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Ogiji ED, Aboheimed N, Ross K, Voller C, Siner R, Jensen RL, Jolly CE, Carr DF. Greater mechanistic understanding of the cutaneous pathogenesis of Stevens-Johnson syndrome/toxic epidermal necrolysis can shed light on novel therapeutic strategies: a comprehensive review. Curr Opin Allergy Clin Immunol 2024; 24:218-227. [PMID: 38753537 PMCID: PMC11213502 DOI: 10.1097/aci.0000000000000993] [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] [Indexed: 05/18/2024]
Abstract
PURPOSE OF REVIEW Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) are severe cutaneous adverse drug reactions (SCARs) characterized by widespread epithelial detachment and blistering, which affects the skin and mucocutaneous membranes. To date, therapeutic interventions for SJS/TEN have focused on systematic suppression of the inflammatory response using high-dose corticosteroids or intravenous immunoglobulin G (IgG), for example. No targeted therapies for SJS/TEN currently exist. RECENT FINDINGS Though our understanding of the pathogenesis of SJS/TEN has advanced from both an immunological and dermatological perspective, this knowledge is yet to translate into the development of new targeted therapies. SUMMARY Greater mechanistic insight into SJS/TEN would potentially unlock new opportunities for identifying or repurposing targeted therapies to limit or even prevent epidermal injury and blistering.
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Affiliation(s)
- Emeka D. Ogiji
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Department of Pharmacology and Therapeutics, Ebonyi State University, Abakaliki, Nigeria
| | - Nourah Aboheimed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Department of Pharmacy Practice, Princess Nourah bint Abdulrahman University, Saudi Arabia
| | - Kehinde Ross
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University
| | - Calum Voller
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Ryan Siner
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Rebecca L. Jensen
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Carol E. Jolly
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Daniel F. Carr
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
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Leigh RM, Horton L, Lee BA, Min MS. Recurrent erythema multiforme in the setting of COVID-19 infection and oral candidiasis: A case for dysregulation of the T helper 17/interleukin 17 axis. JAAD Case Rep 2024; 49:73-76. [PMID: 38883173 PMCID: PMC11179536 DOI: 10.1016/j.jdcr.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024] Open
Affiliation(s)
- Rebekah M Leigh
- Loma Linda University, School of Medicine, Loma Linda, California
| | - Luke Horton
- Department of Dermatology, University of California Irvine, Irvine, California
| | - Bonnie A Lee
- Department of Dermatology, University of California Irvine, Irvine, California
- Department of Dermatopathology, University of California Irvine, Irvine, California
| | - Michelle S Min
- Department of Dermatology, University of California Irvine, Irvine, California
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Stewart TJ, Farrell J, Frew JW. A systematic review of case-control studies of cytokines in blister fluid and skin tissue of patients with Stevens Johnson syndrome and toxic epidermal necrolysis. Australas J Dermatol 2024. [PMID: 38831709 DOI: 10.1111/ajd.14329] [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: 03/28/2024] [Revised: 05/09/2024] [Accepted: 05/22/2024] [Indexed: 06/05/2024]
Abstract
Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions characterised by keratinocyte apoptosis, necroptosis and epidermal detachment. Several cytokines and cytotoxic proteins have been shown to be elevated in the blood and skin of SJS/TEN sufferers and biologics such as intravenous immune globulin and tumour necrosis factor (TNF)-alpha inhibitors have demonstrated good therapeutic potential. The exact pathogenic model of SJS/TEN however remains elusive. This systematic review aimed to evaluate the case-control studies of cytokines and cytotoxic proteins in the blister fluid and skin of adults with Stevens Johnson syndrome and/or toxic epidermal necrolysis. This review was registered with INPLASY and conducted in accordance with the PRISMA reporting guidelines. Potential bias was assessed using the NIH criteria. Eleven articles describing results from 96 cases and 170 controls were included. Fas, Fas ligand, Interleukin (IL)-8 and B-cell lymphoma (Bcl)-2 were elevated in SJS/TEN blister fluid and skin tissue, compared with healthy controls. IL-2, IL-6, TNF-alpha, tumour necrosis factor-related apoptosis-inducing ligand (TRAIL), interferon-gamma and matrix metalloproteinase-2 were elevated in SJS/TEN blister fluid compared with fluid sampled from lesional controls. Granulysin, IL-33, TGF-beta-1 and IL-13 were elevated in SJS/TEN skin tissue compared with lesional lichen planus tissue, as was IL-13, IFN-gamma, IL-2 and IL-5, when compared with erythema multiforme tissue. A wide array of cytokines and cytotoxic proteins are present at higher concentrations in the blister fluid and skin tissue of SJS/TEN patients compared with healthy and lesional controls. Our findings suggest that these proteins may be pathogenic, as well as possibly markers for diagnosis, disease severity and course. They may also prove to be useful therapeutic targets. More research is needed.
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Affiliation(s)
- Thomas Jonathan Stewart
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Joshua Farrell
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - John Walter Frew
- School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
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Gurumurthy S, Srinivasan B, Agarwal S, Matai H, Angayarkanni N, Iyer G. Unique cytokine signature in ocular Stevens-Johnson syndrome non-responders. Ocul Surf 2024; 32:173-181. [PMID: 38490474 DOI: 10.1016/j.jtos.2024.03.007] [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: 05/29/2023] [Revised: 03/06/2024] [Accepted: 03/12/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE To clinically define a subset of patients with chronic ocular Stevens-Johnson syndrome non-responders (SJS-NR) and analyze their cytokine profile compared to clinical responders (SJS-CR). METHODS A total of 32 SJS cases (n = 32, 64 eyes) managed over a period of three years were segregated into clinical responders (n = 24, 48 eyes) and non-responders (n = 8, 16 eyes). Cases were determined as non-responders based on persistent, refractory, and non-mechanical inflammation of the conjunctiva. Age- and sex-matched healthy controls (n = 25, 50 eyes) were recruited. Tear specimens collected using Schirmer's strip were profiled for 27 cytokines using an immunoassay-based 27-bioplex array. RESULTS Tear cytokine profiling revealed 18 cytokines to be differentially expressed in SJS-NR compared to SJS-CR. While PDGF-BB, IL-4, IL-1β, VEGF, IL-12p70, IFN-γ, IL-9, and IL-1RA were upregulated, GM-CSF, eotaxin, IP-10, IL-10, MCP-1, G-CSF, IL-6, IL-13, and bFGF were downregulated in SJS-NR compared to SJS-CR. The cytokines IL-13, IL-10, and IP-10 were decreased in both SJS-NR and SJS-CR compared to controls. CONCLUSION The inflammation in SJS-NR continues to worsen despite the correction of mechanical causes, resulting in progressive deterioration of the cornea. The cytokine profile of SJS-NR was remarkably different from that of SJS-CR, indicating a T helper 2-type protective proliferative response and an impaired migratory potential of the conjunctival epithelium. These factors could possibly lead to poor healing of the corneal epithelium in a markedly pro-inflammatory and pro-angiogenic milieu. The top four differentially expressed cytokines, PDGF-BB, IL-4, IL-10, and IL-6, are proposed as potential biomarkers of SJS-NR.
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Affiliation(s)
- Srividya Gurumurthy
- R. S. Mehta Jain Dept. of Biochemistry and Cell Biology, KBIRVO, Vision Research Foundation, Chennai, 600 006, India
| | - Bhaskar Srinivasan
- C. J. Shah Cornea Services, Dr. G Sitalakshmi Memorial Clinic for Ocular Disorders, SN-Sanmar Center of Excellence for SJS, Medical Research Foundation, Sankara Nethralaya, Chennai, 600 006, India
| | - Shweta Agarwal
- C. J. Shah Cornea Services, Dr. G Sitalakshmi Memorial Clinic for Ocular Disorders, SN-Sanmar Center of Excellence for SJS, Medical Research Foundation, Sankara Nethralaya, Chennai, 600 006, India
| | - Hiren Matai
- C. J. Shah Cornea Services, Dr. G Sitalakshmi Memorial Clinic for Ocular Disorders, SN-Sanmar Center of Excellence for SJS, Medical Research Foundation, Sankara Nethralaya, Chennai, 600 006, India
| | - Narayanasamy Angayarkanni
- R. S. Mehta Jain Dept. of Biochemistry and Cell Biology, KBIRVO, Vision Research Foundation, Chennai, 600 006, India.
| | - Geetha Iyer
- C. J. Shah Cornea Services, Dr. G Sitalakshmi Memorial Clinic for Ocular Disorders, SN-Sanmar Center of Excellence for SJS, Medical Research Foundation, Sankara Nethralaya, Chennai, 600 006, India.
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Lee JM, Lee YJ, Choi YJ, Lee JH, Choi JE, Han TY. A case of persistent erythema multiforme treated with upadacitinib. J Dermatol 2024; 51:e3-e5. [PMID: 37641556 DOI: 10.1111/1346-8138.16938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/29/2023] [Accepted: 08/12/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Jung Min Lee
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Yu Jin Lee
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Yun Jeong Choi
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - June Hyunkyung Lee
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Jae Eun Choi
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Tae Young Han
- Department of Dermatology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
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Nwikue G, Olsson‐Brown A, Aboheimed N, Yip V, Jolly C, Luchian A, Ressel L, Sharma A, Bergfeld W, Ahmed S, Dickinson A, Pirmohamed M, Carr DF. TNF-α induced extracellular release of keratinocyte high-mobility group box 1 in Stevens-Johnson syndrome/toxic epidermal necrolysis: Biomarker and putative mechanism of pathogenesis. J Dermatol 2023; 50:1129-1139. [PMID: 37269158 PMCID: PMC10947163 DOI: 10.1111/1346-8138.16847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/21/2023] [Accepted: 05/10/2023] [Indexed: 06/04/2023]
Abstract
Decreased epidermal high-mobility group box 1 (HMGB1) expression is an early marker of epidermal injury in Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). Etanercept, an anti-tumor necrosis factor therapeutic, is effective in the treatment of SJS/TEN. The objective was to characterize antitumor necrosis factor-alpha (TNF-α)-mediated HMGB1 keratinocyte/epidermal release and etanercept modulation. HMGB1 release from TNF-α treated (± etanercept), or doxycycline-inducible RIPK3 or Bak-expressing human keratinocyte cells (HaCaTs) was determined by western blot/ELISA. Healthy skin explants were treated with TNF-α or serum (1:10 dilution) from immune checkpoint inhibitor-tolerant, lichenoid dermatitis or SJS/TEN patients ± etanercept. Histological and immunohistochemical analysis of HMGB1 was undertaken. TNF-α induced HMGB1 release in vitro via both necroptosis and apoptosis. Exposure of skin explants to TNF-α or SJS/TEN serum resulted in significant epidermal toxicity/detachment with substantial HMGB1 release which was attenuated by etanercept. Whole-slide image analysis of biopsies demonstrated significantly lower epidermal HMGB1 in pre-blistered SJS/TEN versus control (P < 0.05). Keratinocyte HMGB1 release, predominantly caused by necroptosis, can be attenuated by etanercept. Although TNF-α is a key mediator of epidermal HMGB1 release, other cytokines/cytotoxic proteins also contribute. Skin explant models represent a potential model of SJS/TEN that could be utilized for further mechanistic studies and targeted therapy screening.
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Affiliation(s)
- Gospel Nwikue
- Department Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative BiologyUniversity of LiverpoolLiverpoolUK
| | - Anna Olsson‐Brown
- Department Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative BiologyUniversity of LiverpoolLiverpoolUK
| | - Nourah Aboheimed
- Department Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative BiologyUniversity of LiverpoolLiverpoolUK
| | - Vincent Yip
- Department Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative BiologyUniversity of LiverpoolLiverpoolUK
| | - Carol Jolly
- Department Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative BiologyUniversity of LiverpoolLiverpoolUK
| | - Andreea Luchian
- Department of Veterinary Pathology and Public Health, Institute of Veterinary ScienceUniversity of LiverpoolLiverpoolUK
| | - Lorenzo Ressel
- Department of Veterinary Pathology and Public Health, Institute of Veterinary ScienceUniversity of LiverpoolLiverpoolUK
| | - Anurag Sharma
- Department of Dermatology and DermatopathologyCleveland Clinic FoundationClevelandOhioUSA
| | - Wilma Bergfeld
- Department of Dermatology and DermatopathologyCleveland Clinic FoundationClevelandOhioUSA
| | | | | | - Munir Pirmohamed
- Department Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative BiologyUniversity of LiverpoolLiverpoolUK
| | - Daniel F. Carr
- Department Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative BiologyUniversity of LiverpoolLiverpoolUK
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Liu Y, Feng J, Ren Y, Shi W, Kang H, Peng Y, Tan Y, Wu R, Zhang G, He Y. Ocular surface involvement and histopathologic changes in the acute stage of Stevens-Johnson syndrome and toxic epidermal necrolysis: a cross-sectional study. BMC Ophthalmol 2023; 23:297. [PMID: 37400766 DOI: 10.1186/s12886-023-03052-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/19/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and extremely serious drug-induced dermatological disorders. The ocular surface condition at the early stage has been little studied and should contribute to novel perspectives in early and effective topical therapy of these diseases. The objectives of the study were to evaluate the acute phase of ocular surface involvement and histopathologic changes in patients with acute SJS/TEN. METHODS Ten patients with acute phase of SJS/TEN onset and eleven age- and sex-matched healthy volunteers were recruited. Ocular surface symptoms and signs, conjunctival impression cytology, and tear multi-cytokine were assessed. RESULTS Ocular surface objective signs were normal at the acute stage of SJS/TEN, while most patients have abnormal ocular surface subjective symptoms and meibomian gland secretion. Conjunctival impression cytology showed a significant decrease in goblet cell density and severe ocular surface squamous metaplasia in acute SJS/TEN patients. Tear multi-cytokine analysis showed all 21 pro- and anti-inflammatory cytokines all sharply elevated. Goblet cell density was significantly negatively correlated with tear C-X3-C motif chemokine ligand 1 (CX3CL1) and interleukin 13. CONCLUSIONS Severe pathologic squamous metaplasia and inflammation onset in the ocular surface at the acute stage of the SJS/TEN, even if the ocular surface condition seemed basically normal with adequate systemic immunosuppressant and general supportive treatment. Early topical anti-inflammatory therapy should be carried out actively.
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Affiliation(s)
- Yingyi Liu
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
| | - Jianing Feng
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
- Xi'an People's Hospital (Xi'an Fourth Hospital), Shaanxi Eye Hospital, Northwest University Affiliated People's Hospital, Xi'an, Shaanxi Province, China
| | - Yuerong Ren
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
| | - Wen Shi
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
| | - Huanmin Kang
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
| | - Yingqian Peng
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China
| | - Yixin Tan
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ruifang Wu
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guiying Zhang
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yan He
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
- Hunan Clinical Research Center of Ophthalmic Disease, Changsha, Hunan, China.
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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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Ben Salem C, Bouraoui H, Ben Azouz C, Sahnoun D, Slim R, Denguezli M. Carbocisteine-induced Stevens-Johnson syndrome confirmed by inadvertent re-exposure. J Eur Acad Dermatol Venereol 2023; 37:e348-e349. [PMID: 36222530 DOI: 10.1111/jdv.18661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/05/2022] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | | | - Raoudha Slim
- Pharmacovigilance Center of Sousse, Sousse, Tunisia
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Long XH, Jiang HS, Lai JD, Liu YH, Wang WL. Erythema multiforme (EM)-like drug eruption associated with dupilumab treatment: report of an unusual case. Dermatol Ther 2022; 35:e15792. [PMID: 36038515 DOI: 10.1111/dth.15792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/14/2022] [Accepted: 08/26/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Xiao-Huan Long
- Department of Dermatology, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Hui-Shan Jiang
- Department of Dermatology, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Jun-Dong Lai
- Department of Dermatology, Yangjiang People's Hospital affiliated to Guangdong Medical University, Yangjiang, Guangdong, China
| | - Yan-Huan Liu
- Department of Dermatology, Yangjiang People's Hospital affiliated to Guangdong Medical University, Yangjiang, Guangdong, China
| | - Wei-Liang Wang
- Department of Dermatology, Yangjiang People's Hospital affiliated to Guangdong Medical University, Yangjiang, Guangdong, China
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A Review of the Systemic Treatment of Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis. Biomedicines 2022; 10:biomedicines10092105. [PMID: 36140207 PMCID: PMC9495335 DOI: 10.3390/biomedicines10092105] [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: 07/10/2022] [Revised: 08/10/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022] Open
Abstract
Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are uncommon but life-threatening diseases mostly caused by drugs. Although various systemic immunomodulating agents have been used, their therapeutic efficacy has been inconsistent. This study aimed to provide an evidence-based review of systemic immunomodulating treatments for SJS/TEN. We reviewed 13 systematic review and meta-analysis articles published in the last 10 years. The use of systemic corticosteroids and IVIg is still controversial. An increasing number of studies have suggested the effectiveness of cyclosporine and biologic anti-TNF-α in recent years. There were also some promising results of combination treatments. Further large-scale randomized controlled trials are required to provide more definitive evidence of the effectiveness of these treatments. The pathogenesis of SJS/TEN has been elucidated in recent years and advances in the understanding of SJS/TEN may inspire the discovery of potential therapeutic targets.
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12
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Advances in the Pathomechanisms of Delayed Drug Hypersensitivity. Immunol Allergy Clin North Am 2022; 42:357-373. [PMID: 35469623 DOI: 10.1016/j.iac.2022.01.002] [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: 12/30/2022]
Abstract
Delayed drug hypersensitivity continues to contribute to major clinical problems worldwide. The clinical presentations of delayed drug hypersensitivity are diverse, ranging from mild skin rashes to life-threatening systemic reactions. The pathomechanism of delayed drug hypersensitivity involves human leukocyte antigens (HLA) presentation of drugs/metabolites to T cell receptors (TCR), resulting in T-cell activation. The pathogenesis of delayed drug hypersensitivity also has reactivation of the virus, and activation of many immune mediators. In this review, we discuss the immune pathogenesis, molecular interactions of HLA/drugs/TCR, and downstream signaling of cytotoxic proteins/cytokines/chemokines, as well as disease prevention and management for delayed drug hypersensitivity.
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Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in the Era of Systems Medicine. METHODS IN MOLECULAR BIOLOGY (CLIFTON, N.J.) 2022; 2486:37-54. [PMID: 35437717 DOI: 10.1007/978-1-0716-2265-0_3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are severe mucocutaneous bullous disorders characterized by widespread skin and mucosal necrosis and detachment, which are most commonly triggered by medications. Despite their rarity, these severe cutaneous adverse drug reactions will result in high mortality and morbidity as well as long-term sequela. The immunopathologic mechanisms is mainly cell-mediated cytotoxic reaction against keratinocytes leading to massive skin necrolysis. Subsequent studies have demonstrated that immune synapse composed of cytotoxic T cells with drug-specific human leukocyte antigen (HLA) class I restriction and T cell receptors (TCR) repertoire is the key pathogenic for SJS/TEN. Various cytotoxic proteins and cytokines such as soluble granulysin, perforin, granzyme B, interleukin-15, Fas ligand, interferon-γ, tumor necrosis factor-α have been as mediators involved in the pathogenesis of SJS/TEN. Early recognition and immediate withdrawal of causative agents, and critical multidisciplinary supportive care are key management of SJS/TEN. To date, there is yet to be a sufficient consensus or recommendation for the immunomodulants of the treatment in SJS/TEN. Systemic corticosteroids remain one of the most common treatment options for SJS/TEN, though the efficacy remain uncertain. Currently, there is increasing evidence showing that cyclosporine and TNF-α inhibitors decrease the mortality of SJS/TEN. Further multicenter double-blinded, randomized, placebo-controlled trials are required to confirm the efficacy and safety.
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Aimo C, Mariotti EB, Corrà A, Cipollini E, Le Rose O, Serravalle C, Pimpinelli N, Caproni M. Stevens-Johnson Syndrome induced by Vaxvetria (AZD1222) Covid-19 vaccine. J Eur Acad Dermatol Venereol 2022; 36:e417-e419. [PMID: 35133674 PMCID: PMC9114927 DOI: 10.1111/jdv.17988] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/12/2021] [Accepted: 01/07/2022] [Indexed: 11/28/2022]
Affiliation(s)
- C Aimo
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - E B Mariotti
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - A Corrà
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - E Cipollini
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - O Le Rose
- Azienda Usl Toscana Centro, P.O. Piero Palagi, Hospital, Florence, Italy
| | - C Serravalle
- Department of Internal Medicine, P.O. Nuovo Ospedale del Mugello, Azienda USL Toscana Centro, Florence, Italy
| | - N Pimpinelli
- Department of Health Sciences, Section of Dermatology, University of Florence, Florence, Italy
| | - M Caproni
- Rare Diseases Unit, Section of Dermatology, Department of Health Sciences, Azienda USL Toscana Centro, University of Florence, European Reference Network-Skin Member, Florence, Italy
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Tran TH, Lan PT, Khang TH, Luong VH. Systemic Corticosteroid Therapy for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in Vietnam: Clinical Evaluation and Analysis of Serum Cytokines. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract
BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis are severe cutaneous adverse drug reactions. There are some immunological and genetic factors which are believed to be involved in the pathogenesis of SJS/TEN. The treatment of SJS/TEN is still controversial in which several studies showed variable results.
AIMS: To evaluate clinically the efficacy of systemic corticosteroid and to analyze some related cytokines in the treatment of SJS/TEN.
METHODS: This open, pilot and uncontrolled study was conducted at National Hospital of Dermatology and Venereology, in Hanoi, Vietnam, from October 2017 to September 2019. Methylprednisolone was indicated from the first day of hospitalization with the dose of 0.5-2.5 mg/kg/day (calculated according to prednisolone dose) once daily. It was continued until the patients got re-epithelialization. The efficacy of methylprednisolone was evaluated by observing clinically and analyzing related cytokines before and after the treatment.
RESULTS: The mean time of re-epithelialization was 15.9 days, of hospitalization was 15.9 days (range 5-30 days). There was no in-hospital mortality in this study. The most common complication was transient glycaemia (40.6%), there was no patient with sepsis. At the day of hospitalization, serum concentrations of TNF-α, IFN-γ, IL-2, IL-5, IL-13 and IL-10 were significantly higher than those at the day of re-epithelialization (p<0.05). Serum levels of IL-4, did not have significant differences between two time points (p>0.05).
CONCLUSION: The systemic corticosteroid is a good choice in the treatment of SJS/TEN. It can reduce serum levels of some cytokines that help SJS/TEN patients with avoiding mortality.
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Murphy MJ, Gruenstein D, Wang A, Peterson D, Levitt J, King B, Damsky W. Treatment of Persistent Erythema Multiforme With Janus Kinase Inhibition and the Role of Interferon Gamma and Interleukin 15 in Its Pathogenesis. JAMA Dermatol 2021; 157:1477-1482. [PMID: 34757416 PMCID: PMC8581795 DOI: 10.1001/jamadermatol.2021.4084] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/06/2021] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Persistent erythema multiforme (PEM) is poorly understood and lacks effective therapies other than glucocorticoids. OBJECTIVE To report outcomes following treatment of PEM with Janus kinase (JAK) inhibition and to elucidate cytokine drivers of erythema multiforme (EM). DESIGN, SETTING, AND PARTICIPANTS This was a retrospective case series of 4 patients with PEM treated with tofacitinib and/or upadacitinib in 2015 to 2021 at the dermatology clinics of 2 major tertiary referral centers. Four consecutive patients with PEM refractory to multiple treatment approaches were treated. In 1 patient, skin biopsy specimens were obtained for RNA sequencing and proteomic analysis before and during treatment. Molecular findings were validated through RNA in situ hybridization analysis of cytokine expression in biopsy specimens from a total of 12 patients with EM (3 treated with tofacitinib in this study and 9 historic samples). INTERVENTIONS Treatment with tofacitinib, 5 to 10 mg, twice daily or upadacitinib, 15 mg, once daily. MAIN OUTCOMES AND MEASURES Change in PEM activity was assessed in all 4 patients treated with a JAK inhibitor. Median (range) follow-up was 20.5 months (10.0-36.0 mo). RESULTS The study population of 4 female patients had a mean (SD) age of 46.2 (13.7) years and a mean (SD) disease duration of 21.75 (11.30) years. Marked clinical improvement was noted in all 4 patients. In 1 patient with a robust improvement following treatment with tofacitinib, RNA sequencing identified interferon gamma (IFN-γ) and interleukin 15 (IL-15) as cytokines with activity both highly upregulated at baseline in lesional skin and subsequently suppressed following tofacitinib treatment. Measurement of IFNG- and IL15-positive cells in additional EM biopsy specimens of 12 patients showed significant upregulation of IFNG (8.72 cells per mm; 95% CI, 2.60-14.84) and IL15 (14.13 cells per mm; 95% CI, 0.14-28.11) compared with normal skin (P = .008 and P = .045, respectively). CONCLUSIONS AND RELEVANCE The results of this case series study suggest that JAK inhibition may be effective in treating PEM and that IFN-γ and IL-15 may be important cytokine mediators of the disease.
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Affiliation(s)
- Michael J. Murphy
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Diana Gruenstein
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alice Wang
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Danielle Peterson
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jacob Levitt
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brett King
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, Yale University, New Haven, Connecticut
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18
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Wang Y, Wang F, Li H, Hao X, Shen G, Sun Y, Xia J. Toxic Epidermal Necrolysis Induced by Leflunomide in a Patient With Rheumatoid Arthritis. J Clin Rheumatol 2021; 27:S565-S567. [PMID: 30720701 DOI: 10.1097/rhu.0000000000000997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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19
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Panpruk R, Puangsricharern V, Klaewsongkram J, Rerknimitr P, Kittipibul T, Chongpison Y, Buranapraditkun S. Clinical parameters and biological markers associated with acute severe ocular complications in Stevens-Johnson syndrome and toxic epidermal necrolysis. Sci Rep 2021; 11:20275. [PMID: 34642376 PMCID: PMC8510998 DOI: 10.1038/s41598-021-99370-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/23/2021] [Indexed: 12/22/2022] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse drug reactions with high mortality rates. Its sequelae, such as blindness, persist even after recovery. Patients with SJS/TEN should be accurately diagnosed and receive appropriate treatment as soon as possible. Therefore, identifying the factors for severity prediction is necessary. We aimed to clarify the clinical parameters and biological markers that can predict acute severe ocular complications (SOCs) in SJS/TEN. This retrospective cross-sectional study enrolled 47 patients with SJS/TEN who were divided into two groups according to ocular severity at acute onset: non-severe ocular complications group (n = 27) and severe ocular complications group (n = 20). Multivariate logistic regression analysis revealed that disease severity (body surface area detachment ≥ 10%) was a predictive factor for acute SOCs, and older age (≥ 60 years) was marginally significantly predictive of SOCs. Serum biomarker levels of S100A8/A9 and granulysin were marginally significant and tended to increase in the SOC group. Therefore, during the early acute stage, focusing on disease severity, patient age, and serum inflammatory biomarkers (S100A8/A9 and granulysin) might help predict SOC progression in patients with SJS/TEN who need prompt and aggressive ocular management to prevent severe ocular sequelae.
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Affiliation(s)
- Rawiphan Panpruk
- Cornea and Refractive Surgery Unit, Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center of Cornea and Limbal Stem Cell Transplantation, Department of Ophthalmology, 1873 King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Pathumwan, Bangkok, 10330, Thailand
| | - Vilavun Puangsricharern
- Cornea and Refractive Surgery Unit, Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. .,Excellence Center of Cornea and Limbal Stem Cell Transplantation, Department of Ophthalmology, 1873 King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Pathumwan, Bangkok, 10330, Thailand.
| | - Jettanong Klaewsongkram
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Pawinee Rerknimitr
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Thanachaporn Kittipibul
- Cornea and Refractive Surgery Unit, Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center of Cornea and Limbal Stem Cell Transplantation, Department of Ophthalmology, 1873 King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Pathumwan, Bangkok, 10330, Thailand
| | - Yuda Chongpison
- Center of Excellence in Biostatistics, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Supranee Buranapraditkun
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence in Vaccine Research and Development (Chula Vaccine Research Center, Chula VRC), Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.,Thai Pediatric Gastroenterology, Hepatology and Immunology (TPGHAI) Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
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20
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Yoshioka M, Sawada Y, Nakamura M. Diagnostic Tools and Biomarkers for Severe Drug Eruptions. Int J Mol Sci 2021; 22:ijms22147527. [PMID: 34299145 PMCID: PMC8306321 DOI: 10.3390/ijms22147527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/09/2021] [Accepted: 07/11/2021] [Indexed: 12/19/2022] Open
Abstract
In accordance with the development of human technology, various medications have been speedily developed in the current decade. While they have beneficial impact on various diseases, these medications accidentally cause adverse reactions, especially drug eruption. This delayed hypersensitivity reaction in the skin sometimes causes a life-threatening adverse reaction, namely Stevens-Johnson syndrome and toxic epidermal necrolysis. Therefore, how to identify these clinical courses in early time points is a critical issue. To improve this problem, various biomarkers have been found for these severe cutaneous adverse reactions through recent research. Granulysin, Fas ligands, perforin, and granzyme B are recognized as useful biomarkers to evaluate the early onset of Stevens-Johnson syndrome and toxic epidermal necrolysis, and other biomarkers, such as miRNAs, high mobility group box 1 protein (HMGB1), and S100A2, which are also helpful to identify the severe cutaneous adverse reactions. Because these tools have been currently well developed, updates of the knowledge in this field are necessary for clinicians. In this review, we focused on the detailed biomarkers and diagnostic tools for drug eruption and we also discussed the actual usefulness of these biomarkers in the clinical aspects based on the pathogenesis of drug eruption.
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21
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Gui MZ, Ni M, Yin XD, Zhang T, Li ZL. Ibuprofen induced Stevens-Johnson syndrome and liver injury in children: a case report. Transl Pediatr 2021; 10:1737-1742. [PMID: 34295789 PMCID: PMC8261580 DOI: 10.21037/tp-21-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/23/2021] [Indexed: 01/11/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) is a disorder that causes severe damage to the skin and mucous membranes with bullous and erosive properties. Drug-induced liver injury (DILI) is closely related to non-steroidal anti-inflammatory drugs (such as ibuprofen). Liver injury caused by ibuprofen is often related to overdose, and liver injury caused by normal dose is rare, and there are individual differences in different situations. In this case, a child developed SJS and acute liver injury after treatment with ibuprofen suspension. We described the characteristics of related adverse reactions induced by ibuprofen, and analyzed the relationship between SJS caused by the drug and related drug genes. Glucocorticoids and antihistamines were used to treat dermatitis, reduced glutathione (GSH) to protect the liver and plasma exchange detoxification. Finally, the patient's dermatitis healed and the liver injury was significantly improved. Many studies have suggested that DILI may be related to human leukocyte antigen (HLA) genotyping. The detection of drug-related genes revealed that the SJS and liver damage caused by ibuprofen might have been related to the positive HLA-B*5801. This article suggests that attention should be paid to checking liver function indicators after taking ibuprofen, and genetic screening can be used to reduce the risk of gene-related adverse reactions when necessary.
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Affiliation(s)
- Ming-Zhu Gui
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Pediatrics, Luodian Hospital, Shanghai, China
| | - Ming Ni
- Department of Pediatrics, Luodian Hospital, Shanghai, China.,Department of Clinical Pharmacy, Shaoxing Maternity and Child Health Care Hospital, Shaoxing, China
| | - Xue-Dong Yin
- Department of Pediatrics, Luodian Hospital, Shanghai, China
| | - Ting Zhang
- Department of Gastroenterology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhi-Ling Li
- Department of Pediatrics, Luodian Hospital, Shanghai, China
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22
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Cheng L. Current Pharmacogenetic Perspective on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Front Pharmacol 2021; 12:588063. [PMID: 33981213 PMCID: PMC8107822 DOI: 10.3389/fphar.2021.588063] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/22/2021] [Indexed: 12/19/2022] Open
Abstract
Adverse drug reactions are a public health issue that draws widespread attention, especially for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) which have high mortality and lack of efficacious treatment. Though T-cell-mediated HLA-interacted immune response has been extensively studied, our understanding of the mechanism is far from satisfactory. This review summarizes infection (virus, bacterial, and mycoplasma infection), an environmental risk factor, as a trigger for SJS/TEN. The mutations or polymorphisms of drug metabolic enzymes, transporters, receptors, the immune system genes, and T-cell-mediated apoptosis signaling pathways that contribute to SJS/TEN are discussed and summarized. Epigenetics, metabolites, and mobilization of regulatory T cells and tolerogenic myeloid precursors are emerged directions to study SJS/TEN. Ex vivo lymphocyte transformation test has been exploited to aid in identifying the causative drugs. Critical questions on the pathogenesis of SJS/TEN underlying gene polymorphisms and T cell cytotoxicity remain: why some of the patients carrying the risky genes tolerate the drug and do not develop SJS/TEN? What makes the skin and mucous membrane so special to be targeted? Do they relate to skin/mucous expression of transporters? What is the common machinery underlying different HLA-B alleles associated with SJS/TEN and common metabolites?
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Affiliation(s)
- Lin Cheng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.,School of Ophthalmology and Optometry, Eye Hospital, Wenzhou Medical University, Wenzhou, China
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23
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Hsu YSO, Lu KL, Fu Y, Wang CW, Lu CW, Lin YF, Chang WC, Yeh KY, Hung SI, Chung WH, Chen CB. The Roles of Immunoregulatory Networks in Severe Drug Hypersensitivity. Front Immunol 2021; 12:597761. [PMID: 33717075 PMCID: PMC7953830 DOI: 10.3389/fimmu.2021.597761] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022] Open
Abstract
The immunomodulatory effects of regulatory T cells (Tregs) and co-signaling receptors have gained much attention, as they help balance immunogenic and immunotolerant responses that may be disrupted in autoimmune and infectious diseases. Drug hypersensitivity has a myriad of manifestations, which ranges from the mild maculopapular exanthema to the severe Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome (DRESS/DIHS). While studies have identified high-risk human leukocyte antigen (HLA) allotypes, the presence of the HLA allotype at risk is not sufficient to elicit drug hypersensitivity. Recent studies have suggested that insufficient regulation by Tregs may play a role in severe hypersensitivity reactions. Furthermore, immune checkpoint inhibitors, such as anti-CTLA-4 or anti-PD-1, in cancer treatment also induce hypersensitivity reactions including SJS/TEN and DRESS/DIHS. Taken together, mechanisms involving both Tregs as well as coinhibitory and costimulatory receptors may be crucial in the pathogenesis of drug hypersensitivity. In this review, we summarize the currently implicated roles of co-signaling receptors and Tregs in delayed-type drug hypersensitivity in the hope of identifying potential pharmacologic targets.
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Affiliation(s)
- Yun-Shiuan Olivia Hsu
- Department of Medical Education, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kun-Lin Lu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yun Fu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chuang-Wei Wang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Linkou, Taiwan
| | - Chun-Wei Lu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Fen Lin
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Nursing, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wen-Cheng Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kun-Yun Yeh
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shuen-Iu Hung
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Linkou, Taiwan
| | - Wen-Hung Chung
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Linkou, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Chang Gung Hospital, Xiamen, China
- Department of Dermatology, Beijing Tsinghua Chang Gung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chun-Bing Chen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Chang Gung Immunology Consortium, Linkou, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Dermatology, Chang Gung Hospital, Xiamen, China
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
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24
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Shahidi-Dadras M, Araghi F, Ahmadzadeh A, Rakhshan A, Tabary M, Dadkhahfar S. TEN/SJS-like lupus erythematosus presentation complicated by COVID-19. Dermatol Ther 2020; 34:e14612. [PMID: 33258528 PMCID: PMC7744967 DOI: 10.1111/dth.14612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/09/2020] [Accepted: 11/27/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Farnaz Araghi
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arman Ahmadzadeh
- Department of Rheumatology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Azadeh Rakhshan
- Department of Pathology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Tabary
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Dadkhahfar
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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25
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Hasan MJ, Rabbani R. Intravenous N-acetylcysteine in severe cutaneous drug reaction treatment: A case series. SAGE Open Med Case Rep 2020; 8:2050313X20934708. [PMID: 32612831 PMCID: PMC7307482 DOI: 10.1177/2050313x20934708] [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] [Received: 12/16/2019] [Accepted: 05/25/2020] [Indexed: 12/17/2022] Open
Abstract
Drug-induced serious adverse reaction is an unpleasant event with high rate of mortality. Stevens-Johnson Syndrome and toxic epidermal necrolysis are most common among the serious adverse drug reactions. There is no selective drug therapy for the management of serious adverse drug reactions-associated mucocutaneous blisters. The use of N-acetylcysteine in the treatment of mucocutaneous blisters has limited evidence worldwide. Three cases of toxic epidermal necrolysis or Stevens-Johnson Syndrome-associated mucocutaneous blisters are presented in this study where intravenous N-acetylcysteine (600 mg, every 8 h) was given in early hospitalization hours for the treatment of mucocutaneous fluid-filled blisters. Here, one patient with toxic epidermal necrolysis received intravenous immunoglobulin along with intravenous N-acetylcysteine and the other two patients (toxic epidermal necrolysis/Stevens-Johnson Syndrome) received only N-acetylcysteine intravenously. In response, mucocutaneous fluid-filled blisters stopped progressing within 48 h and were healed within 2 weeks of admission in the intensive care unit. Thus, intravenous N-acetylcysteine with or without having intravenous immunoglobulin in the treatment of serious adverse drug reactions-associated mucocutaneous blisters may be an effective therapeutic option for better clinical outcome.
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Affiliation(s)
- Md Jahidul Hasan
- Clinical Pharmacy Services, Department of Pharmacy, Square Hospitals Ltd., Dhaka, Bangladesh
| | - Raihan Rabbani
- Department of Internal Medicine and ICU, Square Hospitals Ltd., Dhaka, Bangladesh
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26
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Lin CC, Chen CB, Wang CW, Hung SI, Chung WH. Stevens-Johnson syndrome and toxic epidermal necrolysis: risk factors, causality assessment and potential prevention strategies. Expert Rev Clin Immunol 2020; 16:373-387. [DOI: 10.1080/1744666x.2020.1740591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Chu-Chi Lin
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Bing Chen
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
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Zhang X, Lu WS, Qin XM. Cytokines/Chemokines: Novel Biomarkers Associated with Severe Cutaneous Adverse Reactions. J Interferon Cytokine Res 2020; 40:172-181. [PMID: 32195616 DOI: 10.1089/jir.2019.0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although the incidence of severe cutaneous adverse reactions (SCARs) is very low, if it is not diagnosed and treated in time, it can not only cause skin and mucous membrane involvement, but can also cause multiple organ failure and even death. The diagnostic criteria and treatment guidelines for severe drug eruptions have not been unified. Many medical centers have used human leukocyte antigen alleles to diagnose SCARs. Some prospective studies have shown that susceptibility gene testing can prevent SCARs as early as possible, but the widespread implementation of its technology is limited by being ethnically specific. With the unique advantages of cytokine detection technology, cytokines are increasingly important for the diagnosis and treatment of SCARs. Related cytokines/chemokines involved in the pathogenesis, adjuvant diagnosis, and treatment of SCARs are discussed.
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Affiliation(s)
- Xiang Zhang
- Department of Dermatology, The Second Affiliated Hospital, WanNan Medical College, Wuhu, China
| | - Wen-Shen Lu
- Department of Dermatology, Affiliated Provincial Hospital, University of Science and Technology of China, Hefei, China
| | - Xiao-Ming Qin
- Department of Dermatology, The Second Affiliated Hospital, WanNan Medical College, Wuhu, China
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Tang JT, Li YY, Zhang Y, Liu J, Guan W, Wang RR, He LP, Zhang JB, Kuang YQ. HIV infection confers distinct mechanisms in severe drug eruption: Endogenous virus activation with aberrant Th2/Th1 and CD8 + T cells function. Clin Exp Pharmacol Physiol 2020; 47:1005-1013. [PMID: 31991490 DOI: 10.1111/1440-1681.13266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/19/2020] [Accepted: 01/23/2020] [Indexed: 12/13/2022]
Abstract
Severe drug eruption (SDE), a common skin disease, becomes dangerous when it occurs in patients with human immunodeficiency virus (HIV). However, the molecular mechanisms are poorly understood. Forty patients including HIV+ SDE+ (n = 15), HIV- SDE+ (n = 15) and HIV+ SDE- (n = 10) subjects were enrolled in our study. All HIV+ patients were at acquired immune deficiency syndrome (AIDS) stage. Serum levels of TNF-α, IFN-γ, IL-4, IL-13, IL-6, CXCL9, and CCL17 were quantified by ELISA. Epstein-Barr virus (EBV) and cytomegalovirus (CMV) loads were quantified by RT-qPCR. CD4, CD8, Th1, Th2, TNF-α-CD8, and IFN-γ-CD8 T cell populations were measured by flow cytometry. Levels of biochemical indexes in HIV+ SDE+ patients were significantly different from in HIV- SDE+ patients (P < .05). EBV and CMV viral loads were significantly higher in HIV+ SDE+ patients, but not in HIV- SDE+ patients (P < .05). Inflammatory cytokines TNF-α and IFN-γ were significantly elevated in HIV+ SDE+ patients (P < .05). Th2/Th1 populations and TNF-α secreting or IFN-γ secreting CD8+ T cells, were significantly up-regulated in HIV+ SDE+ patients compared to HIV- SDE+ patients (P < .05). Conversely, the CD4/CD8 ratio was significantly down-regulated in HIV+ SDE+ patients compared to HIV- SDE+ patients (P < .05). HIV infection confers distinct clinical phenotypes and immune inflammatory mechanisms in SDE. Sustained EBV and CMV activation, unbalanced Th2/Th1 and overactive CD8+ T cells mediating a pro-inflammatory response could act as distinct mechanisms in the aggravation of SDE in HIV+ SDE+ patients.
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Affiliation(s)
- Jun-Ting Tang
- Department of Dermatology and Venerology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yu-Ye Li
- Department of Dermatology and Venerology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yi Zhang
- Department of Chinese Medicine, Yunnan University of Chinese Medicine, Kunming, China
| | - Jun Liu
- Department of HIV/AIDS, Third People's Hospital of Kunming, Kunming, China
| | - Wei Guan
- Department of HIV/AIDS, Third People's Hospital of Kunming, Kunming, China
| | - Rui-Rui Wang
- Department of Chinese Medicine, Yunnan University of Chinese Medicine, Kunming, China
| | - Li-Ping He
- School of Public Health, Kunming Medical University, Kunming, China
| | - Jian-Bo Zhang
- Department of Dermatology and Venerology, Second People's Hospital of Dali, Dali, China
| | - Yi-Qun Kuang
- NHC Key Laboratory of Drug Addiction Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China.,Scientific Research Laboratory Center, First Affiliated Hospital of Kunming Medical University, Kunming, China
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Shen M, Lim JME, Chia C, Ren EC. CD39 + regulatory T cells modulate the immune response to carbamazepine in HLA-B*15:02 carriers. Immunobiology 2019; 225:151868. [PMID: 31784043 DOI: 10.1016/j.imbio.2019.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/31/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022]
Abstract
The HLA-B*15:02 allele is associated with an increased risk of developing carbamazepine (CBZ)-induced Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Many studies, however, have demonstrated that a large majority of HLA-B*15:02 individuals are unlikely to develop the adverse drug reaction while on CBZ. This phenomenon suggests that other factors that modulate the allergic immune response, such as regulatory T cells (Tregs), might contribute to an uncontrolled immune response in SJS/TEN. Peripheral blood mononuclear cells (PBMCs) from 15 healthy HLA-B*15:02 carriers were isolated to investigate the role of Tregs in controlling the immune response towards CBZ. Recognition of CBZ was assessed using enzyme linked immunosorbent spot (ELISPOT) assay for IFN-γ, and the donor T-cell profiles were quantified by flow cytometry to differentiate CBZ responders from non-responders. As CD39 expression on Tregs promotes immune tolerance, we investigated the mechanisms of Treg suppression using inhibitors targeting the CD39/adenosinergic pathway. PBMCs from seven donors (responders) produced high levels of IFN-γ when re-exposed to CBZ, while eight donors (non-responders) did not. Flow cytometric analysis revealed that non-responders produced significantly higher frequencies of CD4+CD25+CD127loCD39+FoxP3+ Tregs compared to responders. CD39 inhibition using POM-1 inhibitor converted five of the eight non-responders into responders (P < 0.05). Higher frequencies of CD4+CD25+CD127loCD39+FoxP3+ Tregs was correlated with lower production of IFN-γ (P < 0.01). Our data suggest that CD4+CD25+CD127loCD39+FoxP3+ Tregs may play a role in promoting CBZ tolerance in HLA-B*15:02 carriers. The CD39/adenosinergic axis can be a potential target to alleviate the uncontrolled immune response during this adverse drug event.
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Affiliation(s)
- Meixin Shen
- Singapore Immunology Network (SIgN), A*STAR, Singapore
| | | | - Cheryl Chia
- Singapore Immunology Network (SIgN), A*STAR, Singapore
| | - Ee Chee Ren
- Singapore Immunology Network (SIgN), A*STAR, Singapore; Department of Microbiology and Immunology, National University of Singapore (NUS), Singapore, Singapore.
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Yang L, Zhang S, Duan H, Dong M, Hu X, Zhang Z, Wang Y, Zhang X, Shi W, Zhou Q. Different Effects of Pro-Inflammatory Factors and Hyperosmotic Stress on Corneal Epithelial Stem/Progenitor Cells and Wound Healing in Mice. Stem Cells Transl Med 2018; 8:46-57. [PMID: 30302939 PMCID: PMC6312447 DOI: 10.1002/sctm.18-0005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 07/19/2018] [Indexed: 12/12/2022] Open
Abstract
Chronic inflammation and severe dry eye are two important adverse factors for the successful transplant of cultured limbal stem cells. The aim of this study was to investigate the effects of inflammation and hyperosmotic stress (a key pathological factor in dry eye) on corneal epithelial stem cells (CESCs) and corneal epithelial wound healing. We observed that the CESCs exhibited significant morphological changes when treated with interleukin‐1 beta (IL‐1β), tumor necrosis factor alpha (TNF‐α), or hyperosmotic stress. Colony‐forming efficiency or colony‐forming size was decreased with the increasing concentrations of IL‐1β, TNF‐α, or hyperosmotic stress, which was exacerbated when treated simultaneously with pro‐inflammatory factors and hyperosmotic stress. However, the colony‐forming capacity of CESCs recovered more easily from pro‐inflammatory factor treatment than from hyperosmotic stress treatment. Moreover, when compared with pro‐inflammatory factors treatment, hyperosmotic stress treatment caused a more significant increase of apoptotic and necrotic cell numbers and cell cycle arrest in the G2/M phase. Furthermore, the normal ability of corneal epithelial wound healing in the mice model was suppressed by both pro‐inflammatory factors and hyperosmotic stress treatment, and especially severely by hyperosmotic stress treatment. In addition, inflammation combined with hyperosmotic stress treatment induced more serious epithelial repair delays and apoptosis in corneal epithelium. Elevated levels of inflammatory factors were found in hyperosmotic stress‐treated cells and mice corneas, which persisted even during the recovery period. The results suggested that pro‐inflammatory factors cause transient inhibition, while hyperosmotic stress causes severe apoptosis and necrosis, persistent cell cycle arrest of CESCs, and severe corneal wound healing delay. Stem Cells Translational Medicine2019;8:46–57
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Affiliation(s)
- Lingling Yang
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, People's Republic of China
| | - Songmei Zhang
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, People's Republic of China
| | - Haoyun Duan
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, People's Republic of China
| | - Muchen Dong
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, People's Republic of China
| | - Xiaoli Hu
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, People's Republic of China
| | - Zhaohua Zhang
- Shandong Lunan Eye Hospital, Linyi, People's Republic of China
| | - Yao Wang
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, People's Republic of China
| | - Xiaoping Zhang
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, People's Republic of China
| | - Weiyun Shi
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, People's Republic of China
| | - Qingjun Zhou
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, People's Republic of China
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Desmoglein1 Deficiency Is a Potential Cause of Cutaneous Eruptions Induced by Shuanghuanglian Injection. Molecules 2018; 23:molecules23061477. [PMID: 29921748 PMCID: PMC6099613 DOI: 10.3390/molecules23061477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/13/2018] [Indexed: 12/15/2022] Open
Abstract
Cutaneous eruption is a common drug-adverse reaction, characterised by keratinocytes inflammation and apoptosis. Shuanghuanglian injeciton (SHLI) is a typical Chinese medicine injection, which is used to treat influenza. It has been reported that SHLI has the potential to induce cutaneous adverse eruptions. However, the mechanisms remain unclear. Since desmoglein 1 (DSG1) shows a crucial role in maintaining skin barrier function and cell susceptibility, we assume that DSG1 plays a critical role in the cutaneous eruptions induced by SHLI. In our study, retinoic acid (RA) was selected to downregulate the DSG1 expression, and lipopolysaccharide (LPS) was first used to identify the susceptibility of the DSG1-deficiency Hacat cells. Then, SHLI was administrated to normal or DSG1-deficient Hacat cells and mice. The inflammatory factors and apoptosis rate were evaluated by RT-PCR and flow cytometry. The skin pathological morphology was observed by hematoxylin and eosin (HE) staining. Our results show that treated only with SHLI could not cause IL-4 and TNF-α mRNA increases in normal Hacat cells. However, in the DSG1-deficient Hacat cells or mice, SHLI induced an extreme increase of IL-4 and TNF-α mRNA levels, as well as in the apoptosis rate. The skin tissue showed a local inflammatory cell infiltration when treated with SHIL in the DSG1-deficient mice. Thus, we concluded that DSG1 deficiency was a potential causation of SHLI induced eruptions. These results indicated that keratinocytes with DSG1 deficiency were likely to induce the cutaneous eruptions when stimulated with other medicines.
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Wang F, Ye Y, Luo ZY, Gao Q, Luo DQ, Zhang X. Diverse expression of TNF-α and CCL27 in serum and blister of Stevens-Johnson syndrome/toxic epidermal necrolysis. Clin Transl Allergy 2018; 8:12. [PMID: 29713456 PMCID: PMC5909236 DOI: 10.1186/s13601-018-0199-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 03/14/2018] [Indexed: 01/13/2023] Open
Abstract
Background The pathogenesis of Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) is not fully understood. Our previous study reported that chemokine CCL27 was overexpressed in serum of SJS/TEN patients. The objective of this study was to investigate the levels of CCL27 and TNF-α in serum and blister fluid from patients with SJS/TEN during the acute stage or resolution phase. Methods A total of 27 patients with SJS/TEN and 39 healthy donors were recruited to the study. Serum and vesicular levels of CCL27 and TNF-α were determined by enzyme-linked immunosorbent assays. Results Serum levels of CCL27 and TNF-α were significantly elevated in patients with SJS/TEN during the acute stage as compared to the resolution phase and also compared with levels observed in normal controls (P = 0.001/< 0.001; P = 0.012/< 0.001). Serum TNF-α levels were significantly higher in patients with SJS/TEN during the resolution phase compared with normal controls (P < 0.001). Serum CCL27 levels were positively correlated with TNF-α levels during the acute stage (rs = 0.660; P < 0.001). Blister fluid exhibited much lower CCL27 levels than serum did during the acute stage (P = 0.008). TNF-α levels were much higher in vesicles in contrast to serum from acute stage (P = 0.040) as well as serum from resolution phase (P = 0.029). Conclusions Our study demonstrated roles of CCL27 and TNF-α in promoting the course of SJS/TEN. CCL27 may act early in the course of disease, via the circulation, whereas TNF-α acts throughout the course of disease, in skin lesions.
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Affiliation(s)
- Fang Wang
- 1Department of Dermatology, First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080 China
| | - Yanting Ye
- 1Department of Dermatology, First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080 China
| | - Ze-Yu Luo
- 1Department of Dermatology, First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080 China
| | - Qian Gao
- 1Department of Dermatology, First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080 China
| | - Di-Qing Luo
- 2Department of Dermatology, Eastern Hospital of First Affiliated Hospital, Sun Yat-sen University, 183 Huangpu Rd. E, Guangzhou, 510700 China
| | - Xingqi Zhang
- 1Department of Dermatology, First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080 China
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An Updated Review of the Molecular Mechanisms in Drug Hypersensitivity. J Immunol Res 2018; 2018:6431694. [PMID: 29651444 PMCID: PMC5830968 DOI: 10.1155/2018/6431694] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/09/2017] [Indexed: 02/07/2023] Open
Abstract
Drug hypersensitivity may manifest ranging from milder skin reactions (e.g., maculopapular exanthema and urticaria) to severe systemic reactions, such as anaphylaxis, drug reactions with eosinophilia and systemic symptoms (DRESS)/drug-induced hypersensitivity syndrome (DIHS), or Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). Current pharmacogenomic studies have made important strides in the prevention of some drug hypersensitivity through the identification of relevant genetic variants, particularly for genes encoding drug-metabolizing enzymes and human leukocyte antigens (HLAs). The associations identified by these studies are usually drug, phenotype, and ethnic specific. The drug presentation models that explain how small drug antigens might interact with HLA and T cell receptor (TCR) molecules in drug hypersensitivity include the hapten theory, the p-i concept, the altered peptide repertoire model, and the altered TCR repertoire model. The broad spectrum of clinical manifestations of drug hypersensitivity involving different drugs, as well as the various pathomechanisms involved, makes the diagnosis and management of it more challenging. This review highlights recent advances in our understanding of the predisposing factors, immune mechanisms, pathogenesis, diagnostic tools, and therapeutic approaches for drug hypersensitivity.
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Gurumurthy S, Iyer G, Srinivasan B, Agarwal S, Angayarkanni N. Ocular surface cytokine profile in chronic Stevens-Johnson syndrome and its response to mucous membrane grafting for lid margin keratinisation. Br J Ophthalmol 2017; 102:169-176. [PMID: 28689166 DOI: 10.1136/bjophthalmol-2017-310373] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/04/2017] [Accepted: 05/01/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND To study the tear cytokine and the conjunctival and oral mucosal marker profile in chronic ocular Stevens-Johnson syndrome (SJS) and their alteration following mucous membrane grafting (MMG) for lid margin keratinisation (LMK). METHODS In a 1-year prospective study, SJS cases (n=25) and age-matched/sex-matched healthy controls (n=25) were recruited. Tear specimen (Schirmer's strip), conjunctival and oral mucosal imprints were collected from controls and SJS cases pre-MMG and post-MMG (at first follow-up, n=17). Tear cytokines were profiled using 27-bioplex array. Transforming growth factor-beta (TGF-β)-mediated extracellular matrix changes in conjunctival and oral mucosal cells were analysed by gene expression studies. 30 RESULTS: Tear cytokine profiling of chronic SJS cases at pre-MMG stage revealed significant upregulation of cytokines granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin (IL)-8, IL-1β, monocyte chemoattractant protein-1, IL-15, IL-2, IL-17A and basic fibroblast growth factor (bFGF) with downregulation of IP-10 (interferon gamma-induced protein 10), tumour necrosis factor-α, interferon-γ, IL-10, vascular endothelial growth factor, regulated upon activation normal T-cell expressed and secreted (RANTES), IL-7, IL-12p70 and IL-13, with maximal increase in GM-CSF and maximal downregulation of IP-10, respectively. Of these, IL-2, IL-15, bFGF and IL-17A showed significant correlation with disease severity, pre-MMG. Conjunctival cells pre-MMG showed increase in TGF-β1, TGF-βRII, connective tissue growth factor and collagen-III gene expression by 10, 67, 173 and 184 folds, respectively, which dropped to 1.3, 11, 13.5 and 19 folds correspondingly, post-MMG. However, their expressions in oral mucosa were negligible. CONCLUSION A proinflammatory, profibrotic, antiapoptotic ocular surface milieu characterises chronic ocular SJS. IP-10, an antifibrotic cytokine was noted to be maximally downregulated, unlike in other forms of chronic dry eye disease. The alterations in the ocular surface are seen to reverse largely with MMG for LMK.
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Affiliation(s)
- Srividya Gurumurthy
- R.S. Mehta Jain Department of Biochemistry and Cell Biology, KBIRVO Block, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - Geetha Iyer
- C.J. Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Disorders, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Bhaskar Srinivasan
- C.J. Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Disorders, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Shweta Agarwal
- C.J. Shah Cornea Services, Dr G Sitalakshmi Memorial Clinic for Ocular Disorders, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Narayanasamy Angayarkanni
- R.S. Mehta Jain Department of Biochemistry and Cell Biology, KBIRVO Block, Vision Research Foundation, Sankara Nethralaya, Chennai, India
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Momen S, Dangiosse C, Wedgeworth E, Walsh S, Creamer D. A case of toxic epidermal necrolysis and vanishing bile duct syndrome, requiring liver transplantation. J Eur Acad Dermatol Venereol 2017; 31:e450-e452. [DOI: 10.1111/jdv.14290] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- S. Momen
- Department of Dermatology; King's College Hospital; SE5 9RS London UK
| | - C. Dangiosse
- Department of Hepatology; King's College Hospital; SE5 9RS London UK
| | - E. Wedgeworth
- St John's Institute of Dermatology; Guy's and St Thomas Foundation Trust; SE1 9RT London UK
| | - S. Walsh
- Department of Dermatology; King's College Hospital; SE5 9RS London UK
| | - D. Creamer
- Department of Dermatology; King's College Hospital; SE5 9RS London UK
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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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Interleukin-15 Is Associated with Severity and Mortality in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. J Invest Dermatol 2016; 137:1065-1073. [PMID: 28011147 DOI: 10.1016/j.jid.2016.11.034] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/20/2016] [Accepted: 11/23/2016] [Indexed: 01/31/2023]
Abstract
Early diagnosis and prognosis monitoring for Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN) still remain a challenge. This study aims to explore any cytokine/chemokine with prognostic potential in Stevens-Johnson syndrome/TEN. Through screening a panel of 28 serological factors, IL-6, IL-8, IL-15, tumor necrosis factor-α, and granulysin were upregulated in patients with Stevens-Johnson syndrome/TEN and selected for the further validation in total 155 patients with Stevens-Johnson syndrome/TEN, including 77 from Taiwan and 78 from the Registry of Severe Cutaneous Adverse Reactions. Among these factors evaluated, the levels of IL-15 (r = 0.401; P < 0.001) and granulysin (r = 0.223; P = 0.026) were significantly correlated with the disease severity in 112 samples after excluding patients with insufficient data to calculate the score of TEN. In addition, IL-15 was also associated with mortality (P = 0.002; odds ratio, 1.09; 95% confidence interval, 1.03-1.14; P = 0.001; adjusted odds ratio, 1.10; 95% confidence interval, 1.04-1.16). Consistent results were obtained after the exclusion of Taiwanese patients with sepsis to rule out possible confounders. Moreover, IL-15 was shown to enhance cytotoxicity of cultured natural killer cells and blister cells from patients with TEN. Our findings highlight a usefulness of IL-15 in prognosis monitoring and therapeutic intervention of this devastating condition.
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Idiopathic erythema multiforme: Evidence of underlying Janus kinase-signal transducer and activator of transcription activation and successful treatment with tofacitinib. JAAD Case Rep 2016; 2:502-504. [PMID: 28004029 PMCID: PMC5161778 DOI: 10.1016/j.jdcr.2016.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Saito K, Ueta M, Maekawa K, Sotozono C, Kinoshita S, Saito Y. Plasma Lipid Profiling of Patients with Chronic Ocular Complications Caused by Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. PLoS One 2016; 11:e0167402. [PMID: 27898730 PMCID: PMC5127552 DOI: 10.1371/journal.pone.0167402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 11/14/2016] [Indexed: 11/18/2022] Open
Abstract
Stevens-Johnson syndrome (SJS) and its severe variant, toxic epidermal necrolysis (TEN), are drug-induced acute inflammatory vesiculobullous reactions of the skin and mucous membranes, including the ocular surface. Even after recovery from skin symptoms, some SJS/TEN patients continue to suffer with severe ocular complications (SOCs). Therefore, this study aims to understand the pathophysiology of chronic SOCs. Because plasma lipid profiling has emerged as a useful tool to understand pathophysiological alterations in the body, we performed plasma lipid profiling of 17 patients who suffered from SJS/TEN-associated chronic SOCs. A lipidomics approach yielded 386 lipid molecules and demonstrated that plasma levels of inflammatory oxylipins increased in patients with SJS/TEN-associated chronic SOCs. In addition, oxidized phosphatidylcholines and ether-type diacylglycerols increased in the patients with chronic SOCs, while phosphoglycerolipids decreased. When we compared these lipidomic profiles with those of patients with atopic dermatitis, we found that patients with chronic SOCs, specifically, had decreased levels of ether-type phosphatidylcholines (ePCs) containing arachidonic acid (AA), such as PC(18:0e/20:4) and PC(20:0e/20:4). To confirm our finding, we recruited additional patients, who suffered from SOC associated with SJS/TEN (up to 51 patients), and validated the decreased plasma levels of AA-containing ePCs. Our study provides insight into the alterations of plasma lipidomic profiles in chronic SOCs and into the pathophysiology of SJS/TEN-associated chronic SOCs.
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Affiliation(s)
- Kosuke Saito
- Division of Medical Safety Science, National Institute of Health Sciences, Setagaya, Tokyo, Japan
| | - Mayumi Ueta
- Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
- * E-mail: (MU); (YS)
| | - Keiko Maekawa
- Division of Medical Safety Science, National Institute of Health Sciences, Setagaya, Tokyo, Japan
| | - Chie Sotozono
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - Shigeru Kinoshita
- Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - Yoshiro Saito
- Division of Medical Safety Science, National Institute of Health Sciences, Setagaya, Tokyo, Japan
- * E-mail: (MU); (YS)
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Chang VS, Chodosh J, Papaliodis GN. Chronic Ocular Complications of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: The Role of Systemic Immunomodulatory Therapy. Semin Ophthalmol 2016; 31:178-87. [PMID: 26959145 DOI: 10.3109/08820538.2015.1114841] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, but potentially blinding diseases that affect the skin and mucous membranes. Although the cutaneous manifestations tend to be self-limited and resolve without sequelae, the chronic ocular complications associated with SJS/TEN can persist despite local therapy. Poor understanding of the underlying pathophysiology and lack of a standardized clinical approach have resulted in a paucity of data in regards to suitable treatment options. Inflammatory cellular infiltration and elevated levels of ocular surface cytokines in the conjunctival specimens of affected patients give credence to an underlying immunogenic etiology. Furthermore, the presence of ongoing ocular surface inflammation and progressive conjunctival fibrosis in the absence of exogenous aggravating factors suggest a possible role for systemic immunomodulatory therapy (IMT). We review in detail the proposed immunogenesis underlying chronic ocular SJS/TEN and the possible utility of systemic IMT.
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Affiliation(s)
- Victoria S Chang
- a Department of Ophthalmology , Harvard Medical School, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
| | - James Chodosh
- a Department of Ophthalmology , Harvard Medical School, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
| | - George N Papaliodis
- a Department of Ophthalmology , Harvard Medical School, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
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Immunopathogenesis and risk factors for allopurinol severe cutaneous adverse reactions. Curr Opin Allergy Clin Immunol 2016; 16:339-45. [DOI: 10.1097/aci.0000000000000286] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Yamane Y, Matsukura S, Watanabe Y, Yamaguchi Y, Nakamura K, Kambara T, Ikezawa Z, Aihara M. Retrospective analysis of Stevens-Johnson syndrome and toxic epidermal necrolysis in 87 Japanese patients--Treatment and outcome. Allergol Int 2016; 65:74-81. [PMID: 26666483 DOI: 10.1016/j.alit.2015.09.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 07/25/2015] [Accepted: 07/28/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but severe adverse drug reactions with high mortality. METHODS To present the clinical characteristics of SJS and TEN in Japan and evaluate the efficacy of treatments, we retrospectively analyzed cases of SJS and TEN treated in 2 university hospitals during 2000-2013. RESULTS Fifty-two cases of SJS (21 males and 31 females; average age, 55.1 years) and 35 cases of TEN (17 males and 18 females; average age, 56.6 years) were included in this study. Twenty-eight cases of SJS (53.8%) and all cases of TEN were caused by drugs. Hepatitis was the most common organ involvement in both SJS and TEN. Renal dysfunction, intestinal disorder, and respiratory disorder were also involved in some cases. The major complication was pneumonia and sepsis. All cases except for 3 cases were treated systemically with corticosteroids. Steroid pulse therapy was performed in 88.6% of TEN. Plasmapheresis and/or immunoglobulin therapy was combined with steroid therapy mainly in TEN after 2007. The mortality rate was 6.9% and the rates for SJS and TEN were 1.9% and 14.3%, respectively. These were much lower than predicted mortality according to a severity-of-illness scoring system for TEN prognosis (SCORTEN) score. When comparing the mortality rate between 2000-2006 and 2007-2013, it was decreased from 4.5% to 0.0% in SJS and from 22.2% to 5.3% in TEN. CONCLUSIONS Treatment with steroid pulse therapy in combination with plasmapheresis and/or immunoglobulin therapy seems to have contributed to prognostic improvement in SJS/TEN.
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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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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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Trichloroethylene Hypersensitivity Syndrome Is Potentially Mediated through Its Metabolite Chloral Hydrate. PLoS One 2015; 10:e0127101. [PMID: 26020924 PMCID: PMC4447350 DOI: 10.1371/journal.pone.0127101] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 04/10/2015] [Indexed: 11/19/2022] Open
Abstract
Background We documented previously the entity of trichloroethylene (TCE) hypersensitivity syndrome (THS) in occupational workers. Objectives To identify the culprit causative compound, determine the type of hypersensitivity of THS, and establish a screening test for subjects at risk of THS. Methods TCE and its main metabolites chloral hydrate (CH), trichloroethanol (TCOH) and trichloroacetic acid (TCA) were used as allergens at different concentrations in skin patch tests. The study included 19 case subjects diagnosed with occupational THS, 22 control healthy workers exposed to TCE (exposure >12 weeks), and 20 validation new workers exposed to TCE for <12 weeks free of THS. All subjects were followed-up for 12 weeks after the patch test. Results The highest patch test positive rate in subjects with THS was for CH, followed by TCOH, TCA and TCE. The CH patch test positive rate was 100% irrespective of CH concentrations (15%, 10% and 5%). The TCOH patch test positive rate was concentration-dependent (89.5%, 73.7% and 52.6% for 5%, 0.5% and 0.05%, respectively). Lower patch test positive rates were noted for TCA and TCE. All patch tests (including four allergens) were all negative in each of the 22 control subjects. None of the subjects of the validation group had a positive 15% CH patch test. Conclusions Chloral hydrate seems to be the culprit causative compound of THS and type IV seems to be the major type of hypersensitivity of THS. The CH patch test could be potentially useful for screening workers at risk of THS.
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The study of severe cutaneous drug hypersensitivity reactions from a systems biology perspective. Curr Opin Allergy Clin Immunol 2015; 14:301-6. [PMID: 24905771 DOI: 10.1097/aci.0000000000000076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Stevens-Johnson syndrome and toxic epidermal necrolysis are severe hypersensitivity reactions, the majority of which are drug induced. The underlying mechanisms are not fully understood. Here, we review recent findings concerning both mechanistic and genetic factors related to these diseases and propose future approaches to unravel their complexity. RECENT FINDINGS Genome-wide association study studies have identified several variants in the human leukocyte antigen region associated with these reactions. These are highly dependent on the population studied and the triggering drug. The T-cell receptor repertoire of the patient is also key. Fas-Fas ligand interactions, perforin and granulysin have also been identified as important players. Furthermore, a high-throughput gene expression study has identified a number of genes that increase in expression in patients during the acute phase of these reactions. SUMMARY We review recent high-throughput studies on these diseases and suggest ways in which the data can be combined and reanalyzed using integrative systems biology techniques. We also suggest future lines of research using recent technology that could shed further light on their underlying mechanisms.
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Marzano AV, Fanoni D, Antiga E, Quaglino P, Caproni M, Crosti C, Meroni PL, Cugno M. Expression of cytokines, chemokines and other effector molecules in two prototypic autoinflammatory skin diseases, pyoderma gangrenosum and Sweet's syndrome. Clin Exp Immunol 2014; 178:48-56. [PMID: 24903614 DOI: 10.1111/cei.12394] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2014] [Indexed: 12/23/2022] Open
Abstract
Pyoderma gangrenosum (PG) and Sweet's syndrome (SS) are two inflammatory skin diseases presenting with painful ulcers and erythematous plaques, respectively; both disorders have a debilitating clinical behaviour and PG is potentially life-threatening. Recently, PG and SS have been included among the autoinflammatory diseases, which are characterized by recurrent episodes of sterile inflammation, without circulating autoantibodies and autoreactive T cells. However, an autoinflammatory pattern clearly supporting this inclusion has never been demonstrated. We studied 16 patients with PG, six with SS and six controls, evaluating, using a sandwich-based protein antibody array method, the expression profile of inflammatory effector molecules in PG, SS and normal skin. The expressions of interleukin (IL)-1 beta and its receptor I were significantly higher in PG (P = 0·0001 for both) and SS (P = 0·004-0·040) than in controls. In PG, chemokines such as IL-8 (P = 0·0001), chemokine (C-X-C motif) ligand (CXCL) 1/2/3 (P = 0·002), CXCL 16 (P = 0·003) and regulated upon activation normal T cell expressed and secreted (RANTES) (P = 0·005) were over-expressed. In SS, IL-8 (P = 0·018), CXCL 1/2/3 (P = 0·006) and CXCL 16 (P = 0·036) but not RANTES were over-expressed, suggesting that chemokine-mediated signals are lower than in PG. Fas/Fas ligand and CD40/CD40 ligand systems were over-expressed in PG (P = 0·0001 for Fas, P = 0·009 for Fas ligand, P = 0·012 for CD40, P = 0·0001 for CD40 ligand), contributing to tissue damage and inflammation, while their role seems to be less significant in SS. Over-expression of cytokines/chemokines and molecules amplifying the inflammatory network supports the view that PG and SS are autoinflammatory diseases. The differences in expression profile of inflammatory effectors between these two disorders may explain the stronger local aggressiveness in PG than SS.
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Affiliation(s)
- A 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
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Expression of interleukin-17 in lesions of erythema multiforme may indicate a role for T helper 17 cells. Cent Eur J Immunol 2014; 39:370-6. [PMID: 26155150 PMCID: PMC4439997 DOI: 10.5114/ceji.2014.45950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 06/24/2014] [Indexed: 01/09/2023] Open
Abstract
Introduction The aim of this study was to evaluate levels of interleukin (IL)-2, IL-6, IL-8, IL-10, IL-17A and interferon γ (IFN-γ) in the serum of patients with erythema multiforme (EM) and to search for the presence of IL-17-expressing cells in lesional samples of EM. Material and methods A total of 32 patients (22 females and 10 males) diagnosed with EM of the minor or major type were included in the study. Levels of IL-2, IL-6, IL-8, IL-10, IL-17A and IFN-γ in the serum were determined and compared with healthy controls. Biopsy specimens were stained with haematoxylin and eosin (HE) and monoclonal antibodies to CD4, CD8 and IL-17 for immunohistochemical examination. Results IL-2, 6, 8 and 17A were significantly higher in the patient group (p = 0.016, p = 0.001, p = 0.004, p = 0.006, respectively) and levels of IL-10 were significantly lower than in the control group (p = 0.046). The cellular infiltrate in lesions of EM was composed mainly of CD4+ T lymphocytes. The presence of IL-17-expressing cells, at proportion of 5 to 50%, was observed in the infiltrate. Conclusions The demonstration of IL-17-expressing cells in lesions of EM in this study has brought forth the assumption that Th17 cells may be involved in the pathogenesis of EM.
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Yager JA. Erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis: a comparative review. Vet Dermatol 2014; 25:406-e64. [PMID: 24990284 DOI: 10.1111/vde.12142] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Human erythema multiforme (EM) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) are separate conditions. There is no consensus on classification criteria for the eponymous diseases in animals. RESULTS Animal EM is very different from 90% of human EM, which is herpes virus associated (HAEM). Animals lack acrally distributed, typical raised targets. Unlike canine parvovirus 'EM', HAEM is not an active infection. Animal EM is often attributed to drugs, but this is rarely proved. Conversely, human and animal SJS/TEN are almost identical, life-threatening disorders of epidermal necrosis and detachment, typically triggered by drugs (occasionally by infectious agents). Both EM and SJS/TEN are mediated by cytotoxic lymphocyte responses against altered keratinocytes (infectious agents or drugs). Apoptosis results from direct cytotoxicity or through soluble mediators, namely Fas ligand, granzymes, perforin and granulysin. Diagnosis in humans is clinicopathological, with emphasis on clinical lesions; histopathology confirms the pathological process as interface (cytotoxic) dermatitis. Human EM is self-limiting; only recurrent and rare persistent cases require antiviral/immunosuppressive therapies. Drug-induced EM responds to drug withdrawal. Idiopathic canine EM (>40%) is usually chronic, refractory to treatment and may represent heterogeneous conditions. Early identification and removal of the causative drug and high-quality supportive care are critical in SJS/TEN. Mortality rate is nevertheless high. CONCLUSIONS AND CLINICAL IMPORTANCE (1) Histopathological lesions do not reliably differentiate EM, SJS and TEN. (2) A multicentre study to develop a consensus set of clinical criteria for EM and SJS/TEN in animals is overdue. (3) No adjunctive therapies, including intravenous immunoglobulin and ciclosporin, have met evidence-based standards.
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Affiliation(s)
- Julie A Yager
- Department of Pathobiology, University of Guelph, Guelph, Ontario, Canada, N1G2W1
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Ballester I, Guijarro J, Silvestre JF, Niveiro M. Erythema multiforme induced by imiquimod 5% cream. Int J Dermatol 2014; 53:e347-8. [DOI: 10.1111/ijd.12265] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Irene Ballester
- Department of Dermatology; Hospital General Universitario Sta. María del Rosell de Cartagena; Murcia Spain
| | - Jaime Guijarro
- Department of Dermatology; Hospital General Universitario Alicante; Alicante Spain
| | | | - María Niveiro
- Department of Pathology; Hospital General Universitario Alicante; Alicante Spain
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