1
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Caux F, Patsatsi A, Karakioulaki M, Antiga E, Baselga E, Borradori L, Caproni M, Cardones AR, Chandran NS, Dräger S, Drenovska K, Goebeler M, Günther C, Hofmann SC, Ioannides D, Joly P, Marinović B, Mariotti EB, Marzano AV, Morel KD, Murrell DF, Prost C, Sárdy M, Setterfield J, Skiljevic D, Uzun S, Vassileva S, Zambruno G, Schmidt E. S2k guidelines on diagnosis and treatment of linear IgA dermatosis initiated by the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol 2024; 38:1006-1023. [PMID: 38421060 DOI: 10.1111/jdv.19880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/19/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Linear IgA dermatosis (LAD) is a rare subepidermal autoimmune bullous disease (AIBD) defined by predominant or exclusive immune deposits of immunoglobulin A at the basement membrane zone of skin or mucous membranes. This disorder is a rare, clinically and immunologically heterogeneous disease occurring both in children and in adults. The aim of this project is to present the main clinical features of LAD, to propose a diagnostic algorithm and provide management guidelines based primarily on experts' opinion because of the lack of large methodologically sound clinical studies. METHODS These guidelines were initiated by the European Academy of Dermatology and Venereology (EADV) Task Force Autoimmune Bullous Diseases (AIBD). To achieve a broad consensus for these S2k consensus-based guidelines, a total of 29 experts from different countries, both European and non-European, including dermatologists, paediatric dermatologists and paediatricians were invited. All members of the guidelines committee agreed to develop consensus-based (S2k) guidelines. Prior to a first virtual consensus meeting, each of the invited authors elaborated a section of the present guidelines focusing on a selected topic, based on the relevant literature. All drafts were circulated among members of the writing group, and recommendations were discussed and voted during two hybrid consensus meetings. RESULTS The guidelines summarizes evidence-based and expert opinion-based recommendations (S2 level) on the diagnosis and treatment of LAD. CONCLUSION These guidelines will support dermatologists to improve their knowledge on the diagnosis and management of LAD.
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Affiliation(s)
- Frédéric Caux
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - Aikaterini Patsatsi
- Autoimmune Bullous Diseases Unit, 2nd Department of Dermatology, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Meropi Karakioulaki
- Department of Dermatology and Venereology, Medical Center, University Hospital Freiburg, Freiburg, Germany
| | - Emiliano Antiga
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Eulalia Baselga
- Department of Dermatology, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Luca Borradori
- Department of Dermatology, University of Bern, Inselspital, Berne, Switzerland
| | - Marzia Caproni
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Adela R Cardones
- Division of Dermatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nisha Suyien Chandran
- Division of Dermatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Sören Dräger
- Department of Dermatology, Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Kossara Drenovska
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University-Sofia, Sofia, Bulgaria
| | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Claudia Günther
- Department of Dermatology, University Hospital, Technical University Dresden, Dresden, Germany
| | - Silke C Hofmann
- Department of Dermatology, Allergy and Dermatosurgery, Helios University Hospital Wuppertal, University Witten-Herdecke, Wuppertal, Germany
| | - Dimitrios Ioannides
- 1st Department of Dermatology, Aristotle University School of Medicine, Hospital of Skin and Venereal Diseases, Thessaloniki, Greece
| | - Pascal Joly
- Department of Dermatology, Rouen University Hospital, INSERM 1234, Normandie University, Rouen, France
| | - Branka Marinović
- Department of Dermatology and Venereology, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Elena Biancamaria Mariotti
- Department of Health Sciences, Section of Dermatology, Azienda USL Toscana Centro, Rare Diseases Unit, European Reference Network-Skin Member, University of Florence, Florence, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Kimberly D Morel
- Departments of Dermatology and Pediatrics at Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Catherine Prost
- Department of Dermatology and Referral Center for Autoimmune Bullous Diseases, Groupe Hospitalier Paris Seine-Saint-Denis, AP-HP and University Paris 13, Bobigny, France
| | - Miklós Sárdy
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Jane Setterfield
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Host-Microbiome Interactions, King's College London Faculty of Dentistry, Oral & Craniofacial Sciences, London, UK
| | - Dusan Skiljevic
- Department of Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Soner Uzun
- Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Snejina Vassileva
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University-Sofia, Sofia, Bulgaria
| | - Giovanna Zambruno
- Genodermatosis Unit, Translational Pediatrics and Clinical Genetics Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Enno Schmidt
- Department of Dermatology, Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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Khan S, Bae E, Mathieu RJ, Elco C, Massoud CM, Firoz EF. Revisiting the "jelly-roll" technique: New utility in diagnosing linear IgA bullous dermatosis mimicking toxic epidermal necrolysis. JAAD Case Rep 2023; 41:75-76. [PMID: 37877093 PMCID: PMC10590713 DOI: 10.1016/j.jdcr.2023.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Affiliation(s)
- Samavia Khan
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, New Jersey
| | - Edward Bae
- Department of Dermatology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Regine J. Mathieu
- Department of Dermatology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Christopher Elco
- Department of Dermatology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Pathology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Cathy M. Massoud
- Department of Dermatology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Pathology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Elnaz F. Firoz
- Department of Dermatology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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3
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Kwinta BD, Queen D, Husain S, Gallitano SM. Drug-Induced Linear IgA Bullous Dermatosis Mimicking Stevens-Johnson Syndrome Treated With Etanercept: A Case Report. Am J Dermatopathol 2023; 45:189-191. [PMID: 36729131 DOI: 10.1097/dad.0000000000002352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/22/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Bradley D Kwinta
- Columbia University, Vagelos College of Physicians and Surgeons, New York, NY
| | - Dawn Queen
- Department of Dermatology, Columbia University Irving Medical Center, New York, NY; and
| | - Sameera Husain
- Department of Dermatology, Division of Dermatopathology, Columbia University Irving Medical Center, New York, NY
| | - Stephanie M Gallitano
- Department of Dermatology, Columbia University Irving Medical Center, New York, NY; and
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4
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Salah E. TEN mimics: Classification and practical approach to toxic epidermal necrolysis-like dermatoses. Indian J Dermatol Venereol Leprol 2022; 89:337-346. [PMID: 36688885 DOI: 10.25259/ijdvl_244_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
Toxic epidermal necrolysis (TEN) is an acute life-threatening dermatologic emergency. However, many dermatoses can present with a TEN-like eruption. Those "TEN-mimics" are a true diagnostic challenge and an alarming differential diagnosis to such a serious condition. Herein, we will expose and classify the landscape of TEN-mimics. Also, the key differentiating clinical and/or laboratory points will be highlighted to help an accurate diagnosis of either a TEN or a TEN-like presentation.
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Affiliation(s)
- Eman Salah
- Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Zagazig University, Egypt
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5
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Muacevic A, Adler JR. Linear Immunoglobulin A (IgA) Bullous Dermatosis Mimicking Stevens-Johnson Syndrome. Cureus 2022; 14:e30309. [PMID: 36381872 PMCID: PMC9650960 DOI: 10.7759/cureus.30309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 01/24/2023] Open
Abstract
Linear IgA bullous dermatosis (LABD) is a rare autoimmune blistering disease characterized by linear IgA deposition along the dermo-epidermal junction on direct immunofluorescence (DIF). LABD appears clinically as erythematous polycyclic lesions in younger patients but can show considerable phenotypic heterogeneity in older patients, often leading to misdiagnoses such as bullous pemphigoid, pemphigus vulgaris, Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), or other bullous conditions. Cases of LABD mimicking SJS/TEN require prompt skin biopsies for histopathology and DIF for disease differentiation and medical decision-making. In cases of suspected drug-induced LABD or SJS/TEN, identification and removal of the offending agent are paramount. The preferred treatment for LABD is oral dapsone, while SJS/TEN may respond better to cyclosporine or a combination of intravenous immunoglobulin and systemic corticosteroids. This case highlights the rare occurrence of LABD mimicking SJS/TEN and emphasizes the details that clinicians must know to guide patient management.
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6
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Tassavor M, Tassavor B, Al Awadhi A. Purpura Fulminans Following Toxic Epidermal Necrolysis-Like Presentation of Spontaneous Linear IgA Bullous Disease. Cureus 2021; 13:e12989. [PMID: 33659124 PMCID: PMC7920214 DOI: 10.7759/cureus.12989] [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] [Indexed: 11/18/2022] Open
Abstract
Purpura fulminans (PF) is a life-threatening disease of cutaneous microvascular thrombosis and hemorrhagic necrosis. Linear IgA bullous disease (LABD) is an autoimmune disease of subepidermal blistering. We present the first known case of PF following a toxic epidermal necrolysis-like presentation of spontaneous LABD in a 70-year-old female.
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Affiliation(s)
| | - Bryan Tassavor
- Dermatology, Boston University School of Medicine, Boston, USA
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7
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Wiggins CJ, Chon SY. Vancomycin-induced linear IgA bullous dermatosis. Proc (Bayl Univ Med Cent) 2021; 34:83-84. [DOI: 10.1080/08998280.2020.1809759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Claire J. Wiggins
- Department of Dermatology, MD Anderson Cancer Center, Houston, Texas
| | - Susan Y. Chon
- Department of Dermatology, MD Anderson Cancer Center, Houston, Texas
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8
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Acral Vesicular Eruption: Answer. Am J Dermatopathol 2020; 42:892. [DOI: 10.1097/dad.0000000000001503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Abstract
Neutrophilic drug reactions are unique eruptions that can affect hospitalized patients and share a common pathophysiology with neutrophils as the key mediators of inflammation. They range in clinical presentation from papules and plaques to bullae and erosions to pustules. Although there is some overlap in presentation, each has distinguishing features that aid the clinician in differentiation from one another and from other drug hypersensitivity reactions. Much of the data on these reactions are from case reports and series or retrospective review studies. There are limited prospective observational studies dedicated to these adverse drug reactions. We review the more common and life-threatening neutrophilic drug reactions, their proposed mechanism of action, and their management.
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Affiliation(s)
- Alexandra J Coromilas
- Department of Dermatology, Columbia University Medical Center, New York, New York, USA
| | - Stephanie M Gallitano
- Department of Dermatology, Columbia University Medical Center, New York, New York, USA.
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10
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Glycopeptide Hypersensitivity and Adverse Reactions. PHARMACY 2020; 8:pharmacy8020070. [PMID: 32326261 PMCID: PMC7357119 DOI: 10.3390/pharmacy8020070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 03/23/2020] [Accepted: 04/18/2020] [Indexed: 12/27/2022] Open
Abstract
Glycopeptides, such as vancomycin and teicoplanin, are primarily used in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections, such as cellulitis, endocarditis, meningitis, pneumonia, and septicemia, and are some of the most commonly prescribed parenteral antimicrobials. Parenteral glycopeptides are first-line therapy for severe MRSA infections; however, oral vancomycin is used as a first-line treatment of Clostridioides difficile infections. Also, we currently have the longer-acting lipoglycopeptides, such as dalbavancin, oritavancin, and telavancin to our armamentarium for the treatment of MRSA infections. Lastly, vancomycin is often used as an alternative treatment for patients with β-lactam hypersensitivity. Common adverse effects associated with glycopeptide use include nephrotoxicity, ototoxicity, and Redman Syndrome (RMS). The RMS is often mistaken for a true allergy; however, it is a histamine-related infusion reaction rather than a true immunoglobulin E (IgE)-mediated allergic reaction. Although hypersensitivity to glycopeptides is rare, both immune-mediated and delayed reactions have been reported in the literature. We describe the various types of glycopeptide hypersensitivity reactions associated with glycopeptides and lipoglycopeptides, including IgE-mediated reactions, RMS, and linear immunoglobulin A bullous dermatosis, as well as describe cross-reactivity with other glycopeptides.
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11
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Abstract
Cutaneous drug reactions are a common reason for calls and visits. This term chiefly refers to hypersensitivity reactions ranging from benign rash without contraindication of treatment to severe life-threatening clinical pictures, such as anaphylactic shock and epidermal necrolysis. They should be carefully managed from the outset. Indeed, history taking and precise semiological description of the lesions are crucial to the formulation of recommendations for the patient. Allergological investigation of such reactions has developed greatly in recent decades and must now be carried out much more extensively. The arrival of new drug families such as biotherapies and the development of drug habituation protocols constitute the challenges of tomorrow for cutaneous drug reactions.
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Affiliation(s)
- J-L Bourrain
- Allergologie, Hôpital Arnaud de Villeneuve, CHU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex, France.
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12
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Colmant C, Camboni A, Dekeuleneer V, Marot L, Dachelet C, Baeck M. Linear IgA dermatosis in association with angioimmunoblastic T-cell lymphoma infiltrating the skin: A case report with literature review. J Cutan Pathol 2019; 47:251-256. [PMID: 31482600 DOI: 10.1111/cup.13576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 08/09/2019] [Accepted: 08/14/2019] [Indexed: 11/26/2022]
Abstract
Angioimmunoblastic T-cell lymphoma (AITL) is an aggressive form of peripheral T-cell lymphoma, characterized by systemic symptoms, diffuse lymphadenopathy, hepatosplenomegaly and immunodysregulation. Half of AITL is associated with cutaneous symptoms, but only few cases with bullous eruption have been described. Association with a linear IgA dermatosis is extremely rare. Linear IgA dermatosis can be idiopathic, or linked with drug intake or neoplastic disorders. Some cases of linear IgA dermatosis presenting as toxic epidermal necrolysis (TEN) have been described, most of them being drug induced. We here present the case of a 72-year-old man recently diagnosed with AITL who developed a bullous eruption, presenting as TEN. Histopathology showed deep cutaneous involvement of the lymphoma with a sub-epidermal blistering and direct immunofluorescence revealed a heavy IgA linear deposit on the dermal-epidermal junction. A diagnosis of linear IgA dermatosis associated with cutaneous involvement of an angioimmunoblastic T-cell lymphoma was made. Chemotherapy and corticosteroids allowed cutaneous improvement but the patient died of his lymphoma shortly after.
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Affiliation(s)
- Caroline Colmant
- Dermatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Alessandra Camboni
- Anatomopathology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Valérie Dekeuleneer
- Dermatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Liliane Marot
- Dermatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Anatomopathology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Claire Dachelet
- Anatomopathology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Marie Baeck
- Dermatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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13
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Visentainer L, Massuda JY, Cintra ML, Magalhães RF. Vancomycin-induced linear IgA bullous dermatosis (LABD)-an atypical presentation. Clin Case Rep 2019; 7:1091-1093. [PMID: 31110752 PMCID: PMC6509886 DOI: 10.1002/ccr3.2039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 11/26/2018] [Accepted: 12/04/2018] [Indexed: 11/15/2022] Open
Abstract
We report an uncommon presentation of bullous dermatosis by linear IgA. There are few cases reported in the literature with this form of presentation starting with mucosal lesions and then evolving into a similar bullous pemphigoid pattern. In addition, we emphasize the importance of direct immunofluorescence for the definitive diagnosis.
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14
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Sarikaya Solak S, Ficicioglu S. Cephalosporin-induced linear IgA dermatosis in a child: Case report and literature review. Dermatol Ther 2019; 32:e12927. [PMID: 30977941 DOI: 10.1111/dth.12927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/10/2019] [Indexed: 11/29/2022]
Abstract
Linear IgA dermatosis (LAD) is a rare, subepidermal blistering disease with mucocutaneous involvement. It may be idiopathic or drug induced. We describe a 4-year-old girl who presented with a vesiculobullous eruption after she had been treated with cefixime for urinary tract infection. A diagnosis of drug-induced LAD was made based on clinical, histopathological, and immunofluorescence findings. Naranjo adverse drug reaction algorithm was used to assess imputability resulting with a "probable" association. In literature, cephalosporin antibiotics are rarely reported in association with LAD. To our knowledge, this is the first case of a cefixime-induced LAD among adults and children.
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Affiliation(s)
- Sezgi Sarikaya Solak
- Faculty of Medicine, Department of Dermatology, Trakya University, Edirne, Turkey
| | - Sezin Ficicioglu
- Faculty of Medicine, Department of Dermatology, Trakya University, Edirne, Turkey
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15
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Garel B, Ingen-Housz-Oro S, Afriat D, Prost-Squarcioni C, Tétart F, Bensaid B, Bara Passot C, Beylot-Barry M, Descamps V, Duvert-Lehembre S, Grootenboer-Mignot S, Jeudy G, Soria A, Valnet-Rabier MB, Barbaud A, Caux F, Lebrun-Vignes B. Drug-induced linear immunoglobulin A bullous dermatosis: A French retrospective pharmacovigilance study of 69 cases. Br J Clin Pharmacol 2019; 85:570-579. [PMID: 30511379 DOI: 10.1111/bcp.13827] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/08/2018] [Accepted: 11/23/2018] [Indexed: 11/27/2022] Open
Abstract
AIMS Linear immunoglobin A (IgA) bullous dermatosis is a rare autoimmune dermatosis considered spontaneous or drug-induced (DILAD). We assessed all DILAD cases, determined the imputability score of drugs and highlighted suspected drugs. METHODS Data for patients with DILAD were collected retrospectively from the French Pharmacovigilance network (from 1985 to 2017) and from physicians involved in the Bullous Diseases French Study Group and the French Investigators for Skin Adverse Reactions to Drugs. Drug causality was systematically determined by the French imputability method. RESULTS Of the 69 patients, 42% had mucous membrane involvement, 20% lesions mimicking toxic epidermal necrolysis (TEN), 21% eosinophil infiltrates and 10% keratinocytes necrosis. Direct immunofluorescence, in 80%, showed isolated linear IgA deposits. Vancomycin (VCM) was suspected in 39 cases (57%), 11 had TEN-like lesions, as compared with three without VCM suspected. Among the 33 patients with a single suspected drug, 85% had an intrinsic imputability score of I4. Among them, enoxaparin, minocycline and vibramycin were previously unpublished. For all patients, the suspect drug was withdrawn; 15 did not receive any treatment. First-line therapy for 31 patients was topical steroids. Among the 60 patients with available follow-up, 52 achieved remission, 10 without treatment. Four patients experienced relapse, four died and five had positive accidental rechallenges. CONCLUSIONS There is no major clinical difference between DILAD and idiopathic linear IgA bullous dermatosis, but the former features a higher prevalence of patients mimicking TEN. VCM, suspected in more than half of the cases, might be responsible for more severe clinical presentations. We report three new putative drugs.
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Affiliation(s)
- Bethsabée Garel
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris (APHP), Henri-Mondor Hospital, 94010, Créteil, France
| | - Saskia Ingen-Housz-Oro
- Department of Dermatology, Assistance Publique-Hôpitaux de Paris (APHP), Henri-Mondor Hospital, 94010, Créteil, France.,EA 7379 EpiDermE, Université Paris Est Créteil Val de Marne UPEC, Créteil, France.,Reference Center for toxic bullous diseases and severe drug reactions, Créteil, France
| | - Daniele Afriat
- Regional Center of Pharmacovigilance, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Catherine Prost-Squarcioni
- Dermatology Department, APHP, Avicenne Hospital, Bobigny, France.,Pathology Department, APHP, Avicenne Hospital, Bobigny, France.,Université Paris 13, Bobigny, France
| | - Florence Tétart
- Department of Dermatology, Rouen University Hospital, Rouen, France
| | - Benoit Bensaid
- Drug Allergy Unit-CCR2A, Department of Allergy and Clinical Immunology, CHU Lyon-Sud, Pierre Benite, France
| | | | - Marie Beylot-Barry
- Department of Dermatology, Bordeaux University Hospital, Bordeaux, France
| | - Vincent Descamps
- Department of Dermatology, APHP, Bichat Claude Bernard Hospital, Paris Diderot University
| | | | | | - Géraldine Jeudy
- Department of Dermatology, Dijon University Hospital, Dijon, France
| | - Angèle Soria
- Department of Dermatology and Allergology, APHP, Tenon Hospital, Paris, France.,Sorbonne Université, Faculté de Médecine Sorbonne Université, Paris, France.,Inserm, UMR 1135, Paris, France
| | | | - Annick Barbaud
- Reference Center for toxic bullous diseases and severe drug reactions, Créteil, France.,Department of Dermatology and Allergology, APHP, Tenon Hospital, Paris, France.,Sorbonne Université, Faculté de Médecine Sorbonne Université, Paris, France
| | - Frédéric Caux
- Dermatology Department, APHP, Avicenne Hospital, Bobigny, France.,Université Paris 13, Bobigny, France
| | - Bénédicte Lebrun-Vignes
- EA 7379 EpiDermE, Université Paris Est Créteil Val de Marne UPEC, Créteil, France.,Reference Center for toxic bullous diseases and severe drug reactions, Créteil, France.,Regional Center of Pharmacovigilance, APHP, Pitié-Salpêtrière Hospital, Paris, France
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16
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Abstract
We have explored the rash that appears as target lesions, with the central and dominant diseases belonging to the Stevens-Johnson syndrome/toxic epidermal necrolysis group. After presenting the clinical patterns of an individual target lesion and classifying them into different types of lesions, the contribution has been organized with groups characterized by such specific findings according to the type of lesion: flat or raised, typical or atypical, presence or absence of fever, presence or absence of mucosal ulcerations, presence or absence of arthralgias, and/or internal organ involvement. Other specific features, such as histologic appearance, immunofluorescence findings, and laboratory changes, are considered. We provide clinicians with an algorithmic, systematic, and logical approach to diagnose the condition of the patients who present with targetoid lesions, and enable them to differentiate between those with serious systemic and life-threatening diseases from others with ordinary skin ailments.
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Affiliation(s)
- Ronni Wolf
- The School of Medicine, Hebrew University, Jerusalem, Israel; Hadassah Medical Center, Jerusalem, Israel.
| | - Jennifer L Parish
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA; Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Lawrence Charles Parish
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Baldini E, Odorisio T, Tuccilli C, Persechino S, Sorrenti S, Catania A, Pironi D, Carbotta G, Giacomelli L, Arcieri S, Vergine M, Monti M, Ulisse S. Thyroid diseases and skin autoimmunity. Rev Endocr Metab Disord 2018; 19:311-323. [PMID: 29948572 DOI: 10.1007/s11154-018-9450-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The skin is the largest organ of the body, at the boundary with the outside environment. Primarily, it provides a physical and chemical barrier against external insults, but it can act also as immune organ because it contains a whole host of immune-competent cells of both the innate and the adaptive immune systems, which cooperate in eliminating invading pathogens following tissue injury. On the other hand, improper skin immune responses lead to autoimmune skin diseases (AISD), such as pemphigus, bullous pemphigoid, vitiligo, and alopecia. Although the interplay among genetic, epigenetic, and environmental factors has been shown to play a major role in AISD etiology and progression, the molecular mechanisms underlying disease development are far from being fully elucidated. In this context, epidemiological studies aimed at defining the association of different AISD with other autoimmune pathologies revealed possible shared molecular mechanism(s) responsible for disease progression. In particular, over the last decades, a number of reports have highlighted a significant association between thyroid diseases (TD), mainly autoimmune ones (AITD), and AISD. Here, we will recapitulate the epidemiology, clinical manifestations, and pathogenesis of the main AISD, and we will summarize the epidemiological evidence showing the associations with TD as well as possible molecular mechanism(s) underlying TD and AISD pathological manifestations.
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Affiliation(s)
- Enke Baldini
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Teresa Odorisio
- Laboratory of Molecular and Cell Biology, Istituto Dermopatico dell'Immacolata-IRCCS, Rome, Italy
| | - Chiara Tuccilli
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | | | - Salvatore Sorrenti
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Antonio Catania
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Daniele Pironi
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Giovanni Carbotta
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Laura Giacomelli
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Stefano Arcieri
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Massimo Vergine
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Massimo Monti
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy
| | - Salvatore Ulisse
- Department of Surgical Sciences, "Sapienza" University of Rome, Viale Regina Elena, 324, 00161, Rome, Italy.
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a delayed-type hypersensitivity reaction to drugs. They represent true medical emergencies and an early recognition and appropriate management is decisive for the survival. SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms. The difference between SJS, SJS/TEN overlap, and TEN is defined by the degree of skin detachment: SJS is defined as skin involvement of < 10%, TEN is defined as skin involvement of > 30%, and SJS/TEN overlap as 10-30% skin involvement. The diagnosis of different degrees of epidermal necrolysis is based on the clinical assessment in conjunction with the corresponding histopathology. The mortality rates for SJS and TEN have decreased in the last decades. Today, the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is available for SJS/TEN severity assessment. Drugs with a high risk of causing SJS/TEN are anti-infective sulfonamides, anti-epileptic drugs, non-steroidal anti-inflammatory drugs of the oxicam type, allopurinol, nevirapine, and chlormezanone. Besides conventional drugs, herbal remedies and new biologicals should be considered as causative agents. The increased risk of hypersensitivity reactions to certain drugs may be linked to specific HLA antigens. Our understanding of the pathogenesis of SJS/TEN has improved: drug-specific T cell-mediated cytotoxicity, genetic linkage with HLA- and non-HLA-genes, TCR restriction, and cytotoxicity mechanisms were clarified. However, many factors contributing to epidermal necrolysis still have to be identified, especially in virus-induced and autoimmune forms of epidermal necrolysis not related to drugs. In SJS/TEN, the most common complications are ocular, cutaneous, or renal. Nasopharyngeal, esophageal, and genital mucosal involvement with blisters, erosions as well as secondary development of strictures also play a role. However, in the acute phase, septicemia is a leading cause of morbidity and fatality. Pulmonary and hepatic involvement is frequent. The acute management of SJS/TEN requires a multidisciplinary approach. Immediate withdrawal of potentially causative drugs is mandatory. Prompt referral to an appropriate medical center for specific supportive treatment is of utmost importance. The most frequently used treatments for SJS/TEN are systemic corticosteroids, immunoglobulins, and cyclosporine A.
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Alraddadi BS, Magliah T, Al Otaibi Y. Case Report: Linear IgA Bullous Dermatosis Triggered by Amoxicillin-clavulanic acid. ACTA ACUST UNITED AC 2018. [DOI: 10.32648/2639-3298/1/1/002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Linear IgA bullous dermatosis (LABD) is rare autoimmune disease that can be caused with or without drugs. We present a 32 year old male with LABD secondary to Amoxicillin-clavulanic acid with complete recovery after the antibiotic was discontinued.
Keywords: Linear IgA Bullous disease, Vancomycin, Amoxicillin-clavulanic acid
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Affiliation(s)
| | - Tahani Magliah
- Senior dermatology resident, King abdulaziz medical city, jeddah, Saudi Arabia
| | - Yasser Al Otaibi
- Dermatologist, King fahad armed force hospital, Jeddah, Saudi Arabia
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20
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Tieppo Francio V, Towery C, Davani S, Allen T, Brown TL. Previously misdiagnosed linear IgA dermatosis resolved with dapsone. BMJ Case Rep 2018; 2018:bcr-2017-220623. [PMID: 29695389 DOI: 10.1136/bcr-2017-220623] [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: 11/04/2022] Open
Abstract
This is the case of a 25-year-old African American woman with a 3-week history of itching with burning, blistering lesions on her torso and extremities. Medical history was unremarkable. Medical treatments included three visits to urgent care, where she was treated with antivirals, oral and topical steroids, antibiotics and antifungals unsuccessfully. We performed a skin biopsy, and immunoflorescent studies revealed a linear deposition of IgA antigen at the basement membrane. The clinical diagnosis of linear IgA dermatosis (LAD) was established, with no eliciting cause, other than potential occupational exposure to Chlamydophila psittaci via her employment in a pet store. This is the first case to our knowledge to report such an association. However, confirmation of the exposure would only establish correlation, not causality. Resolution of symptoms and blisters was achieved with dapsone treatment. Accordingly, we highlight the crucial importance of reviewing exposures, along with the potential aetiology of LAD.
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Affiliation(s)
- Vinicius Tieppo Francio
- College of Medicine; MD/PhD Program, University of Science, Art and Technology, Olveston, BWI, Montserrat
| | - Chris Towery
- College of Medicine; MD/PhD Program, University of Science, Art and Technology, Olveston, BWI, Montserrat.,FACES Dermatology, Santa Clarita, California, USA
| | - Saeid Davani
- College of Medicine; MD/PhD Program, University of Science, Art and Technology, Olveston, BWI, Montserrat
| | - Travis Allen
- College of Medicine; MD/PhD Program, University of Science, Art and Technology, Olveston, BWI, Montserrat.,Internal Medicine, Maricopa Medical Center, Phoenix, AZ, USA
| | - Tony L Brown
- Harvard University, Cambridge, Massachusetts, USA
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21
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Prieto-Barrios M, Velasco-Tamariz V, Tous-Romero F, Burillo-Martinez S, Zarco-Olivo C, Rodriguez-Peralto JL, Ortiz-Romero PL. Linear immunoglobulin A dermatosis mimicking toxic epidermal necrolysis: a case report of etanercept treatment. Br J Dermatol 2017; 178:786-789. [PMID: 28222222 DOI: 10.1111/bjd.15400] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2017] [Indexed: 11/29/2022]
Abstract
A 65-year-old pluripathological woman attended our hospital with a cutaneous eruption of sudden appearance after vancomycin treatment. She presented targetoid lesions affecting approximately 25-30% of her body surface, large erosions with mucosal lesions and positive Nikolsky sign. Under the initial clinical suspicion of toxic epidermal necrolysis (TEN), and considering the recent literature of successful use of etanercept in these cases, she was treated with a single dose of this antitumour necrosis factor (anti-TNF) agent. Subsequently, the exanthema progression stopped and resolution of the lesions happened in a few days. Later on, histopathology revealed a subepidermal blister with dense neutrophilic infiltrate and linear deposits of immunoglobulin A (IgA) on the dermoepidermal junction, allowing us to establish the diagnosis of drug-induced linear IgA dermatosis mimicking TEN. Linear IgA dermatosis can have severe clinical manifestations, even mimicking TEN, and can have high mortality, especially in drug-induced cases. We have not found any other report of linear IgA dermatosis treated with etanercept in the English literature. Anti-TNF medications could represent useful therapeutic alternatives in this dermatosis.
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Affiliation(s)
- M Prieto-Barrios
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - V Velasco-Tamariz
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - F Tous-Romero
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - S Burillo-Martinez
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - C Zarco-Olivo
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - J L Rodriguez-Peralto
- Departments of Pathology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
| | - P L Ortiz-Romero
- Departments of Dermatology, Hospital Universitario 12 de Octubre, I + 12 Research Institute, Universidad Complutense, Madrid, Spain
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22
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Ruiz-Rivero J, Hernández-Aragüés I, Pulido-Pérez A, Suárez-Fernández R. Linear IgA Bullous Dermatosis Presenting as Toxic Epidermal Necrolysis. ACTAS DERMO-SIFILIOGRAFICAS 2017; 108:880-882. [PMID: 28751000 DOI: 10.1016/j.ad.2017.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/09/2017] [Accepted: 02/14/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- J Ruiz-Rivero
- Servicio de Dermatología y Venereología Médico-Quirúrgica, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - I Hernández-Aragüés
- Servicio de Dermatología y Venereología Médico-Quirúrgica, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - A Pulido-Pérez
- Servicio de Dermatología y Venereología Médico-Quirúrgica, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - R Suárez-Fernández
- Servicio de Dermatología y Venereología Médico-Quirúrgica, Hospital General Universitario Gregorio Marañón, Madrid, España
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23
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Pereira AR, Moura LHBD, Pinheiro JRS, Pasin VP, Enokihara MMSES, Porro AM. Vancomycin-associated linear IgA disease mimicking toxic epidermal necrolysis. An Bras Dermatol 2017; 91:35-38. [PMID: 28300888 PMCID: PMC5324987 DOI: 10.1590/abd1806-4841.20164665] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 05/27/2015] [Indexed: 01/21/2023] Open
Abstract
Linear IgA dermatosis is a rare subepidermal autoimmune blistering disease characterized by linear deposition of IgA along the basement membrane zone. In the last three decades, many different drugs have been associated with the drug-induced form of the disease, especially vancomycin. We report a case of vancomycin-induced linear IgA disease mimicking toxic epidermal necrolysis. The aim of this work is to emphasize the need to include this differential diagnosis in cases of epidermal detachment and to review the literature on the subject and this specific clinical presentation.
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Pediatric Stevens-Johnson syndrome and toxic epidermal necrolysis in the United States. J Am Acad Dermatol 2017; 76:811-817.e4. [PMID: 28285784 DOI: 10.1016/j.jaad.2016.12.024] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Little is known about the epidemiology of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in children. OBJECTIVE We sought to determine the morbidity, mortality, and comorbid health conditions of SJS and TEN in US children. METHODS This was a cross-sectional study of the 2009 to 2012 Nationwide Inpatient Sample, which contains a representative 20% sample of all US hospitalizations. Sociodemographics, inflation-adjusted cost, length of stay, comorbidities, and mortality were analyzed using descriptive statistics and multivariate regression analyses. RESULTS The incidences of SJS, SJS-TEN, and TEN were a mean 5.3, 0.8, and 0.4 cases per million children per year in the US, respectively. Prolonged length of stay and higher costs of care (SJS: 9.4 ± 0.6 days, $24,947 ± $3171; SJS-TEN: 15.7 ± 1.5 days, $63,787 ± $8014; TEN: 20.4 ± 6.3 days, $102,243 ± $37,588) were observed compared with all other admissions (4.6 ± 0.1 days, $10,496 ± $424). Mortality was 0% for SJS, 4% for SJS-TEN, and 16% for TEN. In regression models, predictors of mortality included renal failure (adjusted OR [aOR] 300.28, 95% confidence interval [CI] 48.59->999.99), malignancy (aOR 54.33, 95% CI 9.40-314.22), septicemia (aOR 30.45, 95% CI 7.91-117.19), bacterial infection (aOR 20.38, 95% CI 5.44-76.36), and epilepsy (aOR 5.56, 95% CI 1.37-26.2). LIMITATIONS Data regarding treatment were not available. Date of diagnosis of comorbidities was not present, precluding temporal analysis. CONCLUSIONS Pediatric SJS/TEN poses a substantial health burden in the United States.
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25
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Adler NR, McLean CA, Aung AK, Goh MSY. Piperacillin-tazobactam-induced linear IgA bullous dermatosis presenting clinically as Stevens-Johnson syndrome/toxic epidermal necrolysis overlap. Clin Exp Dermatol 2017; 42:299-302. [PMID: 28084616 DOI: 10.1111/ced.13030] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 11/29/2022]
Abstract
Linear IgA bullous dermatosis (LABD) is a subepidermal autoimmune bullous disease characterized by linear IgA deposition at the basement membrane zone, which is visualized by direct immunofluorescence. Patients with LABD typically present with widespread vesicles and bullae; however, this is not necessarily the case, as the clinical presentation of this disease is heterogeneous. LABD clinically presenting as Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) is an infrequent, yet well-described phenomenon. Most cases of LABD are idiopathic, but some cases are drug-induced. Multiple drugs have been implicated in the development of LABD. We report a case of piperacillin-tazobactam-induced LABD presenting clinically as SJS/TEN overlap. This is the first reported case of a strong causal association between piperacillin-tazobactam and the development of LABD.
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Affiliation(s)
- N R Adler
- Department of General Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - C A McLean
- Department of Anatomical Pathology, Alfred Hospital, Melbourne, VIC, Australia
| | - A K Aung
- Department of General Medicine, Alfred Hospital, Melbourne, VIC, Australia.,Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - M S Y Goh
- Department of Dermatology, Alfred Hospital, Melbourne, VIC, Australia
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26
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Konvinse KC, Phillips EJ, White KD, Trubiano JA. Old dog begging for new tricks: current practices and future directions in the diagnosis of delayed antimicrobial hypersensitivity. Curr Opin Infect Dis 2016; 29:561-576. [PMID: 27753687 PMCID: PMC5113146 DOI: 10.1097/qco.0000000000000323] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Antimicrobials are a leading cause of severe T cell-mediated adverse drug reactions (ADRs). The purpose of this review is to address the current understanding of antimicrobial cross-reactivity and the ready availability of and evidence for in-vitro, in-vivo, and ex-vivo diagnostics for T cell-mediated ADRs. RECENT FINDINGS Recent literature has evaluated the efficacy of traditional antibiotic allergy management, including patch testing, skin prick testing, intradermal testing, and oral challenge. Although patch and intradermal testing are specific for the diagnosis of immune-mediated ADRs, they suffer from drug-specific limitations in sensitivity. The use of ex-vivo diagnostics, especially enzyme-linked immunospot, has been highlighted as a promising new approach to assigning causality. Knowledge of true rates of antimicrobial cross-reactivity aids empirical antibiotic choice in the setting of previous immune-mediated ADRs. SUMMARY In an era of increasing antimicrobial resistance and use of broad-spectrum antimicrobial therapy, ensuring patients are assigned the correct 'allergy label' is essential. Re-exposure to implicated antimicrobials, especially in the setting of severe adverse cutaneous reaction, is associated with significant morbidity and mortality. The process through which an antibiotic label gets assigned, acted on and maintained is still imprecise. Predicting T cell-mediated ADRs via personalized approaches, including human leukocyte antigen-typing, may pave future pathways to safer antimicrobial prescribing guidelines.
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Affiliation(s)
- Katherine C Konvinse
- aDepartment of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA bInstitute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia cDepartment of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA dDepartment of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA eDepartment of Infectious Diseases, Austin Hospital, Victoria, Australia fDepartment of Infectious Diseases, Alfred Hospital, Victoria, Australia gDepartment of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria, Australia hDepartment of Medicine, University of Melbourne, Victoria, Australia
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27
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Minhas JS, Wickner PG, Long AA, Banerji A, Blumenthal KG. Immune-mediated reactions to vancomycin: A systematic case review and analysis. Ann Allergy Asthma Immunol 2016; 116:544-53. [PMID: 27156746 PMCID: PMC4946960 DOI: 10.1016/j.anai.2016.03.030] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/17/2016] [Accepted: 03/25/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vancomycin is a broad-spectrum antibiotic whose use may be limited by adverse drug reactions (ADRs). Although vancomycin toxic effects are known, there are limited data on vancomycin hypersensitivity reactions (HSRs). OBJECTIVE To understand the most commonly reported vancomycin HSRs through systematic case review. METHODS We performed a literature search for English-language case reports and series from 1982 through 2015 (last search July 31, 2015) on Ovid MEDLINE and PubMed. The search included the subject heading vancomycin with the subheading adverse effects and separate text searches for vancomycin with a list of specified HSRs. References of identified articles were reviewed to find additional articles. Clinical data were collected and summarized. RESULTS Of 201 identified articles, 84 were screened and 57 fully assessed; these 57 articles contained 71 vancomycin HSR cases that were included in analysis. Vancomycin HSRs were immediate (anaphylaxis, n = 7) and nonimmediate (n = 64). Nonimmediate HSRs included linear IgA bullous dermatosis (LABD, n = 34), drug rash eosinophilia and systemic symptoms (DRESS) syndrome (n = 16), acute interstitial nephritis (AIN, n = 8), and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN, n = 6). Median times of vancomycin therapy before HSR onset was 7 days (interquartile range [IQR], 4-10 days) for LABD, 9 days (IQR, 9-22 days) for SJS/TEN, 21 days (IQR, 17-28 days) for DRESS syndrome, and 26 days (IQR, 7-29 days) for AIN. Overall, 11 patients (16%) died, and 4 (6%) had deaths attributed to the HSR. CONCLUSION Vancomycin causes a variety of HSRs; the most commonly identified were nonimmediate HSRs, with LABD being most frequent. We observed a high frequency of HSR mortality. Further data are needed to understand the frequency and severity of vancomycin HSRs.
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Affiliation(s)
- Jasmit S Minhas
- Department of Medicine, Lahey Clinic, Burlington, Massachusetts.
| | - Paige G Wickner
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Aidan A Long
- Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aleena Banerji
- Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly G Blumenthal
- Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts
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28
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Morbidity and Mortality of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in United States Adults. J Invest Dermatol 2016; 136:1387-1397. [PMID: 27039263 DOI: 10.1016/j.jid.2016.03.023] [Citation(s) in RCA: 190] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 03/08/2016] [Accepted: 03/16/2016] [Indexed: 11/24/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening disorders. Our study objective was to describe the incidence, costs of care, length of stay, comorbidities, and mortality of SJS and TEN in US adults. The Nationwide Inpatient Sample 2009-2012, containing a 20% sample of all US hospitalizations, was analyzed. We used a validated approach involving International Classification of Disease, 9th edition, Clinical Modification codes to identify SJS, SJS/TEN, and TEN (n = 2,591, n = 502, and n = 564, respectively). The mean estimated incidences of SJS, SJS/TEN, and TEN were 9.2, 1.6, and 1.9 per million adults per year, respectively. SJS/TEN was associated with nonwhite race, particularly Asians (odds ratio = 3.27, 95% confidence interval = 3.02-3.54) and blacks (odds ratio = 2.01, 95% confidence interval = 1.92-2.10). Significantly prolonged length of stay and higher costs of care (SJS: 9.8 ± 0.3 days, $21,437 ± $807; SJS/TEN: 16.5 ± 1.0 days, $58,954 ± $5,238; TEN: 16.2 ± 1.0 days, $53,695 ± $4,037) were observed compared with all other admissions (4.7 ± 0.02 days, $11,281 ± $98). Mean adjusted mortality was 4.8% for SJS, 19.4% for SJS/TEN, and 14.8% for TEN. SJS, SJS/TEN, and TEN pose a substantial health care burden. Predictors of mortality included increasing age, increasing number of chronic conditions, infection (septicemia, pneumonia, tuberculosis), hematological malignancy (non-Hodgkin's lymphoma, leukemia), and renal failure (P ≤ 0.03 for all). Further studies are needed to confirm mortality findings to improve prognostication of SJS/TEN.
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Rizzo JA, Johnson R, Cartie RJ. Pediatric Toxic Epidermal Necrolysis: Experience of a Tertiary Burn Center. Pediatr Dermatol 2015; 32:704-9. [PMID: 26227567 DOI: 10.1111/pde.12657] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pediatric toxic epidermal necrolysis (TEN) is a rare and potentially fatal skin disease with a multitude of causative factors and no consensus on treatment guidelines and, as a result, it has a variety of short- and long-term outcomes. We present the experience of a large specialty burn center to share our diagnostic and treatment principles. METHODS A retrospective review from 1989 to 2010 at the Joseph M. Still Burn Center was performed to find patients with a diagnosis of Steven-Johnson syndrome (SJS) or TEN. Information was obtained on demographic and physiologic parameters such as age, race, total body surface area involved, treatments, hospital stay, and need for ventilator support. RESULTS We identified SJS or TEN in 21 patients. Prescription drugs were the most common etiology (in 15 patients), with antibiotics as the most common causative agent. Histology confirmed the clinical diagnosis of TEN in 14 patients. Our treatment plan included a multidisciplinary team, early initiation of intravenous immunoglobulin, bronchoscopy, strict management of electrolyte and fluid balances, and meticulous surgical wound care. Mortality was 9.5%. CONCLUSION Our experience in treating this rare but devastating disease affords us the opportunity to share the diagnostic dilemmas we faced and the treatment principles we used to treat this unique patient population successfully.
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Affiliation(s)
- Julie A Rizzo
- Institute of Surgical Research, U.S. Army, Fort Sam Houston, Texas
| | - Rebekah Johnson
- Department of Surgery, Dwight David Eisenhower Army Medical Center, Ft. Gordon, Georgia
| | - Richard J Cartie
- Pediatric Intensive Care Services, Joseph M. Still Burn Centers, Augusta, Georgia
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Hoffmann J, Hadaschik E, Enk A, Stremmel W, Gauss A. Linear IgA Bullous Dermatosis Secondary to Infliximab Therapy in a Patient with Ulcerative Colitis. Dermatology 2015; 231:112-5. [DOI: 10.1159/000431172] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 05/01/2015] [Indexed: 11/19/2022] Open
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