Review of Toxic Epidermal Necrolysis

Spatial proteomics identifies JAKi as treatment for a lethal skin disease

Toxic epidermal necrolysis (TEN) is a fatal drug-induced skin reaction triggered by common medications and is an emerging public health issue1-3. Patients with TEN undergo severe and sudden epidermal detachment caused by keratinocyte cell death. Although molecular mechanisms that drive keratinocyte cell death have been proposed, the main drivers remain unknown, and there is no effective therapy for TEN4-6. Here, to systematically map molecular changes that are associated with TEN and identify potential druggable targets, we utilized deep visual proteomics, which provides single-cell-based, cell-type-resolution proteomics7,8. We analysed formalin-fixed, paraffin-embedded archived skin tissue biopsies of three types of cutaneous drug reactions with varying severity and quantified more than 5,000 proteins in keratinocytes and skin-infiltrating immune cells. This revealed a marked enrichment of type I and type II interferon signatures in the immune cell and keratinocyte compartment of patients with TEN, as well as phosphorylated STAT1 activation. Targeted inhibition with the pan-JAK inhibitor tofacitinib in vitro reduced keratinocyte-directed cytotoxicity. In vivo oral administration of tofacitinib, baricitinib or the JAK1-specific inhibitors abrocitinib or upadacitinib ameliorated clinical and histological disease severity in two distinct mouse models of TEN. Crucially, treatment with JAK inhibitors (JAKi) was safe and associated with rapid cutaneous re-epithelialization and recovery in seven patients with TEN. This study uncovers the JAK/STAT and interferon signalling pathways as key pathogenic drivers of TEN and demonstrates the potential of targeted JAKi as a curative therapy.

Two Rare Cases of Feline Toxic Epidermal Necrolysis: A Novel Therapeutic Approach With Medical-Grade Honey

Toxic epidermal necrolysis (TEN) is an acute and life-threatening dermatological condition that is drug-induced and characterized by extensive epidermal detachment. These lesions should be protected from infection using a product that has a low risk of reactivity. Medical-grade honey (MGH) exerts antimicrobial and wound-healing effects while posing a low risk of exacerbating TEN. In this case report, we are the first to describe the use of MGH for wound management in two feline TEN patients. Case 1 involved a 1-year-old female British shorthair cat, while Case 2 featured a 1-year-old female mixed-breed cat. Both patients presented to the hospital with various symptoms, including fever, tongue lesions, and lesions in the abdominal area following ovariohysterectomy surgery. TEN was confirmed via histopathological examination. The suspected cause of TEN in both cases was the iodine present in the surgical scrub. Tongue lesions were addressed with a liquid diet, and all xenobiotics were immediately withdrawn as a precaution. MGH products supplemented with vitamins were applied to the abdominal wounds following a wound lavage with Ringer's lactate. Daily dressing changes were performed without discomfort, pain, or any adverse reactions. In both cases, debridement became evident after just 1 day, and the patients fully recovered after 12 days of MGH therapy. This case report demonstrates for the first time the successful use of supplemented MGH for wound management in veterinary patients with TEN. The patients did not have any adverse reactions to the treatment, while MGH dressings provided antimicrobial protection and wound-healing effects. Furthermore, these cases highlight the importance of rapid diagnosis and immediate drug withdrawal to increase the survival rate. Overall, supplemented MGH is a safe and effective method to treat TEN-related lesions in feline patients.

Acute and chronic ocular outcomes in SJS/TEN patients treated with oral ciclosporin vs intravenous immunoglobulin

Background/Aim

To evaluate differences in ocular complications of Stevens Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN) patients receiving either systemic IVIG or Ciclosporin (CsA) as initial treatments.

Methods

Retrospective review of consecutive patients admitted for SJS/TEN at the Singapore General Hospital (SGH) from 2011 to 2017 who received either IVIG or Ciclosporin at the onset of the disease and had ophthalmological follow-up of at least 6 months were included. Acute ocular severity of SJS/TEN was graded using the Gregory grading score; chronic ocular complications were graded using the Sotozono system.

Results

A total of 18 subjects were included for analysis, with eight in the IVIG group and 10 in the CsA group. There were no significant differences in acute Gregory severity grading between the two groups. The CsA group had a trend towards worse overall chronic Sotozono grading scores compared to the IVIG group (median [IQR]: 2 [0-3] vs. 1 [0-6.5], p = 0.27), with a higher incidence of acute severe cornea involvement (60% vs. 25%, p = 0.93) and chronic corneal and eyelid involvement in the former than the latter. SJS/TEN patients with worse acute ocular involvement were more likely to have TEN and perianal mucosal involvement (50% vs. 0, p = 0.01).

Conclusion

Compared to those who received IVIG, SJS/TEN patients who received CsA at the acute disease stage, seemed to have worse acute corneal and chronic corneal and eyelid complications. Larger studies are needed to confirm this finding.

Dermatological conditions in the intensive care unit at a tertiary care hospital in Riyadh, Saudi Arabia

OBJECTIVES

To evaluate the various skin conditions diagnosed in intensive care unit (ICU) patients.

METHODS

This is a descriptive retrospective study of all adults, pediatric, and neonatal patients who were admitted to the ICU and had a dermatological manifestation during hospital stay or patients who had dermatological condition that requires ICU admission. All skin conditions were categorized and analyzed.

RESULTS

A total of 344 ICU patients with 365 different dermatological conditions were included in the study. The age of patients ranged from less than 1-96 years, with a mean age of 43.6±30.1 years. Of the patients, 189 (54.9%) were males. The top 3 general disease categories observed were skin infections, inflammatory and autoimmune diseases, and drug reactions. The most commonly reported dermatological disorders included morbilliform drug eruption (6.8%), contact dermatitis (6.3%), vasculitis (5.5%), herpes zoster (4.6%), purpura due to thrombocytopenia (3.8%), dermatitis/eczema (3.8%), candidiasis (3.8%), infantile hemangioma (2.7%), unclassified drug reaction (2.5%), intertrigo (2.5%), and herpes simplex virus (2.5%).

CONCLUSION

Dermatological disorders can occur at various levels of severity in the ICU. Skin infections, inflammatory and autoimmune diseases, and drug reactions were found to be the most prevalent conditions.

Fast, bedside diagnosis of toxic epidermal necrolysis using ex vivo confocal laser scanning microscopy: A retrospective study

BACKGROUND

Toxic epidermal necrolysis (TEN) is a severe life-threatening drug eruption with rapid evolution. A fast histologic differentiation between TEN and clinically similarly looking staphylococcal scalded skin syndrome is of vital importance for relevant treatment decision. The recently developed ex vivo confocal laser scanning microscopy (CLSM) offers innovative and extremely fast histological visualization of fresh tissue specimens.

OBJECTIVE

To assess the diagnostic efficacy of ex vivo CLSM in comparison with standard histopathology for TEN.

METHODS

We performed side-by-side comparison of TEN specimens analysed with ex vivo CLSM and haematoxylin and eosin staining. Analysis focused on typical histopathological features of TEN, including epidermal cleavage in the basal layer and confluent epidermal necrosis. We retrospectively assessed the diagnostic performance of ex vivo CLSM for TEN in clinically confirmed cases.

RESULTS

We report substantial agreement between ex vivo CLSM and classical histology for the detection of subepidermal cleavage and confluent epidermal necrosis. When considering full-thickness epidermal loss, epidermal cleavage in the basal layer showed the highest diagnostic performance, reaching 87.5% sensitivity and 100% specificity.

CONCLUSION

Based on our data, ex vivo CSLM appears as a rapid, resource-optimizing, and reliable approach for morphological TEN emergency screening on fresh skin samples.

The First Documented Ibuprofen-Induced Toxic Epidermal Necrolysis in the Middle East and North Africa Region: A Case Report, Complications, and Management

INTRODUCTION

Stevens-Johnson syndrome (SJS), Stevens-Johnson/toxic epidermal necrolysis overlap syndrome (SJS/TEN) and toxic epidermal necrolysis (TEN) are rare, acute, potentially lethal conditions, considered to be part of the severe cutaneous adverse reactions (SCARs) spectrum, with TEN being the most life-threatening. The distinction between these three entities is based on the extent of total skin surface involvement, with SJS involving < 10%, SJS/TEN involving 10-30% and TEN involving > 30% of total body surface area. These mucocutaneous reactions are most commonly caused by a hypersensitivity reaction to a drug, with infections and vaccines being possible, less common etiologies.

CASE PRESENTATION

In the following case report, we summarize a rare case of a 43-year-old, previously healthy male patient who presented with TEN after taking ibuprofen, a non-steroidal anti-inflammatory drug. According to PubMed literature, this is the first documented case of ibuprofen-induced TEN in the Middle East and North Africa (MENA) region.

DISCUSSION

TEN is an autoimmune bullous disorder that results in the death of keratinocytes, leading to complete dermo-epidermal separation. In the case of our patient, the desquamation was extensive, involving 70% of the total body surface area, and was complicated by a triple bacterial infection with Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The patient was treated with colistin and meropenem, in addition to supportive management, hydration and nutritional support.

CONCLUSION

In the case of TEN, early diagnosis and hospitalization in a burn centre are crucial to allow rapid healing, and improve the quality of life of the affected patients. Immediate cessation of the causative mediation is critical. Supportive management, hydration, nutritional support, and maintenance of aseptic conditions are highly encouraged to reduce the mortality and morbidity associated with TEN.

Why drug exposure is frequently associated with T-cell mediated cutaneous hypersensitivity reactions

Cutaneous hypersensitivity reactions represent the most common manifestation of drug allergy seen in the clinic, with 25% of all adverse drug reactions appearing in the skin. The severity of cutaneous eruptions can vastly differ depending on the cellular mechanisms involved from a minor, self-resolving maculopapular rash to major, life-threatening pathologies such as the T-cell mediated bullous eruptions, i.e., Stevens Johnson syndrome/toxic epidermal necrolysis. It remains a significant question as to why these reactions are so frequently associated with the skin and what factors polarise these reactions towards more serious disease states. The barrier function which the skin performs means it is constantly subject to a barrage of danger signals, creating an environment that favors elicitation. Therefore, a critical question is what drives the expansion of cutaneous lymphocyte antigen positive, skin homing, T-cell sub-populations in draining lymph nodes. One answer could be the heterologous immunity hypothesis whereby tissue resident memory T-cells that express T-cell receptors (TCRs) for pathogen derived antigens cross-react with drug antigen. A significant amount of research has been conducted on skin immunity in the context of contact allergy and the role of tissue specific antigen presenting cells in presenting drug antigen to T-cells, but it is unclear how this relates to epitopes derived from circulation. Studies have shown that the skin is a metabolically active organ, capable of generating reactive drug metabolites. However, we know that drug antigens are displayed systemically so what factors permit tolerance in one part of the body, but reactivity in the skin. Most adverse drug reactions are mild, and skin eruptions tend to be visible to the patient, whereas minor organ injury such as transient transaminase elevation is often not apparent. Systemic hypersensitivity reactions tend to have early cutaneous manifestations, the progression of which is halted by early diagnosis and treatment. It is apparent that the preference for cutaneous involvement of drug hypersensitivity reactions is multi-faceted, therefore this review aims to abridge the findings from literature on the current state of the field and provide insight into the cellular and metabolic mechanisms which may contribute to severe cutaneous adverse reactions.

Autologous Skin Cell Suspension in Toxic Epidermal Necrolysis: A Case Series

Toxic epidermal necrolysis (TEN) is a dermatological process which has lacked both clear pathophysiological definition and efficacious medical treatment. This leads to metabolic dysfunction due to the inability to regulate fluid and electrolytes after the loss of skin. It is a deadly and costly disease which is associated with long lengths of stay and high-mortality rates. The depth of TEN mimics that of a partial-thickness burn. There has been documentation of successful usage of autologous skin cell suspension (ASCS) in TEN. This study expands upon our previous experience using ASCS in TEN to a series of three. Dermatology is consulted for biopsy along with the burn surgery team for wound care, where a Score for TEN is performed for risk stratification. Aggressive operative debridement is performed in the operative suite and a healthy, uninvolved donor site is harvested and processed per standard protocol. Dressings are taken down at postoperative day 4 for evaluation. The average length of stay when compared to historical data in literature is a reduction by 48%. ICU days were reduced by 64%. Cost was reduced by 54%. There was no mortality in our population of three. ASCS is both therapeutically and cost effective at treating TEN. The question of type of dressing and decision to operate is mitigated by this intervention. As an efficacious intervention, it reduces hospital stay, reduces wound cares, speeds healing, and provides a cosmetically acceptable outcome.

Management of Toxic Epidermal Necrolysis Using Early Combination Therapy of Intravenous Immunoglobulin and Amniotic Membrane Grafting: A Case Report

Toxic epidermal necrolysis (TEN) is a devastating challenge faced by wound care practitioners. However, surgical management with amniotic membrane graft (AMG) promises better results in scar healing, but there is a lack of additional intervention to reduce the high mortality rate in those patients who are admitted with poor prognosis clinical situation. There is supportive evidence that combination therapy with AMG and early high-dose intravenous immunoglobulin (IVIG) as early management in TEN could improve the prognosis. In this study, the authors present a 61-year-old female who presented with a widespread macular lesion on the trunk, upper extremities, and face. The patient was treated with early amniotic membrane grafting and high-dose IVIG and achieved satisfactory results. Complete wound healing was achieved in 21 days. There were no acute or chronic complications, consisting of infection of the skin areas, gastrointestinal bleeding, pleural effusion, and severe ocular mucous membrane damage.

Severe Cutaneous Adverse Drug Reactions at a Tertiary Care Center in Saudi Arabia

Background

Severe cutaneous adverse drug reactions (SCARs), although rare, are known to be associated with significant morbidity and mortality. SCARs include drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), and acute generalized exanthematous pustulosis (AGEP). Studies on SCARs are limited in Saudi Arabia. This study aims to characterize SCARs at a tertiary care center in Saudi Arabia.

Methods

A cross-sectional study was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia. All inpatient and emergency department consultations to dermatology were electronically reviewed during the period from January 2016 to December 2020. All patients who developed an adverse cutaneous drug reaction were enrolled. Detailed analysis was performed only for SCARs. The culprit medication was determined based on the latency period, history of previous intake of the medication, and drug notoriety.

Results

There were 3050 hospital consultations to dermatology during the study period. Cutaneous adverse drug reactions constituted 253 (8.3%) cases. A total of 41 patients with SCARs were identified, accounting for 16.2% of all cutaneous drug reactions. Antibiotics and anticonvulsants were the most common causative drug groups accounting for 28 (68.3%) and 9 (22%) cases, respectively. DRESS was the most common SCAR. The latency period was the longest for DRESS and shortest for AGEP. Vancomycin was responsible for approximately a third of DRESS cases. Piperacillin/tazobactam was the most common cause for SJS/TEN and AGEP. The majority of drugs causing AGEP were antibiotics. The mortality rate was the highest in SJS/TEN (5/11 (45.5%)), followed by DRESS (1/23 (4.4%)) and AGEP (1/7 (14.3%)).

Conclusion

SCARs are rare in Saudis. DRESS appears to be the most common SCAR in our region. Vancomycin is responsible for most cases of DRESS. SJS/TEN had the highest mortality rate. More studies are required to further characterize SCARs in Saudi Arabia and Arabian Gulf countries. More importantly, thorough studies of HLA associations and lymphocyte transformation tests among Arabs with SCARs are likely to further improve patient care in the Arabian Gulf region.

Clinical Manifestations and Genetic Influences in Sulfonamide-Induced Hypersensitivity

Drug hypersensitivity is an inflammatory or immune reaction induced by drugs. It can be fatal if not appropriately treated and cause the risk of long-term complications. Sulfonamides are classified as antimicrobial drugs with a broad spectrum effective for gram-positive and gram-negative bacteria. This antibacterial agent works by competitively inhibiting folic acid synthesis, which prevents the growth and proliferation of microorganisms. In its use as antibiotics, sulfonamides can also cause adverse reactions in specific individuals. It has been widely reported that sulfonamide antimicrobials cause hypersensitivity reactions mediated by IgE or T cells. This review identifies symptoms or signs that can appear, as well as genes associated with sulfonamide hypersensitivity reactions, as sulfonamide may cause hypersensitivity in the form of uveitis, skin rash, Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), parotitis, angioedema, drug reaction with eosinophilia and systemic symptoms (DRESS), and pruritus. In addition, several genes were found to be associated with sulfonamide hypersensitivity, including HLA-A29, HLA-B12, HLA-DR7, HLA-B44, and HLA A*11:01.

The Association Between Allergic Contact Dermatitis and Erythema Multiforme: A Systematic Review of the Literature

ABSTRACT

The relationship between erythema multiforme (EM) and allergic contact dermatitis (ACD) remains unclear. There have been multiple reports of EM-like lesions occurring in conjunction with or presenting after ACD; however, various definitions and terminologies have been used to denote the patient's diagnosis in these cases. In this systematic review, we summarize the key presenting features of recent cases of EM-like eruptions associated with ACD, as well as diagnostic findings, responsible allergens, treatments, and outcomes. We propose that, whenever possible, these cases should be classified into 2 distinct categories: (1) EM-like ACD and (2) EM after ACD (ACD-induced EM). Because the clinical courses, potential complications, and treatment plans differ between the two, a critical need exists for further characterization and distinguishment of EM-like ACD and ACD-induced EM.

Autologous skin cell suspension application for toxic epidermal necrolysis: a case report

Toxic epidermal necrolysis is a drug-mediated disease process which mimics a partial thickness thermal injury. It has long been treated with frequent wound dressing changes and supportive care. There has been minimal efficacious system therapy. The pathophysiology is poorly understood but causes necrosis of keratinocytes at the dermal-epidermal junction leading to sloughing of the epidermis. The disease is rare with high mortality rates associated with long hospital stays. This case report describes the application of autologous skin cell suspension to a patient with toxic epidermal necrolysis after antihypertensive and hyperglycemic therapy. This was associated with minimal wound care and efficacious arrest of patient disease process and timely closure of wound.

Toxic Epidermal Necrolysis Caused by Allopurinol: A Serious but Still Underestimated Adverse Reaction

Patient: Female, 75-year-old

Final Diagnosis: Toxic epidermal necrolysis

Symptoms: Exanthema • rash • shivers • weakness

Medication: —

Clinical Procedure: Analgesia • ciclosporine • corticosteroids • topical and systemic treatment

Specialty: Critical Care Medicine • Dermatology

Case Report: Positive Outcome of a Suspected Drug-Associated (Immune Mediated) Reaction in a 4-Year-Old Male French Bulldog

Toxic epidermal necrolysis (TEN) is a rare and severe life-threatening syndrome characterized by apoptosis of keratinocytes resulting in devitalization of the epidermis affecting more than 30% of skin surface. In humans and animals, this condition is mostly triggered by drugs. Identification of the putative agent and its withdrawal are crucial to successful management of a patient with TEN. In this case study, we report the clinical features, histopathological findings and management of a dog with TEN. A 4-year-old intact male French bulldog presented with acute onset of severe lethargy and cutaneous ulcerations on the footpads, scrotum, and hind limbs associated with marked pain. A Stevens-Johnson syndrome/TEN was suspected and drugs, especially beta-lactams, were withdrawn. Histopathology confirmed the diagnosis of epidermal necrosis. Advanced supportive therapy, pain management and skin care led to rapid remission. Early identification and removal of the suspected medication was crucial to improving TEN prognosis in this dog. Antibiotics (penicillin, ampicillin, cephalexin, and sulfonamides) are frequently involved in adverse cutaneous reactions in dogs. Ideal treatment remains elusive is humans and dogs and this disease has a poor prognosis. Supportive care combined with pain management and treatment of the cutaneous ulcerations is essential.

Lethal macrophage-related complications of juvenile myelomonocytic leukemia with a blastic crisis: an autopsy case report

For hematopoietic stem cell transplantation to be successful, complications must be managed. Graft-versus-host disease is particularly important, but various other complications, treatment side effects, and relapse of primary disease may also occur. We report an autopsy case of juvenile myelomonocytic leukemia with a blastic crisis, in which activated and recovered autologous macrophage-related complications after cord blood transplantation caused the patient's death. Pathological analysis of autopsy specimens revealed diffuse infiltration of mature macrophages into the skin but scarce lymphocytes. These macrophages were found in the bone marrow interspersed with a small number of blasts that had previously occupied about 60% of the bone marrow before death. The direct cause of death was an opportunistic airway infection due to bone marrow and immune failures triggered by overactivation and proliferation of macrophages. Genetic analysis showed the activated macrophages were autologous. Together these findings indicate that the patient died from macrophage-mediated complications, but not from a blastic crisis or conventional graft-versus-host disease. When macrophage activation persists after hematopoietic stem cell transplantation, macrophage-mediated complications should be considered as a differential diagnosis. To manage this complication, pathology specimens should be examined to check for the presence of effector cells at an early stage.

HLA-B*58:01 screening to prevent allopurinol-induced severe cutaneous adverse reactions in Chinese patients with chronic kidney disease

Human leukocyte antigen (HLA)-B*58:01 allele is a significant risk factor for allopurinol-induced severe cutaneous adverse reactions (SCARs) which is potentially fatal. In some studies, chronic kidney disease (CKD) was also implicated to compound the risk of SCARs. We aim to investigate if pre-treatment HLA-B*58:01 screening can prevent allopurinol-induced SCARs in Chinese patients with CKD and its cost-effectiveness. We prospectively recruited Chinese CKD patients who required allopurinol during 2011-2015 and performed pre-treatment HLA testing (HLA screening group). Patients tested positive for HLA-B*58:01 were refrained from allopurinol while those tested negative were prescribed allopurinol. The incidence of SCARs in the HLA screening group was compared with the historical control in previous 5 years and the cost-effectiveness of HLA testing was analyzed. In the historical control (2006-2010), 3605 patients on allopurinol were screened, 22 out of 1027 (2.14%) CKD Chinese patients newly started on allopurinol developed SCARs, including 6 SJS/TEN. In the HLA screening group, 28 out of 192 patients (14.6%) tested HLA-B*58:01 positive were advised to avoid allopurinol; 156 out of 164 HLA-B*58:01-negative patients received allopurinol and none developed SCARs. The incidence rate of SCARs was significantly lower in the HLA screening group compared with controls (0% vs 2.14% respectively, p = 0.037*). The targeted HLA screening approach was associated with lower healthcare costs compared with no HLA screening (US$ 92,430 vs US$ 281,226). Pre-treatment HLA-B*58:01 screening is cost-effective to target on patients with CKD in Chinese to prevent allopurinol-induced SCARs.

Stevens-Johnson syndrome and toxic epidermal necrolysis in a referral center in Taiwan

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are potentially fatal adverse drug reactions. The characteristics of these diseases are changing with the use of novel drugs, posing new challenges to doctors. We aimed to review recent SJS/TEN cases in order to assist general practitioners with timely diagnosis and correct management.

METHODS

We conducted a retrospective chart review of SJS/TEN patients in a referral center in Taiwan from 2009 to 2019. We included 24 patients' charts and analyzed demographic data, medication histories, clinical courses, human leukocyte antigen (HLA) alleles, and long-term complications.

RESULTS

The average age was 63.4 years, and the average toxic epidermal necrolysis-specific severity of illness score was 1.9. The most common culprit drug was carbamazepine (33.3%), followed by antibiotics (12.5%) and nonsteroidal anti-inflammatory drugs (8.3%). Two cases were caused by immune checkpoint inhibitors, and one of them had a long latency of 210 days. Three out of the four patients carrying HLA-B*15:02 had carbamazepine-induced SJS/TEN. All patients were treated with systemic corticosteroids in the acute stage of the diseases. The length of in-hospital stay did not correlate with the average daily dose of corticosteroids. The overall mortality rate was 4.2%, and the disease-specific mortality rate was 0%.

CONCLUSIONS

The most common culprit drug was carbamazepine, which had strong association with HLA-B*15:02. There was no statistically significant correlation between in-hospital stay and the average daily dose of corticosteroids. Immune checkpoint inhibitor-related SJS/TEN may have an extended latent period.

Early Diagnosis of Stevens-Johnson Syndrome in the Dental Clinic Setting

Stevens-Johnson syndrome (SJS) is a life-threatening acute and fatal dermatological disease. It can present with many variations and rapidly worsens in a short period of time. Early diagnosis and management play an important role in stopping SJS from progression. Various drugs such as antibiotics, anticonvulsants and non-steroidal anti-inflammatory drugs can trigger the disease as an adverse effect. Oral and dental manifestation of SJS is uncommon. However, dentists should be clinically oriented towards signs and symptoms of the disease, both oral and systemic. We present a case of a 37-year-old male with no past medical history who presented to the dental emergency clinic complaining of dysphagia and burning sensation in the mouth. On oral examination, oral rash and blisters were observed. In addition, a bilateral forearm erythematous, non-blanching painful rash with some blisters was found after antibiotic administration three days earlier. The antibiotic was stopped and the patient was started on topical betamethasone for 14 days, topical chlorhexidine for 10 days, and oral nystatin suspension 100,000 units. A complete resolution of the oral and systemic manifestation was seen without the need for hospital admission.

Drug hapten-specific T-cell activation: Current status and unanswered questions

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.

Impact of Antibiotics Associated with the Development of Toxic Epidermal Necrolysis on Early and Late-Onset Infectious Complications

Toxic epidermal necrolysis (TEN) is a rare disease, which predominantly manifests as damage to the skin and mucosa. Antibiotics count among the most common triggers of this hypersensitive reaction. Patients with TEN are highly susceptible to infectious complications due to the loss of protective barriers and immunosuppressant therapy. The aim of this study was to investigate the potential relationship between antibiotics used before the development of TEN and early and late-onset infectious complications in TEN patients. In this European multicentric retrospective study (Central European Lyell syndrome: therapeutic evaluation (CELESTE)), records showed that 18 patients with TEN used antibiotics (mostly aminopenicillins) before the disease development (group 1), while in 21 patients, TEN was triggered by another factor (group 2). The incidence of late-onset infectious complications (5 or more days after the transfer to the hospital) caused by Gram-positive bacteria (especially by Enterococcus faecalis/faecium) was significantly higher in group 1 than in group 2 (82.4% vs. 35.0%, p = 0.007/p_corr = 0.014) while no statistically significant difference was observed between groups of patients with infection caused by Gram-negative bacteria, yeasts, and filamentous fungi (p > 0.05). Patients with post-antibiotic development of TEN are critically predisposed to late-onset infectious complications caused by Gram-positive bacteria, which may result from the dissemination of these bacteria from the primary focus.

The Role of Frozen Section in the Rapid Diagnosis of Severe Cutaneous Adverse Drug Reactions

CONTEXT

Early diagnosis is the mainstay in the management of severe cutaneous adverse reactions (SCARs) to drugs.

AIMS

To study the role of frozen section in the rapid diagnosis of SCARs and the impact on outcome of the affected patients.

SETTINGS AND DESIGN

A single-blind, hospital-based study was conducted from December 2014-July 2016.

METHODS AND MATERIAL

We biopsied 32 adults with SCARs diagnosed by clinical features and standard criteria. The histopathological features seen on frozen sections were compared to that of paraffin blocks. The impact of rapid diagnosis on the clinical outcome was studied in toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS), drug rash with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP).

STATISTICAL ANALYSIS

Z test was used to compare two proportions. Kappa statistic, sensitivity, specificity, positive predictive value, and negative predictive value of the frozen section diagnosis were calculated in TEN/SJS and DRESS using MedCalc software.

RESULTS

Frozen and paraffin sections were done in TEN/SJS spectrum (13), DRESS (17), and AGEP (2). The sensitivity, specificity and kappa values for frozen section diagnosis in SJS/TEN and DRESS were 91.7%, 95%, 0.867 and 94.4%, 100%, 0.937 respectively. The concordance between frozen and paraffin section diagnosis was 100% in TEN, SJS, DRESS and AGEP. All the 6 patients with TEN and 2 with AGEP survived. Taking the worst-case scenario, the mortality in SJS was 28.6%. The mortality among patients with DRESS was 11.8%.

CONCLUSIONS

Frozen section helps in the rapid diagnosis and early treatment of SCARs and differentiates it from diseases that mimic it.

Carbamazepine-Induced Toxic Epidermal Necrolysis Managed by Mobile Teledermatology in COVID-19 Pandemic in Rural Nepal

Toxic epidermal necrolysis is a life-threatening dermatological emergency with high mortality if not treated in time. Here we report a case of toxic epidermal necrolysis due to carbamazepine in rural Nepal in COVID-19 pandemic who was successfully treated with the help of mobile teledermatology. The clinical impression of toxic epidermal necrolysis was made from “WhatsApp” video calls using a smart phone. The supportive features were the history of starting of carbamazepine 2 weeks prior for seizure disorder, clinical findings in serial photographs of skin with 40 percent body surface area involvement of necrotic skin lesions and bulla, and involvement of oral mucosa and eyes. The patient was immediately asked to stop carbamazepine and was treated with intravenous fluids and systemic steroids along with symptomatic management. As the whole world was suffering from lockdown due to COVID-19 crisis, it was impossible for the rural area patient to visit a dermatologist. Thus, with the help of paramedics staff in a community health center and mobile teledermatology, the patient was diagnosed as carbamazepine-induced toxic epidermal necrolysis and treated successfully with good outcome.

Toxic Epidermal Necrolysis and Steven-Johnson Syndrome: A Comprehensive Review

Significance: Toxic epidermal necrolysis (TEN) and Steven-Johnson syndrome (SJS) are potentially fatal acute mucocutaneous vesiculobullous disorders. Evidence to date suggests that outcomes for patients with both TEN and SJS are largely dependent on stopping the causative agent, followed by supportive care and appropriate wound management in a specialized burns unit. These are life-threatening conditions characterized by widespread full-thickness cutaneous and mucosal necrosis. This article outlines the approach to holistic management of such patients, in a specialized unit, highlighting various practical aspects of wound care to prevent complications such as infection, mucosal and adhesions, and ocular scaring. Recent Advances: There is improved understanding of pain and morbidity with regard to the type and frequency of dressing changes. More modern dressings, such as nanocrystalline, are currently favored as they may be kept in situ for longer periods. The most recent evidence on systemic agents, such as corticosteroids and cyclosporine, and novel treatments, are also discussed. Critical Issues: Following cessation of the culprit trigger, management in a specialized burns unit is the most important management step. It is now understood that a multidisciplinary team is essential in the care of these patients. Following admission of such patients, dermatology, ear, nose, and throat surgery, ophthalmology, urology, colorectal surgery, and gynecology should all be consulted to prevent disease sequelae. Future Directions: Looking forward, research is aimed at achieving prospective data on the efficacy of systemic immunomodulating agents and dressing types. Tertiary centers with burns units should develop policies for such patients to ensure that the relevant teams are consulted promptly to avoid mucocutaneous complications.

Ex Vivo Exposure of Human Melanoma Tissue to Cold Physical Plasma Elicits Apoptosis and Modulates Inflammation

Cutaneous melanoma is the most aggressive type of skin cancer with a not-sufficient clinical outcome. High tumor mutation rates often hamper a remedial treatment, creating the need for palliative care in many patients. To reduce pain and burden, local palliation often includes cryo-ablation, immunotherapy via injection of IL2, or electrochemotherapy. Yet, a fraction of patients and lesions do not respond to those therapies. To reach even these resistances in a redox-mediated way, we treated skin biopsies from human melanoma ex vivo with cold physical plasma (kINPen MED plasma jet). This partially ionized gas generates a potent mixture of reactive oxygen species (ROS). Physical plasmas have been shown to be potent antitumor agents in preclinical melanoma and clinical head and neck cancer research. The innovation of this technology lies in its ease-of-use without anesthesia, as the “cold” plasma temperature of the kINPen MED does not exceed 37 °C. In metastatic melanoma skin biopsies from six patients, we identified a marked increase of apoptosis with plasma treatment ex vivo. This had an impact on the chemokine/cytokine profile of the cultured biopsies, e.g., three of six patient-derived biopsy supernatants showed an apparent decrease in VEGF compared to non-plasma treated specimens. Moreover, the baseline release levels of 24 chemokines/cytokines investigated may serve as a useful tool for future research on melanoma skin biopsy treatments. Our findings suggest a clinically useful role of cold physical plasma therapy in palliation of cutaneous melanoma lesions, possibly in a combinatory setting with other immune therapies.

Colonic Involvement of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Rare Cause of Gastrointestinal Bleeding

Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) represents a spectrum of rare but severe mucocutaneous drug reactions. Gastrointestinal involvement of SJS/TEN is associated with high morbidity and mortality and often presents 2-3 weeks after the initial appearance of skin lesions. There are no evidence-based treatment algorithms for the management of SJS/TEN. We report a case of life-threatening gastrointestinal bleeding from colonic involvement of SJS/TEN and discuss potential therapeutic options.

Mutant GNLY is linked to Stevens-Johnson syndrome and toxic epidermal necrolysis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare severe cutaneous adverse reactions to drugs. Granulysin (GNLY) plays a key role in keratinocyte apoptosis during SJS/TEN pathophysiology. To determine if GNLY-encoding mutations might be related to the protein's functional disturbances, contributing to SJS/TEN pathogenesis, we performed direct sequencing of GNLY's coding region in a group of 19 Colombian SJS/TEN patients. A GNLY genetic screening was implemented in a group of 249 healthy individuals. We identified the c.11G > A heterozygous sequence variant in a TEN case, which creates a premature termination codon (PTC) (p.Trp4Ter). We show that a mutant protein is synthesised, possibly due to a PTC-readthrough mechanism. Functional assays demonstrated that the mutant protein was abnormally located in the nuclear compartment, potentially leading to a toxic effect. Our results argue in favour of GNLY non-synonymous sequence variants contributing to SJS/TEN pathophysiology, thereby constituting a promising, clinically useful molecular biomarker.

Ribociclib-Related Stevens-Johnson Syndrome: Oncologic Awareness, Case Report, and Literature Review

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis belong to a severe dermatopathic spectrum that includes frequently fatal mucocutaneous manifestations consisting of whole epidermal necrosis and sloughing with bullous transformation, blistering, and further skin detachment. Notably, cancer patients are at higher risk of developing SJS than the general population as a consequence of both the nature of neoplastic disease and frequent exposure to anticancer drugs. Ribociclib is a newly approved cycline-dependent kinase inhibitor that has been recently associated with a single case of SJS. We hereby present a case of ribociclib-related SJS. Early detection of threatening skin lesions is crucial to permit the immediate discontinuation of ribociclib given the predictable and unacceptable risk level. In cases of established SJS, early aggressive support should be initiated, ribociclib should be abruptly discontinued, and specific treatment based on actual evidence should be started.

A 10-year retrospective cohort study of the management of toxic epidermal necrolysis and Stevens-Johnson syndrome in a New South Wales state referral hospital from 2006 to 2016

IMPORTANCE

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are life-threatening severe cutaneous drug reactions. There have been no Australian data published since 2007.

OBJECTIVE

To explore whether there is an association between prognosis and the type of systemic immune-modulation treatment administered in a cohort of patients with SJS, SJS-TEN overlap, and TEN at the New South Wales State SJS/TEN referral center - Concord Repatriation General Hospital.

METHODS

This is a retrospective, single center, cohort study of patients admitted with SJS/TEN from January 1, 2006, to December 31, 2016, at Concord Repatriation General Hospital. Data on demographic information, the causative agent, treatment, and final survival outcome were analyzed.

RESULTS

Forty-two patients included: 26 (62%) with TEN, six (14%) with SJS/TEN overlap, and 10 (24%) with SJS. Overall mortality was 19% (n = 8), and seven suffered TEN. The average age of those who died was 60 years. Eighty-one percent of patients were managed within the burn unit. Twenty-nine patients (70%) received IVIG within this group; 13 individuals also received systemic corticosteroids. Seven (17%) were managed with corticosteroid therapy alone. The incidence of death was 0% in the combined IVIG and corticosteroid group.

CONCLUSION

This series of 42 patients contributes valuable information to a serious condition with low global incidence and high mortality. There appears to be an apparent reduced mortality in the group of SJS/TEN patients managed with combined IVIG and corticosteroid. Larger cohorts are required to validate this relationship due to the risk of bias inherent to the retrospective study design and small sample size.

A diagnosis of Stevens-Johnson Syndrome (SJS) in a patient presenting with superficial keratitis

Purpose

To describe a case of Stevens-Johnson syndrome (SJS) diagnosed in a patient presenting with primarily ocular findings where SJS had not been initially suspected.

Observations

A 23-year-old female presented with a 2 day history of bilateral eye pain, conjunctival injection, decreased visual acuity, and photophobia in the context of a 4 day history of fever, headache, and sore throat. She was found to have bilateral superficial keratitis and treated for suspected early infectious keratitis secondary to extended contact lens wear. She returned the next day with worsening visual symptoms, a new macular rash over her upper torso, and new ulcerating lesions over her buccal and perioral tissue. The patient was diagnosed with SJS. She was successfully treated using systemic cyclosporine with antibiotics and steroid eye drops.

Conclusions and importance

Ophthalmologists may be the first physicians to diagnose SJS, a life-threatening condition that can initially present with non-specific viral prodromal symptoms and ocular signs alone. This case emphasizes the importance of considering a patient's entire clinical history, especially when the presentation is atypical and the diagnosis is not obviously apparent.

Drug-induced Stevens-Johnson syndrome and toxic epidermal necrolysis in vietnamese spontaneous adverse drug reaction database: A subgroup approach to disproportionality analysis

WHAT IS KNOWN AND OBJECTIVE

Despite the numerous studies investigating drug-induced Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), the understanding and quantitative data in developing countries remain limited. The study aimed to describe and quantify the drug-related risk of SJS/TEN in a resource-limited context using the Vietnamese spontaneous reporting database (VSRD) of adverse drug reactions.

METHODS

Spontaneous reports relating to medium- and late-onset severe cutaneous adverse reactions (MLOSCAR) and SJS/TEN recorded in the VSRD from 2010 to 2015 were retrospectively analysed. The demographic characteristics and drug information were described and compared between SJS/TEN and other MLOSCAR reports. The drug-induced SJS/TEN signals were estimated using subgrouped disproportionality analysis with calculation of the reporting odds ratio (ROR) and the respective 95% confidence interval (CI).

RESULTS

The VSRD received 2,849 MLOSCAR reports, 136 of which focus on SJS/TEN over a 6-year period. About 60% of SJS/TEN patients were male, and the majority of them were adults (mean age 42.5 ± 22.9). Up to 91.8% of drugs induced SJS/TEN within 1-28 days, and 45% SJS/TEN cases were evaluated as life-threatening. Positive signals were generated with carbamazepine (n = 25, ROR [95% CI] = 11.99 [7.07-19.92]), allopurinol (n = 15, ROR [95% CI] = 4.2 [2.20-7.59]), traditional/herbal medicines (n = 7, ROR [95% CI] = 2.76 [1.12-5.86]), colchicine (n = 4, ROR [95% CI] = 6.22 [1.69-18.72]), valproic acid (n = 3, ROR [95% CI] = 8.71 [1.89-30.19]) and meloxicam (n = 3, ROR [95% CI] = 7.09 [1.55-24.29]), which are well known for SJS/TEN. Cefixime (n = 5, ROR [95% CI] = 3.34 [1.13-8.00]) and paracetamol (n = 22, ROR [95% CI] = 5.23 [3.10-8.49]) also generated positive signals despite their popularity in Vietnam.

WHAT IS NEW AND CONCLUSION

This first Vietnamese population-based study has highlighted original characteristics and signals of drug-induced SJS/TEN, which are relatively consistent with other worldwide data and typical for a developing country.

Stevens-Johnson Syndrome: A Challenging Diagnosis

Stevens-Johnson syndrome is a rare, yet life-threatening, delayed-type hypersensitivity reaction characterized by mucocutaneous epidermal necrolysis. Toxic epidermal necrolysis is a severe manifestation of Stevens-Johnson syndrome, defined as greater than 30% skin detachment. Stevens-Johnson syndrome with toxic epidermal necrolysis is characterized as an adverse cutaneous drug reaction and is associated with the use of sulfonamides, antiepileptics, and some classes of nonsteroidal anti-inflammatory drugs. The case presented in this report is that of a 17-year-old female who presented to her primary care provider with a chief complaint of headache; she was initially diagnosed with a urinary tract infection and prescribed nitrofurantoin (Macrobid). Over the next 2 days, her symptoms worsened, she presented to the emergency department twice, and was transferred to a burn unit for definitive care. This case highlights the importance of prompt identification and diagnosis of Stevens-Johnson syndrome and underscores the need for emergency providers to have a comprehensive knowledge of adverse cutaneous drug reactions.

Revisiting the Functional Impact of NK Cells

Immune responses are critical for the maintenance of homeostasis but can also upset the equilibrium, depending on the context and magnitude of the response. Natural killer (NK) cells are well known for their important roles in antiviral and antitumor immune responses, and they are currently used, mostly under optimized forms, as immunotherapeutic agents against cancer. Nevertheless, with accumulating examples of deleterious effects of NK cells, it is paramount to consider their negative contributions. Here, we critically review and comment on the literature surrounding undesirable aspects of NK cell activity, focusing on situations where they play a harmful rather than a protective role.

Congenital Infantile Fibrosarcoma in the Premature Infant

BACKGROUND

Congenital infantile fibrosarcoma (CIF) is rare and represents less than 1% of all childhood cancers. It is a tumor that originates in the connective fibrous tissue found at the ends of long bones and then spreads to other surrounding soft tissues. These lesions are typically large, grow rapidly, and can often be mistaken for teratomas. Diagnosis is confirmed by pathology, where cellular proliferation of fibroblasts occurs. Imaging is an important part of the diagnosis, which includes the use of magnetic resonance imaging and/or computed tomography scan. Although surgical resection is the primary treatment, chemotherapeutic agents may be used as adjuvant therapy.

PURPOSE

To describe modalities for accurate diagnosis and treatment of CIF.

METHODS/SEARCH STRATEGY

PubMed was searched using terms "congenital infantile fibrosarcoma" and "infantile fibrosarcoma." Eleven relevant, English language articles were identified and utilized in the preparation of this case presentation.

FINDINGS/RESULTS

Complications addressed in this case presentation are prenatal diagnostic challenges, pharmacologic interventions in the setting of prematurity, immunosuppression, and acute liver and renal failure. Pharmacologic treatments will include chemotherapy agents, antimicrobial agents, as well as granulocyte colony-stimulating factor for immunosuppression. Nursing challenges included positioning and integumentary disturbances.

IMPLICATIONS FOR PRACTICE

Utilization of diagnostic imaging and pathology to accurately identify and diagnose CIF is essential.

IMPLICATIONS FOR RESEARCH

Safety and efficacy of chemotherapeutic agents in premature infants with CIF need to be established.

TFOS DEWS II pathophysiology report

The TFOS DEWS II Pathophysiology Subcommittee reviewed the mechanisms involved in the initiation and perpetuation of dry eye disease. Its central mechanism is evaporative water loss leading to hyperosmolar tissue damage. Research in human disease and in animal models has shown that this, either directly or by inducing inflammation, causes a loss of both epithelial and goblet cells. The consequent decrease in surface wettability leads to early tear film breakup and amplifies hyperosmolarity via a Vicious Circle. Pain in dry eye is caused by tear hyperosmolarity, loss of lubrication, inflammatory mediators and neurosensory factors, while visual symptoms arise from tear and ocular surface irregularity. Increased friction targets damage to the lids and ocular surface, resulting in characteristic punctate epithelial keratitis, superior limbic keratoconjunctivitis, filamentary keratitis, lid parallel conjunctival folds, and lid wiper epitheliopathy. Hybrid dry eye disease, with features of both aqueous deficiency and increased evaporation, is common and efforts should be made to determine the relative contribution of each form to the total picture. To this end, practical methods are needed to measure tear evaporation in the clinic, and similarly, methods are needed to measure osmolarity at the tissue level across the ocular surface, to better determine the severity of dry eye. Areas for future research include the role of genetic mechanisms in non-Sjögren syndrome dry eye, the targeting of the terminal duct in meibomian gland disease and the influence of gaze dynamics and the closed eye state on tear stability and ocular surface inflammation.