OCCURRENCE OF BULLOUS LESIONS IN ACUTE BARBITURATE INTOXICATION

Skin necrosis after intradermal injection of lyophilized exosome: A case report and a review of the literature

BACKGROUND

Exosomes have gained attention for their potential in skin rejuvenation. Currently, most exosome products are available for topical administration, and the use of subdermal injection as a route of administration has not been approved.

AIMS

The purpose of this case report is to describe a case of skin necrosis that occurred following an intradermal injection of lyophilized exosomes.

MATERIALS AND METHODS

We hereby report a case of a middle-aged man who experienced adverse effects after receiving an intradermal injection of lyophilized exosomes. Multiple injections of an exosome product were administered to treat enlarged facial pores. Shortly after the injection, the patient felt pain and noticed several dark red bumps. Three days after injection, the lesions transformed into palpable, painful, non-blanchable purplish papules and nodules, accompanied by central, tiny crusted erosions. The residual product was injected into the upper arm using an intradermal method. Similar lesions also appeared, and a skin biopsy showed necrotic keratinocytes, leukocytoclastic vasculitis, and eccrine necrosis.

RESULTS

There are few reports available regarding complications, especially those related to intradermal exosomes. These complications include multiple foreign-body granulomatous reactions at the injection sites. In our case, oral prednisolone was administered for a duration of 7 days. After the treatment, the lesions exhibited notable improvement, eventually leaving post-inflammatory hyperpigmentation.

CONCLUSION

Utilizing exosomes through unapproved methods should be avoided due to the possibility of adverse reactions that could cause aesthetic issues.

Cutaneous eccrine inflammation and necrosis: review of inflammatory disorders affecting the eccrine apparatus including new associations

Despite being frequently overlooked during the examination of histopathological sections, eccrine sweat glands can offer clues for diagnosing various skin conditions. They provide important functions and can lead to several diseases when inflamed or injured. This review article provides information regarding eccrine physiology as well as well-established and novel entities that occur in association with eccrine gland pathology.

Drug Overdose-Induced Coma Blisters: Pathophysiology and Clinical and Forensic Diagnosis

BACKGROUND

Coma blisters or coma bullae are bullous lesions that have been associated with cases of drug overdose-induced coma. Previous history of suicide attempt by administering benzodiazepines, barbiturates, ethanol, antipsychotics, antidepressants or opioids have been particularly implicated. Patients may present also painful deep skin and soft tissue involvement, edema and functional impairment. The pathophysiology remains unknown and lesions are usually self-limited and typically resolve without scarring.

OBJECTIVE

This work aims to fully review the state of the art regarding the causes pathophysiology, diagnosis and treatment of drug overdose-induced coma blisters.

CONCLUSION

Coma blisters are a benign, self-limiting condition that should be suspected in patients who develop pressure blisters several hours after an altered state of consciousness.

Bullous lesions, sweat gland necrosis and rhabdomyolysis in alcoholic coma

A 42-year-old male developed hemorrhagic bullae and erosions while in alcohol induced coma. The lesions were limited to areas of the body in prolonged contact with the ground in the comatose state. He developed rhabdomyolysis, progressing to acute renal failure (ARF). Histopathological examination of the skin showed spongiosis, intraepidermal vesicles, and necrosis of eccrine sweat glands with denudation of secretory epithelial lining cells. With supportive treatment and hemodialysis, the patient recovered in 3 weeks time. This is the first reported case of bullous lesions and sweat gland necrosis occurring in alcohol-induced coma complicated by rhabdomyolysis and ARF.

Immunohistochemical investigation of the coma blister and its pathogenesis

The erythematous patches and vesicles that are observed in coma patients, usually from an overdose of medication, are known as coma blisters. However, it is unknown whether the degenerated sweat gland is a necrosis or apoptosis. We immunohistochemically examined such skin lesions to investigate the characteristics and pathogenesis of the coma blister. Skin lesions were obtained from a forensic autopsy case, a woman in her thirties, of caffeine intoxication. Those lesions were observed in the left femoral, the lower left thigh, and the right knee. Histologically, the skin lesions showed that the keratinocytes had necrosed and the epidermis was thin in some areas. Eccrine sweat gland degeneration was observed. Obvious inflammatory cell infiltrations were not detected. Immunohistochemically, we stained each skin lesion against CD3, CD8, CD45RO, cytokeratin, 70 kD heat shock protein, ubiquitin, 150 kD oxygen regulated protein, and caspase-cleaved keratin 18 neo-epitope M30. They were also stained with an in situ apoptosis detection kit. Degenerated sweat glands featured CD45RO and M30 immunoreactivity. Immunohistochemical staining for CD45RO, CK-L, and M30 might be useful to observe sweat gland degeneration in the coma blister. Therefore, the apoptosis might be related to coma blisters and sweat gland degenerations.

Bullae and sweat gland necrosis in the differential diagnosis for Vibrio vulnificus infection in an alcoholic patient

Bullae and sweat gland necrosis remain rare cutaneous manifestation, and these conditions can be misdiagnosed as Vibrio vulnificus infections or other soft tissue infections because of their low index of suspicion. A 46-yr-old man with a history of continued alcohol consumption presented with erythematous and hemorrhagic bullous lesions on his left arm. The patient reported that after the ingestion of clams, he slept for 12 hr in a heavily intoxicated state. Then the skin lesions started as a reddish patch that subsequently became hemorrhagic bullae. V. vulnificus infection, cellulitis, and necrotizing fasciitis were considered in initial differential diagnosis. However, on the basis of sweat gland necrosis on histopathologic examinations and negative results on bacterial cultures, we made the diagnosis of bullae and sweat gland necrosis. Therefore, bullae and sweat gland necrosis should also be considered in chronic alcoholic patients who present with bullae and a previous history of unconsciousness.

The approach to the patient with an unknown overdose

Toxic overdose can present with various clinical signs and symptoms. These may be the only clues to diagnosis when the cause of toxicity is unknown at the time of initial assessment. The prognosis and clinical course of recovery of a patient poisoned by a specific agent depends largely on the quality of care delivered within the first few hours in the emergency setting. Usually the drug or toxin can be quickly identified by a careful history, a directed physical examination, and commonly available laboratory tests. Once the patient has been stabilized, the physician must consider how to minimize the bioavailability of toxin not yet absorbed, which antidotes (if any) to administer, and if other measures to enhance elimination are necessary.

Phenobarbital-induced bullous lesions in a non-comatose patient

The occurrence of dermatologic bullous lesions is well documented after barbiturate-induced intoxication. However, this rare clinicopathological entity is only reported in the setting of a coma or lethal toxicity. This case report presents a case of a noncomatose, nonimmobilized patient who developed systemic bullous lesions after an acute ingestion of oral phenobarbital. This case illustrates that bullous lesions can occur as a result of nontoxic phenobarbital doses, in the setting of subtherapeutic barbiturate blood levels. All previous case reports suggest phenobarbital produces either systemic bullae only after coma-inducing doses or a localized bullous reaction after a high-dose intravenous injection. This case challenges this previously held association. Although the exact mechanism of the bullous lesions remains unknown, the clinical course of the lesions is self-limiting and does not require additional care beyond the treatment of a superficial burn. Resolution of the bullae occured within two weeks. Since phenobarbital continues to be prescribed orally, physicians should recognize bullous lesions as a potential adverse dermatological reaction from non-lethal oral doses of phenobarbital.

Drug-induced sweat gland necrosis in a non-comatose patient: a case presentation

BACKGROUND

Coma-induced bullae and sweat gland necrosis is a rare clinicopathological entity often associated with drug-induced coma.

SUBJECT

We report a case with clinical and histopathologic findings characteristic of blisters and sweat gland necrosis occurring in a non-comatose patient.

CONCLUSIONS

Skin blisters with underlying sweat gland necrosis is an entity previously reported to occur in comatose patients, our findings open new questions about the role of the drugs in the pathogenesis of those conditions.

Coma-induced bullae and sweat gland necrosis following clobazam

Coma-induced bullae and sweat gland necrosis is a rare clinicopathological entity described in association with a variety of aetiopathological conditions all of which have resulted in an impairment of conscious level. We report the first case observed in association with clobazam, used as adjunctive therapy for resistant epilepsy in a 4-year old. The potential underlying mechanisms and previously reported associations are discussed.

Nonneoplastic disorders of the eccrine glands

Eccrine glands are uniquely susceptible to a variety of pathologic processes. Alteration in the rate of sweat secretion manifests as hypohidrosis and hyperhidrosis. Obstruction of the eccrine duct leads to miliaria. The excretion of drugs into eccrine sweat may be a contributory factor in neutrophilic eccrine hidradenitis (NEH), syringosquamous metaplasia (SSM), coma bulla, and erythema multiforme (EM). Alterations in the electrolyte composition of eccrine sweat can be observed in several systemic diseases, most notably cystic fibrosis. This article summarizes current knowledge of eccrine gland pathophysiology.

Occurrence of oral mucosal necrosis in a patient with barbiturate-induced coma

Although dermal lesions in patients with drug poisoning have been widely documented, similar oral conditions are seldom reported. A case of cutaneous and oral mucosal necrosis related to barbiturate-induced coma is reported.

Skin blisters as a manifestation of oxazepam toxicity

A 75 year-old comatous patient was admitted after ingestion of 200 mg oxazepam. Skin blisters, attributed to oxazepam toxicity, appeared on the left forearm the following day and regressed spontaneously nine days later.

Lake Nyos disaster, Cameroon, 1986: the medical effects of large scale emission of carbon dioxide?

Carbon dioxide was blamed for the deaths of around 1700 people in Cameroon, west Africa, in 1986 when a massive release of gas occurred from Lake Nyos, a volcanic crater lake. The clinical findings in 845 survivors seen at or admitted to hospital were compatible with exposure to an asphyxiant gas. Rescuers noted cutaneous erythema and bullae on an unknown proportion of corpses and 161 (19%) survivors treated in hospital; though these lesions were initially believed to be burns from acidic gases, further investigation suggested that they were associated with coma states caused by exposure to carbon dioxide in air. The disaster at Lake Nyos and a similar event at Lake Monoun, Cameroon, two years previously provide new information on the possible medical effects of large scale emissions of carbon dioxide, though the presence of other toxic factors in these gas releases cannot be excluded.

Bullous skin eruption associated with carbamazepine overdosage

A patient who developed a bullous skin eruption associated with carbamazepine overdosage is described. The authors believe this previously unreported phenomenon to be of clinical importance. Carbamazepine should be considered in the differential diagnosis of drug-induced coma with associated bullous lesions.

"Barbiturate burns" caused by glutethimide

A case of glutethimide overdose associated with skin lesions resembling burns is reported. These characteristic skin lesions are usually ascribed to barbiturates. Their aetiology, incidence, and association with other drugs and neurological disorders are discussed.

Epidemiology of acute drug intoxications: patient characteristics, drugs, and medical complications

Of 415 adult patients treated for acute drug intoxications in a university hospital emergency room, 64 (15.4%) required admission to the medical service for intensive care. A significantly larger proportion of patients over 40 years of age required hospitalization. Forty-eight of the episodes requiring hospitalization were identified as intentional drug intoxication. Women were admitted in 41 (64.0%) instances while men were admitted on 23 (36.0%) occasions. Non-barbiturate depressants, barbiturates, tranquilizers, and antidepressants were the drug classes most commonly incriminated. Almost one-half of all patients, however, had taken multiple drugs. Medical complications in these 64 patients included coma in 43 (67.2%), acute hypertension or hypotension in 21 (32.8%), and pneumonia in 16 (25%). Complications occurring less frequently were cardiac arrest in three (4.7%), anemia in two (3.2%), neuropathies, soft tissue necrosis, quadraplegia, renal failure, bullous dermatitis, and fetal death in one patient each. Two (3.2%) patients died as a result of drug ingestions. Forty per cent of patients had experienced previous episodes of acute drug intoxication.

Bullous lesions in poisoning

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Effects of poisoning on serum enzyme activities, coagulation, and fibrinolysis

Prolonged coma due to acute overdosage with hypnotic drugs is shown to be associated with a pronounced increase in the activity of serum creatine kinase and in the concentration of fibrin degradation products and with less pronounced abnormalities of other serum enzymes and of other indices of coagulation and fibrinolysis. Evidence is presented that skeletal muscle damage occurs and that this is related to the coagulation abnormality. These findings probably explain some of the non-specific features such as fever which commonly occur in recovery from severe poisoning.

Ischaemic contracture of muscle associated with carbon monoxide and barbiturate poisoning

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