Stevens - Johnson Syndrome and Toxic Epidermal Necrolysis; Extensive Review of Reports of Drug-Induced Etiologies, and Possible Therapeutic Modalities

Moderate and serious adverse reactions to antimicrobials among hospitalized children: A systematic review

AIMS

This systematic review aimed to investigate the occurrence of moderate and severe adverse drug reactions (ADRs) to antimicrobials among hospitalized children.

METHODS

The PubMed/Medline, Cochrane Library, Embase, Web of Science, Scopus, Lilacs and CINAHL databases were searched in April 2023 to systematically review the published data describing the characteristics of moderate and severe ADRs to antimicrobials among hospitalized children. The search was carried out without date restrictions, up to the search date (April, 2023).

RESULTS

At the end of the selection process, 30 articles met the inclusion criteria. Cutaneous reactions were the primary serious clinical manifestations in most articles (19/30), followed by erythema multiforme (71 cases), Stevens-Johnson syndrome (72 cases), and toxic epidermal necrolysis (22 cases). The main antimicrobials involved in moderate and severe ADRs were penicillins, cephalosporins and sulfonamides. Regarding the primary outcomes, 30% (9/30) of the articles reported deaths, and 46.7% (14/30) of studies reported increased lengths of hospital stay, need for intensive care, and transfer to another hospital. Regarding the main interventions, 10% (3/30) of the articles mentioned greater monitoring, suspension, medication substitution or prescription of specific medications for the symptomatology.

CONCLUSIONS

The findings of this review could be used to identify areas for improvement and help health professionals and policymakers develop strategies. In addition, we emphasize the importance of knowing about ADRs so that there is adequate management to avoid undesirable consequences.

Pemphigus vulgaris mimicking Steven-Johnson syndrome/toxic epidermal necrolysis: report of an unusual case

Pemphigus vulgaris (PV) is an autoimmune blistering disease affecting the skin and mucosa. It clinically presents as painful erosions, mainly in the oral cavity, and flaccid blisters and erosions on the skin. Steven-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a severe mucocutaneous drug hypersensitivity reaction characterized by painful, dusky, erythematous eruptions that often progress to blisters, erosions, and extensive epidermal detachment accompanied by systemic symptoms. Herein, we report the case of a 48-year-old man who presented with extensive skin and mucosal lesions following the ingestion of an unknown medication. The patient's symptoms clinically mimicked SJS, and accordingly, a preliminary diagnosis of SJS/TEN was made. However, clinical investigation of skin biopsy and direct immunofluorescence assay results indicated PV, and a final diagnosis of PV was established.

Phenytoin-Associated Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Overlap in Focus: A Case Report

Stevens-Johnson syndrome and toxic epidermal necrolysis overlap is a rare but severe cutaneous hypersensitivity reaction that can lead to death if not treated aggressively and adequately. Drug-induced hypersensitivity reactions are often related to drug exposure, with sulfonamides, anti-epileptics, fluoroquinolones, cephalosporins, and nonsteroidal anti-inflammatory drugs being the most common culprits. This case report describes a 10-year-old boy who was administered phenytoin at a local clinic to manage his seizures. This treatment led to the onset of SJS-TEN overlap, ultimately resulting in his demise.

Stevens-Johnson Syndrome in a Patient With Recent SARS-CoV-2 Infection and Ciprofloxacin Administration

Stevens-Johnson syndrome (SJS) is an acute, rare, and potentially life-threatening condition with high morbidity and mortality. It is characterized by a blistering rash and erosions with mucosal involvement, which depending on the extent of the skin area involved may be categorized as epidermal necrolysis, along with systemic symptoms. Symptoms are preceded by the administration of a newly introduced drug in almost 80% of cases and less commonly by infections in genetically predisposed individuals. We report a case of SJS in a female patient secondary to a recent SARS-CoV-2 infection and subsequent ciprofloxacin administration.

Association of Acetaminophen With Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Pharmacologic Considerations and Treatment Options

Acetaminophen is an extremely common drug with many implications for its analgesic and antipyretic properties. It has a unique mechanism of action and downstream effects that separate it categorically from non-steroidal anti-inflammatory drugs. These differences come with potential adverse effects that range from mild drug reactions to severe life-threatening emergencies. While acetaminophen's toxic liver effects are well known, a lesser-known adverse effect of this drug is its association with the development of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). These dermatological emergencies involve similar pathological processes, including apoptosis of the epidermis and sloughing of the dermis and mucosa from the underlying layers with a positive Nikolsky sign. Currently, SJS and TEN are considered immune-mediated type IV hypersensitivity reactions predominantly involving CD8+ T lymphocytes. Other immune mediators, including regulatory T cells, natural killer cells, interleukins, and drug metabolites are speculated to be involved, but their mechanisms have not been entirely determined. These conditions are differentially diagnosed by the percentage of body area affected with SJS and TENS, involving <10% and >30%, respectively. Genomic variations in human leukocyte antigens (HLA) genes have been implicated in the susceptibility and severity of acetaminophen-induced SJS/TENS, however, details of these interactions remain unclear. Acetaminophen's widespread use and the morbidity of its associated skin pathologies SJS and TENS warrant an in-depth examination of the causative processes involved in their pathogenesis. It is critical that both physicians and patients be made aware that while acetaminophen is widely tolerated by most individuals, severe and potentially fatal interactions do occur, and further investigation is necessary to reduce these adverse effects.

Atopic Dermatitis and Water: Is There an Optimum Water Intake Level for Improving Atopic Skin?

Water is a vital nutrient with innumerable functions for every living cell. The functions of human skin include protection against dehydration of the body. Atopic dermatitis (AD) is a chronic pruritic inflammatory skin disease that presents with dry skin, erythematous and eczematous lesions, and lichenification. This paper discusses the question of whether extra water intake in children with AD affects skin hydration and the skin barrier function. Among the methods used to treat dry skin, topical leave-on products are the first-line treatment, intended to improve hydration and the skin barrier function. The effectiveness of adequate water intake as a measure to treat dry skin is still under debate. Normal skin hydration increases with dietary water intake, particularly in those with prior lower water consumption. Skin dryness in AD is instrumental to the itch and inflammation cycle, contributing to barrier impairment and aggravating disease severity and flares. Certain emollients provide significant hydration to AD skin, with relief of dryness and reduction in barrier impairment, disease severity, and flares. Further investigations are needed to evaluate the optimum water intake levels in children with AD, as important questions remain unanswered, namely, does oral hydration provide relief of skin dryness and reduce barrier impairment, disease severity, and flares; is there any additional benefit from using mineral or thermal spring water; or is there a need to specifically study the fluid/water intake in children with AD and food allergy (FA) restrictions?

Pembrolizumab-Induced Toxic Epidermal Necrolysis

Immunotherapy has nowadays become part of the mainstay of treatment for several cancers. In this report, we present a case of toxic epidermal necrolysis (TEN) occurring as a relatively rare complication of pembrolizumab, which is a humanized monoclonal anti-programmed cell death-1 (anti-PD1) IgG4 antibody that targets tumours expressing PDL-1. In our case, this monoclonal antibody (MAB) was being used for the treatment of metastatic non-small cell lung cancer, before being withheld because of this potentially life-threatening reaction. There are no guidelines on the optimal management of TEN, with varying reports on the efficacy on steroids, intravenous immunoglobulin (IVIG), and cyclosporin. In this report, we describe a case of TEN following the second dose of three-weekly pembrolizumab in a 50-year-old man, comparing it to four similar cases reported in the literature. It is important that oncologists are aware of this potentially life-threatening adverse reaction of pembrolizumab, as early recognition and treatment of TEN are essential to improve clinical outcome.

Clinical characteristics of drug-induced Stevens-Johnson syndrome and toxic epidermal necrolysis: A single-center study

Background

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe adverse cutaneous reactions, most commonly triggered by medications, characterized by extensive necrosis and detachment of the epidermis.

Objective

We investigated the differences in clinical characteristics of drug-induced SJS/TEN depending on the type of drug in a single center.

Methods

The relevance of sex, age, culprit drugs, clinical features, courses, treatment options, and follow-up results were retrospectively evaluated in patients diagnosed with drug-induced SJS/TEN at Pusan National University Hospital between 2008 and 2019.

Results

Ninety-two patients with a mean age of 58.7 ± 20.2 years (range, 10-93 years) were included in the study. Those aged 60-80 years accounted for the largest number of patients (42.4%). Patients with drug-induced SJS/TEN comprised 40 women (43.5%) and 52 men (56.5%). We categorized drug-induced SJS/TEN cases by culprit drugs into 6 groups: antibiotics, allopurinol, antiepileptic (AED), nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and other drugs. The rate of NSAID-induced disease significantly increased from SJS to TEN (p = 0.016). Among the patients in the NSAID group, the proportion of TEN (40%) was higher than that in the other groups (p = 0.021). The mean body surface area was significantly lower in the AED group than in the non-AED groups (7.1 ± 9.8 vs. 23.1 ± 27.3, p = 0.020) and higher in the NSAID group than in the non-NSAID groups (47.5 ± 39.5 vs. 15.7 ± 20.0, p = 0.010).

Conclusion

This study showed that the clinical characteristics of each causative drug group may be different in drug-induced SJS/TEN. Our findings may help clinicians better understand drug-induced SJS/TEN.

A Life-Threatening Case of Torsemide-Induced Toxic Epidermal Necrolysis Associated With the Treatment of Anasarca

Toxic Epidermal Necrolysis (TEN), along with Stevens-Johnson Syndrome (SJS), are rare, life-threatening delayed type IV hypersensitivity mucocutaneous skin disorders that can often be precipitated by medications. The most common culprits are sulfonamide antibiotics and various antiseizure medications. We report a case of a 41-year-old Black female that initially presented with SJS, which then rapidly progressed to TEN, confirmed by hematoxylin and eosin stain skin biopsies. Approximately 80% of her body surface area had necrosis and epidermal detachment lesions. It was concluded that TEN was caused by the use of torsemide for treatment of her underlying diffuse anasarca attributable to alcoholic cirrhosis. During her one-month hospital stay, a multi-disciplinary team consisting of dermatology, gynecology, rheumatology, nephrology, and infectious disease evaluated and treated the patient. Interventions included various supportive care measures as well as intravenous steroids, cyclosporine, plasma exchange, and intravenous immunoglobulin. Given that the mortality rate for TEN is over 30%, and this patient had end-stage cirrhosis, her prognosis was extremely poor. Even though her TEN eventually healed slowly, the patient experienced complications. This case demonstrates the importance of cautiously using sulfonamide medications in patients with known hypersensitivity to sulfa drugs.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis

OBJECTIVE

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and severe skin and mucosal reactions that are associated with high mortality. Despite the severity, an evidence-based treatment protocol for SJS/TEN is still lacking.

METHOD

In this systematic review and meta-analysis, the PubMed database was searched using the following terms: [Stevens-Johnson syndrome] OR [toxic epidermal necrolysis] AND [therapy] OR [treatment] over a 20-year period (1999-2019) in the German and English language. All clinical studies reporting on the treatment of SJS/TEN were included, and epidemiological and diagnostic aspects of treatment were analysed. A meta-analysis was conducted on all comparative clinical studies that met the inclusion criteria.

RESULTS

A total of 88 studies met the inclusion criteria, reporting outcomes in 2647 patients. Treatment was either supportive or used systemic corticosteroid, intravenous immunoglobulin, plasmapheresis, cyclosporine, thalidomide or cyclophosphamide therapy. The meta-analysis included 16 (18%) studies, reporting outcomes in 976 (37%) patients. Systemic glucocorticoids showed a survival benefit for SJS/TEN patients in all analyses compared with other forms of treatment. Cyclosporine treatment also showed promising results, despite being used in a small cohort of patients. No beneficial effects on mortality could be demonstrated for intravenous immunoglobulins.

CONCLUSION

Glucocorticoids and cyclosporine may be tentatively recommended as the most promising immunomodulatory therapies for SJS/TEN, but these results should be investigated in future prospective controlled trials.

Agreement among different scales for causality assessment in drug-induced Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

BACKGROUND AND OBJECTIVE

Identification of the offending drug is crucial and challenging in cases of severe cutaneous adverse drug reactions (CADR) like Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Poor reproducibility and varying levels of agreement have been observed among different causality assessment tools (CATs) in assessing severe CADRs. This study was conducted to examine the agreement among four different CATs in assessing cases of drug-induced SJS, TEN and SJS/TEN overlap.

METHODS

All cases of drug-induced SJS, TEN and SJS/TEN overlap, which were reported between January 2012 and January 2020 were identified from the ADR register at an ADR monitoring center. Causality assessment was done in these reported cases using the following CATs: The World Health Organization-Uppsala Monitoring Centre (WHO-UMC) scale, Naranjo algorithm, Liverpool algorithm and Algorithm of drug causality for epidermal necrolysis (ALDEN). Weighted kappa (κw) test was used to calculate the agreement among four CATs.

RESULTS

A total of 30 cases of drug-induced SJS, TEN and SJS/TEN overlap were included in our analyses. The most common offending group of drugs were anticonvulsants (46.7%), antimicrobials (40%) and nonsteroidal anti-inflammatory drugs (13.3%). Of the anticonvulsants, phenytoin (13.3%), carbamazepine (10%) and valproate (10%) were the commonly reported offending drugs. Poor agreement was observed among the four different causality assessment scales.

CONCLUSION

Discrepancies were observed among four different CATs in assessing drug-induced SJS and TEN. A CAT that is more specific to drug-induced SJS and TEN, simple, user-friendly with limited subjective interpretation, incorporating new immunological and pharmacogenetic markers is necessary.

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.

Commercial Cannabinoid Oil-Induced Stevens-Johnson Syndrome

Purpose

To report an unusual presentation of commercial cannabidiol (CBD) oil-induced Stevens-Johnson Syndrome/toxic epidermal necrolysis (SJS-TEN).

Methods

A 56-year-old woman presented with acute onset of a diffuse, blistering, maculopapular rash with over 30% total body surface area (BSA) involvement two days after taking CBD oil sublingually for chronic pain. Biopsy confirmed SJS-TEN. Ophthalmology was consulted and mild eye involvement was found. She was started on topical cyclosporine, prednisone, moxifloxacin, and erythromycin ointment to prevent progression, which was successful. She was otherwise treated with supportive therapy in the intensive care burn unit and ultimately passed away from septic shock.

Conclusion

In this case, we described an unusual drug-induced SJS from a commercial, non-FDA-regulated cannabis product. The use of a commercial CBD product should be cautioned due to potential for series of drug reactions to the cannabis product and the risk for reaction to other unregulated other pharmacological components.

Aetiopathogenesis of severe cutaneous adverse reactions (SCARs) in children: A 9-year experience in a tertiary care paediatric hospital setting

BACKGROUND

Severe cutaneous adverse reactions (SCARs) are delayed-type hypersensitivity reactions to drugs including as follows: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), Stevens-Johnson syndrome (SJS), Toxic Epidermal Necrolysis (TEN) and Acute Generalized Exanthematous Pustulosis (AGEP). Incidence, triggers and management of SCARs have not been investigated in large-scale epidemiological studies on children.

OBJECTIVE

The aim of our study was to collect epidemiological, clinical and aetiological data from children with SCARs referred to our tertiary care paediatric hospital of Florence.

METHODS

From 2010 to 2018 charts of children with diagnosis of SCAR were reviewed, and data collected during the acute phase and/or the subsequent allergy evaluation. Patients underwent patch tests, intradermal tests and lymphocyte transformation tests. All children were investigated for infectious diseases.

RESULTS

Incidence of SCARs in hospitalized children was 0.32% over a 9-year period. Fifty-four children were enrolled (31 M; 23 F; median age 6.5 years): 17 cases of DRESS, 30 SJS, 3 TEN, 2 AGEP, 1 linear immunoglobulin A bullous disease (LABD) and 1 pemphigus. Twenty-eight out of 54 patients underwent drug allergy investigations, and 50% of them resulted positive. Combining clinical history and results of allergy work-up, 74% SCARs seem to be caused by drugs, 18.6% by both drugs and infections, 3.7% by infections, and 3.7% remained idiopathic. No deaths occurred.

CONCLUSIONS

In this study, SCARs incidence is in line with literature data. Drugs were most commonly the leading cause. Management of SCARs requires cooperation among professional figures for an early diagnosis and a prompt treatment. Mortality rate seems to be lower in children.

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.

Allopurinol-induced toxic epidermal necrolysis featuring almost 60% skin detachment

RATIONALE

Toxic epidermal necrolysis (TEN) is a life-threatening, immunologically mediated, and usually drug-induced disease. Rarely, clinical pharmacists participating in finding the etiology have been reported.

PATIENTS CONCERNS

A 33-year-old male presented to the emergency department with a 1-day history of fever and rash. The patient, being newly diagnosed with gout 10 days ago, received allopurinol at a dose of 250 mg by mouth daily. After 10 days' exposure to allopurinol, the patient manifested with an "influenza-like" prodromal phase (fever of 38°C, throat pains), which was treated with amoxicillin and nonsteroidal anti-inflammatory drugs of the oxicam type. The next day, he developed a worsening fever of 39.5°C, accompanied by a pruriginous rash all over his body.

DIAGNOSIS

On physical examination, we observed coalescing dusky red macules over >60% of his body surface area, with blisters and detachment of large sheets of necrolytic epidermis all over his chest and face. The diagnosis of TEN was confirmed.

INTERVENTIONS

The patient recovered following treatment with short-term high-dose methylprednisolone sodium succinate, immunoglobulin therapy, topical medication, and supportive therapy.

OUTCOMES

He showed a slow but progressive improvement both in symptoms and cutaneous manifestations. Reepithelization of the skin was achieved after 3 weeks.

LESSONS

Drug-induced-TEN is potentially fatal. This case underlines the necessity of asking medication history in detail and detecting related drug gene to correctly identify the cause of TEN.

Late-onset Stevens-Johnson syndrome due to nivolumab use for hepatocellular carcinoma

Nivolumab is a fully human immunoglobulin G4 immune checkpoint inhibitor antibody approved for use in the treatment of several malignancies. Severe side effects such as Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) have only extremely rarely been reported with this drug. We present herein a patient who developed SJS after 16 weeks of therapy with nivolumab. A week prior to this event, he developed a pruriginous papulo-erythematous rash. Prompt recognition of this phenomenon, immune checkpoint inhibitor discontinuation and steroid therapy are necessary steps in order to avoid dismal outcomes.

Severe Cutaneous Adverse Reactions in Korean Pediatric Patients: A Study From the Korea SCAR Registry

PURPOSE

Although severe cutaneous adverse drug reactions (SCARs) are rare, they are associated with high morbidity and mortality, and thus early diagnosis and treatment are critical for improving prognoses. However, few studies have reported the characteristics of SCARs in children. Thus, we aimed to evaluate the clinical characteristics, current management and prognosis of pediatric SCARs.

METHODS

We analyzed pediatric data in the Korean SCARs registry, which was built retrospectively in 2016 with SCAR cases treated in 34 tertiary referral university hospitals during 2010-2015. Using these cases, we descriptively analyzed detailed data regarding etiology, clinical and laboratory features, treatment strategies, and prognosis.

RESULTS

Forty-seven pediatric SCAR cases from 15 tertiary referral hospitals were included. The median patient age was 10 (interquartile range, 3-15.5) years and 68.1% (n = 32) were males. The culprit drug was identified in 95.7% (n = 45) of the patients; antibiotics (44.7%) and antiepileptic drugs (19.1%) were the most common and second most common culprits, respectively. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) cases presented with the largest area of skin involvement without permanent sequelae. Stevens-Johnson syndrome (SJS) cases involved relatively small areas of skin but serious sequelae in two children. Of 4 patients with toxic epidermal necrolysis (TEN), 1 died. Of all patients assessed, 36 (76.6%) received systemic steroids and 21 (44.7%) received intravenous immunoglobulin (IVIG). Thirteen (27.7%) received both systemic steroids and IVIG. Cyclosporine was administered to only 1 patient along with a systemic steroid.

CONCLUSIONS

In patients with pediatric SCARs, including those with DRESS, SJS and TEN, clinical presentations were variable. Thus, there was no clear continuous disease spectrum. Although the mortality rate was low (2.1%), clinical suspicion may be the best tool for proactive SCAR management.

Stevens-Johnson syndrome manifesting late in the course of pembrolizumab therapy

Pembrolizumab is a humanized antibody that targets programmed cell death receptor-1. This agent is approved for use in the treatment of several malignancies. While pruritus and papulo-erythematous rash are not uncommon with its use, severe reactions such as Stevens-Johnson syndrome/toxic epidermal necrolysis are very rare. We present herein a case of Stevens-Johnson syndrome occurring in a patient who had previously tolerated pembrolizumab without significant side effects for seven months. Prompt recognition of Stevens-Johnson syndrome/toxic epidermal necrolysis and discontinuation of the offending agent are paramount to ensure a favorable outcome.