Toxic epidermal necrolysis

Toxic epidermal necrolysis associated with sorafenib and tosufloxacin in a patient with hepatocellular carcinoma

This is the first case report to describe a 44-year-old woman with a history of advanced hepatocellular carcinoma who developed toxic epidermal necrolysis (TEN) clinically after taking 400 mg sorafenib (Nexavar®, BAY 43-9006) and tosufloxacin orally once per day. Both sorafenib and tosufloxacin were eventually discontinued, and the TEN resolved with corticosteroids and supportive treatment. Clinical physicians should be aware of this possible complication so that early interventions can be made.

Intravenous Immunoglobulin for Treatment of Toxic Epidermal Necrolysis

We report three female patients suffering from toxic epidermal necrolysis, with 30% to 70% epidermal detachment. Alleged causative agents were dipyrone, dibenzazepine, and allopurinol. All patients were treated by intravenous immunoglobulins (IVIG) and survived without further complications, although poor prognostic factors such as concomitant diabetes, large areas of epidermal detachment, and pancytopenia were present. We report these cases with emphasis on the concept that prompt diagnosis, withdrawal of causative drugs, and immediate treatment are imperative for the favorable outcome of the disease. Our patients can be added to the list of those patients who were successfully treated by IVIG, as indicated in this review of the literature.

Treatment of toxic epidermal necrolysis with moisture-retentive ointment: a case report and review of the literature

Toxic epidermal necrolysis (TEN) is a rare condition that was described by Lyell in 1956. It is a severe, acute, adverse, primarily drug-induced, potentially fatal, cutaneous reaction that is characterized by large areas of skin desquamation and sloughing, similar in many aspects to second-degree burns. The treatment of cutaneous drug reactions rests essentially on immediate diagnosis and recognition of the disease process, accurate history, thorough physical examination, prompt discontinuation of the offending drug, and supportive care. TEN patients are best managed in specialized burn units. Nevertheless, the management remains very much individualized, based on the clinical setting. Topical wound care remains an essential factor in the treatment of burn-like syndromes and is a main determining parameter for morbidity and mortality. As the value of moist environment in wound healing is being fully appreciated, we report on the use of a newly introduced ointment, the Moist Exposed Burn Ointment (Julphar; Gulf Pharmaceutical industries, Ras El-Khaymah, United Arab of Emirutes), a moisture-retentive ointment, in the successful management of a case of TEN.

Drug-induced Stevens-Johnson syndrome/toxic epidermal necrolysis

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare (occurring in approximately 2 to 3 people/million population/year in Europe and the US), life-threatening, intolerance reaction of the skin. It is most often caused by drugs (most commonly sulfonamides, nonsteroidal anti-inflammatory drugs, antimalarials, anticonvulsants, and allopurinol). SJS/TEN is characterized by a macular exanthema ('atypical targets') which focusses on the face, neck, and the central trunk regions. Lesions show rapid confluence, a positive Nikolsky's sign, and quickly result in widespread detachment of the epidermis and erosions. Mucosal, conjunctival, and anogenital mucous membranes are prominently involved. Histopathology shows satellite cell necrosis in the early stages progressing to full thickness necrosis of the epidermis, contrasting with rather inconspicuous inflammatory infiltrates of the dermis. Damage to the skin is thought to be mediated by cytotoxic T lymphocytes and mononuclear cells which induce apoptosis in keratinocytes expressing drug-derived antigens at their surfaces. No guidelines for the treatment of SJS/TEN exist since no controlled clinical trials have ever been performed. The controversy over whether systemic corticosteroids should be used to curtail progression is still unresolved; while many authors agree that corticosteroids do in fact suppress progression, it is obvious that they also greatly enhance the risk of infection, the complication which most frequently leads to a fatal outcome. It appears reasonable to only administer corticosteroids in the phase of progression and to withdraw them as soon as possible, and to add antibacterials for prophylaxis. Recently, in a small series of patients, intravenous immunoglobulins were presumed to be effective by the blockade of lytic Fas ligand-mediated apoptosis in SJS/TEN. However, these results have to be confirmed by large clinical trials. Supportive treatment and monitoring of vital functions is of utmost importance in SJS/TEN, and out-patient treatment is unacceptable. Recovery is usually slow, depending on the extent and severity and the presence of complications, and may take 3 to 6 weeks. Skin lesions heal without scars as a rule, but scarring of mucosal sites is a frequent late complication, potentially leading to blindness, obliteration of the fornices and anogenital strictures. There is no reliable laboratory test to determine the offending drug; diagnosis rests on the patient's history and the empirical risk of drugs to elicit skin SJS/TEN. Provocation tests are not indicated since re-exposure is likely to elicit a new episode of SJS/TEN of increased severity.

Toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a rare but life-threatening adverse drug reaction. Implicated drugs are sulfonamides, anticonvulsants, allopurinol, and pyrazolone derivatives. Recently, advances in pathogenesis have been made in two directions. It is now known that (1) most patients with TEN have an abnormal metabolism to the culprit drug; and (2) the mechanism leading to epidermal necrolysis seems to be a cell-mediated cytotoxic reaction. The treatment remains symptomatic.

Plasmapheresis as an adjunct treatment in toxic epidermal necrolysis

BACKGROUND

Toxic epidermal necrolysis (TEN) is a severe, progressive disease characterized by the sudden onset of skin necrosis. It is frequently associated with systemic involvement and has a high rate of morbidity and mortality. Standard therapy includes meticulous wound care, fluid replacement, and nutritional support in an intensive care setting.

OBJECTIVE

We evaluated the outcomes of patients treated in a burn unit for TEN over a 9-year period and compared the outcomes of a subset of patients treated with plasmapheresis with those managed by conventional means.

METHODS

The records of 16 patients with a diagnosis of TEN obtained from a computerized database were reviewed. Parameters recorded included extent of body surface area involvement and number of mucous membranes involved at admission, complications such as sepsis or need for mechanical ventilation, length of stay, and disposition.

RESULTS

Sixteen patients were included in this study. Ten were treated with conventional support measures alone. Six were treated with plasmapheresis. The average age was 42.4 years; the male/female ratio was 1:2.2. Sulfamethoxazole/trimethoprim was implicated in causation in 6 patients. The average extent of involvement on admission in all patients was 51.5% total body surface area. The average length of stay in all patients was 14.8 days. Eight patients (50%) were discharged home, 4 (25%) were discharged to a rehabilitation facility, and 4 (25%) died (2 of sepsis, 2 of cardiopulmonary arrest). None of the plasmapheresis-treated patients died.

CONCLUSION

Plasmapheresis is a safe intervention in extremely ill TEN patients and may reduce the mortality in this severe disease. Prospective studies are needed to further define its usefulness.

A study of the efficacy of plasmapheresis for the treatment of drug induced toxic epidermal necrolysis

The efficacy of plasmapheresis for the treatment of toxic epidermal necrolysis (TEN) in our patient and related reports in the literature were examined. The patient, a 41-year-old female, was diagnosed as having drug (Sedes-G [isopropylantipyrin, arylisopropylacetoureid, and phenacetinum]) induced TEN. Upon admission to our hospital, extensive corticostroid therapy was initiated. After 6 days, because more than 90% of the patient's body surface was affected by TEN, it was concluded that the patient was unresponsive to corticosteroid therapy. Double filtration plasmapheresis (DFPP) was therefore begun. After 2 sessions of DFPP, extensive reepithelialization rapidly occurred, and after 3 sessions of DFPP, the improvement was dramatic. The patient's condition had almost healed during 1 month's hospitalization. It has been reported in the literature that 22 patients with drug induced TEN have been treated with plasmapheresis. The mortality rate of 23 patients, including our patient, was 17.4%. The rate of effectiveness of plasmapheresis on drug induced TEN is 82.6%. It appears that some kind of necrolytic factors were removed by the plasmapheresis. This suggests that plasmapheresis may be an effective treatment for drug induced TEN.

The clinical spectrum of desquamative gingivitis

Desquamative gingivitis is a fairly common complaint. Typically seen in females who are middle-aged or older, it is predominantly a manifestation of a range of vesiculobullous disorders. The main complaint is of persistent soreness of the gingiva. Most cases are related to lichen planus or pemphigoid, but it is also important to exclude pemphigus, dermatitis herpetiformis, linear IgA disease, chronic ulcerative stomatitis, and other conditions. Biopsy is invariably required to confirm the diagnosis after a full history, general, and oral examination. Apart from improving the oral hygiene, immunosuppressive therapy is typically required to control the condition.

Advances in toxic epidermal necrolysis

On the basis of the clinicopathologic and causative characteristics, one can separate an erythema multiformis spectrum from a toxic epidermal necrolysis (TEN)-Stevens Johnson syndrome which is a drug induced disease. Despite a well-known clinical aspect, several cutaneous diseases may be mistaken for TEN. Responsible drugs are sulfonamides anticonvulsants, and nonsteroidal antiinflammatory drugs--patients infected with HIV are at a higher risk of developing TEN. Pathogenesis includes abnormal drug metabolism and cell mediated immune keratinocyte apoptosis. Treatment relies on symptomatic management and so-called specific treatments including steroids are probably harmful.

Toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a rare, drug-induced, life-threatening syndrome with widespread epidermal loss and mucosal erosions. The classification, pathophysiology, clinical features and treatment are discussed in this review. Prognosis has improved as admission to a burns unit and early treatment of infection has become standard management. The role of corticosteroids in treatment is still controversial.

Clinical pattern of cutaneous drug eruption among children and adolescents in north India

Various types of cutaneous drug eruptions and the incriminating drugs were analyzed in 50 children and adolescents up to 18 years of age (34 or 65% boys, 16 or 32% girls). Thirteen (26%) patients had a maculopapular rash, 11 (22%) a fixed drug eruption (FDE), 10 erythema multiforme (EM), 6 (12%) toxic epidermal necrolysis (TEN), 5 (10%) Stevens-Johnson syndrome (SJS), 3 (6%) urticaria, and 2 (4%) erythroderma. The incubation period for maculopapular rashes, SJS and TEN due to commonly used antibiotics and sulfonamides was short, a few hours to two to three days, reflecting reexposure, and for drugs used sparingly such as antiepileptics and antituberculosis agents, was approximately one week or more, suggesting a first exposure. Antibiotics were responsible for cutaneous eruptions in 27 patients, followed by antiepileptics in 17, analgin in 4, and metronidazole and albendazole in 1 each. Cotrimoxazole, a combination of sulfamethoxazole and trimethoprim, was the most common antibacterial responsible for eruptions (11 patients), followed by penicillin and its semisynthetic derivatives (8 patients), sulfonamide alone (3 patients), and other antibiotics (4 patients). Antiepileptics were the most frequently incriminated drugs in EM, TEN, and SJS. The role of systemic corticosteroids in the management of SJS and TEN is controversial. We administered prednisolone or an equivalent corticosteroid 2 mg/kg/day for 7 to 14 days.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mycoplasma infection with Stevens-Johnson syndrome and antiphospholipid antibodies: apropos of 2 cases]

We report two cases of Mycoplasma pneumoniae infections associated with Stevens-Johnson syndrome and antiphospholipid antibodies. Such an association has been noted once in the literature. The relationship between antiphospholipid antibodies and Stevens-Johnson syndrome and others cutaneous manifestations of infections diseases is discussed. Though mainly described in systemic lupus erythematosus and autoimmune diseases, anticardiolipin antibodies and lupus anticoagulant have been found in many infectious disorders. But in the latter conditions, they have been considered by many authors as "non pathogenic" or "non prothrombotic" on epidemiologic and immunologic data. We suggest that antiphospholipid antibodies could possibly play a role in their pathogenesis especially as the mechanisms are not to date clearly understood.

Ciprofloxacin-induced toxic epidermal necrolysis

OBJECTIVE

To report a case of probable ciprofloxacin-induced toxic epidermal necrolysis (TEN) in an adult with systemic lupus erythematosus (SLE).

CASE SUMMARY

A 31-year-old woman with SLE developed a pruritic rash following her first dose of oral ciprofloxacin. She continued taking ciprofloxacin, and the rash progressively worsened, becoming painful and covering her entire body. She discontinued the ciprofloxacin six days later and presented to the hospital, where two days later, her rash began to desquamate with epidermal erosions and a positive Nikolsky's sign. Skin biopsy was positive for TEN. She then was transferred to a burn-treatment unit because of the severity of the skin involvement. The patient recovered following prolonged hospitalization and rehabilitation.

CONCLUSIONS

Although TEN occurs rarely with ciprofloxacin, extensive postmarketing surveillance needs to be performed to determine other risk factors for its development and to establish the incidence of TEN and other severe cutaneous reactions caused by ciprofloxacin or the other fluoroquinolones.