Toxic epidermal necrolysis associated with chemoimmunotherapy for lymphoma: case report and literature review

Emerging Insights into Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Induced by Immune Checkpoint Inhibitor and Tumor-Targeted Therapy

Objective

Anticancer drugs have revolutionized tumor therapy, with cutaneous toxicities such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) being common immune-related adverse events. The debate over the efficacy of systemic corticosteroids in treating these conditions persists, while tumor necrosis factor (TNF)-alpha inhibitors show promise. This study aims to evaluate the effectiveness and safety of combination therapy involving the TNF-α inhibitor adalimumab for SJS/TEN induced by anticancer drugs.

Methods

A literature review of SJS/TEN cases induced by anticancer drugs from 1992 to 2023 was conducted, alongside an analysis of patients admitted to the First Affiliated Hospital of Fujian Medical University during the same period. Clinical characteristics, skin healing time, mortality, and adverse events were evaluated in two treatment groups: SJS/TEN patients treated with targeted anticancer therapies and immunotherapies.

Results

Among the 27 patients studied (18 with SJS or SJS-TEN overlapping and 9 with TEN), combination therapy with adalimumab significantly reduced mucocutaneous reepithelization time and healing duration compared to corticosteroid monotherapy. Patients receiving adalimumab combined with corticosteroids had lower actual mortality rates than those on corticosteroid monotherapy. The combination therapy also showed a trend towards reducing standardized mortality rates based on the Score of Toxic Epidermal Necrolysis (SCORTEN).

Conclusion

The findings suggest that adalimumab in combination with corticosteroids provides significant clinical benefits and is safer than corticosteroids alone for treating SJS/TEN induced by targeted anticancer therapies and immunotherapies. This study contributes valuable insights into potential treatment strategies for severe cutaneous adverse reactions to anticancer drugs, highlighting the importance of exploring alternative therapies such as TNF-α inhibitors in managing these conditions effectively.

Sintilimab-induced erythema multiforme drug eruption in the treatment of sigmoid colon cancer: A case report and literature review

RATIONALE

Dermatologic toxicity has been reported as the most common immune-related side effect of programmed cell death 1 inhibitors. Previous reports related to Sintilimab include rash, pruritus, vitiligo, Stevens-Johnson syndrome, toxic epidermal necrolysis, and so on.

PATIENT CONCERNS

A 66-year-old man was treated with Sintilimab as monotherapy for sigmoid colon cancer. After the second prescription, he developed a more severe and widespread rash.

DIAGNOSES

The diagnose of erythema multiforme drug eruption induced by Sintilimab was considered.

INTERVENTIONS

The patient received intravenous and oral methylprednisolone, routine antihistamines and topical gluccorticoids.

OUTCOMES

The patient's symptoms were gradually relieved during hospitalization and was discharged following resolution of symptoms. He refused to continue using Sintilimab.

LESSONS

This is the first reported case of Sintilimab-induced erythema multiforme drug eruption. It is advisable to inform patients of potential dermatologic toxicity that may occur after using immune checkpoint inhibitors, so that we may prevent the further development of it and avoid the discontinuation of immune checkpoint inhibitors.

Lichenoid dermatitis following PD-1 inhibitor-induced toxic epidermal necrolysis: a case report and literature review

Immune checkpoint inhibitors such as anti-PD-1 receptor antibodies have been shown to be effective in patients with advanced gastric cancer. However, there is a growing concern about immune-related adverse events. A case of a patient with gastric adenocarcinoma who developed toxic epidermal necrolysis (TEN) induced by sintilimab and subsequently developed lichenoid dermatitis is reported. TEN was diagnosed according to a history of sintilimab use, clinical symptoms and physical examination. During hospitalization, the patient developed recurrent fever caused by bacteremia and recovered from TEN after anti-infection and anti-inflammatory treatments. However, when TEN was controlled, the patient developed the lesional manifestations of lichenoid dermatitis. To date, no cases of lichenoid dermatitis after TEN have been reported following the use of PD-1 inhibitors.

Successful treatment of immune-related lichenoid dermatitis by Weiling decoction in a patient with non-small cell lung cancer: A case report and review of literature

BACKGROUND

Immune checkpoint inhibitors (ICIs) have emerged as a revolutionary therapy in advanced squamous non-small cell lung cancer (sqNSCLC) and ushered a new era of immunotherapy. Despite of remarkable outcomes, a wide spectrum of immune-related adverse events (irAEs) was reported, among which cutaneous reactions were the most common. Cutaneous irAEs were mainly managed by glucocorticoids, whereas prolonged use of glucocorticoids may cuase kinds of side effects, especially in elderly paitients, and diminish the anti-tumor efficacy of ICIs, thus finding a safe and effective alternative approach to managing cutaneous irAEs is imperative.

CASE SUMMARY

A 71-year-old man who was diagnosed with advanced sqNSCLC suffered from sporadic maculopapulars one week later after the fifth cycle of sintilimab treatment, and the skin lesions had been deteriorating rapidly. Skin biopsy revealed epidermal parakeratosis with a dense band-like lymphocytic infiltrate and acanthosis, indicating a diagnosis of immune-induced lichenoid dermatitis. Oral administration of traditional Chinese herbal formula modified Weiling decoction significantly alleviated the symptoms of the patient. The dosage of Weiling decoction were maintained for about three months without recurrence of cutaneous adverse reactions and any other side effects. The patient refused to receive further anti-tumor medication and stayed alive without disease progression at follow up.

CONCLUSION

We present modified Weiling decoction successfully ameliorates immune-induced lichenoid dermatitis in a patient with sqNSCLC for the first time. This report indicates that Weiling decoction may be an effective and safe complementary or alternative approach for the treatment of cutaneous irAEs. Further investigation of the underling mechanism is required in the future.

Case Report: Toxic epidermal necrolysis associated with sintilimab in a patient with relapsed thymic carcinoma

Immune checkpoint inhibitors (ICIs) such as anti-programmed death 1 (PD-1) receptor monoclonal antibody has been shown to be effective in patients with relapsed thymic carcinoma. However, immune-related adverse events (irAE) are increasingly recognized. There is a paucity of clinical data, especially in elderly patients. A patient in his late 80s with a history of thymic carcinoma was treated with sintilimab, an anti-PD1 antibody. After one week of administration, the patient developed diffuse rash. After two cycles of sintilimab, there was rapid progression of the rash with gradual development of blisters and skin detachment. Sintilimab was immediately discontinued, and skin biopsy was performed. The histopathological findings were consistent with the diagnosis of toxic epidermal necrolysis (TEN), which was considered as an irAE. Intravenous methylprednisolone was initially administered, followed by oral prednisone. The patient showed dramatic improvement within 72 hours of initiation of treatment. Unfortunately, the patient died of severe pneumonia three months later. We report a case of TEN, a rare toxicity induced by anti-PD-1 sintilimab in an elderly patient with thymic carcinoma. Since TEN is a life-threatening condition, early recognition and management of this complication is a key imperative.