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Erduran F, Adışen E, Emre S, Hayran Y, Başkan EB, Yazıcı S, Bilgiç A, Alpsoy E, Günaydın SD, Elmas L, Akyol M, Güner R, Arıca DA, Aypek Y, Ergun T, Karavelioğlu D, Yazıcı AC, Aydoğan K, Bayramgürler D, Kıran R, Erdoğan HK, Acer E, Aktaş A. Evaluation of the Factors Influencing Mortality in Patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Multicenter Study of 166 Patients. Dermatol Ther (Heidelb) 2024; 14:1547-1560. [PMID: 38758423 PMCID: PMC11169098 DOI: 10.1007/s13555-024-01180-6] [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: 03/04/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening acute mucocutaneous disorders usually triggered by drugs. In this study, we aimed to evaluate the factors affecting mortality in patients with SJS-TEN. METHODS Our study is a retrospective cohort study, analyzing data collected from a total of 12 tertiary care centers between April 2012 and April 2022. RESULTS The study included 59 males and 107 females, a total of 166 patients, with an average age of 50.91 ± 21.25 years. Disease classification was TEN in 50% of cases, SJS in 33.1%, and SJS-TEN overlap in 16.9%. The average SCORTEN within the first 24 h was 2.44 ± 1.42. Supportive care was provided to 99.4% of patients. The most commonly used systemic immunomodulatory treatments were systemic steroids (84.3%), IVIG (intravenous immunoglobulin) (49.3%), and cyclosporine (38.6%). Plasmapheresis was administered to five patients. While 66.3% of patients were discharged, 24.1% resulted in exitus. Our comparative analysis of survivors and deceased patients found no effect of systemic steroids, IVIG, and cyclosporine treatments on mortality. Univariate analysis revealed that the SCORTEN scores on days 1 and 3 as well as the rates of detachment at the onset and during follow-up were significantly higher in deceased patients compared to survivors. The rates of fever, positive blood cultures, and systemic antibiotic use were higher in deceased patients compared to survivors. The presence of comorbidities, diabetes, and malignancy were significantly more common in deceased patients. Multivariate regression analysis indicated that over SCORTEN 2, the mortality risk exponentially rose with each SCORTEN increment, culminating in an 84-fold increase in mortality at SCORTEN 5-6 (odds ratio [95% confidence interval]: 13.902-507.537, p < 0.001) compared to SCORTEN 0-1. Additionally, the utilization of plasmapheresis was associated with a 22-fold increase in mortality (odds ratio [95% confidence interval]: 1.96-247.2, p = 0.012). CONCLUSION Our study found that a high SCORTEN score within the first 24 h and the use of plasmapheresis were related to increased mortality, while systemic steroids, IVIG, and cyclosporine treatments had no impact on mortality. We believe that data gathered from one of the most comprehensive studies which we conducted on SJS-TEN will enrich the literature, although additional research is warranted.
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Affiliation(s)
- Funda Erduran
- Ankara Bilkent City Hospital, Department of Dermatology, Ankara, Turkey.
| | - Esra Adışen
- Department of Dermatology, Gazi University, Ankara, Turkey
| | - Selma Emre
- Department of Dermatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Yıldız Hayran
- Ankara Bilkent City Hospital, Department of Dermatology, Ankara, Turkey
| | | | - Serkan Yazıcı
- Department of Dermatology, Bursa Uludağ University, Bursa, Turkey
| | - Aslı Bilgiç
- Department of Dermatology, Akdeniz University, Antalya, Turkey
| | - Erkan Alpsoy
- Department of Dermatology, Akdeniz University, Antalya, Turkey
| | | | - Leyla Elmas
- Department of Dermatology, Hacettepe University, Ankara, Turkey
| | - Melih Akyol
- Department of Dermatology, Sivas Cumhuriyet University, Sivas, Turkey
| | - RukiyeYasak Güner
- Department of Dermatology, Sivas Cumhuriyet University, Sivas, Turkey
| | - Deniz Aksu Arıca
- Department of Dermatology, Karadeniz Technical University, Trabzon, Turkey
| | - Yağmur Aypek
- Department of Dermatology, Gazi University, Ankara, Turkey
| | - Tülin Ergun
- Department of Dermatology, Marmara University, Istanbul, Turkey
| | | | | | - Kübra Aydoğan
- Department of Dermatology, Mersin University, Mersin, Turkey
| | | | - Rebiay Kıran
- Department of Dermatology, Kocaeli University, Kocaeli, Turkey
| | - Hilal Kaya Erdoğan
- Department of Dermatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Ersoy Acer
- Department of Dermatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Akın Aktaş
- Department of Dermatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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Lowell JA, Wright J, Eisenberg S, Teperman J, Dastagir M. Rash from the past: A case of recurrent reactive infectious mucocutaneous eruption triggered by common coronavirus. JAAD Case Rep 2024; 47:26-29. [PMID: 38576904 PMCID: PMC10993116 DOI: 10.1016/j.jdcr.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Affiliation(s)
- Jeffrey A. Lowell
- Department of Internal Medicine, Hofstra Zucker School of Medicine and North Shore University Hospital-Long Island Jewish Medical Center at Northwell Health, Manhasset, New York
| | - Jervon Wright
- Department of Internal Medicine, Hofstra Zucker School of Medicine and North Shore University Hospital-Long Island Jewish Medical Center at Northwell Health, Manhasset, New York
| | - Samuel Eisenberg
- Department of Internal Medicine, Hofstra Zucker School of Medicine and North Shore University Hospital-Long Island Jewish Medical Center at Northwell Health, Manhasset, New York
| | - Jacob Teperman
- Department of Internal Medicine, Hofstra Zucker School of Medicine and North Shore University Hospital-Long Island Jewish Medical Center at Northwell Health, Manhasset, New York
| | - Manile Dastagir
- Department of Internal Medicine, Hofstra Zucker School of Medicine and North Shore University Hospital-Long Island Jewish Medical Center at Northwell Health, Manhasset, New York
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Hao L, Cai W, Zeng Z, Geng X, Li Q, Chen H, Zhang Y, Ding J. Toxic epidermal necrolysis after injection of sclerosing agent and medical adhesive into oesophageal variceal ligation in a patient with a malignant liver tumour: A case report. Exp Ther Med 2024; 27:20. [PMID: 38125343 PMCID: PMC10728904 DOI: 10.3892/etm.2023.12309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 10/13/2023] [Indexed: 12/23/2023] Open
Abstract
Chronic liver disease can cause an increase in portal sinus pressure, which may lead to rupture and bleeding of esophageal and gastric varices. Oesophageal variceal ligation, with use of sclerosing agent and tissue glue injection is commonly used in clinical practice to address oesophageal bleeding. A 58-year-old male patient with chronic liver disease was treated with oesophageal variceal ligation, sclerosing agent and tissue glue injection due to oesophageal and gastric variceal bleeding. After 2 days, the skin of the patient exhibited erythema to different degrees. After 10 days of dexamethasone treatment, the whole-body rash worsened, and a severe skin reaction appeared that was suggestive of toxic epidermal necrolysis (TEN). Strict mucosal care was provided, and corticosteroids, γ globulin and adalimumab were concurrently used for treatment. After 20 days, the patient recovered from the skin problems. To the best of our knowledge, TEN after endoscopic surgery has rarely been reported in the relevant literature. Furthermore, when patients being treated with multiple drugs have erythema multiforme, physicians should be alert to the possibility of its development into TEN. The present case report summarizes the treatment methods for patients with TEN, providing a practical clinical basis and direction for the future diagnosis and treatment of the condition.
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Affiliation(s)
- Liangchao Hao
- Department of Dermatology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
- Department of Plastic Surgery, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
| | - Wei Cai
- Department of Dermatology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
| | - Zhaomu Zeng
- Department of Neurosurgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi 330000, P.R. China
| | - Xiuchao Geng
- School of Medicine, Taizhou University, Taizhou, Zhejiang 318000, P.R. China
| | - Qiang Li
- School of Medicine, Taizhou University, Taizhou, Zhejiang 318000, P.R. China
| | - Hong Chen
- Department of Dermatology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
| | - Yuhao Zhang
- Department of Neurosurgery, Cancer Centre, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang 310000, P.R. China
| | - Juan Ding
- Department of Dermatology, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, P.R. China
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Gong T, Zhang P, Ruan SF, Xiao Z, Chen W, Lin M, Zhong Q, Luo R, Xu Q, Peng J, Cheng B, Chen F, Chen L, Chung WH, Ji C. APOA4 as a novel predictor of prognosis in Stevens-Johnson syndrome/toxic epidermal necrolysis: A proteomics analysis from two prospective cohorts. J Am Acad Dermatol 2023; 89:45-52. [PMID: 36963506 DOI: 10.1016/j.jaad.2023.02.058] [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: 01/05/2023] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening adverse drug reactions. Conventional systemic therapies are of limited efficacy and often exhibit strong side effects. OBJECTIVE To assess the efficacy and safety of the combination treatment with a tumor necrosis factor-α antagonist adalimumab and delineate the underlying mechanisms. METHODS We evaluated the efficacy and safety of the combination therapy with adalimumab by comparing 2 treatment cohorts of SJS/TEN patients. Patient plasma samples were collected for proteomics analysis. RESULTS The combination therapy with adalimumab significantly shortened the time to mucocutaneous re-epithelization and healing, with reduced side effects caused by corticosteroids. Plasma proteomic profiling showed that apolipoprotein A-IV (APOA4) was one of the most significant differentially expressed proteins. Multivariate regression analysis revealed that APOA4 level was significantly associated with prognosis parameter of SJS/TEN (P = .004), but not with disease severity score (severity-of-illness score for toxic epidermal necrolysis [SCORTEN]) (P = .118). Thus further research will be helpful to effectively incorporate APOA4 into current SCORTEN-driven protocols. LIMITATIONS The cohort size is relatively small. Both cohorts had low overall SCORTEN scores. CONCLUSION Adalimumab in combination with corticosteroids demonstrates significant clinical benefits over corticosteroids alone in SJS/TEN patients. Moreover, APOA4 may serve as a novel prognostic marker of SJS/TEN.
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Affiliation(s)
- Ting Gong
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Central Laboratory, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Peng Zhang
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Shi-Fan Ruan
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Zhixun Xiao
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Wen Chen
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Min Lin
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Qingmei Zhong
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Renwei Luo
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Qiuyun Xu
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Jiamei Peng
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Bo Cheng
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Fa Chen
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, Fujian, China
| | - Lihong Chen
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, and Keelung, Taiwan.
| | - Chao Ji
- Department of Dermatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; Key Laboratory of Skin Cancer of Fujian Higher Education Institutions, Fujian Medical University, Fuzhou, Fujian, 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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Stevens-Johnson syndrome in children. Curr Opin Pediatr 2022; 34:341-348. [PMID: 35836393 DOI: 10.1097/mop.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The concept of Stevens-Johnson syndrome (SJS) in children is evolving. This manuscript reviews recent advances with the lens of new terminology namely infection-triggered reactive infectious mucocutaneous eruption and drug-induced epidermal necrolysis, with the objective of integrating this novel terminology practically. RECENT FINDINGS Traditionally considered to exist on a spectrum with toxic epidermal necrolysis, SJS in children is more often caused or triggered by infections instead of medications. Proposed pediatric-specific terminology can be applied to literature to gain further insights into blistering severe cutaneous adverse reactions. SUMMARY Distinguishing infection-triggered from drug-triggered blistering reactions is useful for 3 main reasons: (1) early clinically recognizable different features such as isolated or predominant mucositis, (2) different initial management depending on trigger, (3) avoiding the label of a drug reaction on cases triggered by infection.
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Abstract
Virale und paravirale Exantheme sind die häufigsten Exantheme des Kindesalters, die auch meist zu einer Vorstellung in der Praxis inklusive der Notaufnahme führen. Die Kenntnis der verschiedenen Krankheitsbilder ist entscheidend für die adäquate Diagnostik und Betreuung der kleinen Patient:innen, die entsprechende Aufklärung der Familie und ggf. das Minimieren des Infektionsrisikos. In der aktuellen Arbeit werden die kürzlich beschriebenen „reactive infectious mucocutaneous eruptions“ (RIME) und das „pediatric inflammatory multisystem syndrome“ (PIMS) vorgestellt. Zusätzlich werden wir einige atypische Manifestationen des Gianotti-Crosti-Syndroms und der Hand-Fuß-Mund-Erkrankung – wie z. B. die mit Mollusken assoziierte „Gianotti-Crosti-like reaction“ und das „eczema coxsackium“ – erläutern.
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Affiliation(s)
- Julia E Fromme
- Klinik und Poliklinik für Dermatologie und Venerologie, Universität zu Köln, Köln, Deutschland
- Mildred Scheel School of Oncology Aachen Bonn Cologne Düsseldorf (MSSO ABCD), Köln, Deutschland
| | - Iliana Tantcheva-Poór
- Klinik und Poliklinik für Dermatologie und Venerologie, Universität zu Köln, Köln, Deutschland
| | - Regina Fölster-Holst
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Rosalind-Franklin-Str. 7, 24105, Kiel, Deutschland.
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Tonkin R, Ladha M, Johnson N, Astle WF, Britton A, Shear NH, Murguía-Favela L, Ramien M. Reactive infectious mucocutaneous eruption – repeat etanercept after intravenous immunoglobulin: A case report. SAGE Open Med Case Rep 2022; 10:2050313X221117887. [PMID: 36003890 PMCID: PMC9393491 DOI: 10.1177/2050313x221117887] [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] [Indexed: 12/04/2022] Open
Abstract
Reactive infectious mucocutaneous eruption is a recently distinguished mucosal-predominant blistering eruption triggered by respiratory infections. We describe a previously healthy 11-year-old Black female with rapidly progressive mucocutaneous blistering after prodromal respiratory infection symptoms. Reactive infectious mucocutaneous eruption was suspected and treated with systemic corticosteroids followed by etanercept. Twenty-four hours after etanercept, the diagnosis of multisystem inflammatory syndrome in children was raised and intravenous immunoglobulin was given. Rapidly worsening mucocutaneous disease ensued but was controlled by a second dose of etanercept. Our case highlights the following: (1) the novel observation of possible interaction/neutralization of etanercept by intravenous immunoglobulin, (2) the challenging differential diagnosis of multisystem inflammatory syndrome in children for reactive infectious mucocutaneous eruption patients in the Coronavirus disease 2019 (COVID-19) pandemic, and (3) the role of early treatment to prevent dyspigmentation.
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Affiliation(s)
- Rochelle Tonkin
- Division of Dermatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Malika Ladha
- Department of Dermatology, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nicole Johnson
- Section of Rheumatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - William F Astle
- Pediatric Ophthalmology, Vision Clinic, Alberta Children’s Hospital, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Ami Britton
- Wound Care/Surgery Clinic Nurse, Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, AB, Canada
| | - Neil H Shear
- Department of Dermatology, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Luis Murguía-Favela
- Section of Hematology and Immunology, Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, AB, Canada
| | - Michele Ramien
- Division of Dermatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Community Pediatrics (Dermatology), Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, AB, Canada
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Frantz R, Huang S, Are A, Motaparthi K. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review of Diagnosis and Management. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:895. [PMID: 34577817 PMCID: PMC8472007 DOI: 10.3390/medicina57090895] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022]
Abstract
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare diseases that are characterized by widespread epidermal necrosis and sloughing of skin. They are associated with significant morbidity and mortality, and early diagnosis and treatment is critical in achieving favorable outcomes for patients. In this scoping review, Excerpta Medica dataBASE and PubMed were searched for publications that addressed recent advances in the diagnosis and management of the disease. Multiple proteins (galectin 7 and RIP3) were identified that are promising potential biomarkers for SJS/TEN, although both are still in early phases of research. Regarding treatment, cyclosporine is the most effective therapy for the treatment of SJS, and a combination of intravenous immunoglobulin (IVIg) and corticosteroids is most effective for SJS/TEN overlap and TEN. Due to the rare nature of the disease, there is a lack of prospective, randomized controlled trials and conducting these in the future would provide valuable insights into the management of this disease.
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Affiliation(s)
- Robert Frantz
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (R.F.); (A.A.)
| | - Simo Huang
- Department of Dermatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA;
| | - Abhirup Are
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (R.F.); (A.A.)
| | - Kiran Motaparthi
- College of Medicine, University of Florida, Gainesville, FL 32606, USA; (R.F.); (A.A.)
- Department of Dermatology, College of Medicine, University of Florida, Gainesville, FL 32606, USA
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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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Lipový B, Hladík M, Štourač P, Forostyak S. Case Report: Wound Closure Acceleration in a Patient With Toxic Epidermal Necrolysis Using a Lyophilised Amniotic Membrane. Front Bioeng Biotechnol 2021; 9:649317. [PMID: 33937217 PMCID: PMC8085411 DOI: 10.3389/fbioe.2021.649317] [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] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/23/2021] [Indexed: 01/03/2023] Open
Abstract
Background: Toxic epidermal necrolysis (TEN) is a rare life-threatening disease that mainly affects the skin and mucous membranes, resulting from a toxic delayed-type hypersensitivity (DTH) reaction (type IV reaction) to the presence of foreign antigens such as drugs. The clinical symptoms are caused by pathophysiological processes leading to massive apoptosis of keratinocytes in the dermo-epidermal junction. This results in the formation of a bulla and subsequent separation of the entire epidermis with the exposure of the dermis. The current approach in the local therapy of TEN prefers the use of biological dressings, which helps provide several critical requirements for defect healing; in particular, it helps in the acceleration of the spontaneous wound closure (re-epithelialization) of the skin defect and the reduction of the risk of development of various complications and infections, such as the risk of pathological scar maturation. This paper is a case report of the use of a lyophilized amniotic membrane (AM) for accelerating wound healing in a patient with TEN. Case Presentation: We report a case of an 8-year-old girl transferred to our center with a histologically confirmed diagnosis of TEN. Despite the application of immunosuppressive therapy consisting of corticosteroids and intravenous immunoglobulins, we have observed disease progression and exfoliation of up to 60% of the total body surface area (TBSA). In the facial area, which is cosmetically privileged, we decided to use the lyophilized amniotic membrane (Amnioderm®) to cover up approximately 2% of the TBSA. Within 2 days after the application, we observed accelerated reepithelialisation, with rapid wound closure. We have not observed any side effects nor infections during the subsequent phases of wound healing. Skin defects in non-facial areas of the body were treated with synthetic dressings. When compared to the areas covered with the lyophilized AM, the healing process was prolonged. Conclusions: To our knowledge, this is the first case study using a lyophilized amniotic membrane in the treatment of a patient with TEN. The AM application in the cosmetically-privileged area (face), proved to be very efficient in the treatment of TEN patients. The use of this allogeneic material demonstrated excellent biocompatibility and caused a unique acceleration of epithelialization and wound healing, yielding also excellent long-term results. The current study opens broad possibilities for clinical application of the used material, the improvement of current therapy of patients with TEN and better outcomes and recovery of patients.
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Affiliation(s)
- Bretislav Lipový
- Department of Burns and Plastic Surgery, Faculty of Medicine, University Hospital Brno, Masaryk University, Brno, Czechia
- Central European Institute of Technology, Brno University of Technology, Brno, Czechia
| | - Martin Hladík
- Department of Burns and Plastic Surgery, Faculty of Medicine, University Hospital Brno, Masaryk University, Brno, Czechia
| | - Petr Štourač
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, Brno, Czechia
| | - Serhiy Forostyak
- Department of Burns and Plastic Surgery, Faculty of Medicine, University Hospital Brno, Masaryk University, Brno, Czechia
- PrimeCell Bioscience Inc., Prague, Czechia
- National Tissue Centre Inc., Ostrava, Czechia
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Sachdeva M, Maliyar K, Ponzo MG. A Systematic Review of Efficacy and Safety of Monotherapy and Combination Therapy With Biologic for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. J Cutan Med Surg 2021; 25:598-615. [PMID: 33631950 DOI: 10.1177/1203475421993779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Biologic drugs have the potential to halt the progression of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) by decreasing concentrations of tumor necrosis factor-α, a cytokine implicated in epithelial cell death. The objective of this systematic review is to investigate the efficacy and safety of biologic monotherapy and combination therapy for SJS/TEN. METHODS MEDLINE and EMBASE in OVID were searched on October 28, 2020. Inclusion criteria were original studies containing human participants diagnosed with SJS/TEN and treated with biologics. Studies were excluded if they were literature reviews, systematic reviews, letters to the editor, or conference abstracts. RESULTS The 38 articles reviewed included 27 (71.1%) case reports, 6 (15.8%) case series, 3 (7.9%) retrospective reviews, and 2 (5.3%) RCTs. The age range of the included studies was 2 to 85 years, the mean age was 46.4 years. The mean body surface (BSA) across the 38 included articles was 31.0%. The average actual mortality reported within the 38 included articles was 9.2%. Both biologic monotherapy and combination therapy were associated with improved outcomes in SJS/TEN. Furthermore, anti TNF-alpha therapy, specifically etanercept, showed improved outcomes as monotherapy. CONCLUSIONS Overall, reviewed studies presented a strong case for biologic treatment, both monotherapy and combination use, in SJS/TEN treatment. Based on the number of fatal adverse events observed, biologic monotherapy may be safer compared to combination therapy. Further research with a larger sample size and a randomized control trial design is required.
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Affiliation(s)
- Muskaan Sachdeva
- 7938 University of Toronto, Faculty of Medicine, Toronto, Ontario
| | - Khalad Maliyar
- 7938 University of Toronto, Faculty of Medicine, Toronto, Ontario
| | - Marisa G Ponzo
- 8166 Department of Dermatology and Skin Science, University of British Columbia; Division of Dermatology, St. Paul's Hospital, Vancouver, British Columbia
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13
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Ramien ML. Reactive infectious mucocutaneous eruption: Mycoplasma pneumoniae-induced rash and mucositis and other parainfectious eruptions. Clin Exp Dermatol 2020; 46:420-429. [PMID: 32918499 DOI: 10.1111/ced.14404] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/21/2020] [Indexed: 12/21/2022]
Abstract
Mycoplasma pneumoniae-induced rash and mucositis is the most accurate diagnosis for patients with blistering mucocutaneous disease provoked by an infection. Recent literature suggests expansion of the name is required, as other infections have caused a clinically similar presentation. This review provides a concise update on current understanding of M. pneumoniae-induced rash and mucositis and other reactive infectious mucocutaneous eruptions.
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Affiliation(s)
- M L Ramien
- Division of Community Medicine, Department of Pediatrics, University of Calgary Cummings School of Medicine, Alberta Children's Hospital, Calgary, Alberta, Canada.,Division of Dermatology, Department of Medicine, University of Calgary Cummings School of Medicine, Alberta Children's Hospital, Calgary, Alberta, Canada
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14
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Abstract
Stevens–Johnson syndrome and toxic epidermal necrolysis are rare severe blistering skin reactions triggered by medications or infections. Over the last 5 to 10 years, a number of important publications have advanced understanding of these diseases and their response to treatment. Importantly, a subset of patients with disease triggered by infection has been identified as having Mycoplasma pneumoniae–induced rash and mucositis, suggesting a reconsideration of the diagnostic paradigm. We present an update on pediatric Stevens–Johnson syndrome and toxic epidermal necrolysis in the broader context of cutaneous adverse drug reactions and focus on challenges and recent advances in diagnosis, management, and prevention.
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Affiliation(s)
- Michele Ramien
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, 28 Oki Dr NW, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jennifer L Goldman
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA.,Division of Pediatric Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
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15
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Estébanez A, Sáez-Martín LC, Muñoz JI, Silva E, Monrabal A, Monteagudo C, Ramón MD. Levetiracetam-induced pediatric toxic epidermal necrolysis successfully treated with etanercept. Pediatr Dermatol 2020; 37:701-705. [PMID: 32319121 DOI: 10.1111/pde.14179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Successful management of toxic epidermal necrolysis (TEN) with tumor necrosis factor-α inhibitors has been described in adults, but few cases have been reported in children. To date, only four pediatric cases of TEN treated with infliximab and one with etanercept have been published. We present the case of an 8-year-old boy diagnosed with TEN induced by levetiracetam, successfully treated with etanercept, systemic corticosteroids, and intravenous immunoglobulin.
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Affiliation(s)
- Andrea Estébanez
- Department of Dermatology, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Luis Carlos Sáez-Martín
- Department of Dermatology, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Juan Ignacio Muñoz
- Department of Paediatric Intensive Care, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Esmeralda Silva
- Department of Dermatology, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Alicia Monrabal
- Department of Paediatric Intensive Care, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Carlos Monteagudo
- Department of Pathology, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - María Dolores Ramón
- Department of Dermatology, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
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Abstract
Tumor necrosis factor alpha (TNF) inhibitors have had a significant impact in medicine since the approval of the first drug of its class by the US FDA in 1998. New clinical data and indications have emerged for TNF inhibitors in recent years. Currently, four TNF inhibitors have been approved by the US FDA for dermatology, two of which include US FDA-approved pediatric use. In particular, growing evidence supports the use of etanercept and adalimumab as attractive therapies for pediatric psoriasis. Data for use of etanercept in treating toxic epidermal necrolysis and either etanercept or infliximab for Kawasaki disease is expanding. In addition, there have been clinical reports on the use of TNF inhibitors to treat a variety of other pediatric dermatologic conditions. To help clinicians keep pace with the new data provided by many pediatric dermatology studies involving TNF inhibitors, this review provides an overview of the use of TNF inhibitors in the treatment of pediatric plaque psoriasis, hidradenitis suppurativa, atopic dermatitis, pyoderma gangrenosum, toxic epidermal necrolysis, and Kawasaki disease. For TNF inhibitors with little data in the pediatric population, data on adult use is discussed. Furthermore, the review summarizes available clinical data on efficacy, safety, and tolerability of agents currently available.
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