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Frederiks AJ, Kumarasinghe SP, Wood F, Rowe S, Cunneen T, Raby E, Bourke J, Ricciardo B. Toxic epidermal necrolysis in adult patients: Experience from the West Australian Collaboration. Australas J Dermatol 2022; 63:437-451. [PMID: 35904488 DOI: 10.1111/ajd.13903] [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: 03/05/2022] [Revised: 07/02/2022] [Accepted: 07/14/2022] [Indexed: 11/30/2022]
Abstract
Toxic epidermal necrolysis (TEN) is a rare and life-threatening mucocutaneous disease triggered by a reaction to a drug. Despite reported mortality of 30%, management differs between healthcare settings. Our hospital was established in February 2015 becoming the new state burns centre in Western Australia (WA). Following this, we collaborated on comprehensive multidisciplinary guidelines for the management of TEN. These guidelines are updated annually to reflect the weight of emerging evidence in managing TEN. Our aim was to review the management and outcomes of TEN patients presenting to our hospital between February 2015 and May 2021 (inclusive). We collected data for 10 patients on year, age, ethnicity, gender, medical history, culprit drug and exposure, SCORTEN, length of stay, maximum percentage of skin detachment, mucosal surface involvement, ophthalmic amniotic membrane transplant, burns unit input/admission, intensive care unit admission, weight, systemic treatment(s), complications and outcome. We excluded 7 out of 17 flagged patients who did not strictly meet the definition of TEN as greater than 30% epidermal detachment, with epidermal detachment defined as bullae, erosions, and/or positive Nikolsky. We found that the mortality rate in WA from TEN is improving compared with two previous WA studies, with a mortality rate in our study of 20% (2 deaths). Though limited by small sample size and retrospective design, our study suggests a shift towards at least one systemic therapy per patient (most commonly cyclosporine), the growing use of etanercept and the ophthalmic use of amniotic membrane transplants. It demonstrates the importance of burns unit input and the utility of comprehensive multidisciplinary guidelines. While the management and outcomes of TEN patients in WA are continuing to improve, we support calls for large registry data to facilitate evidence growth and collaboration for this rare life-threatening condition.
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Affiliation(s)
- Aaron J Frederiks
- Department of Dermatology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Faculty of Health and Medical Sciences, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - S Prasad Kumarasinghe
- Department of Dermatology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Faculty of Health and Medical Sciences, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Fiona Wood
- Faculty of Health and Medical Sciences, School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,State Burns Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Sharon Rowe
- State Burns Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Tom Cunneen
- Faculty of Health and Medical Sciences, School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Department of Ophthalmology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Edward Raby
- Faculty of Health and Medical Sciences, School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Jack Bourke
- Department of Immunology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Bernadette Ricciardo
- Department of Dermatology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Faculty of Health and Medical Sciences, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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Bose R, Finstad A, Ogbalidet S, Boshra M, Fahim S. Lab-Based Culprit Drug Identification Methods for Cutaneous Drug Eruptions: A Scoping Review. J Cutan Med Surg 2022; 26:291-296. [PMID: 35086349 DOI: 10.1177/12034754211073667] [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: 11/15/2022]
Abstract
BACKGROUND Identification of culprit drugs when managing cutaneous drug eruptions is essential. Causality assessment methods (CAMs) have been proposed, including lab-based techniques. However, no consensus guidelines exist. OBJECTIVES To identify and map the functionality and feasibility of lab-based CAMs. METHODS A scoping review was conducted to identify culprit drug identification methods. Publications on lab-based methods were analyzed. Medline, Embase, and Cochrane Central Register of Controlled Trials databases were searched. RESULTS Twenty-five publications met inclusion criteria. Nine lab-based CAMs were studied, including lymphocyte transformation test, cytokine measurement (ELISpot, ELISA, beads array assay), modified IFN-ɣ ELISpot, CellScan, histamine release, granzyme B-ELISpot, intracellular granulysin, lymphocyte toxicity assay, and HLA allele genotyping. Diagnostic accuracy was reported for 8/9 methods. Clinical assessment and operational algorithms were commonly used as validation benchmarks. Lab-based methods were assessed at different phases of a drug eruption including in the acute (18.1%), recovery (27.3%), acute and recovery (27.3%), or an unspecified phase (27.3%). Lymphocyte transformation test (specificity 30% to 100%, sensitivity 27% to 73%) and cytokine measurement (specificity 76% to 100%, sensitivity 20% to 84%) were the most common methods studied. CONCLUSIONS Lab-based CAMs can be low-risk, effective, and complementary of clinical methods. High-quality studies are needed to adequately develop and validate these tools for clinical practice.
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Affiliation(s)
- Reetesh Bose
- 1530066363 Division of Dermatology, University of Ottawa, ON, Canada.,27337 Division of Dermatology, The Ottawa Hospital, Canada
| | | | | | - Mina Boshra
- 12365 Faculty of Medicine, University of Ottawa, ON, Canada
| | - Simone Fahim
- 1530066363 Division of Dermatology, University of Ottawa, ON, Canada.,27337 Division of Dermatology, The Ottawa Hospital, Canada.,12365 Faculty of Medicine, University of Ottawa, ON, Canada
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Brandt C, McGuire L, Uetrecht J. Severe cutaneous adverse reaction associated with antiseizure medications: Diagnosis, management, and prevention. Epilepsy Behav 2021; 117:107844. [PMID: 33639435 DOI: 10.1016/j.yebeh.2021.107844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 02/06/2023]
Abstract
Severe cutaneous adverse reactions (SCARs) are potentially life-threatening, with considerable morbidity and mortality. They are nonimmediate hypersensitivity reactions that occur in specifically predisposed patients with delayed T-cell-mediated hypersensitivity reaction. Antiseizure medications (ASMs) are among the drugs that can induce SCAR. Increased awareness of SCAR among clinicians treating patients with ASMs is critically important for early recognition of symptoms, prompt identification and removal of the causal drug, and early intervention to reduce SCAR-related acute and long-term morbidity and mortality. The diagnosis, management, and prevention of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) are reviewed, along with the current understanding of the pathomechanisms and role of genetics in SCAR development. Supportive care and immunomodulating treatments for SCAR are discussed.
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Affiliation(s)
- Christian Brandt
- Department of General Epileptology, Bethel Epilepsy Centre, Mara Hospital, Bielefeld, Germany.
| | - Lynanne McGuire
- MedVal Scientific Information Services, LLC, Princeton, NJ, USA
| | - Jack Uetrecht
- Department of Pharmacology & Toxicology, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
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