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Wu PC, Lin WC, Wang CW, Chung WH, Chen CB. Cutaneous adverse reactions associated with COVID-19 vaccines: Current evidence and potential immune mechanisms. Clin Immunol 2024; 263:110220. [PMID: 38642783 DOI: 10.1016/j.clim.2024.110220] [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: 09/26/2023] [Revised: 03/04/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
As the number of vaccinated individuals has increased, there have been increasing reports of cutaneous hypersensitivity reactions. The main COVID-19 vaccines administered include messenger ribonucleic acid vaccines, non-replicating viral vector vaccines, inactivated whole-virus vaccines, and protein-based vaccines. These vaccines contain active components such as polyethylene glycol, polysorbate 80, aluminum, tromethamine, and disodium edetate dihydrate. Recent advances in understanding the coordination of inflammatory responses by specific subsets of lymphocytes have led to a new classification based on immune response patterns. We categorize these responses into four patterns: T helper (Th)1-, Th2-, Th17/22-, and Treg-polarized cutaneous inflammation after stimulation of COVID-19 vaccines. Although the association between COVID-19 vaccination and these cutaneous adverse reactions remains controversial, the occurrence of rare dermatoses and their short intervals suggest a possible relationship. Despite the potential adverse reactions, the administration of COVID-19 vaccines is crucial in the ongoing battle against severe acute respiratory syndrome coronavirus 2.
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Affiliation(s)
- Po-Chien Wu
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wan-Chen Lin
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan; Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan; Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan; Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Dermatology, Beijing Tsinghua Chang Gung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China; Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chun-Bing Chen
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan; Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan; Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.
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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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Martinez JD, Cardenas JA, Soria M, Saenz LM, Estrada K, Delgado SM, Ionescu MA, Busila C, Tatu AL. Role of Silver Nitrate Spray for Skin Wound Care in Patients with Toxic Epidermal Necrolysis: Our Experience in 4 Patients. Life (Basel) 2023; 13:2341. [PMID: 38137943 PMCID: PMC10744695 DOI: 10.3390/life13122341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/04/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are examples of severe cutaneous adverse reactions to drugs (SCARs) with several international recommendations for global medical management, ranging from pharmacological systemic therapy to skin wound care. There is no defined best management of the skin wounds in SJS/TEN. The care of wounds is essential to initiate re-epithelialization. Our objective is to improve the cicatrization process, avoiding scarring due to deepening of the wounds, as well as prevent infections, achieve pain control, and avoid loss of serum proteins, fluids, and electrolytes. In this retrospective case series, we highlight the value of systemic therapy and the use of silver nitrate for wound management in four patients with TEN.
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Affiliation(s)
- Jose Dario Martinez
- Department of Internal Medicine, Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico
| | - Jesus Alberto Cardenas
- Department of Rheumatology, Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 66455, Mexico;
| | - Manuel Soria
- Dermatology Department, Hospital Civil, Guadalajara 44630, Mexico;
| | - Luis Manuel Saenz
- Medical Students, Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 64460, Mexico; (L.M.S.); (K.E.); (S.M.D.)
| | - Kattya Estrada
- Medical Students, Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 64460, Mexico; (L.M.S.); (K.E.); (S.M.D.)
| | - Sergio Maximo Delgado
- Medical Students, Faculty of Medicine, University Hospital José Eleuterio González, University Autonomous of Nuevo León, Monterrey 64460, Mexico; (L.M.S.); (K.E.); (S.M.D.)
| | - Marius-Anton Ionescu
- Department of Dermatology, University Hospital Saint Louis, 75010 Paris, France;
| | - Camelia Busila
- “Sf. Ioan” Emergency Clinical Paediatric Hospital, 800179 Galati, Romania
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, 800008 Galati, Romania;
| | - Alin Laurentiu Tatu
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University, 800008 Galati, Romania;
- Dermatology Department, “SfantaCuvioasaParascheva” Hospital of Infectious Diseases, 800179 Galati, Romania
- Multidisciplinary Integrated Center of Dermatological Interface Research MIC-DIR (Centrul Integrat Multidisciplinar de Cercetare de InterfataDermatologica—CIM-CID), “Dunărea de Jos” University, 800201 Galati, Romania
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Paulmann M, Reinkemeier F, Lehnhardt M, Mockenhaupt M. Case report: Generalized bullous fixed drug eruption mimicking epidermal necrolysis. Front Med (Lausanne) 2023; 10:1125754. [PMID: 37644986 PMCID: PMC10461315 DOI: 10.3389/fmed.2023.1125754] [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: 12/16/2022] [Accepted: 07/13/2023] [Indexed: 08/31/2023] Open
Abstract
Generalized bullous fixed drug eruption (GBFDE) is the most severe form of fixed drug eruption and can be misdiagnosed as epidermal necrolysis (EN). We report the case of a 42-year-old male patient presenting with more than 50% skin detachment without defined areas of exanthema or erythema and a history of one prior event of EN caused by acetaminophen (paracetamol), allopurinol, or amoxicillin 1.5 years ago. The initial diagnosis was GBFDE or EN. The histology of a skin biopsy was unable to distinguish between the two diseases. The course of the disease, the later clinical presentation, and the medical and medication history, however, were in favor of a diagnosis of GBFDE with two potentially culprit drugs: metamizole and ibuprofen. Moxifloxacin, enoxaparin sodium, hydromorphone, and insulin human were administered concomitantly, which makes them suspicious as well. Unfortunately, the patient received an additional dose of metamizole, one of the possible causative drugs, and he developed another bullous reaction within 1 month. This led to the diagnosis of GBFDE due to metamizole. This report highlights the challenges of distinguishing two rare diseases and elucidates the importance of distinct clinical presentation and detailed medication history.
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Affiliation(s)
- Maren Paulmann
- Dokumentationszentrum schwerer Hautreaktionen (dZh), Department of Dermatology, Medical Center—University of Freiburg, Freiburg, Germany
| | - Felix Reinkemeier
- Department of Plastic Surgery and Hand Surgery, Burn Center, Sarcoma Center, Berufsgenossenschaft University Hospital Bergmannsheil Bochum, Bochum, Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery and Hand Surgery, Burn Center, Sarcoma Center, Berufsgenossenschaft University Hospital Bergmannsheil Bochum, Bochum, Germany
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen (dZh), Department of Dermatology, Medical Center—University of Freiburg, Freiburg, Germany
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Amos K, Garcia-Bournissen F, Zhao L, Taheri S. Carbamazepine-induced liver injury in an 11-year-old female: Case report and review of the literature. J Paediatr Child Health 2023; 59:165-168. [PMID: 36069405 DOI: 10.1111/jpc.16200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Kiersten Amos
- Department of Paediatrics, Western University, London, Ontario, Canada
| | | | - Liena Zhao
- Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada
| | - Sepideh Taheri
- Department of Paediatrics, Western University, London, Ontario, Canada
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Clinical features and prognostic factors of severe cutaneous adverse drug reactions: A single-center retrospective study of 209 cases in China. Int Immunopharmacol 2023; 114:109530. [PMID: 36508915 DOI: 10.1016/j.intimp.2022.109530] [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: 08/21/2022] [Revised: 11/13/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Severe cutaneous adverse drug reactions (SCAR) are life-threatening and contain drug reactions with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). METHODS We aimed to evaluate clinical features and prognostic factors for SCAR patients. From January 2010 to April 2022, 209 patients with SCAR (DRESS, n = 46, SJS/TEN, n = 128, AGEP, n = 35) were included in this study. Clinical symptoms, laboratory tests, causative drugs, disease courses, treatments, and outcomes were investigated. RESULTS Antibiotics ranked first (35.9 %) followed by traditional Chinese medicine (15.8 %) and antiepileptic drugs (14.8 %) among causative drugs of SCAR. One patient (2.2 %) with DRESS and seven patients (5.5 %) with SJS/TEN died in the hospital, while there was no AGEP-related mortality. The multivariate logistic regression analysis showed that high Registry of Severe Cutaneous Adverse Reactions score (OR = 2.340, 95 % CI = 1.192-4.591) and hemoglobin < 100 g/L (OR = 0.126, 95 % CI = 0.016-0.983) were independent risk factors of DRESS. Anemia (OR = 0.191, 95 % CI = 0.037-0.984) and body surface area detached involved at day 1 (OR = 2.749, 95 % CI = 1.115-6.778) were independent risk factors of SJS/TEN for severe acute complications and hospital death (P < 0.05). Lymphocytopenia (OR = 0.004, 95 % CI = 0.000-0.553) was a risk factor of AGEP for acute complications (P = 0.028). CONCLUSION This study reveals the clinical features and independent prognostic factors for SCAR, which may be helpful in the clinical management for SCAR patients.
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Kategeaw W, Nakkam N, Kiertiburanakul S, Sukasem C, Tassaneeyakul W, Chaiyakunapruk N. Cost-effectiveness analysis of HLA-B*13:01 screening for the prevention of co-trimoxazole-induced severe cutaneous adverse reactions among HIV-infected patients in Thailand. J Med Econ 2023; 26:1330-1341. [PMID: 37830976 DOI: 10.1080/13696998.2023.2270868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/11/2023] [Indexed: 10/14/2023]
Abstract
Studies found a strong association between HLA-B*13:01 allele and co-trimoxazole-induced severe cutaneous adverse reactions (SCARs). Genetic screening before initiation of co-trimoxazole may decrease the incidence of co-trimoxazole-induced SCARs. This study aims to evaluate the cost-effectiveness of HLA-B*13:01 screening before co-trimoxazole initiation in HIV-infected patients in Thailand. A combination of a decision tree model and a Markov model was used to estimate lifetime costs and outcomes of two strategies including 1) HLA-B*13:01 screening before co-trimoxazole initiation and 2) usual practice from a societal perspective. Alternative drugs are not considered because dapsone (the second-line drug) also presents a genetic risk. Input parameters were obtained from literature, government documents, and part of the TREAT Asia HIV Observational Database (TAHOD). One-way sensitivity analyses and probabilistic analyses were performed to determine robustness of the findings. HLA-B*13:01 screening resulted in 0.0061 quality-adjusted life years (QALYs) loss with an additional cost of 370 THB ($11.84). At the cost-effectiveness threshold of 160,000 THB ($5,112.85), the probability of the genetic screening strategy being cost-effective is 9.54%. This analysis demonstrated that HLA-B*13:01 allele screening before initiation of co-trimoxazole among HIV-infected patients is unlikely to be cost-effective in Thailand. Our findings will help policymakers make an evidence-informed decision making.
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Affiliation(s)
- Warittakorn Kategeaw
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Nontaya Nakkam
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sasisopin Kiertiburanakul
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
- The Thai Severe Cutaneous Adverse Drug Reaction (THAI-SCAR) Research Group, Bangkok, Thailand
| | | | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
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Yordanova K, Pföhler C, Schweitzer LF, Bourg C, Adam L, Vogt T. Etanercept leads to a rapid recovery of a Dabrafenib-/Trametinib-associated toxic epidermal necrolysis-like severe skin reaction. SKIN HEALTH AND DISEASE 2022; 3:e185. [PMID: 36751314 PMCID: PMC9892424 DOI: 10.1002/ski2.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
Targeted therapy with BRAF- and MEK-Inhibitors (BRAFi, MEKi) provides an excellent therapeutic option for patients with malignant melanomas with a BRAF-Mutation. Mild cutaneous adverse events have been common under the BRAF- and MEK-Inhibitor therapy, on the contrary, severe cutaneous adverse reactions to drugs (SCARs) are rarely reported. We present the case of a 59- year-old female patient who after the resection of cutaneous in-transit metastases of a malignant melanoma received one adjuvant cycle of Nivolumab followed by a switch of the therapy to an oral BRAFi/MEKi therapy. 3-4 Weeks after the therapy switch she developed high fever, chills, progredient general weakness, headaches, abdominal complaints, generalised rash as well as thrombocytopaenia, eosinophilia, elevated liver enzymes, declining kidney, and pulmonary function as well as a maculopapular exanthema. She was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS) and quickly started recovery after initiation of a high steroid substitution. Under steroid dose reduction, the exanthema worsened and toxic epidermal necrolysis (TEN) was histologically diagnosed. After a series of unsuccessful therapeutic approaches (high dose steroid, human immunoglobulins and ciclosporin) the patient received a single dose of the TNF-alpha inhibitor etanercept, which led to a quick recovery. This case demonstrates that DRESS and TEN can present a spectrum of possibly transitioning SCARs providing a diagnostic and therapeutic challenge. Nevertheless, in a such complicated therapeutic setting, etanercept may be lifesaving even after multiple previous unsuccessful therapies. This effective approach provides evidence SCARs due to BRAF/MEK targeted therapy may be driven by TNF-alpha.
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Affiliation(s)
- Krista Yordanova
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
| | - Claudia Pföhler
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
| | - Luca F. Schweitzer
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
| | - Catherine Bourg
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
| | - Leonie Adam
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
| | - Thomas Vogt
- Department of Dermatology, Venereology and AllergologySaarland University Medical CenterHomburg/SaarGermany
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Chua KY, Tey KE. Cutaneous adverse drug reactions among people living with human immunodeficiency virus in a tertiary care hospital in Johor, Malaysia. Int J STD AIDS 2022; 33:812-820. [PMID: 35775121 DOI: 10.1177/09564624221103743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cutaneous adverse drug reactions (cADRs) among people living with HIV (PLWH) are common. Data on drug eruptions among PLWH in Malaysia are limited. Thus, our study aimed to determine the clinical patterns of cADRs among PLWH and the risk factors associated with severe cutaneous adverse reactions (SCAR). METHODS A cross-sectional study was conducted among PLWH who developed cADRs presenting to our dermatology clinic from June 2020 to December 2020. The Naranjo scale was used for drug causality assessment. RESULTS A total of 78 PLWH were recruited with a male-to-female ratio of 12:1. The maculopapular eruption was the commonest type of cADRs (75.6%), followed by drug reaction with eosinophilia and systemic symptoms (DRESS) (15.4%). SCAR is defined as a potentially life-threatening, immunologically mediated, drug-induced disease, accounting for 17.9% of the cases. Most of the patients were on antiretroviral therapy (ART) (85.9%), with efavirenz + tenofovir/emtricitabine being the most common combination (80.6%). Efavirenz (51.3%) was the main culprit drug implicated, followed by trimethoprim/sulfamethoxazole (23.1%) and nevirapine (11.5%). CD4 T-cell count <100 cells/μL (p = 0.006) was the independent risk factor for SCAR. Most cases had probable causal relationships with the culprit drugs (84.6%) and were not preventable (93.6%). CONCLUSIONS The commonest cADR seen in PLWH was maculopapular eruption, while efavirenz, trimethoprim/sulfamethoxazole, and nevirapine were the three main implicated drugs. Most of the cases had probable drug causality and were not preventable. PLWH with CD4 count <100 cells/μL were particularly at risk of developing SCAR. Overall, this study showed that immune suppression and polypharmacy as a consequence of opportunistic infection prophylaxis are important factors contributing to the increased risk of ADRs among PLWH.
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Affiliation(s)
- Keow Yin Chua
- Department of Dermatology, 58981Hospital Sultanah Aminah Johor Bahru, Johor, Malaysia
| | - Kwee Eng Tey
- Department of Dermatology, 58981Hospital Sultanah Aminah Johor Bahru, Johor, Malaysia
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Mashayekhi F, Seirafianpour F, Pour Mohammad A, Goodarzi A. Severe and life-threatening COVID-19-related mucocutaneous eruptions: A systematic review. Int J Clin Pract 2021; 75:e14720. [PMID: 34411409 PMCID: PMC8420487 DOI: 10.1111/ijcp.14720] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/08/2021] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Earlier diagnosis and the best management of virus-related, drug-related or mixed severe potentially life-threatening mucocutaneous reactions of COVID-19 patients are of great concern. These patients, especially hospitalised cases, are usually in a complicated situation (because of multi-organ failures), which makes their management more challenging. In such consultant cases, achieving by the definite beneficial management strategies that therapeutically address all concurrent comorbidities are really hard to reach or even frequently impossible. METHODS According to the lack of any relevant systematic review, we thoroughly searched the databases until 5 October 2020 and finally found 57 articles including 93 patients. It is needed to know clinical presentations of these severe skin eruptions, signs and symptoms of COVID in these patients, time of skin rash appearance, classifying drug-related or virus-related skin lesions, classifying the type of skin rash, patients' outcome and concurrent both COVID-19 therapy and skin rash treatment. RESULT Severe and potential life-threatening mucocutaneous dermatologic manifestations of COVID-19 usually may be divided into three major categories: virus-associated, drug-associated, and those with uncertainty about the exact origin. Angioedema, vascular lesions, toxic shock syndrome, erythroderma, DRESS, haemorrhagic bulla, AGEP, EM, SJS and TEN, generalised pustular figurate erythema were the main entities found as severe dermatologic reactions in all categories. CONCLUSION We can conclude vascular injuries may be the most common cause of severe dermatologic manifestations of COVID-19, which is concordant with many proposed hypercoagulation tendencies and systemic inflammatory response syndrome as one of the most important pathomechanisms of COVID-19 so the skin may show these features in various presentations and degrees.
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Affiliation(s)
- Farzaneh Mashayekhi
- Department of General MedicineRasool Akram Medical ComplexIran University of Medical Sciences (IUMS)TehranIran
| | - Farnoosh Seirafianpour
- Student Research CommitteeSchool of MedicineIran University of Medical SciencesTehranIran
| | - Arash Pour Mohammad
- Student Research CommitteeSchool of MedicineIran University of Medical SciencesTehranIran
| | - Azadeh Goodarzi
- Department of DermatologyRasool Akram Medical ComplexIran University of Medical Sciences (IUMS)TehranIran
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Kvedariene V, Orvydaite M, Petraityte P, Rudyte J, Edvardas Tamosiunas A. Inherent clinical properties of non-immediate hypersensitivity to iodinated contrast media. Int J Clin Pract 2021; 75:e14766. [PMID: 34473887 DOI: 10.1111/ijcp.14766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/14/2021] [Accepted: 08/31/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Iodinated contrast media (ICM) is a frequently used compound in radiology. Non-immediate hypersensitivity reactions (HSR) appear when a patient leaves the department and usually are undocumented. True hypersensitivity in this group is rarely proved. METHODS Single-centre 2014-2018 data were retrospectively analysed. HSR to ICM were classified and investigated according to the time of occurrence (immediate <1 hour, non-immediate >1 hour). ENDA questionnaire and skin tests (prick or intradermal test) were performed according to ENDA/EAACI recommendations. RESULTS 69 patients with a clinical history of HSR to ICM were identified, 72.46% were females (n = 50). The average age was 56 (SD ± 13.16) years. Non-immediate HSR occurred in 28.99% (n = 20) patients. The suspected culprit drugs were: iodixanol 20% (n = 4), iopromide 5% (n = 1), diatrizoate 10% (n = 2) and iohexol 10% (n = 2). Among non-immediate HSR 96.00% (n = 19) of patients had skin rashes. A statistically significant correlation was found between the clinical symptoms and the type of reaction (p-value <0.05): isolated skin manifestations mostly occurred in non-immediate HSR 75.00% (n = 15). Only 13.04% (n = 9) of all the patients were proved to be allergic to a certain ICM after the proposed diagnostic workup. CONCLUSIONS One-third of the hypersensitivity reactions investigated were classified as non-immediate type. Most of them manifested with isolated skin symptoms. The most frequent culprit drug encountered was iodixanol. The overall non-immediate hypersensitivity confirmation rate after diagnostic evaluation was only 15%.
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Affiliation(s)
- Violeta Kvedariene
- Institute of Clinical Medicine, Clinic of Chest Diseases, Allergology and Immunology, Vilniaus University Hospital Santaros Klinikos, Vilnius, Lithuania
- Faculty of Medicine, Institute of Biomedical Science, Vilnius, Lithuania
| | | | | | - Justina Rudyte
- Institute of Clinical Medicine, Clinic of Chest Diseases, Allergology and Immunology, Vilniaus University Hospital Santaros Klinikos, Vilnius, Lithuania
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Algirdas Edvardas Tamosiunas
- Faculty of Medicine, Institute of Biomedical Science, Vilnius, Lithuania
- Centre of Radiology and Nuclear Medicine, Vilniaus University Hospital Santaros Klinikos, Vilnius, Lithuania
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12
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Sussman M, Napodano A, Huang S, Are A, Hsu S, Motaparthi K. Pustular Psoriasis and Acute Generalized Exanthematous Pustulosis. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1004. [PMID: 34684041 PMCID: PMC8538083 DOI: 10.3390/medicina57101004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/12/2021] [Accepted: 09/16/2021] [Indexed: 01/15/2023]
Abstract
The similarity between pustular psoriasis (PP) and acute generalized exanthematous pustulosis (AGEP) poses problems in the diagnosis and treatment of these two conditions. Significant clinical and histopathologic overlap exists between PP and AGEP. PP is an inflammatory disorder that has numerous clinical subtypes, but all with sterile pustules composed of neutrophils. AGEP is a severe cutaneous adverse reaction that is also characterized by non-follicular sterile pustules. Clinical features that suggest a diagnosis of PP over AGEP include a history of psoriasis and the presence of scaling plaques. Histologically, eosinophilic spongiosis, vacuolar interface dermatitis, and dermal eosinophilia favor a diagnosis of AGEP over PP. Importantly, PP and AGEP vary in clinical course and treatment. PP treatment involves topical steroids, oral retinoids, and systemic immunosuppressants. Newer therapies targeting IL-36, IL-23, IL-1, and PDE-4 have been investigated. The removal of the offending agent is a crucial part of the treatment of AGEP.
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Affiliation(s)
- Morgan Sussman
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA; (M.S.); (S.H.); (S.H.)
| | - Anthony Napodano
- Department of Dermatology, University of Florida College of Medicine, Gainesville, FL 32610, USA;
| | - Simo Huang
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA; (M.S.); (S.H.); (S.H.)
| | - Abhirup Are
- College of Medicine, University of Florida, Gainesville, FL 32606, USA;
| | - Sylvia Hsu
- Department of Dermatology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA; (M.S.); (S.H.); (S.H.)
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, FL 32610, USA;
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13
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Barootes HC, Peebles ER, Matsui D, Rieder M, Abuzgaia A, Mohammed JA. Severe Generalized Bullous Fixed Drug Eruption Treated with Cyclosporine: A Case Report and Literature Review. Case Rep Dermatol 2021; 13:154-163. [PMID: 33790760 PMCID: PMC7989674 DOI: 10.1159/000513469] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/29/2020] [Indexed: 02/05/2023] Open
Abstract
Generalized bullous fixed drug eruptions (GBFDEs) are rare in the paediatric population. We present the case of a 7-year-old girl with GBFDE believed to be secondary to oral ibuprofen, who experienced rapid resolution of lesions and cessation of blistering with a 3-week course of oral cyclosporine. To the best of our knowledge, this is the first report of a paediatric case of GBFDE treated with cyclosporine. In our report, we review published cases of GBFDE in children, and all adult cases managed with cyclosporine.
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Affiliation(s)
- Hailey C Barootes
- Department of Paediatrics, Children's Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Erin R Peebles
- Department of Paediatrics, Children's Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Doreen Matsui
- Department of Paediatrics, Children's Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael Rieder
- Department of Paediatrics, Division of Paediatric Clinical Pharmacology, Children's Hospital, London Health Sciences Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Awatif Abuzgaia
- Department of Paediatrics, Division of Paediatric Clinical Pharmacology, Children's Hospital, London Health Sciences Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Javed A Mohammed
- Department of Paediatrics, Children's Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
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14
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Adair K, Meng X, Naisbitt DJ. Drug hapten-specific T-cell activation: Current status and unanswered questions. Proteomics 2021; 21:e2000267. [PMID: 33651918 DOI: 10.1002/pmic.202000267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 11/07/2022]
Abstract
Drug haptens are formed from the irreversible, covalent binding of drugs to nucleophilic moieties on proteins, which can warrant adverse reactions in the body including severe delayed-type, T-cell mediated, drug hypersensitivity reactions (DHRs). While three main pathways exist for the activation of T-cells in DHRs, namely the hapten model, the pharmacological interaction model and the altered peptide repertoire model, the exact antigenic determinants responsible have not yet been defined. In recent years, progress has been made using advanced mass spectrometry-based proteomic methods to identify protein carriers and characterise the structure of drug-haptenated proteins. Since genome-wide association studies discovered a link between human leukocyte antigens (HLA) and an individual's susceptibility to DHRs, much effort has been made to define the drug-associated HLA ligands driving T-cell activation, including the elution of natural HLA peptides from HLA molecules and the generation of HLA-binding peptides. In this review, we discuss our current methodology used to design and synthesise drug-modified HLA ligands to investigate their immunogenicity using T-cell models, and thus their implication in drug hypersensitivity.
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Affiliation(s)
- Kareena Adair
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Liverpool, UK
| | - Xiaoli Meng
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Liverpool, UK
| | - Dean J Naisbitt
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Liverpool, UK
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15
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Rollinson V, Turner R, Pirmohamed M. Pharmacogenomics for Primary Care: An Overview. Genes (Basel) 2020; 11:E1337. [PMID: 33198260 PMCID: PMC7696803 DOI: 10.3390/genes11111337] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022] Open
Abstract
Most of the prescribing and dispensing of medicines happens in primary care. Pharmacogenomics (PGx) is the study and clinical application of the role of genetic variation on drug response. Mounting evidence suggests PGx can improve the safety and/or efficacy of several medications commonly prescribed in primary care. However, implementation of PGx has generally been limited to a relatively few academic hospital centres, with little adoption in primary care. Despite this, many primary healthcare providers are optimistic about the role of PGx in their future practice. The increasing prevalence of direct-to-consumer genetic testing and primary care PGx studies herald the plausible gradual introduction of PGx into primary care and highlight the changes needed for optimal translation. In this article, the potential utility of PGx in primary care will be explored and on-going barriers to implementation discussed. The evidence base of several drug-gene pairs relevant to primary care will be outlined with a focus on antidepressants, codeine and tramadol, statins, clopidogrel, warfarin, metoprolol and allopurinol. This review is intended to provide both a general introduction to PGx with a more in-depth overview of elements relevant to primary care.
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16
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17
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Yang CW, Cho YT, Hsieh YC, Hsu SH, Chen KL, Chu CY. The interferon-γ-induced protein 10/CXCR3 axis is associated with human herpesvirus-6 reactivation and the development of sequelae in drug reaction with eosinophilia and systemic symptoms. Br J Dermatol 2020; 183:909-919. [PMID: 32037509 DOI: 10.1111/bjd.18942] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a condition caused by a drug-induced immune response. Previous reports have found that CXCL10, also known as interferon-γ-induced protein (IP)-10, may participate in the pathogenesis of cutaneous adverse drug reactions. However, the exact role of IP-10 in DRESS and Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) has remained unknown. OBJECTIVES This comparative prospective cohort study aimed to ascertain the roles of the IP-10/CXCR3 axis in DRESS and SJS/TEN. METHODS Plasma IP-10 levels were analysed, and univariate analyses were conducted to assess the relationship between IP-10, human herpesvirus (HHV)-6 reactivation and the development of long-term sequelae. We also performed immunohistochemical staining using skin specimens and flow cytometry to determine the expression of CXCR3 in peripheral blood mononuclear cells (PBMCs). RESULTS Significantly higher plasma IP-10 levels were observed in patients with DRESS with long-term sequelae (effect size 0·81) and also in those with HHV-6 reactivation (effect size 0·83). By immunohistochemistry, more abundant IP-10+ and CXCR3+ cells were demonstrated in the skin lesions of patients with DRESS with HHV-6 reactivation. The percentages of CLA+ CXCR3+ CD4+ cells and CLA+ CXCR3+ CD8+ cells were also higher in the PBMCs of HHV-6-reactivated patients with DRESS than in those of patients with SJS/TEN. CONCLUSIONS Higher plasma IP-10 levels are associated with the development of long-term sequelae in DRESS. Higher IP-10/CXCR3 expression in skin and more abundant CLA+ CXCR3+ CD4+ cells and CLA+ CXCR3+ CD8+ cells were observed in patients with DRESS with HHV-6 reactivation. The IP-10/CXCR3 axis is associated with HHV-6 reactivation and development of long-term sequelae in DRESS. What is already known about this topic? Elevated levels of interferon-γ-induced protein-10 (IP-10) have been observed in patients with drug reaction with eosinophilia and systemic symptoms (DRESS) and Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). Patients with DRESS tend to develop long-term autoimmune sequelae, including type 1 diabetes and autoimmune thyroiditis. IP-10 has been associated with these autoimmune diseases in previous studies. What does this study add? The patients with DRESS with HHV-6 reactivation exhibited higher levels of IP-10 in the plasma and skin than the patients with DRESS without HHV-6 reactivation and the patients with SJS/TEN. Patients with DRESS with higher plasma IP-10 levels tended to develop sequelae during long-term follow-up. What is the translational message? IP-10 is a useful biomarker to predict the development of long-term sequelae in patients with DRESS. Linked Comment: Belloón and Kardaun. Br J Dermatol 2020; 183:804-805.
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Affiliation(s)
- C-W Yang
- Department of Dermatology, Cathay General Hospital, Taipei, Taiwan.,Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Y-T Cho
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Y-C Hsieh
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - S-H Hsu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Dermatology, National Taiwan University Hospital, Yun-Lin Branch, Douliou, Taiwan
| | - K-L Chen
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - C-Y Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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18
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Abstract
Cutaneous adverse drug reactions are unpredictable and include various different skin conditions of varying degrees of severity. The most concerning are usually referred to as severe cutaneous adverse reactions (SCARs) and include acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome (DiHS) or hypersensitivity syndrome (HSS), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). All are delayed type IV hypersensitivity reactions in which a T-cell-mediated drug-specific immune response is responsible for causing the disease. Nonetheless, specific T-cell subpopulations develop in response to certain environmental conditions and produce cytokines that orchestrate the various phenotypes. Cytotoxic T lymphocytes (CTLs), T-helper type 1 (Th1), Th2, Th17, and regulatory T cells (Treg), among other T-cell subpopulations, participate in the development of SCAR phenotypes. Cell subpopulations belonging to the innate immune system, comprising natural killer cells, innate lymphoid cells, monocytes, macrophages and dendritic cells, can also participate in shaping specific immune responses in various clinical conditions. Additionally, tissue-resident cells, including keratinocytes, can contribute to epidermal damage by secreting chemokines that attract pro-inflammatory immunocytes. The final phenotypes in each clinical entity result from the complex interactions between a variety of cell lineages, their products, soluble mediators and genetic and environmental factors. Although the pathophysiology of these reactions is not fully understood, intensive research in recent years has led to major progress in our understanding of the contribution of certain cell types and soluble mediators to the variability of SCAR phenotypes.
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Affiliation(s)
- Teresa Bellón
- La Paz Hospital Health Research Institute-IdiPAZ, Pº Castellana 261, 28046, Madrid, Spain.
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19
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Tang JT, Li YY, Zhang Y, Liu J, Guan W, Wang RR, He LP, Zhang JB, Kuang YQ. HIV infection confers distinct mechanisms in severe drug eruption: Endogenous virus activation with aberrant Th2/Th1 and CD8 + T cells function. Clin Exp Pharmacol Physiol 2020; 47:1005-1013. [PMID: 31991490 DOI: 10.1111/1440-1681.13266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/19/2020] [Accepted: 01/23/2020] [Indexed: 12/13/2022]
Abstract
Severe drug eruption (SDE), a common skin disease, becomes dangerous when it occurs in patients with human immunodeficiency virus (HIV). However, the molecular mechanisms are poorly understood. Forty patients including HIV+ SDE+ (n = 15), HIV- SDE+ (n = 15) and HIV+ SDE- (n = 10) subjects were enrolled in our study. All HIV+ patients were at acquired immune deficiency syndrome (AIDS) stage. Serum levels of TNF-α, IFN-γ, IL-4, IL-13, IL-6, CXCL9, and CCL17 were quantified by ELISA. Epstein-Barr virus (EBV) and cytomegalovirus (CMV) loads were quantified by RT-qPCR. CD4, CD8, Th1, Th2, TNF-α-CD8, and IFN-γ-CD8 T cell populations were measured by flow cytometry. Levels of biochemical indexes in HIV+ SDE+ patients were significantly different from in HIV- SDE+ patients (P < .05). EBV and CMV viral loads were significantly higher in HIV+ SDE+ patients, but not in HIV- SDE+ patients (P < .05). Inflammatory cytokines TNF-α and IFN-γ were significantly elevated in HIV+ SDE+ patients (P < .05). Th2/Th1 populations and TNF-α secreting or IFN-γ secreting CD8+ T cells, were significantly up-regulated in HIV+ SDE+ patients compared to HIV- SDE+ patients (P < .05). Conversely, the CD4/CD8 ratio was significantly down-regulated in HIV+ SDE+ patients compared to HIV- SDE+ patients (P < .05). HIV infection confers distinct clinical phenotypes and immune inflammatory mechanisms in SDE. Sustained EBV and CMV activation, unbalanced Th2/Th1 and overactive CD8+ T cells mediating a pro-inflammatory response could act as distinct mechanisms in the aggravation of SDE in HIV+ SDE+ patients.
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Affiliation(s)
- Jun-Ting Tang
- Department of Dermatology and Venerology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yu-Ye Li
- Department of Dermatology and Venerology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yi Zhang
- Department of Chinese Medicine, Yunnan University of Chinese Medicine, Kunming, China
| | - Jun Liu
- Department of HIV/AIDS, Third People's Hospital of Kunming, Kunming, China
| | - Wei Guan
- Department of HIV/AIDS, Third People's Hospital of Kunming, Kunming, China
| | - Rui-Rui Wang
- Department of Chinese Medicine, Yunnan University of Chinese Medicine, Kunming, China
| | - Li-Ping He
- School of Public Health, Kunming Medical University, Kunming, China
| | - Jian-Bo Zhang
- Department of Dermatology and Venerology, Second People's Hospital of Dali, Dali, China
| | - Yi-Qun Kuang
- NHC Key Laboratory of Drug Addiction Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China.,Scientific Research Laboratory Center, First Affiliated Hospital of Kunming Medical University, Kunming, China
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20
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Copaescu AM, Bouffard D, Masse MS. Acute generalized exanthematous pustulosis simulating toxic epidermal necrolysis: case presentation and literature review. Allergy Asthma Clin Immunol 2020; 16:9. [PMID: 32042284 PMCID: PMC7001236 DOI: 10.1186/s13223-020-0407-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 01/22/2020] [Indexed: 12/18/2022] Open
Abstract
Background Acute generalized exanthematous pustulosis (AGEP) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions. These rare conditions differ in clinical presentation, pathological features, treatment and prognosis, but overlap has been described implying a challenging clinical management. Case presentation We describe a case of overlap between TEN and AGEP probably secondary to beta-lactams in a 77-year-old patient treated for a complicated cholangitis. We review the diagnosis and the management of these two conditions. The diagnosis of TEN was suggested by the initial clinical presentation with severe hemodynamic instability, skin detachment, positive Nikolsky sign and mucosal involvement. However, the skin biopsy as well as the rapid improvement of the skin lesions were discriminative for AGEP. This indicated an overlap presentation. Unfortunately, the patient refused allergy investigations in order to find the culprit drug. Medical photographs, proper physical examination and histopathological results are integrated. Conclusion Despite clinical features indicating a diagnosis of TEN, histopathology was conclusive for AGEP thus indicating a possible clinical-pathological overlap between the two conditions, a scarcely described situation in the medical literature. To our knowledge, this is one of the few cases that portrays a TEN–AGEP overlap probably secondary to Piperacillin Tazobactam. Understanding the immunological implications of these conditions can help us better distinguish and manage these severe reactions.
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Affiliation(s)
- Ana-Maria Copaescu
- 1Allergy and Immunology Department, Centre Hospitalier de l'Université de Montréal (CHUM), 264 Boulevard René-Lévesque E, Montréal, QC H2X 1P1 Canada
| | - Danielle Bouffard
- 2Pathology Department, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | - Marie-Soleil Masse
- 1Allergy and Immunology Department, Centre Hospitalier de l'Université de Montréal (CHUM), 264 Boulevard René-Lévesque E, Montréal, QC H2X 1P1 Canada
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21
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Gelincik A, Cavkaytar O, Kuyucu S. An Update on the Management of Severe Cutaneous Drug Hypersensitivity Reactions. Curr Pharm Des 2019; 25:3881-3901. [DOI: 10.2174/1381612825666191106115556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/01/2019] [Indexed: 12/15/2022]
Abstract
Severe cutaneous drug hypersensitivity reactions involve of different mechanisms , some of which are
life-threatening, such as Stevens-Johnson syndrome/toxic epidermal necrolysis, drug reaction with eosinophilia
and systemic symptoms, acute generalized exanthematous pustulosis, generalized bullous fixed drug eruptions,
serum sickness and serum sickness-like reaction and drug-induced vasculitis. These reactions may have substantial
morbidity and mortality. In the past years, successive studies have provided new evidence regarding the
pathogenesis of some of these severe reactions and revealed that underlying mechanisms are highly variable.
Since these reactions have unique presentations and distinct pathomechanisms, the treatment methods and response
rates might be different among various entities. Although supportive and local therapies are sufficient in
some of these reactions, targeted immunosuppressive treatments and even mechanistic therapies such as plasmapheresis
may be required in severe ones. However, there is still insufficient evidence to support the best treatment
options for these patients since number of patients and large-scale studies are limited. In this review, conventional
and new treatment options for severe cutaneous drug hypersensitivity reactions are presented in detail in
order to provide the contemporary approaches to lessen the morbidity and mortality relevant to these severe iatrogenic
diseases.
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Affiliation(s)
- Aslı Gelincik
- Division of Immunology and Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University, Faculty of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Mersin University, Faculty of Medicine, Mersin, Turkey
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22
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Paulmann M, Mockenhaupt M. Severe skin reactions: clinical picture, epidemiology, etiology, pathogenesis, and treatment. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s40629-019-00111-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
A rash is a disseminated eruption of cutaneous lesions with great variation in appearance, cause, and severity. When the physician is facing a rash, the history and physical examination of the patient are extremely important for the identification of the disease and its causal agent. There are various causes for a rash, which may be infectious, allergic, or rheumatologic, besides many others. Rashes associated with mucosal ulcers may have causes related to viral and bacterial infections or drug reactions. They may be associated with measles; erythema infectiosum; roseola infantum; rubella; hand, foot, and mouth disease; pityriasis rosea; dengue fever; chikungunya; zika; scarlet fever; meningococcal diseases; syphilis; and exanthematous drug eruptions.
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Affiliation(s)
- Maria Cristina Ribeiro de Castro
- Sector of Dermatology and Post-Graduation Course in Dermatology, University Hospital and School of Medicine, Federal University of Rio de Janeiro, Brazil
| | - Marcia Ramos-E-Silva
- Sector of Dermatology and Post-Graduation Course in Dermatology, University Hospital and School of Medicine, Federal University of Rio de Janeiro, Brazil.
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24
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Abstract
Drug eruptions are among the great masqueraders that sometimes cause diagnostic challenges in clinical practice. Pharmacologic agents may induce skin changes, sharing the same pathophysiologic mechanisms of specific dermatoses, or inducing drug eruptions with different pathologic mechanisms that have similar clinical presentations. The former conditions are usually called drug-induced skin diseases, whereas the latter conditions are termed "dermatosis-like drug eruptions." Both types are great imitators in dermatologic practice and can be easily misdiagnosed as other diseases or lead to unrecognized causative agents.
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Affiliation(s)
- Chia-Yu Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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25
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Kuvardina HO, Kharlamova FS, Polesko IV, Shamsheva OV, Ostapuschenko OS. The role of mixed Mycoplasma and Herpesvirus infections in case of skin lesions in children. CHILDREN INFECTIONS 2019. [DOI: 10.22627/2072-8107-2019-18-3-5-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Numerous literature data show the role of mycoplasma infection in the development of non-respiratory lesions of various organs and systems, including the skin. Herpesvirus and mycoplasma infections can trigger the development of immune-mediated inflammatory reactions of the skin and mucous membranes — erythema multiforme exudative, Stevens-Johnson syndrome, vesicular pustular dermatosis — Sneddon-Wilkinson syndrome, etc.In order to study the frequency and nature of skin lesions with mycoplasmosis combined with herpesvirus infection, 45 patients aged 3 to 15 years of life were observed. A comprehensive clinical and laboratory study revealed skin lesions in 27 patients associated with current mycoplasma and herpesvirus infections. Thus, multiforme exudative erythema in the small form variant was diagnosed in 13 patients, skin vasculitis in 4, hemorrhagic purpura in 3, urticaria rash in 3, erythema nodosum in 2, mucositis in 2 children. In 18 children, a combined mycoplasma and herpesvirus infection was established. In 9 children, a mono infection was detected (in 5 — herpes virus and in 4 — mycoplasma).All observed patients showed antibodies to smooth muscle antigens in titers from 1:80 to 1:160 (normal 1:40) and in the vast majority (in 24 patients) — antibodies to vascular endothelial antigens in titers from 1:80 to 1:320 (with the norm of 1:40). Compaction of the intima-media complex was detected in 6 patients with monoinfection and in 16 patients with co-infection, according to ultrasound duplex scanning of the vessels of the brachiocephalic department.Thus, for various immuno-inflammatory, allergic skin diseases, screening for infections, in particular, mycoplasma and herpesvirus, is necessary to optimize treatment.
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Affiliation(s)
- H. O. Kuvardina
- Russian National Research Medical University named after N.I. Pirogov, Ministry of Health of the Russian Federation
| | - F. S. Kharlamova
- Russian National Research Medical University named after N.I. Pirogov, Ministry of Health of the Russian Federation
| | - I. V. Polesko
- Russian National Research Medical University named after N.I. Pirogov, Ministry of Health of the Russian Federation
| | - O. V. Shamsheva
- Russian National Research Medical University named after N.I. Pirogov, Ministry of Health of the Russian Federation
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Böhm R, Proksch E, Schwarz T, Cascorbi I. Drug Hypersensitivity. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:501-512. [PMID: 30135011 DOI: 10.3238/arztebl.2018.0501] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 05/01/2017] [Accepted: 06/07/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Adverse drug reactions (ADRs) can be divided into pharmacological ADRs (type A) and hypersensitivity reactions (type B). Type B reactions can be further subdivided into immediate (<1 h, urticaria, anaphylaxis) and delayed reactions (>1 h, variable manifestation like exanthema, hepatitis, cytopenias). Prevention of hypersensitivity is often still a challenge. METHODS Selective literature search in Medline and Google Scholar as well as research in ADR databases like OpenVigil or SIDER. RESULTS Laboratory tests ([specific] IgE, lymphocyte transformation test), histological examination, dermatological tests (prick tests, epicutaneous testing) and-under certain circumstances-provocation tests can be used for diagnostics. There are only a few pharmacogenetic biomarkers to predict hypersensitivity reactions. Currently, testing for defined HLA genes is mandatory before prescription of abacavir and before the use of carbamazepine in Han Chinese or Thai patients. Immediate discontinuation of the trigger is essential in all allergic hypersensitivity reactions. Immediate reactions are treated with antihistamines, glucocorticoids and occasionally with epinephrine. Delayed reactions are usually treated with glucocorticoids. CONCLUSION Careful, structured diagnostics in case of suspected hypersensitivity together with adequate documentation (allergy passport) is necessary in order to avoid incidents in patients receiving subsequent treatment. Consistent use of existing resources (diagnostics and documentation) can help to avoid hypersensitivity reactions or to rapidly recognize and treat them, respectively.
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Affiliation(s)
- Ruwen Böhm
- Institute of Clinical and Experimental Pharmacology at the University Medical Center Schleswig-Holstein, Kiel; Department of Dermatology, Allergology and Venerology, University Medical Center Schleswig-Holstein, Kiel
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Abrams E, Netchiporouk E, Miedzybrodzki B, Ben-Shoshan M. Antibiotic Allergy in Children: More than Just a Label. Int Arch Allergy Immunol 2019; 180:103-112. [DOI: 10.1159/000501518] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/17/2019] [Indexed: 11/19/2022] Open
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Patterson A, Autry E, Kuhn R, Wurth M. Ivacaftor drug desensitization. Pediatr Pulmonol 2019; 54:672-674. [PMID: 30912311 DOI: 10.1002/ppul.24319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/05/2019] [Accepted: 03/06/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Alexander Patterson
- Department of Medicine, University of Kentucky HealthCare, Lexington, Kentucky
| | - Elizabeth Autry
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky.,Department of Pharmacy Practice and Sciences, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Robert Kuhn
- Department of Pharmacy Practice and Sciences, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Mark Wurth
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky
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Abstract
Stevens-Johnson syndrome and toxic epidermal necrolysis represent a spectrum of severe cutaneous adverse reactions that carry the potential for severe, long-term adverse effects, including death. Although medications are most commonly implicated in the development of these diseases, other factors, including infection and genetics, play a role. Management is generally supportive in nature and includes maintenance of the patient's airway, breathing, and circulation. Special disease considerations include the use of skin barrier management, unique infection prevention measures, and systemic immunomodulatory therapies.
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Cutaneous Adverse Effects of Diabetes Mellitus Medications and Medical Devices: A Review. Am J Clin Dermatol 2019; 20:97-114. [PMID: 30361953 DOI: 10.1007/s40257-018-0400-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Diabetes mellitus is one of the most prevalent chronic diseases in the USA. If uncontrolled, diabetes can lead to devastating complications. Diabetes medications and medical devices largely contribute to the significant financial expense that the disease inflicts on affected individuals and society. Alongside significant economic burden, there are numerous cutaneous adverse effects associated with diabetes medications and medical devices. Despite the large and increasing number of individuals living with diabetes and the wide use of the related medications and medical devices, there is limited literature that comprehensively documents their cutaneous adverse effects. These cutaneous adverse effects are significant as they can worsen glycemic control, increase disease distress, and may increase risk of associated complications. Thus, it is important that providers can recognize these cutaneous adverse effects, identify the culprit agents, and can properly manage them. In this article, we provide a critical review of the cutaneous adverse effects of medications and devices used in the management of diabetes and provide insight into risk factors and prevention and an overview of therapeutic management. An emphasis is placed on clinical recognition and treatment for use of the medical providers who, regardless of practice setting, will treat patients with diabetes.
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Castellazzi ML, Esposito S, Claut LE, Daccò V, Colombo C. Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome in two young children: the importance of an early diagnosis. Ital J Pediatr 2018; 44:93. [PMID: 30111350 PMCID: PMC6094901 DOI: 10.1186/s13052-018-0535-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/06/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a serious life-treating condition characterized by skin eruption, fever, haematologic abnormalities, and multi-organ involvement that can be fatal if unrecognized, especially in patients with liver failure. Diagnosis may be difficult because it is rarely described in children and can mimic many different conditions. CASE PRESENTATION We report two cases of DRESS syndrome due to prolonged antibiotic treatment in young children in whom recovery occurred following different therapeutic approaches. A previously healthy 5-year-old boy had been receiving intravenous vancomycin for right wrist and left elbow osteomyelitis and developed DRESS syndrome on day 30. The patient achieved a complete resolution of all symptoms with pulse methylprednisolone followed by oral prednisone. A 4-year-old girl with cystic fibrosis, pancreatic insufficiency, chronic pulmonary colonization by Gram-positive bacteria admitted for pulmonary exacerbation was treated with intravenous piperacillin-tazobactam and tobramycin. After 14 days of treatment, she developed DRESS syndrome: antibiotic treatment was therefore stopped, and without any further therapy, a progressive resolution of the patient's clinical features was observed within 7 days, while the normalization of laboratory abnormalities was achieved at 14 days. CONCLUSIONS Our cases highlight that paediatricians should be aware of the clinical presentations of and therapeutic approaches for DRESS syndrome, especially in children receiving long-term antibiotic treatment. The removal of the offending drug is crucial and may be the only life-saving measure. In more aggressive cases, corticosteroid or other immunosuppressive drugs should be considered to achieve the best outcome.
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Affiliation(s)
- Massimo Luca Castellazzi
- Cystic Fibrosis Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, 20122 Milan, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06132 Perugia, Italy
| | - Laura Elisabetta Claut
- Cystic Fibrosis Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, 20122 Milan, Italy
| | - Valeria Daccò
- Cystic Fibrosis Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, 20122 Milan, Italy
| | - Carla Colombo
- Cystic Fibrosis Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, 20122 Milan, Italy
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