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Bataille P, Lebrun-Vignes B, Bettuzzi T, Ingen-Housz-Oro S, Hadj-Rabia S, Welfringer-Morin A, Bodemer C. Drugs associated with epidermal necrolysis in children: A World Health Organization pharmacovigilance database analysis. J Eur Acad Dermatol Venereol 2024; 38:1791-1798. [PMID: 38682703 DOI: 10.1111/jdv.20054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening mucocutaneous reactions most often induced by drugs. To date, no large pharmacovigilance study has been conducted in the paediatric population. OBJECTIVES To describe the spectrum of drugs associated with SJS-TEN in children through the analysis of cases reported in the WHO pharmacovigilance database (VigiBase). METHODS Disproportionality study using data from VigiBase. All paediatric (age under 18 years) cases reported between January 1, 1967, and July 6, 2022, were included. For each molecule, a case-non-case study was performed to assess a potential pharmacovigilance signal by computing the lower end of the 95% credibility interval for the information component (IC025). We performed sensitivity analyses, (i) taking into account only cases reported by physicians and (ii) taking into account only cases reported in the last 10 years. RESULTS Among 31,376,783 adverse drug reactions reported in VigiBase, 2,248,727 were paediatric cases and 7342 were encoded as paediatric SJS-TEN. Significant statistical pharmacovigilance signals were observed for 165 drugs. The two most represented drug classes were antiepileptics and anti-infectious drugs. The five drugs with the highest IC025 were lamotrigine (IC025 4.99), carbamazepine (IC025 4.88), phenobarbital (IC025 4.67), phenytoin (IC025 4.52) and nimesulide (IC025 4.23). Acetaminophen was significantly associated with paediatric SJS-TEN (IC025 2.85) and we also described various new suspected drugs. Vaccines had no significant pharmacovigilance signal. These results were confirmed with the sensitivity analyses. CONCLUSIONS This study updates the spectrum of drugs potentially associated with paediatric SJS-TEN.
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Affiliation(s)
- Pauline Bataille
- Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades Hospital, APHP, Paris City University, Paris, France
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
- General Paediatrics, Department of Infectious Disease and Internal Medicine, Robert Debré Mother-Child University Hospital, AP-HP, Paris, France
- Paris City University, Imagine Institute, Data Science Platform, INSERM UMR 1163, Paris, France
| | - Benedicte Lebrun-Vignes
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
- Regional Pharmacovigilance Center, Department of Pharmacology, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
- Université Paris Est Créteil EpidermE, UPEC, Créteil, France
| | - Thomas Bettuzzi
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
- Regional Pharmacovigilance Center, Department of Pharmacology, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
- Université Paris Est Créteil EpidermE, UPEC, Créteil, France
- Dermatology Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Saskia Ingen-Housz-Oro
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
- Université Paris Est Créteil EpidermE, UPEC, Créteil, France
- Dermatology Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Smail Hadj-Rabia
- Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades Hospital, APHP, Paris City University, Paris, France
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
| | - Anne Welfringer-Morin
- Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades Hospital, APHP, Paris City University, Paris, France
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
| | - Christine Bodemer
- Department of Pediatric Dermatology, Hôpital Necker-Enfants Malades Hospital, APHP, Paris City University, Paris, France
- Reference Center of Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Créteil, France
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Fabian IM, Maddox K, Robicheaux C, Islam RK, Anwar A, Dorius B, Robinson CL, Kaye AM, Varrassi G, Ahmadzadeh S, Shekoohi S, Kaye AD. Stevens-Johnson Syndrome From Combined Allopurinol and Angiotensin-Converting Enzyme Inhibitors: A Narrative Review. Cureus 2024; 16:e51899. [PMID: 38333456 PMCID: PMC10850002 DOI: 10.7759/cureus.51899] [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: 12/07/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
Stevens-Johnson syndrome (SJS) is a severe and potentially debilitating skin reaction frequently related to medication use. Allopurinol and angiotensin-converting enzyme (ACE) inhibitors are commonly prescribed medications for prevalent health conditions worldwide, and their interaction associated with SJS warrants further investigation. A comprehensive literature search was performed to investigate cases as studies related to SJS occurring in patients with concomitant use of allopurinol and ACE inhibitors. We identified case reports and studies detailing hypersensitivity reactions, including SJS, attributed to a combination of allopurinol and ACE inhibitors. Despite the drug-drug interactions or lack thereof seen in patient populations, there is no definitive evidence of a pharmacokinetic interaction between allopurinol and ACE inhibitors. We were only able to find one case report specifically detailing SJS in a patient on combined ACE inhibitors and allopurinol. While the exact mechanism of the interaction is unclear, those reported cases of severe hypersensitivity reactions suggest a previous history of impaired renal function as a predisposing factor in the development of SJS. The potential risk of SJS with coadministration of ACE inhibitors and allopurinol is a drug-drug interaction that physicians should be aware of. This topic requires additional attention to determine if this drug combination should be avoided entirely in certain patients.
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Affiliation(s)
- Isabella M Fabian
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Kirsten Maddox
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Cameron Robicheaux
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Rahib K Islam
- School of Medicine, Louisiana State University Health Sciences Center (LSUHSC) New Orleans, New Orleans, USA
| | - Ahmed Anwar
- Department of Psychology, Quinnipiac University, Hamden, USA
| | - Bradley Dorius
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences University of the Pacific, Stockton, USA
| | | | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Yu R, Chen S, Pan Y, Ma C, Hu L, Chen A, Wei B. Combined use of cyclosporine in the treatment of Stevens-Johnson syndrome/toxic epidermal necrolysis. J Dermatol 2022; 49:629-636. [PMID: 35437858 DOI: 10.1111/1346-8138.16369] [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: 01/03/2022] [Revised: 02/10/2022] [Accepted: 03/12/2022] [Indexed: 11/28/2022]
Abstract
The exact efficacy of cyclosporine in the treatment of Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) still needs evidence from more clinical data. This study was designed to compare the effectiveness and side-effects of combined use of cyclosporine in the treatment TEN with glucocorticoids (GC)/i.v. immunoglobulin G (IVIG). A total of 46 patients with SJS/TEN were enrolled and classified into two groups based on the therapeutic drugs used. Clinical characteristics, interventions, outcomes, and disease progressions were collected and compared between the two groups. In our cohort, seven patients eventually died and the overall fatality rate was 15.2%, but there was no difference between the two groups (p = 0.557). On discharge, the median SCORe of Toxic Epidermal Necrosis (SCORTEN) fell from 2.0 at admission to 1.0 and the median body surface area detached fell from 32.0% at admission to 9.5%. Patients in the cyclosporine group had a higher rate of re-epithelialized area than patients in the non-cyclosporine group (p < 0.05). Cyclosporine significantly reduced the length of stay (19.0 vs. 13.0 days, p = 0.019) and the rate of systemic infection (71.4% vs. 36.0%, p = 0.017) compared with the non-cyclosporine group. SCORTEN was the only significant risk factor for death and the risk ratio was 1.96 (1.17-3.31, p = 0.011). Conclusively, the combined use of cyclosporine could reduce the occurrence of systemic infection and accelerate the re-epithelialization.
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Affiliation(s)
- Rentao Yu
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuang Chen
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yun Pan
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chunrong Ma
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Hu
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Aijun Chen
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bin Wei
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Reddy S, Aron BK, Stewart J. A Life-Threatening Case of Torsemide-Induced Toxic Epidermal Necrolysis Associated With the Treatment of Anasarca. Cureus 2022; 14:e22895. [PMID: 35399474 PMCID: PMC8982501 DOI: 10.7759/cureus.22895] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Sujana Reddy
- Internal Medicine, East Alabama Health, Opelika, USA
| | - Bray K Aron
- Osteopathic Dermatology, East Alabama Health, Opelika, USA
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Gleghorn KL, Voigt C, Kelly B. Toxic epidermal necrolysis and Stevens-Johnson syndrome/toxic epidermal necrolysis overlap in pediatric patients with a focus on newer antiepileptic drugs: A 25-year retrospective study at a single tertiary care center. Pediatr Dermatol 2021; 38:812-818. [PMID: 34060145 DOI: 10.1111/pde.14598] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 03/22/2021] [Accepted: 03/27/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis Syndrome (TEN) are rare immune-mediated diseases. Extensive research on adult triggers of SJS and TEN is available; however, research in children is more limited. OBJECTIVE We sought to investigate and report the experience with pediatric SJS and TEN in our center, identifying associated medications. METHODS A retrospective review from 1990 to 2015 at the Shriner's Burn Hospital in Galveston, Texas was performed to identify patients diagnosed with SJS, SJS/TEN overlap, and TEN. Data pertaining to demographic characteristics, medical history, physical exam, treatment, and outcomes were collected. RESULTS We identified SJS/TEN overlap or TEN in 51 patients. Antiepileptic drugs were the most common group of causative agents, closely followed by antibiotics. The most common causative agents were trimethoprim-sulfamethoxazole, phenytoin, and lamotrigine used concomitantly with valproic acid. Newer generation agents, with the definition of agents approved after 1990, were the cause in 13/51 (25.5%) cases. Newer generation agents included lamotrigine, clobazam, and zonisamide. Seven patients died, resulting in a 13.7% mortality rate. Renal failure, liver failure, sepsis, and gastrointestinal involvement each had a statistically significant association with mortality. SCORTEN was statistically significantly greater in patients who died compared to children who lived (3 vs 2). LIMITATIONS This is a retrospective study. CONCLUSION Three drugs introduced into the market since 1990 have emerged as causes of SJS/TEN overlap and TEN: lamotrigine, clobazam, and zonisamide. These medications are being used more widely to treat seizures, as well as mood disorders. It is also important for clinicians to be aware of the extremely commonly used medications such as amoxicillin, tetracyclines, NSAIDs, and acetaminophen that can rarely cause SJS and TEN.
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Affiliation(s)
- Kristyna L Gleghorn
- Department of Dermatology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Charles Voigt
- Burn Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - Brent Kelly
- Department of Dermatology, The University of Texas Medical Branch, Galveston, TX, USA
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Borkar D, Madhok M. Child With a Worrisome Rash. J Emerg Med 2021; 61:430-432. [PMID: 34172335 DOI: 10.1016/j.jemermed.2021.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/10/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Deeksha Borkar
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota.
| | - Manu Madhok
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
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Neerukonda VK, Stagner AM. Stevens Johnson syndrome: A review of a vision and life-threatening mucocutaneous disease including histopathology with updates on pathogenesis and genetic risk factors. Semin Ophthalmol 2021; 36:270-281. [PMID: 33764253 DOI: 10.1080/08820538.2021.1893764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) spectrum of diseases are devastating blistering disorders involving mucosal surfaces with ocular sequelae that manifest particularly profound long-term morbidity. Advances in deoxyribonucleic acid (DNA) sequencing, genome-wide association studies, and both molecular and pharmacogenetics have helped clarify genetic susceptibility and characterize the iatrogenic risk of SJS for a given patient. METHODS A review of peer reviewed publications featured on PubMed pertaining to the clinical, pathologic, pharmacogenetic and molecular genetic features of SJS/TEN was conducted. Propose: To provide an in-depth clinicopathologic description of the ocular, ocular adnexal, and cutaneous findings in SJS/TEN, summarize pathogenesis and related conditions, and provide an update on the molecular genetic modifications that contribute to the phenotypic variations and genetic susceptibilities of SJS. CONCLUSIONS HLA subtyping and other genetic testing may eventually be valuable in the appropriate context to prevent the debilitating ocular sequelae of SJS, particularly as it relates to medication use.
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Rathinam KK, Sabarathinam S, Nuthalapati P, Mahalingam VT. Phenytoin Induced Stevens Johnson Syndrome- Toxic Epidermal Necrolysis Overlap Exacerbated by Cephalexin in a 65-Year-Old Neurosurgical Patient: A Rare Case Report. Curr Drug Res Rev 2021; 14:80-83. [PMID: 34225642 DOI: 10.2174/2589977513666210322160009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/28/2020] [Accepted: 02/12/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To report a rare case of drug induced overlap of Stevens-Johnson syndrome and Toxic Epidermal Necrosis Syndrome exacerbated by cephalexin. CASE SUMMARY In this case report we present a 65-year-old female who had come to the hospital with complaints of Sloughing of the skin and redness all over the body with raised body temperature. She was on therapeutic Phenytoin to prevent the post-surgical complications of Communicating Hydrocephalus. After a detailed examination it was found that the patient had misemployed with an overdose of Phenytoin. The patient was found with nikolsky sign and diagnosed as Stevens-Johnson syndrome and Toxic Epidermal Necrosis overlap. This case report emphasizes phenytoin induced Stevens-Johnson syndrome and Toxic Epidermal Necrosis syndrome exacerbated by cephalexin. PRACTICE IMPLICATIONS By witnessing this phenomenon, we could figure out the association between cephalexin and Stevens-Johnson syndrome- Toxic Epidermal Necrosis syndrome overlap. The Immediate dismissal of the offending agent and commencement of supportive care was found to be effective.
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Affiliation(s)
- Kiran Kumar Rathinam
- Department of Pharmacy Practice, SRM College of Pharmacy, SRM IST, Kattankulathur-603203, kancheepuram, Tamil Nadu, India
| | - Sarvesh Sabarathinam
- Department of Pharmacy Practice, SRM College of Pharmacy, SRM IST, Kattankulathur-603203, kancheepuram, Tamil Nadu, India
| | - Poojith Nuthalapati
- Department of Pharmacy Practice, SRM College of Pharmacy, SRM IST, Kattankulathur-603203, kancheepuram, Tamil Nadu, India
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Venugopal R, Nagpal R, Mohanty S, Sen S, Kashyap S, Agarwal T, Maharana PK, Vajpayee RB, Sharma N. Outcomes of Cultivated Oral Mucosal Epithelial Transplantation in Eyes With Chronic Stevens-Johnson Syndrome Sequelae. Am J Ophthalmol 2021; 222:82-91. [PMID: 32818447 DOI: 10.1016/j.ajo.2020.08.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE To study the outcomes of cultivated oral mucosal epithelial transplantation (COMET) in eyes with chronic Stevens-Johnson syndrome (SJS) sequelae. DESIGN Prospective interventional case series. METHODS Forty-five eyes of 41 patients with chronic SJS sequelae were recruited and evaluated from 2013 to 2017 in an institutional setting. All patients underwent COMET, with an aim of fornix reconstruction and visual rehabilitation. Change in corrected distance visual acuity (CDVA), severity scores of various ocular surface parameters, and the occurrence of complications were documented during a follow up period of 2 years. Attainment and maintenance of a stable ocular surface, as assessed by change in the ocular surface severity scores was the primary outcome measure, while change in CDVA was the secondary outcome measure. RESULTS The mean preoperative CDVA was 2.7± 0.5 logMAR, which improved to 1.5± 0.7 logMAR and 1.49± 0.98 postoperatively, at 1- and 2-year follow-up visit. Overall, 82.2% eyes (37/45) had improvement in visual acuity, 13.3% (6/45) experienced no change, whereas 2 eyes (4.4%) had worsening of visual acuity. The total ocular surface severity scores improved from a mean preoperative value of 29.1± 9.7 to 18.7± 7.2 postoperatively, at 2-year follow-up. Two eyes developed persistent epithelial defects, with progression to corneal melting requiring keratoplasty. CONCLUSIONS COMET allows successful and sustained restoration of ocular surface anatomy with functional improvement, in eyes with chronic sequelae of SJS.
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Affiliation(s)
- Renu Venugopal
- Cornea, Cataract & Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Ritu Nagpal
- Cornea, Cataract & Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Sujata Mohanty
- Stem Cell Facility, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Sen
- Department of Ocular Pathology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Kashyap
- Department of Ocular Pathology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Tushar Agarwal
- Cornea, Cataract & Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Prafulla K Maharana
- Cornea, Cataract & Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Rasik B Vajpayee
- Vision Eye Institute, Royal Victorian Eye and Ear Hospital, North West Academic Centre, University of Melbourne, Melbourne, Australia
| | - Namrata Sharma
- Cornea, Cataract & Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
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Arora R, Pande RK, Panwar S, Gupta V. Drug-related Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review. Indian J Crit Care Med 2021; 25:575-579. [PMID: 34177178 PMCID: PMC8196388 DOI: 10.5005/jp-journals-10071-23826] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening, allergic reactions affecting the skin and mucous membranes. SJS is considered to be a milder form with less than 10% of body surface area (BSA) involvement. We report successful management of two cases of SJS and TEN. Firstly, a case of a 24-year-old female who presented with rashes over face, chest, and upper limbs after the oral intake of ciprofloxacin and local application of moxifloxacin eye drops. She developed high-grade fever and difficulty in breathing requiring intubation and lung-protective mechanical ventilation and was treated with high-dose methylprednisolone, azithromycin, soframycin skin dressings, and topical ocular antibiotics. Secondly, another case of a 16-year-old female who developed bullous eruptions over the trunk, arms, hands, face, and sole involving 60% of BSA, after oral intake of albendazole. She was diagnosed as TEN and successfully managed with sterile silver nitrate, soframycin dressings, and antibiotics. Key message Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening, allergic reactions affecting the skin and mucous membranes. Early identification, withdrawal of the suspected drug, and early transfer to a specialized center decrease mortality. How to cite this article Arora R, Pande RK, Panwar S, Gupta V. Drug-related Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review. Indian J Crit Care Med 2021;25(5):575-579.
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Affiliation(s)
- Rohini Arora
- Department of Critical Care, D BL Kapur Superspeciality Hospital, New Delhi, India
| | - Rajesh K Pande
- Department of Critical Care, D BL Kapur Superspeciality Hospital, New Delhi, India
| | - Shikha Panwar
- Department of Critical Care, D BL Kapur Superspeciality Hospital, New Delhi, India
| | - Vivek Gupta
- Department of Pharmacology, D BL Kapur Superspeciality Hospital, New Delhi, India
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Sabourirad S, Mortezaee R, Mojarad M, Eslahi A, Shahrokhi Y, Kiafar B, Jarahi L, Afkhami Ardakani S, Farrokhi S. Investigating the association of Lamotrigine and Phenytoin-induced Stevens-Johnson syndrome/Toxic Epidermal Necrolysis with HLA-B*1502 in Iranian population. Exp Dermatol 2020; 30:284-287. [PMID: 33217035 DOI: 10.1111/exd.14240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022]
Abstract
Previous studies have found an association between HLA-B*1502 allele and lamotrigine-induced Stevens-Johnson syndrome (SJS)/ toxic epidermal necrosis (TEN) spectrum in Han Chinese populations. This study aims to investigate the association between HLA-B*1502 and lamotrigine- or phenytoin- induced SJS/TEN in an Iranian population. The medical records of twenty-eight lamotrigine-induced SJS/TEN patients and twenty-five lamotrigine-tolerant controls as well as eight phenytoin-induced SJS/TEN and twelve phenytoin-tolerant controls were extracted between March 2013 and March 2019 from the university hospitals in Mashhad, Iran. The presence of HLA-B*1502 allele was determined using real-time polymerase chain reaction (PCR). Among lamotrigine-induced patients with SJS/TEN, 11 (39.3%) patients tested positive for the HLA-B*1502 while only 3 (12.0%) of the lamotrigine-tolerant controls tested positive for this allele. The risk of lamotrigine-induced SJS/TEN was significantly higher in patients with HLA-B*1502, with an odds ratio (OR) of 4.74 [95% confidence interval (CI) 1.14-19.73, p = 0.032]. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of HLA-B*1502 for lamotrigine-induced SJS/TEN was 39.29%, 88.00%, 78.57% and 56.41%, respectively. The HLA-B*1502 allele was present in 2 (25.0%) of phenytoin-induced SJS/TEN cases and 5 (41.7%) of the phenytoin-tolerant controls tested positive for HLA-B*1502 allele. The risk of phenytoin-induced SJS/TEN was not higher in the patients with HLA-B*1502 (OR = 0.467 [95% confidence interval (CI) 0.065-3.34, p = 0.642]). Lamotrigine-induced SJS/TEN is associated with HLA-B*1502 allele in an Iranian population but this is not the case for phenytoin-induced SJS/TEN.
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Affiliation(s)
- Sara Sabourirad
- Cutaneous Leishmaniasis Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Mortezaee
- Dermatology Department, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Young Researchers and Elites Club, Islamic Azad University, Mashhad Branch, Mashhad, Iran
| | - Majid Mojarad
- Genetic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Medical Genetics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Atieh Eslahi
- Department of Medical Genetics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Yahya Shahrokhi
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Kiafar
- Cutaneous Leishmaniasis Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Lida Jarahi
- Department of public health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saman Afkhami Ardakani
- Dermatology Department, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shima Farrokhi
- Department of Medical Genetics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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12
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Ge X, Sun Y, Su X, Zhou F, Yao G. Reconstruction of Major Burns With Stevens-Johnson Syndrome: A Case Report and Literature Review. J Burn Care Res 2020; 42:573-576. [PMID: 33274376 DOI: 10.1093/jbcr/iraa183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Stevens-Johnson syndrome (SJS) is a severe type of pleomorphic erythema and a rare disorder of the skin and mucous membranes, which can lead to serious infections, pulmonary embolism, acute respiratory distress syndrome, multiple organ dysfunction syndrome, and other serious consequences. Patients with SJS are usually treated in burn centers. SJS complicated by severe burns is very rare, and this is associated with a high risk of infection and other more serious complications. With SJS, the availability of donor sites is compromised given the lack of healthy epidermis, and this makes it more difficult to treat. The patient was a 52-year-old man with 45% TBSA burns with 40% TBSA full-thickness burns on both lower limbs. During treatment, his condition was complicated by SJS, renal failure, and respiratory failure. After 31 days, he was transferred to our department. On the 22nd day, the patient recovered from SJS, and after undergoing four skin grafting procedures, the burn wounds healed, and the donor site had healed spontaneously. He was discharged after 86 days of treatment in our department. In conclusion, major burns complicated with SJS are rare clinical presentations. The skin affected by the drug eruptions can be used as a donor site for transplantation to the burn wounds, and this donor area can also heal.
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Affiliation(s)
- Xiaojing Ge
- Department of Plastic and Burn Surgery, The First Affiliated Hospital of Nanjing Medical University, China
| | - Yute Sun
- Department of Plastic and Burn Surgery, The First Affiliated Hospital of Nanjing Medical University, China
| | - Xin Su
- Department of Plastic and Burn Surgery, The First Affiliated Hospital of Nanjing Medical University, China
| | - Fang Zhou
- Department of Plastic and Burn Surgery, The First Affiliated Hospital of Nanjing Medical University, China
| | - Gang Yao
- Department of Plastic and Burn Surgery, The First Affiliated Hospital of Nanjing Medical University, China
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13
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Imatoh T, Sai K, Saito Y. The Association Between Concurrence of Infection and the Onset of Severe Eruption or Liver Injury in Patients Using Antipyretic Analgesics: A Matched, Nested Case-Control Study. J Clin Pharmacol 2020; 60:1177-1184. [PMID: 32521061 DOI: 10.1002/jcph.1613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/04/2020] [Indexed: 02/05/2023]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN) or drug-induced liver injury (DILI) are severe drug-induced reactions, known as idiosyncratic drug reactions. It is believed that immune response can lead to these severe adverse drug reactions. Our previous analysis of the Japanese Spontaneous Drug Reaction database suggested that the onset of SJS/TEN and DILI was strongly associated with infection. Hence, we conducted a matched, nested case-control study to elucidate the association between concurrent infection and the onset of SJS/TEN or liver injury in patients prescribed antipyretic analgesics. We extracted 4 112 055 patients who were prescribed antipyretic analgesics between January 2014 and December 2015. Amongst them, 553 (0.01%) were diagnosed with SJS/TEN and 12 606 (0.3%) with liver injury. In a matched, nested case-control study, 131 and 2847 cases matched for SJS/TEN or liver injury, respectively. For each case, 3 controls were randomly matched with the case for age at index date and sex. In the conditional logistic regression analysis, there was a significant association between the combination of infection and antipyretic analgesics and the onset of SJS/TEN or liver injury (SJS/TEN: adjusted OR, 5.59; 95%CI, 2.01-15.51; liver injury: adjusted OR, 2.79; 95%CI, 2.24-3.46). Although it was not possible to distinguish whether the associations were caused by the infection or were a direct consequence of the antibiotic agents, our findings may help to increase awareness of the possibility of the increased onset of idiosyncratic drug reactions (SJS/TEN and liver injury) in antipyretic analgesic users because of infections.
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Affiliation(s)
- Takuya Imatoh
- Division of Medicinal Safety Science, National Institute of Health Sciences, Kanagawa, Japan
| | - Kimie Sai
- Division of Medicinal Safety Science, National Institute of Health Sciences, Kanagawa, Japan
| | - Yoshiro Saito
- Division of Medicinal Safety Science, National Institute of Health Sciences, Kanagawa, Japan
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14
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Mani R, Monteleone C, Schalock PC, Truong T, Zhang XB, Wagner ML. Rashes and other hypersensitivity reactions associated with antiepileptic drugs: A review of current literature. Seizure 2019; 71:270-278. [PMID: 31491658 DOI: 10.1016/j.seizure.2019.07.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 12/14/2022] Open
Abstract
This article provides an overview of the pathogenesis and risk factors associated with antiepileptic drug (AED) hypersensitivity reactions, provides prescribing guidelines that may minimize the risk of antiepileptic induced rashes, and discusses treatment options for rashes. Articles indexed in PubMed, Science Citation, and Google Scholar (January 1946-March 2019) were systematic searched using the following key terms: hypersensitivity, rash, antiepileptic, epilepsy, cross-sensitivity, desensitization, patch testing and supplemented with our clinical experiences. Additional references were identified from a review of literature citations. AEDs are associated with cutaneous adverse reactions. Aromatic AEDs and higher titration rates are associated with increased risk of hypersensitivity reaction. Patient characteristics, underlying health conditions, and genetic variations may increase the likelihood of a hypersensitivity reaction. Once a hypersensitivity reaction occurs, the likelihood of cross sensitivity to another AED increases, especially among other aromatic AEDs. Withdrawal of the causal agent and initiation of a lower risk agent usually leads to resolution of symptoms. Desensitization protocols may be an option for patients whose seizures only respond to the AED causing the rash.
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Affiliation(s)
- Ram Mani
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States.
| | - Catherine Monteleone
- Division of Allergy, Immunology and Infectious Diseases, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States.
| | - Peter C Schalock
- Department of Surgery (Dermatology), Geisel School of Medicine at Dartmouth, Hanover, NH, United States.
| | - Thu Truong
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers the State University of New Jersey, Piscataway, NJ United States.
| | - Xiao B Zhang
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers the State University of New Jersey, Piscataway, NJ United States.
| | - Mary L Wagner
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers the State University of New Jersey, Piscataway, NJ United States.
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15
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Prakash B, Kumar HM, Palaniswami S, Lakshman BH. Ocular Side Effects of Systemic Drugs Used in Dermatology. Indian J Dermatol 2019; 64:423-430. [PMID: 31896837 PMCID: PMC6862369 DOI: 10.4103/ijd.ijd_353_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Some systemically used drugs in managing dermatologic disorders have associated severe side effects, of which eye involvement is very significant. There are various mechanisms for these drugs to cause damage to the eye. The damage to the eye can be acute as in Stevens–Johnson syndrome or chronic as with chloroquine and hydroxychloroquine toxicity. Knowledge about these drugs and information about the mechanisms and types of damage to the eye are essential. It is also important to understand the monitoring mechanisms to diagnose early and limit the damage. Newer investigative tools, especially the imaging techniques help us to diagnose the adverse effects at an early stage. All these issues are discussed in brief here.
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Affiliation(s)
- Bhanu Prakash
- Department of Dermatology, Vydehi Hospital, VIMS and RC, Bengaluru, Karnataka, India
| | - H Mohan Kumar
- Department of Ophthalmology, Sri Devaraj Urs Medical College and Research Centre, Kolar, Karnataka, India
| | - Saranya Palaniswami
- Department of Dermatology, Vydehi Hospital, VIMS and RC, Bengaluru, Karnataka, India
| | - Borra Harish Lakshman
- Department of Ophthalmology, Sri Devaraj Urs Medical College and Research Centre, Kolar, Karnataka, India
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16
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Sukasem C, Katsila T, Tempark T, Patrinos GP, Chantratita W. Drug-Induced Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Call for Optimum Patient Stratification and Theranostics via Pharmacogenomics. Annu Rev Genomics Hum Genet 2018; 19:329-353. [PMID: 29652519 DOI: 10.1146/annurev-genom-083115-022324] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Global Genomic Medicine Collaborative, a multinational coalition of genomic and policy experts working to implement genomics in clinical care, considers pharmacogenomics to be among the first areas in genomic medicine that can provide guidance in routine clinical practice, by linking genetic variation and drug response. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe life-threatening reactions to medications with a high incidence worldwide. Genomic screening prior to drug administration is a key opportunity and potential paradigm for using genomic medicine to reduce morbidity and mortality and ultimately eliminate one of the most devastating adverse drug reactions. This review focuses on the current understanding of the surveillance, pathogenesis, and treatment of SJS/TEN, including the role of genomics and pharmacogenomics in the etiology, treatment, and eradication of preventable causes of drug-induced SJS/TEN. Gaps, unmet needs, and priorities for future research have been identified for the optimal management of drug-induced SJS/TEN in various ethnic populations. Pharmacogenomics holds great promise for optimal patient stratification and theranostics, yet its clinical implementation needs to be cost-effective and sustainable.
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Affiliation(s)
- Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.,Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.,South East Asian Pharmacogenomics Research Network (SEAPHARM)
| | - Theodora Katsila
- Department of Pharmacy, School of Health Sciences, University of Patras, GR-26504 Patras, Greece
| | - Therdpong Tempark
- Department of Pediatrics, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok 10330, Thailand
| | - George P Patrinos
- Department of Pharmacy, School of Health Sciences, University of Patras, GR-26504 Patras, Greece.,Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Wasun Chantratita
- South East Asian Pharmacogenomics Research Network (SEAPHARM).,Excellence Center for Medical Genomics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
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Zimmermann S, Sekula P, Venhoff M, Motschall E, Knaus J, Schumacher M, Mockenhaupt M. Systemic Immunomodulating Therapies for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Systematic Review and Meta-analysis. JAMA Dermatol 2017; 153:514-522. [PMID: 28329382 PMCID: PMC5817620 DOI: 10.1001/jamadermatol.2016.5668] [Citation(s) in RCA: 191] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/27/2016] [Indexed: 12/13/2022]
Abstract
Importance Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are rare but severe adverse reactions with high mortality. There is no evidence-based treatment, but various systemic immunomodulating therapies are used. Objectives To provide an overview on possible immunomodulating treatments for SJS/TEN and estimate their effects on mortality compared with supportive care. Data Sources A literature search was performed in December 2012 for articles published in MEDLINE, MEDLINE Daily, MEDLINE Inprocess, Web of Science, EMBASE, Scopus, and the Cochrane Library (Central) from January 1990 through December 2012, and updated in December 2015, in the English, French, Spanish, and German languages looking for treatment proposals for SJS/TEN. Other sources were screened manually. Study Selection Initially, 157 randomized and nonrandomized studies on therapies (systemic immunomodulating therapies or supportive care) for SJS/TEN were selected. Data Extraction and Synthesis Relevant data were extracted from articles. Authors were contacted for further information. Finally, 96 studies with sufficient information regarding eligibility and adequate quality scores were considered in the data synthesis. All steps were performed independently by 2 investigators. Meta-analyses on aggregated study data (random-effects model) and individual patient data (IPD) (logistic regression adjusted for confounders) were performed to assess therapeutic efficacy. In the analysis of IPD, 2 regression models, stratified and unstratified by study, were fitted. Main Outcomes and Measures Therapy effects on mortality were expressed in terms of odds ratios (ORs) with 95% CIs. Results Overall, 96 studies (3248 patients) were included. Applied therapies were supportive care or systemic immunomodulating therapies, including glucocorticosteroids, intravenous immunoglobulins, cyclosporine, plasmapheresis, thalidomide, cyclophosphamide, hemoperfusion, tumor necrosis factor inhibitors, and granulocyte colony-stimulating factors. Glucocorticosteroids were associated with a survival benefit for patients in all 3 analyses but were statistically significant in only one (aggregated data: OR, 0.5; 95%% CI, 0.3-1.01; IPD, unstratified: OR, 0.7; 95% CI, 0.5-0.97; IPD, stratified: OR, 0.8; 95% CI, 0.4-1.3). Despite the low patient size, cyclosporine was associated with a promising significant result in the only feasible analysis of IPD (unstratified model) (OR, 0.1; 95% CI, 0.0-0.4). No beneficial findings were observed for other therapies, including intravenous immunoglobulins. Conclusions and Relevance Although all analyses, including the unstratified model, had limitations, glucocorticosteroids and cyclosporine were the most promising systemic immunomodulating therapies for SJS/TEN. Further evaluation in prospective studies is required. However, this work provides a comprehensive overview on proposed systemic immunomodulating treatments for SJS/TEN, which is of great relevance for treating physicians.
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Affiliation(s)
- Stefanie Zimmermann
- Dokumentationszentrum schwerer Hautreaktionen, Department of Dermatology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Pierre Fabre Pharma GmbH, Freiburg, Germany
| | - Peggy Sekula
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Moritz Venhoff
- Dokumentationszentrum schwerer Hautreaktionen, Department of Dermatology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Sander & Kollegen Dental Practice, Haslach im Kinzigtal, Germany
| | - Edith Motschall
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochen Knaus
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Schumacher
- Institute for Medical Biometry and Statistics, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen, Department of Dermatology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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