalized exanthematous pustulosis, generalized bullous fixed drug eruptions,
serum sickness and serum sickness-like reaction and drug-induced vasculitis. These reactions may have substantial
morbidity and mortality. In the past years, successive studies have provided new evidence regarding the
pathogenesis of some of these severe reactions and revealed that underlying mechanisms are highly variable.
Since these reactions have unique presentations and distinct pathomechanisms, the treatment methods and response
rates might be different among various entities. Although supportive and local therapies are sufficient in
some of these reactions, targeted immunosuppressive treatments and even mechanistic therapies such as plasmapheresis
may be required in severe ones. However, there is still insufficient evidence to support the best treatment
options for these patients since number of patients and large-scale studies are limited. In this review, conventional
and new treatment options for severe cutaneous drug hypersensitivity reactions are presented in detail in
order to provide the contemporary approaches to lessen the morbidity and mortality relevant to these severe iatrogenic
diseases.
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Affiliation(s)
- Aslı Gelincik
- Division of Immunology and Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University, Faculty of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Mersin University, Faculty of Medicine, Mersin, Turkey
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12
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Piperacillin/Tazobactam as Cause of Acute Generalized Exanthematous Pustulosis. Case Rep Dermatol Med 2019; 2019:3273987. [PMID: 31179136 PMCID: PMC6507247 DOI: 10.1155/2019/3273987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 03/31/2019] [Accepted: 04/16/2019] [Indexed: 12/15/2022] Open
Abstract
Acute generalized exanthematous pustulosis (AGEP) is a rare cutaneous adverse reaction mainly attributed to antibiotics. It is characterized by numerous, nonfollicular, sterile pustules, arising on an exanthematous and edematous base. It is a serious adverse reaction accompanied by fever and leukocytosis. Piperacillin/tazobactam is indicated for the treatment of patients with moderate to severe infections. Herein is reported a case of AGEP caused by piperacillin/tazobactam. A 78-year-old woman with metastatic breast cancer was presented to the emergency department reporting fever and groin pain. The laboratory analysis and more specifically urine cultivation showed a urinary tract infection by E. coli with sensitivity to piperacillin/tazobactam. She had no known allergies. She was started on intravenous piperacillin/tazobactam; she improved clinically on the second day, but on the fourth day of intravenous therapy, she developed extensive pustular rash on the folds and anterior proximal thighs, accompanied by fever and neutrophilia. Piperacillin/tazobactam administration was interrupted and she was given prednisolone for ten days. The patient improved clinically and her laboratory tests returned to normal after two weeks. AGEP is an uncommon side effect of piperacillin/tazobactam treatment and there are few cases reported.
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Chaabane A, Fadhel NB, Chadli Z, Romdhane HB, Fredj NB, Boughattas NA, Aouam K. Association of non-immediate drug hypersensitivity with drug exposure: A case control analysis of spontaneous reports from a Tunisian pharmacovigilance database. Eur J Intern Med 2018; 53:40-44. [PMID: 29409745 DOI: 10.1016/j.ejim.2018.01.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/16/2018] [Accepted: 01/31/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE To assess delayed-type cutaneous reactions (DTCRs) related to drugs, using a case-control approach to qualify drug risks. METHODS The study used the Tunisian pharmacovigilance database of Monastir. The association between drugs and DTCRs was assessed using a case/non-case method. Drugs were grouped according to the ATC Classification System. Patients were defined as "cases" if they have developed DTCRs regardless of the causality assessment. All other reports were "non-cases". Association between reactions and drugs was calculated using the reporting odds ratio (ROR) with 95% confidence intervals (CIs). A p value < 0.05 was considered significant. RESULTS The analysis was carried out on 1798 reports, of which 867 concerned DTCRs (cases) and 931 concerned non-cases. The calculated risk estimates were significant for cefotaxime (ROR 2.1; 95% CI 1.5 to 3), pristinamycin (ROR 4; 95% CI 2 to 7.9), sulfamethoxazole (ROR 4.4; 95% CI 1.6 to 11.7), oxacillin (ROR 2.2; 95% CI 1.2 to 3.8), doxycycline (ROR 10.8; 95% CI 1.4 to 84.9), carbamazepine (ROR 3.3; 95% CI 1.7 to 6.2), phenobarbital (ROR 2.3; 95% CI 1.03 to 5.1), allopurinol (ROR 3.6; 95% CI 1.8 to 7.2), furosemide (ROR 2.4; 95% CI 1.3 to 6.3), hydrochlorothiazide(ROR 2.9; 95% CI 1.3 to 6.3) and candesartan (ROR 4.7; 95% CI 1.3 to 16.6). CONCLUSION Our findings corroborate risks for a number of drugs, such as antibacterials, antiepileptics and allopurinol in inducing DTCRs. Given the widespread use of these drug classes, awareness should be raised among patients and prescribers about these risks.
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Affiliation(s)
- Amel Chaabane
- Department of Pharmacology, University of Medicine, Monastir, Tunisia.
| | - Najeh Ben Fadhel
- Department of Pharmacology, University of Medicine, Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, University of Medicine, Monastir, Tunisia
| | | | - Nadia Ben Fredj
- Department of Pharmacology, University of Medicine, Monastir, Tunisia
| | | | - Karim Aouam
- Department of Pharmacology, University of Medicine, Monastir, Tunisia
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Acute Generalized Exanthematous Pustulosis Simulating Toxic Epidermal Necrolysis: Overlapping Processes. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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García Abellán J, Matarredona Catalá J, Jaen Larrieu A, Valencia Ramírez I. Acute Generalized Exanthematous Pustulosis Simulating Toxic Epidermal Necrolysis: Overlapping Processes. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:460-462. [PMID: 29402393 DOI: 10.1016/j.ad.2017.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 09/25/2017] [Accepted: 10/30/2017] [Indexed: 11/27/2022] Open
Affiliation(s)
- J García Abellán
- Servicio de Medicina Interna, Hospital General Universitario de Elche, Elche, Alicante, España.
| | - J Matarredona Catalá
- Servicio de Dermatología, Hospital General Universitario de Elche, Elche, Alicante, España
| | - A Jaen Larrieu
- Servicio de Dermatología, Hospital General Universitario de Elche, Elche, Alicante, España
| | - I Valencia Ramírez
- Servicio de Anatomía Patológica, Hospital General Universitario de Elche, Elche, Alicante, España
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16
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Moreno-Arrones OM, Carrillo-Gijon R, Sendagorta E, Rios-Buceta L. Acute generalized exanthematous pustulosis simulating Stevens-Johnson syndrome/toxic epidermal necrolysis associated with the use of vismodegib. JAAD Case Rep 2018; 4:123-125. [PMID: 29387760 PMCID: PMC5789517 DOI: 10.1016/j.jdcr.2017.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - Luis Rios-Buceta
- Department of Dermatology, Ramon y Cajal Hospital, Madrid, Spain
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17
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Tajmir-Riahi A, Wörl P, Harrer T, Schliep S, Schuler G, Simon M. Life-Threatening Atypical Case of Acute Generalized Exanthematous Pustulosis. Int Arch Allergy Immunol 2017; 174:108-111. [PMID: 29065395 DOI: 10.1159/000480700] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 07/31/2017] [Indexed: 12/18/2022] Open
Abstract
Antibiotics are known to cause severe cutaneous adverse reactions, such as the rare acute generalized exanthematous pustulosis (AGEP). Unlike Stevens-Johnson syndrome or toxic epidermal necrolysis, AGEP is rarely life-threatening. Systemic involvement is not typical, and if present usually coincides with a mild elevation of the hepatic enzymes and a decrease in renal function. Hence, AGEP is known to have a good prognosis and to be life-threatening only in elderly patients or patients with chronic diseases. Herein, we report a case of AGEP in a young healthy male leading to systemic inflammatory response syndrome and to treatment in an intensive care unit after being treated with 5 different antibiotics. Initial symptoms were not indicative for AGEP and the patient's course of disease led promptly to critical cardiorespiratory symptoms and systemic inflammatory response syndrome. We assume that the administration of the 5 different antibiotics resulted in type IV allergy as well as secondary infection with Enterococcus faecium and Staphylococcus aureus, while the underlying periodontitis also contributed to the severity of this case.
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Affiliation(s)
- Azadeh Tajmir-Riahi
- Departmens of Dermatology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
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18
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Affiliation(s)
- Aaron W Aday
- From the Departments of Medicine (A.W.A., B.D.L., J.L.) and Dermatology (A.P.S.), Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Arturo P Saavedra
- From the Departments of Medicine (A.W.A., B.D.L., J.L.) and Dermatology (A.P.S.), Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Bruce D Levy
- From the Departments of Medicine (A.W.A., B.D.L., J.L.) and Dermatology (A.P.S.), Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Joseph Loscalzo
- From the Departments of Medicine (A.W.A., B.D.L., J.L.) and Dermatology (A.P.S.), Brigham and Women's Hospital and Harvard Medical School, Boston
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19
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Marzano AV, Borghi A, Cugno M. Adverse drug reactions and organ damage: The skin. Eur J Intern Med 2016; 28:17-24. [PMID: 26674736 DOI: 10.1016/j.ejim.2015.11.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 12/11/2022]
Abstract
Cutaneous adverse drug reactions are frequent, affecting 2-3% of hospitalized patients and in one twentieth of them are potentially life-threatening. Almost any pharmacologic agent can induce skin reactions, and certain drug classes, such as non-steroidal anti-inflammatory drugs, antibiotics and antiepileptics, have drug eruption rates ranging from 1% to 5%. Cutaneous drug reactions recognize several different pathomechanisms: some skin manifestations are immune-mediated like allergic reactions while others are the result of non immunological causes such as cumulative toxicity, photosensitivity, interaction with other drugs or different metabolic pathways. Cutaneous adverse drug reactions can be classified into two groups: common non-severe and rare life-threatening adverse drug reactions. Non-severe reactions are often exanthematous or urticarial whereas life-threatening reactions typically present with skin detachment or necrosis of large areas of the body and mucous membrane involvement, as in the Stevens-Johnson syndrome or toxic epidermal necrolysis. Clinicians should carefully evaluate the signs and symptoms of all cutaneous adverse drug reactions thought to be due to drugs and immediately discontinue drugs that are not essential. Short cycles of systemic corticosteroids in combination with antihistamines may be necessary for widespread exanthematous rashes, while more aggressive corticosteroid regimens or intravenous immunoglobulins associated with supportive treatment should be used for patients with Stevens-Johnson syndrome or toxic epidermal necrolysis.
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Affiliation(s)
- Angelo V Marzano
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Unità Operativa di Dermatologia, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Alessandro Borghi
- Dipartimento di Scienze Mediche, Sezione di Dermatologia e Malattie Infettive, Università degli Studi di Ferrara, Ferrara, Italy
| | - Massimo Cugno
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Unità Operativa di Medicina Interna, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy.
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Horcajada-Reales C, Pulido-Pérez A, Suárez-Fernández R. Severe Cutaneous Drug Reactions: Do Overlapping Forms Exist? ACTAS DERMO-SIFILIOGRAFICAS 2016. [DOI: 10.1016/j.adengl.2015.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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21
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Severe Cutaneous Drug Reactions: Do Overlapping Forms Exist? ACTAS DERMO-SIFILIOGRAFICAS 2015; 107:23-33. [PMID: 26520037 DOI: 10.1016/j.ad.2015.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/13/2015] [Accepted: 08/22/2015] [Indexed: 12/14/2022] Open
Abstract
Acute generalized exanthematous pustulosis, Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms are all severe hypersensitivity reactions to medications. While each of these reactions is a well-established entity with specific diagnostic criteria, clinicians see cases that fulfill criteria for more than one form, prompting discussion on the possibility of combined forms. Such overlapping clinical pictures meeting the criteria for 2 conditions have thus become a topic of debate in dermatology in recent years. We describe 2 patients with cutaneous drug reactions having the characteristics of both acute generalized exanthematous pustulosis and Stevens-Johnson syndrome -toxic epidermal necrolysis. We also review previously published cases and current thinking on such overlapping conditions.
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Duran-Figueroa N, Badillo-Corona JA, Naisbitt DJ, Castrejon-Flores JL. Towards the development of mechanism-based biomarkers to diagnose drug hypersensitivity. Toxicol Res (Camb) 2015. [DOI: 10.1039/c4tx00238e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
T-cells are activated by different mechanisms in the presence of drugs, metabolites or haptens, and they release several molecules that can be used in the diagnosis of drug hypersensitivity.
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Affiliation(s)
- N. Duran-Figueroa
- Instituto Politécnico Nacional
- Unidad Profesional Interdisciplinaria de Biotecnología
- Mexico City
- Mexico
| | - J. A. Badillo-Corona
- Instituto Politécnico Nacional
- Unidad Profesional Interdisciplinaria de Biotecnología
- Mexico City
- Mexico
| | - D. J. Naisbitt
- MRC Centre for Drug Safety Science
- Department of Pharmacology
- University of Liverpool
- Liverpool
- UK
| | - J. L. Castrejon-Flores
- Instituto Politécnico Nacional
- Unidad Profesional Interdisciplinaria de Biotecnología
- Mexico City
- Mexico
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