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Ozerturk S, Derici Yildirim D, Arikoglu T, Kuyucu S, Kont Ozhan A. A Bayesian Network Meta-Analysis of the Effect of Targeted Therapies on the Total Length of Hospital Stay in Children with Drug-Induced Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Syndrome. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2024; 37:22-32. [PMID: 38484271 DOI: 10.1089/ped.2023.0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare potentially life-threatening hypersensitivity disorders characterized by widespread skin and mucosal involvement. However, there is no standardized evidence-based treatment to reduce the complications of SJS/TEN. This article aims to compare the efficacy of different treatments for pediatric SJS/TEN in terms of length of hospital stay (LOS) using a Bayesian network meta-analysis (NMA). A Bayesian NMA is used to compare and combine evidence from multiple studies and allows clinicians to estimate the relative effectiveness of different treatments/interventions while accounting for heterogeneity in the available evidence. Methods: We conducted a comprehensive electronic database search for studies compatible with our inclusion criteria. Six studies with 103 patients were included in the NMA; of them, 37 patients were treated with intravenous immunoglobulin (IVIG), 37 with systemic corticosteroids (CS), 23 with IVIG + CS, and 3 with Etanercept (ET) + CS. Patients with a median age of 10 years were included in the study. Results: CS had the highest probability of being the most optimal treatment for SJS/TEN in terms of shorter LOS based on the Surface Under the Cumulative Ranking curve levels, and CS + IVIG was associated with a statistically nonsignificant trend toward shorter LOS than IVIG alone. Remarkably, none of the treatments showed a significant benefit over the other interventions in terms of LOS. Conclusion: Current evidence suggests that coadministration of CS and IVIG may be associated with a shorter LOS than IVIG alone. Further research with larger randomized controlled trials is needed to reach a definitive conclusion about the efficacy of specific therapy on LOS in pediatric SJS/TEN and to establish more definitive treatment guidelines.
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Affiliation(s)
- Sahure Ozerturk
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Didem Derici Yildirim
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Tugba Arikoglu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Aylin Kont Ozhan
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
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2
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Fabian IM, Maddox K, Robicheaux C, Islam RK, Anwar A, Dorius B, Robinson CL, Kaye AM, Varrassi G, Ahmadzadeh S, Shekoohi S, Kaye AD. Stevens-Johnson Syndrome From Combined Allopurinol and Angiotensin-Converting Enzyme Inhibitors: A Narrative Review. Cureus 2024; 16:e51899. [PMID: 38333456 PMCID: PMC10850002 DOI: 10.7759/cureus.51899] [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: 12/07/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
Stevens-Johnson syndrome (SJS) is a severe and potentially debilitating skin reaction frequently related to medication use. Allopurinol and angiotensin-converting enzyme (ACE) inhibitors are commonly prescribed medications for prevalent health conditions worldwide, and their interaction associated with SJS warrants further investigation. A comprehensive literature search was performed to investigate cases as studies related to SJS occurring in patients with concomitant use of allopurinol and ACE inhibitors. We identified case reports and studies detailing hypersensitivity reactions, including SJS, attributed to a combination of allopurinol and ACE inhibitors. Despite the drug-drug interactions or lack thereof seen in patient populations, there is no definitive evidence of a pharmacokinetic interaction between allopurinol and ACE inhibitors. We were only able to find one case report specifically detailing SJS in a patient on combined ACE inhibitors and allopurinol. While the exact mechanism of the interaction is unclear, those reported cases of severe hypersensitivity reactions suggest a previous history of impaired renal function as a predisposing factor in the development of SJS. The potential risk of SJS with coadministration of ACE inhibitors and allopurinol is a drug-drug interaction that physicians should be aware of. This topic requires additional attention to determine if this drug combination should be avoided entirely in certain patients.
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Affiliation(s)
- Isabella M Fabian
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Kirsten Maddox
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Cameron Robicheaux
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Rahib K Islam
- School of Medicine, Louisiana State University Health Sciences Center (LSUHSC) New Orleans, New Orleans, USA
| | - Ahmed Anwar
- Department of Psychology, Quinnipiac University, Hamden, USA
| | - Bradley Dorius
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences University of the Pacific, Stockton, USA
| | | | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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3
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Zhu X, Luo G, Zheng L. Update on HLA-B*15:02 allele associated with adverse drug reactions. Pharmacogenomics 2024; 25:97-111. [PMID: 38305022 DOI: 10.2217/pgs-2023-0173] [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] [Indexed: 02/03/2024] Open
Abstract
HLA alleles, part of the major histocompatibility complex, are strongly associated with adverse drug reactions (ADRs). This review focuses on HLA-B*15:02 and explores its association with ADRs in various ethnic populations and with different drugs, aiming to provide insights into the safe clinical use of drugs and minimize the occurrence of ADRs. Furthermore, the review explores the potential mechanisms by which HLA-B*15:02 may be associated with ADRs, aiming to gain new insights into drug modification and identification of haptens. In addition, it analyzes the frequency of the HLA-B*15:02, genotyping methods, cost-effectiveness and treatment measures for adverse reactions, thereby providing a theoretical basis for formulating clinical treatment plans.
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Affiliation(s)
- Xueting Zhu
- Clinical Medical Research Center, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Guanghua Luo
- Clinical Medical Research Center, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Lu Zheng
- Clinical Medical Research Center, The Third Affiliated Hospital of Soochow University, Changzhou, China
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4
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Jain A, Meshram RJ. Toxic Epidermal Necrolysis Following the Ingestion of Paracetamol in a Pediatric Patient: A Case Report. Cureus 2023; 15:e48216. [PMID: 38050528 PMCID: PMC10693832 DOI: 10.7759/cureus.48216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/03/2023] [Indexed: 12/06/2023] Open
Abstract
Paracetamol is considered to be a relatively safe drug, even in the pediatric age group, at the recommended doses. Here we present a case of a six-year-old male presenting with symptoms and signs of Steven Johnson syndrome/toxic epidermal necrosis (SJS/TEN) following the ingestion of paracetamol. Steven Johnson syndrome/toxic epidermal necrosis is a potentially life-threatening dermatological emergency requiring intensive treatment. The patient was initially misdiagnosed as a case of chickenpox and was administered paracetamol. However, upon attending a tertiary care facility, he was diagnosed with TEN and treated with immunosuppressants. He recovered fully without any complications and was discharged within a week.
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Affiliation(s)
- Aditya Jain
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences School of Epidemiology and Public Health, Wardha, IND
| | - Revat J Meshram
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences School of Epidemiology and Public Health, Wardha, IND
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5
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Dewi ST, Qomariah LN, Sarkowi WK, Puspitasari M, Khalidah M, Anggatama M, Rizkiani DA, Etnawati K, Febriana SA. Combination of cyclosporine A and methylprednisolone to treat pediatric Stevens-Johnson syndrome/toxic epidermal necrolysis overlap syndrome. Dermatol Reports 2023; 15:9656. [PMID: 37426373 PMCID: PMC10327664 DOI: 10.4081/dr.2023.9656] [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: 12/23/2022] [Accepted: 02/08/2023] [Indexed: 07/11/2023] Open
Abstract
The treatment of epidermal necrolysis in pediatric patients remains a major challenge. Cyclosporine A has emerged as a promising therapy for epidermal necrolysis in adults; however, its efficacy in children is unclear. We present the case of a boy with Stevens-Johnson syndrome/toxic epidermal necrolysis overlap syndrome who was initially resistant to methylprednisolone monotherapy but improved after receiving the combination of cyclosporine A and methylprednisolone. Published reports on the use of cyclosporine A for pediatric epidermal necrolysis are also briefly reviewed.
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Affiliation(s)
- Shinta Trilaksmi Dewi
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | | | | | - Monika Puspitasari
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | - Miya Khalidah
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | - Marcella Anggatama
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | - Dwinanda Almira Rizkiani
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | - Kristiana Etnawati
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | - Sri Awalia Febriana
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
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6
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Liu J, Yan H, Yang C, Li Y. Bronchiolitis obliterans associated with toxic epidermal necrolysis induced by infection: A case report and literature review. Front Pediatr 2023; 11:1116166. [PMID: 36937984 PMCID: PMC10018143 DOI: 10.3389/fped.2023.1116166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/08/2023] [Indexed: 03/06/2023] Open
Abstract
Background Stevens-Johnson syndrome/toxic epidermal necrolysis has a severe impact on patients' eyes, genital mucosa, and many other organs. Bronchiolitis obliterans is a rare complication of Stevens-Johnson syndrome/toxic epidermal necrolysis. Data sources We report a case of bronchiolitis obliterans associated with toxic epidermal necrolysis in our department. Furthermore, we examined the patients with bronchiolitis obliterans induced by Stevens-Johnson syndrome/toxic epidermal necrolysis and summarized the clinical characteristics, treatment, and prognosis. Databases available online in English including PubMed, Medline, and Web of Science were consulted. Results We report one case and review 23 published case reports. Of the 24 patients, 13 were female, the oldest patient was 59 years old and the youngest was 5 years old. The time of bronchiolitis obliterans onset after Stevens-Johnson syndrome/toxic epidermal necrolysis varied from 5 days to 5 months. Bronchoscopy examination showed ulceration, exudative lesions, occlusion, and inflammation. The CT of lung manifestation included mosaic perfusion, bronchiectasis, consolidation, air trapping, pneumatocele, pleural thickening, lung collapse, larger central airway dilatation, lung overinflation, oligemia, and pneumomediastinum. Most cases indicated pulmonary function tests with obstructive ventilation dysfunction. The prognosis was poor; six of the patients died. Conclusions Patients with Stevens-Johnson syndrome/toxic epidermal necrolysis may develop bronchitis obliterans at different stages, so all patients with Stevens-Johnson syndrome/toxic epidermal necrolysis should be followed up for possible respiratory complications.
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7
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Lehloenya RJ. Disease severity and status in Stevens–Johnson syndrome and toxic epidermal necrolysis: Key knowledge gaps and research needs. Front Med (Lausanne) 2022; 9:901401. [PMID: 36172538 PMCID: PMC9510751 DOI: 10.3389/fmed.2022.901401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022] Open
Abstract
Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are on a spectrum of cutaneous drug reactions characterized by pan-epidermal necrosis with SJS affecting < 10% of body surface area (BSA), TEN > 30%, and SJS/TEN overlap between 10 and 30%. Severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is a validated tool to predict mortality rates based on age, heart rate, BSA, malignancy and serum urea, bicarbonate, and glucose. Despite improved understanding, SJS/TEN mortality remains constant and therapeutic interventions are not universally accepted for a number of reasons, including rarity of SJS/TEN; inconsistent definition of cases, disease severity, and endpoints in studies; low efficacy of interventions; and variations in treatment protocols. Apart from mortality, none of the other endpoints used to evaluate interventions, including duration of hospitalization, is sufficiently standardized to be reproducible across cases and treatment centers. Some of the gaps in SJS/TEN research can be narrowed through international collaboration to harmonize research endpoints. A case is made for an urgent international collaborative effort to develop consensus on definitions of endpoints such as disease status, progression, cessation, and complete re-epithelialization in interventional studies. The deficiencies of using BSA as the sole determinant of SJS/TEN severity, excluding internal organ involvement and extension of skin necrosis beyond the epidermis, are discussed and the role these factors play on time to healing and mortality beyond the acute stage is highlighted. The potential role of artificial intelligence, biomarkers, and PET/CT scan with radiolabeled glucose as markers of disease status, activity, and therapeutic response is also discussed.
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Affiliation(s)
- Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
- *Correspondence: Rannakoe J. Lehloenya, ; orcid.org/0000-0002-1281-1789
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8
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Pejcic AV, Milosavljevic MN, Folic M, Fernandes D, Bentes J, Djesevic M, Jankovic S. Amoxicillin-associated Stevens-Johnson syndrome or toxic epidermal necrolysis: systematic review. J Chemother 2022; 35:75-86. [PMID: 35285784 DOI: 10.1080/1120009x.2022.2051128] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Our aim was to explore and summarize available cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) suspected to be associated with amoxicillin reported in the literature. Electronic searches were conducted in several databases. Fifty-one publications describing a total of 64 patients who satisfied inclusion criteria were included in the review. The age of the patients ranged from 1.5-80 years (median: 24.5 years). TEN, SJS and SJS/TEN overlap were diagnosed in 30 (46.9%), 28 (43.8%) and 1 (1.6%) patients, respectively. SJS/TEN may occur promptly after administration of amoxicillin, but it could also be a delayed adverse effect. The total length of hospital stay ranged from 3-70 days (median: 16 days). Amoxicillin-induced SJS/TEN is accompanied by frequent occurrence of serious complications, long-term ocular and skin sequelae and high mortality rate. Clinicians should be aware that amoxicillin alone or combined with clavulanic acid can cause SJS/TEN in patients of all ages.
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Affiliation(s)
- Ana V Pejcic
- Faculty of Medical Sciences, Department of Pharmacology and toxicology, University of Kragujevac, Kragujevac, Serbia
| | - Milos N Milosavljevic
- Faculty of Medical Sciences, Department of Pharmacology and toxicology, University of Kragujevac, Kragujevac, Serbia
| | - Marko Folic
- Faculty of Medical Sciences, Department of Pharmacy, University of Kragujevac, Kragujevac, Serbia.,Clinical Pharmacology Department, University Clinical Centre Kragujevac, Kragujevac, Serbia
| | | | - João Bentes
- Federal University of Roraima, Boa Vista, Brazil
| | - Miralem Djesevic
- Department of Cardiology, Private Policlinic Center Eurofar Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Slobodan Jankovic
- Faculty of Medical Sciences, Department of Pharmacology and toxicology, University of Kragujevac, Kragujevac, Serbia.,Clinical Pharmacology Department, University Clinical Centre Kragujevac, Kragujevac, Serbia
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9
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Cui Y, Shi J, Wang C, Zhou Y, Wang F, Miao H, Sun T, Shan Y, Ding G, Zhang Y. Sequential Blood Purification for Pediatric Fatal Toxic Epidermal Necrolysis: A Case Series. Blood Purif 2021; 51:600-607. [PMID: 34488221 DOI: 10.1159/000517088] [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] [Received: 10/16/2020] [Accepted: 04/20/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Extracorporeal therapy that included therapeutic plasma exchange (TPE) or continuous hemofiltration (CHF) for toxic epidermal necrolysis (TEN) syndrome was used in small number of patients. We aimed to describe the sequential mode of combined application of CHF and TPE in 3 TEN patients with multiple organ dysfunction (MODS) in pediatric intensive care unit. METHODS Three patients with fatal TEN received sequential CHF and TPE due to unsatisfactorily conventional treatments. CHF was initiated and performed on a daily basis with 35-50 mL/kg.h replacement fluid at the rate of 3-5 mL/kg.min blood flow. CHF was temporarily interrupted for TPE, which was performed with exchange 1-1.5-fold of one body calculated plasma volume in each section. RESULTS All 3 fatal TEN (with >30% involvement of body surface and MODS) following unsuccessful treatment with corticosteroids and intravenous immunoglobulin. Antibiotics were suspected in the TEN-triggered drugs. The range number of TPE sessions was 3-5 and the duration of CHF was from 120 h to 202 h. After initiation of TPE and CHF, blistering with extensive epidermal necrosis halted and the skin re-epithelialized within 2 weeks. Serum C-reactive protein, procalcitonin, tumor necrosis factor-α , and interlukin-6 decreased and percentage of natural killer cells increased in surviving children. Two patients survived to discharge and one case died due to nosocomial infection with multidrug-resistant Acinetobacter baumannii. CONCLUSION After sequential TPE and CHF, skin lesions and inflammatory response improved in TEN. Our result indicates extracorporeal therapy could be used as an alternative modality for fatal pediatric TEN.
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Affiliation(s)
- Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yiping Zhou
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Fei Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Huijie Miao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ting Sun
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yijun Shan
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Guodong Ding
- Department of Respiratory Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
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10
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Bechek S, Garcia M, Chiou H. Severe Gastrointestinal Involvement in Pediatric Stevens-Johnson Syndrome: A Case Report and Review of the Literature. Clin Exp Gastroenterol 2020; 13:377-383. [PMID: 33061516 PMCID: PMC7533238 DOI: 10.2147/ceg.s269349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022] Open
Abstract
Stevens-Johnson syndrome and toxic epidermal necrolysis form a rare but severe disease spectrum characterized by widespread epidermal detachment. Gastrointestinal manifestations of the disease, however, are rarely described in the pediatric literature and have a high mortality among adults. There are limited data on the treatment of these cases, with conflicting evidence regarding the benefit of steroids, IVIG, or other immunosuppressive agents. We review previous instances of gastrointestinal involvement in children and report the case of a previously healthy 13-year-old who presented with the typical ocular and skin findings of Stevens-Johnson syndrome, subsequently developed severe life-threatening diarrhea, and was found to have severe esophagitis, duodenitis, and colitis on endoscopic evaluation. Treatment was initiated with an immediate, short course of steroids along with early introduction of an enteral diet via nasogastric tube, and resulted in full gastrointestinal recovery. This case highlights successful medical treatment of the first reported pediatric case of SJS/TEN with both upper and lower gastrointestinal tract involvement.
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Affiliation(s)
- Sophia Bechek
- Stanford University School of Medicine, Stanford, CA, USA
| | - Manuel Garcia
- Division of Pediatric Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - Howard Chiou
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA
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11
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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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12
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Eliades P, Fonseca M, Harp J. Use of Etanercept in a Series of Pediatric Patients With Stevens-Johnson Syndrome–Toxic Epidermal Necrolysis Spectrum Disease. JAMA Dermatol 2020; 156:921-922. [DOI: 10.1001/jamadermatol.2019.3731] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Philip Eliades
- Department of Dermatology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Maíra Fonseca
- Department of Dermatology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
- Lincoln Medical Center, New York, New York
| | - Joanna Harp
- Department of Dermatology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
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13
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Sibbald C, Putterman E, Micheletti R, Treat J, Castelo-Soccio L. Retrospective review of drug-induced Stevens-Johnson syndrome and toxic epidermal necrolysis cases at a pediatric tertiary care institution. Pediatr Dermatol 2020; 37:461-466. [PMID: 32058621 DOI: 10.1111/pde.14118] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/OBJECTIVES Stevens-Johnson syndrome and toxic epidermal necrolysis represent important sources of potential mortality and morbidity in children. There is a need for more clinical data in this population to determine whether specific treatments preferentially improve outcomes. METHODS This was a single-center retrospective review of children admitted with drug-induced Stevens-Johnson syndrome, toxic epidermal necrolysis or Stevens-Johnson syndrome/toxic epidermal necrolysis overlap at a tertiary care pediatric institution in North America from 2008 to 2018. Patients without a dermatology assessment and diagnosis were excluded. Demographic, clinical, and treatment information were abstracted and reviewed for all included patients. RESULTS Sixteen patients were identified, 43% female (7/16), with a mean age at presentation of 10.4 ± 5.2 years. Antibiotics were implicated in 56.3% of patients (9/16) and anticonvulsants in 31.3% (5/16). Sulfamethoxazole-trimethoprim was the triggering antibiotic in 31.3% of patients. The majority of patients were treated with intravenous immunoglobulin alone (50%, 8/16) or intravenous immunoglobulin with steroids (25%, 4/16). Etanercept was added to intravenous immunoglobulin and corticosteroid in a 2-year-old patient, resulting in clinical stabilization and halting of epidermolysis. No patients died. Clinical sequelae were noted in five patients, including ocular complications (n = 4), labial adhesions (n = 1), and persistent skin dyspigmentation (n = 3). CONCLUSIONS Our results highlight that sulfamethoxazole-trimethoprim is an important cause of Stevens-Johnson syndrome-toxic epidermal necrolysis in children. Mortality was reassuringly low, but ocular sequelae were an important cause of morbidity. More data are needed to help determine whether specific treatments including etanercept may provide mortality or morbidity benefit in pediatric populations.
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Affiliation(s)
- Cathryn Sibbald
- Section of Dermatology, Department of Paediatrics, SickKids Hospital, Toronto, Ontario.,Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Elana Putterman
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert Micheletti
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James Treat
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leslie Castelo-Soccio
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 775] [Impact Index Per Article: 155.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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15
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Liccioli G, Mori F, Parronchi P, Capone M, Fili L, Barni S, Sarti L, Giovannini M, Resti M, Novembre EM. Aetiopathogenesis of severe cutaneous adverse reactions (SCARs) in children: A 9-year experience in a tertiary care paediatric hospital setting. Clin Exp Allergy 2019; 50:61-73. [PMID: 31608511 DOI: 10.1111/cea.13513] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/04/2019] [Accepted: 10/09/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Severe cutaneous adverse reactions (SCARs) are delayed-type hypersensitivity reactions to drugs including as follows: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), Stevens-Johnson syndrome (SJS), Toxic Epidermal Necrolysis (TEN) and Acute Generalized Exanthematous Pustulosis (AGEP). Incidence, triggers and management of SCARs have not been investigated in large-scale epidemiological studies on children. OBJECTIVE The aim of our study was to collect epidemiological, clinical and aetiological data from children with SCARs referred to our tertiary care paediatric hospital of Florence. METHODS From 2010 to 2018 charts of children with diagnosis of SCAR were reviewed, and data collected during the acute phase and/or the subsequent allergy evaluation. Patients underwent patch tests, intradermal tests and lymphocyte transformation tests. All children were investigated for infectious diseases. RESULTS Incidence of SCARs in hospitalized children was 0.32% over a 9-year period. Fifty-four children were enrolled (31 M; 23 F; median age 6.5 years): 17 cases of DRESS, 30 SJS, 3 TEN, 2 AGEP, 1 linear immunoglobulin A bullous disease (LABD) and 1 pemphigus. Twenty-eight out of 54 patients underwent drug allergy investigations, and 50% of them resulted positive. Combining clinical history and results of allergy work-up, 74% SCARs seem to be caused by drugs, 18.6% by both drugs and infections, 3.7% by infections, and 3.7% remained idiopathic. No deaths occurred. CONCLUSIONS In this study, SCARs incidence is in line with literature data. Drugs were most commonly the leading cause. Management of SCARs requires cooperation among professional figures for an early diagnosis and a prompt treatment. Mortality rate seems to be lower in children.
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Affiliation(s)
- Giulia Liccioli
- Allergy Unit, Department of Paediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Paediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Paola Parronchi
- Department of Clinical and Experimental Medicine, Unit of Internal Medicine, University of Florence, Florence, Italy
| | - Manuela Capone
- Department of Clinical and Experimental Medicine, Unit of Internal Medicine, University of Florence, Florence, Italy
| | - Lucia Fili
- Department of Clinical and Experimental Medicine, Unit of Internal Medicine, University of Florence, Florence, Italy
| | - Simona Barni
- Allergy Unit, Department of Paediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Paediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Paediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Massimo Resti
- Paediatric Department, Anna Meyer Children's Hospital, Florence, Italy
| | - Elio M Novembre
- Allergy Unit, Department of Paediatrics, Anna Meyer Children's University Hospital, Florence, Italy
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16
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Seccombe EL, Ardern‐Jones M, Walker W, Austin S, Taibjee S, Williams S, Hossain P, Shenoy D, Fityan A. Bronchiolitis obliterans as a long‐term sequela of Stevens–Johnson syndrome and toxic epidermal necrolysis in children. Clin Exp Dermatol 2019; 44:897-902. [DOI: 10.1111/ced.13969] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2019] [Indexed: 01/10/2023]
Affiliation(s)
- E. L. Seccombe
- Department of Dermatology University Hospital Southampton NHS Foundation Trust Southampton Hampshire UK
| | - M. Ardern‐Jones
- Department of Dermatology University Hospital Southampton NHS Foundation Trust Southampton Hampshire UK
| | - W. Walker
- Paediatric Respiratory Department University Hospital Southampton NHS Foundation Trust Southampton Hampshire UK
| | - S. Austin
- Department of Dermatology Dorset County Hospital NHS Foundation Trust Dorchester Dorset UK
| | - S. Taibjee
- Department of Dermatology Dorset County Hospital NHS Foundation Trust Dorchester Dorset UK
| | - S. Williams
- Department of Paediatrics University Hospital Southampton NHS Foundation Trust Southampton Hampshire UK
| | - P. Hossain
- Department of Ophthalmology University Hospital Southampton NHS Foundation Trust Southampton Hampshire UK
| | - D. Shenoy
- Department of Paediatrics University Hospital Southampton NHS Foundation Trust Southampton Hampshire UK
| | - A. Fityan
- Department of Dermatology University Hospital Southampton NHS Foundation Trust Southampton Hampshire UK
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17
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Liotti L, Caimmi S, Bottau P, Bernardini R, Cardinale F, Saretta F, Mori F, Crisafulli G, Franceschini F, Caffarelli C. Clinical features, outcomes and treatment in children with drug induced Stevens-Johnson syndrome and toxic epidermal necrolysis. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:52-60. [PMID: 30830062 PMCID: PMC6502171 DOI: 10.23750/abm.v90i3-s.8165] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/01/2019] [Indexed: 12/15/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which can be considered a late-onset allergic reaction, can cause serious long-term sequelae. SJS/TEN are considered a spectrum of life-threatening adverse drug reactions. They have the same clinical manifestations and the only difference is in the extent of epidermal detachment. These conditions are associated with high mortality, although incidence of SJS/TEN is rare in children. SJS/TEN is an adverse drug reaction influenced by genes that involve pharmacokinetics, pharmacodynamics and immune response. Infective agents are additional influencing factors. Anticonvulsants and antibiotics, and especially sulphonamides and non-steroidal anti-inflammatory drugs, are among the drugs that were predominantly suspected of triggering SJS/TEN. No evidence-based standardized treatment guidelines for SJS or TEN are currently available. The usual treatment is mainly founded on the withdrawal of the suspected causative agent and supportive therapy. In pediatric patients, the specific therapeutic strategies are controversial and comprise systemic corticosteroids and the use of intravenous immunoglobulin (IVIG). More recently, new therapeutic approaches have been used, such as immunosuppressive therapies, including cyclosporine and TNF-α inhibitors.
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Affiliation(s)
- Lucia Liotti
- Department of Pediatrics, Senigallia Hospital, Senigallia, Italy.
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