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Gibson A, Ram R, Gangula R, Li Y, Mukherjee E, Palubinsky AM, Campbell CN, Thorne M, Konvinse KC, Choshi P, Deshpande P, Pedretti S, O’Neil RT, Wanjalla CN, Kalams SA, Gaudieri S, Lehloenya RJ, Bailin SS, Chopra A, Mallal SA, Phillips EJ. Multiomic single-cell sequencing defines tissue-specific responses in Stevens-Johnson Syndrome and Toxic epidermal necrolysis. bioRxiv 2024:2023.11.26.568771. [PMID: 38405793 PMCID: PMC10888802 DOI: 10.1101/2023.11.26.568771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) is a rare but life-threatening cutaneous drug reaction mediated by human leukocyte antigen (HLA) class I-restricted CD8+ T-cells. To obtain an unbiased assessment of SJS/TEN cellular immunopathogenesis, we performed single-cell (sc) transcriptome, surface proteome, and TCR sequencing on unaffected skin, affected skin, and blister fluid from 17 SJS/TEN patients. From 119,784 total cells, we identified 16 scRNA-defined subsets, confirmed by subset-defining surface protein expression. Keratinocytes upregulated HLA and IFN-response genes in the affected skin. Cytotoxic CD8+ T-cell subpopulations of expanded and unexpanded TCRαβ clonotypes were shared in affected skin and blister fluid but absent or unexpanded in SJS/TEN unaffected skin. SJS/TEN blister fluid is a rich reservoir of oligoclonal CD8+ T-cells with an effector phenotype driving SJS/TEN pathogenesis. This multiomic database will act as the basis to define antigen-reactivity, HLA restriction, and signatures of drug-antigen-reactive T-cell clonotypes at a tissue level.
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Affiliation(s)
- Andrew Gibson
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia
| | - Ramesh Ram
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia
| | - Rama Gangula
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Yueran Li
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia
| | - Eric Mukherjee
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Amy M Palubinsky
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Chelsea N Campbell
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Michael Thorne
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia
| | - Katherine C Konvinse
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Phuti Choshi
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Pooja Deshpande
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia
| | - Sarah Pedretti
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Richard T O’Neil
- Department of Veterans Affairs, Ralph H Johnson VA Medical Center and Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Celestine N Wanjalla
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Spyros A Kalams
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Silvana Gaudieri
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
- School of Human Sciences, The University of Western Australia, Western Australia, Australia
| | - Rannakoe J Lehloenya
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Division of Dermatology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Samuel S Bailin
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Abha Chopra
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Jason A Trubiano on behalf of the AUS-SCAR study group
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Victoria, Australia
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Victoria, Australia
| | | | - Simon A Mallal
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
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2
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Misra R, Todd G, Esterhuizen J, Muloiwa R, Peter J, Lehloenya RJ. Stevens-Johnson syndrome and toxic epidermal necrolysis-associated dysgeusia: Natural history and association with dysosmia. J Allergy Clin Immunol Pract 2024; 12:522-525. [PMID: 37898176 DOI: 10.1016/j.jaip.2023.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 10/08/2023] [Accepted: 10/19/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Rupesh Misra
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gail Todd
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Julie Esterhuizen
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Jonny Peter
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa; Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Rannakoe J Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa.
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3
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Thwala BN, Teixeira N, Zitha E, Mpungose A, Isaacs T, Peter JG, Lehloenya RJ. Comment on: Proposal for a new diagnostic classification of photodistributed Stevens-Johnson syndrome and toxic epidermal necrolysis. Eur J Med Res 2024; 29:83. [PMID: 38287381 PMCID: PMC10823635 DOI: 10.1186/s40001-024-01652-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/08/2024] [Indexed: 01/31/2024] Open
Abstract
Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap (SJS/TEN), collectively referred to SJS/TEN, form a spectrum of severe life-threatening adverse drug reactions whose pathomechanism is not fully understood. The article "Photodistributed Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Systematic Review and Proposal for a New Diagnostic Classification" by McKinley et. al., discusses a distinct distribution of epidermal necrosis in SJS/TEN, attributable to preceding exposure to ultraviolet radiation (UVR), and relative sparing of photo-protected areas. After reviewing numerous cases within the Immune-mediated Adverse drug Reactions in African HIV endemic setting Register and Biorepository (IMARI-SA) at the University of Cape Town with a similar clinical pattern as those published by McKinley et. al., we propose that the relative sparing of some areas giving an impression of photo-distribution is due to localised increase in skin pressure that reduces the blood supply in that area below a critical threshold. A dip in blood supply below this critical threshold quantitively limited T lymphocytes and cytokines that drive SJS/TEN to reach and damage the skin.
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Affiliation(s)
- Bukiwe N Thwala
- Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Combined Drug Allergy Clinic and Groote Schuur Hospital, Cape Town, South Africa
| | - Nadine Teixeira
- Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Combined Drug Allergy Clinic and Groote Schuur Hospital, Cape Town, South Africa
| | - Eddy Zitha
- Division of Dermatology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Aneliswa Mpungose
- Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Combined Drug Allergy Clinic and Groote Schuur Hospital, Cape Town, South Africa
| | - Thuraya Isaacs
- Division of Dermatology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Combined Drug Allergy Clinic and Groote Schuur Hospital, Cape Town, South Africa
| | - Jonathan G Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Combined Drug Allergy Clinic and Groote Schuur Hospital, Cape Town, South Africa
| | - Rannakoe J Lehloenya
- Division of Dermatology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.
- Combined Drug Allergy Clinic and Groote Schuur Hospital, Cape Town, South Africa.
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4
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Marks ME, Botta RK, Abe R, Beachkofsky TM, Boothman I, Carleton BC, Chung WH, Cibotti RR, Dodiuk-Gad RP, Grimstein C, Hasegawa A, Hoofnagle JH, Hung SI, Kaffenberger B, Kroshinsky D, Lehloenya RJ, Martin-Pozo M, Micheletti RG, Mockenhaupt M, Nagao K, Pakala S, Palubinsky A, Pasieka HB, Peter J, Pirmohamed M, Reyes M, Saeed HN, Shupp J, Sukasem C, Syu JY, Ueta M, Zhou L, Chang WC, Becker P, Bellon T, Bonnet K, Cavalleri G, Chodosh J, Dewan AK, Dominguez A, Dong X, Ezhkova E, Fuchs E, Goldman J, Himed S, Mallal S, Markova A, McCawley K, Norton AE, Ostrov D, Phan M, Sanford A, Schlundt D, Schneider D, Shear N, Shinkai K, Tkaczyk E, Trubiano JA, Volpi S, Bouchard CS, Divito SJ, Phillips EJ. Updates in SJS/TEN: collaboration, innovation, and community. Front Med (Lausanne) 2023; 10:1213889. [PMID: 37901413 PMCID: PMC10600400 DOI: 10.3389/fmed.2023.1213889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/31/2023] [Indexed: 10/31/2023] Open
Abstract
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is a predominantly drug-induced disease, with a mortality rate of 15-20%, that engages the expertise of multiple disciplines: dermatology, allergy, immunology, clinical pharmacology, burn surgery, ophthalmology, urogynecology, and psychiatry. SJS/TEN has an incidence of 1-5/million persons per year in the United States, with even higher rates globally. One of the challenges of SJS/TEN has been developing the research infrastructure and coordination to answer questions capable of transforming clinical care and leading to improved patient outcomes. SJS/TEN 2021, the third research meeting of its kind, was held as a virtual meeting on August 28-29, 2021. The meeting brought together 428 international scientists, in addition to a community of 140 SJS/TEN survivors and family members. The goal of the meeting was to brainstorm strategies to support the continued growth of an international SJS/TEN research network, bridging science and the community. The community workshop section of the meeting focused on eight primary themes: mental health, eye care, SJS/TEN in children, non-drug induced SJS/TEN, long-term health complications, new advances in mechanisms and basic science, managing long-term scarring, considerations for skin of color, and COVID-19 vaccines. The meeting featured several important updates and identified areas of unmet research and clinical need that will be highlighted in this white paper.
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Affiliation(s)
- Madeline E. Marks
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ramya Krishna Botta
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Thomas M. Beachkofsky
- Departments of Dermatology and Medicine, Uniformed Services University, Bethesda, MD, United States
| | - Isabelle Boothman
- The SFI Centre for Research Training in Genomics Data Science, Dublin, Ireland
| | - Bruce C. Carleton
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia and the British Columbia Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ricardo R. Cibotti
- National Institute of Arthritis and Musculoskeletal and Skin (NIAMS), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Roni P. Dodiuk-Gad
- Department of Dermatology, Emek Medical Center, Afula, Israel
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Dermatology, Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Christian Grimstein
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Akito Hasegawa
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Jay H. Hoofnagle
- Liver Disease Research Branch, Division of Digestive Diseases and Nutrition of NIDDK, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Benjamin Kaffenberger
- Department of Dermatology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniela Kroshinsky
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Michelle Martin-Pozo
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Robert G. Micheletti
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen (dZh), Department of Dermatology, Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Keisuke Nagao
- National Institute of Arthritis and Musculoskeletal and Skin (NIAMS), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Suman Pakala
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Amy Palubinsky
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Helena B. Pasieka
- Departments of Dermatology and Medicine, Uniformed Services University, Bethesda, MD, United States
- The Burn Center, MedStar Washington Hospital Center, Washington, D.C., DC, United States
- Department of Dermatology, MedStar Health/Georgetown University, Washington, D.C., DC, United States
| | - Jonathan Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Melissa Reyes
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Hajirah N. Saeed
- Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Jeffery Shupp
- Department of Surgery, Plastic and Reconstructive Surgery, Biochemistry, and Molecular and Cellular Biology, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, D.C., DC, United States
| | - Chonlaphat Sukasem
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jhih Yu Syu
- Department of Cell Biology and Anatomy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mayumi Ueta
- Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Wan-Chun Chang
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia and the British Columbia Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Patrice Becker
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Disease, Bethesda, MD, United States
| | - Teresa Bellon
- Drug Hypersensitivity Laboratory, La Paz Health Research Institute (IdiPAZ), Madrid, Spain
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
| | - Gianpiero Cavalleri
- The SFI Centre for Research Training in Genomics Data Science, Dublin, Ireland
| | - James Chodosh
- University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Anna K. Dewan
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Arturo Dominguez
- Department of Dermatology and Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Xinzhong Dong
- Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Elena Ezhkova
- Department of Cell, Developmental, and Regenerative Biology and Dermatology, Black Family Stem Cell Institute, Mount Sinai School of Medicine, New York, NY, United States
| | - Esther Fuchs
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - Jennifer Goldman
- Division of Pediatric Infectious Diseases and Clinical Pharmacology, Children’s Mercy, Kansas City, MO, United States
| | - Sonia Himed
- College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Simon Mallal
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Alina Markova
- Department of Dermatology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, United States
| | - Kerry McCawley
- Stevens-Johnson Syndrome Foundation, Westminster, CO, United States
| | - Allison E. Norton
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David Ostrov
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - Michael Phan
- Division of Pharmacovigilance-I, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Arthur Sanford
- Division of Trauma, Surgical Critical Care, and Burns, Loyola University Medical Center, Chicago, IL, United States
| | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
| | - Daniel Schneider
- Department of Psychiatry and Surgery, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, D.C., DC, United States
| | - Neil Shear
- Department of Dermatology, Emek Medical Center, Afula, Israel
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, San Francisco, CA, United States
| | - Eric Tkaczyk
- Department of Veterans Affairs, Vanderbilt Dermatology Translational Research Clinic (VDTRC.org), Nashville, TN, United States
| | - Jason A. Trubiano
- Department of Infectious Diseases and Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Simona Volpi
- National Human Genome Research Institute (NHGRI), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Charles S. Bouchard
- Department of Opthalmology, Loyola University Medical Center, Chicago, IL, United States
| | - Sherrie J. Divito
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Elizabeth J. Phillips
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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McNair M, Porter M, Isaacs T, Pillay K, Williams G, Roberts R, Peter J, Lehloenya RJ. Lichenoid drug eruption in patients on anti-TB therapy in a high HIV prevalence setting. Int J Tuberc Lung Dis 2023; 27:643-645. [PMID: 37491745 PMCID: PMC10365564 DOI: 10.5588/ijtld.23.0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 07/27/2023] Open
Affiliation(s)
| | - M Porter
- Division of Dermatology, Department of Medicine, Faculty of Health Sciences
| | - T Isaacs
- Division of Dermatology, Department of Medicine, Faculty of Health Sciences
| | - K Pillay
- Division of Anatomical Pathology, Department of Pathology, Faculty of Health Sciences
| | | | - R Roberts
- Division of Anatomical Pathology, Department of Pathology, Faculty of Health Sciences
| | - J Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - R J Lehloenya
- Division of Dermatology, Department of Medicine, Faculty of Health Sciences
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Lehloenya RJ. Disease severity and status in Stevens–Johnson syndrome and toxic epidermal necrolysis: Key knowledge gaps and research needs. Front Med (Lausanne) 2022; 9:901401. [PMID: 36172538 PMCID: PMC9510751 DOI: 10.3389/fmed.2022.901401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022] Open
Abstract
Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are on a spectrum of cutaneous drug reactions characterized by pan-epidermal necrosis with SJS affecting < 10% of body surface area (BSA), TEN > 30%, and SJS/TEN overlap between 10 and 30%. Severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is a validated tool to predict mortality rates based on age, heart rate, BSA, malignancy and serum urea, bicarbonate, and glucose. Despite improved understanding, SJS/TEN mortality remains constant and therapeutic interventions are not universally accepted for a number of reasons, including rarity of SJS/TEN; inconsistent definition of cases, disease severity, and endpoints in studies; low efficacy of interventions; and variations in treatment protocols. Apart from mortality, none of the other endpoints used to evaluate interventions, including duration of hospitalization, is sufficiently standardized to be reproducible across cases and treatment centers. Some of the gaps in SJS/TEN research can be narrowed through international collaboration to harmonize research endpoints. A case is made for an urgent international collaborative effort to develop consensus on definitions of endpoints such as disease status, progression, cessation, and complete re-epithelialization in interventional studies. The deficiencies of using BSA as the sole determinant of SJS/TEN severity, excluding internal organ involvement and extension of skin necrosis beyond the epidermis, are discussed and the role these factors play on time to healing and mortality beyond the acute stage is highlighted. The potential role of artificial intelligence, biomarkers, and PET/CT scan with radiolabeled glucose as markers of disease status, activity, and therapeutic response is also discussed.
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Affiliation(s)
- Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
- *Correspondence: Rannakoe J. Lehloenya, ; orcid.org/0000-0002-1281-1789
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7
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Abstract
The imagery of pigmented skin is underrepresented in teaching materials such as textbooks, journals, and online references, and this has resulted in poorer diagnostic and management outcomes of skin pathology, including delayed cutaneous drug hypersensitivity reactions. In this review, we use clinical images to highlight factors that impact clinical presentations and sequelae of drug hypersensitivity reactions in pigmented skin compared with nonpigmented skin. We describe clinical features in some anatomic sites that aid diagnosis or are associated with more severe sequelae. Finally, we discuss strategies that may aid the diagnosis and management of these reactions in pigmented skin.
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Affiliation(s)
- Rannakoe J Lehloenya
- Division of Dermatology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Dermatology ward G23, New Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Dermatology ward G23, New Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa.
| | - Elizabeth J Phillips
- Center for Drug Safety & Immunology, Vanderbilt University Medical Center, Nashville, TN; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Helena B Pasieka
- Department of Dermatology, Uniformed Serviced University, Bethesda, MD, USA; Department of Medicine, Uniformed Serviced University, Bethesda, MD, USA; Department of Dermatology, MedStar Washington Hospital Center/Georgetown University Hospital, Washington, DC, USA; The Burn Center, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jonny Peter
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Dermatology ward G23, New Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa; Division of Allergy and Clinical Immunology, Department of Medicine, Groote Schuur Hospital, University of Cape Town Lung institute, George Street, Mowbray, 7925, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Old Main Building, Groote Schuur Hospital, Anzio Road, 7925, Cape Town, South Africa
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8
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Chang WC, Abe R, Anderson P, Anderson W, Ardern-Jones MR, Beachkofsky TM, Bellón T, Biala AK, Bouchard C, Cavalleri GL, Chapman N, Chodosh J, Choi HK, Cibotti RR, Divito SJ, Dewar K, Dehaeck U, Etminan M, Forbes D, Fuchs E, Goldman JL, Holmes JH, Hope EA, Hung SI, Hsieh CL, Iovieno A, Jagdeo J, Kim MK, Koelle DM, Lacouture ME, Le Pallec S, Lehloenya RJ, Lim R, Lowe A, McCawley J, McCawley J, Micheletti RG, Mockenhaupt M, Niemeyer K, Norcross MA, Oboh D, Olteanu C, Pasieka HB, Peter J, Pirmohamed M, Rieder M, Saeed HN, Shear NH, Shieh C, Straus S, Sukasem C, Sung C, Trubiano JA, Tsou SY, Ueta M, Volpi S, Wan C, Wang H, Wang ZQ, Weintraub J, Whale C, Wheatley LM, Whyte-Croasdaile S, Williams KB, Wright G, Yeung SN, Zhou L, Chung WH, Phillips EJ, Carleton BC. Corrigendum to 'SJS/TEN 2019: From science to translation' [J. Dermatol. Sci. 98/1 (2020) 2-12]. J Dermatol Sci 2021; 104:146-147. [PMID: 34763988 PMCID: PMC9371621 DOI: 10.1016/j.jdermsci.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Wan-Chun Chang
- Division of Translational Therapeutics, Department of
Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC,
Canada,British Columbia Children’s Hospital Research
Institute, Vancouver, BC, Canada
| | - Riichiro Abe
- Niigata University Graduate School of Medical and Dental
Sciences, Niigata, Japan
| | - Paul Anderson
- Stevens-Johnson Syndrome Foundation, Westminster, CO,
USA
| | | | - Michael R. Ardern-Jones
- Faculty of Medicine, University of Southampton, Southampton
General Hospital, Southampton, UK
| | | | - Teresa Bellón
- Drug Hypersensitivity Group. Hospital La Paz Institute for
Health Research (IdiPAZ), Madrid, Spain
| | - Agnieszka K. Biala
- Division of Translational Therapeutics, Department of
Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC,
Canada
| | | | - Gianpiero L. Cavalleri
- School of Pharmacy and Molecular and Cellular Therapeutics,
Royal College of Surgeons in Ireland, Dublin, Ireland,FutureNeuro SFI Research Centre, Royal College of
Surgeons in Ireland, Dublin, Ireland
| | | | - James Chodosh
- Massachusetts Eye and Ear, Harvard Medical School, Boston,
MA, USA
| | - Hyon K. Choi
- Division of Rheumatology, Allergy and Immunology,
Massachusetts General Hospital, Boston, MA, USA
| | - Ricardo R. Cibotti
- National Institute of Arthritis and Musculoskeletal and
Skin Diseases, NIH, USA
| | - Sherrie J. Divito
- Department of Dermatology, Brigham and Women’s
Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Ulrike Dehaeck
- Department of Obstetrics and Gynecology, University of
British Columbia, Vancouver, BC, Canada
| | - Mahyar Etminan
- Department of Ophthalmology and Visual Sciences,
University of British Columbia, Vancouver, BC, Canada
| | - Diane Forbes
- Canadian Institutes of Health Research, Ottawa, ON,
Canada
| | - Esther Fuchs
- Department of Obstetrics and Gynecology, University of
Washington, Seattle, WA, USA
| | | | - James H. Holmes
- Wake Forest University School of Medicine, WFBMC Burn
Center, Winston-Salem, NC, USA
| | | | - Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory,
Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, Taoyuan,
Taiwan,Institute of Pharmacology, National Yang-Ming University,
Taipei, Taiwan
| | | | - Alfonso Iovieno
- Department of Ophthalmology and Visual Sciences,
University of British Columbia, Vancouver General Hospital Eye Care Center,
Vancouver, BC, Canada
| | | | - Mee Kum Kim
- Department of Ophthalmology, Seoul National University
College of Medicine, Seoul, South Korea
| | - David M. Koelle
- Department of Medicine, University of Washington, Seattle,
WA, USA
| | | | - Sophie Le Pallec
- Association des malades des syndromes de Lyell et de
Stevens-Johnson (Amalyste), Paris, France
| | - Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine,
University of Cape Town, Cape Town, South Africa
| | - Robyn Lim
- Health Products and Food Branch, Health Canada, Ottawa,
ON, Canada
| | - Angie Lowe
- SJS/TEN International Awareness (STIA), Lucky Lake, SK,
Canada
| | - Jean McCawley
- Stevens-Johnson Syndrome Foundation, Westminster, CO,
USA
| | - Julie McCawley
- Stevens-Johnson Syndrome Foundation, Westminster, CO,
USA
| | - Robert G. Micheletti
- Department of Dermatology, Perelman School of Medicine,
University of Pennsylvania, Philadelphia, PA, USA
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen (dZh),
Department of Dermatology, Medical Center and Medical Faculty, University of
Freiburg, Freiburg, Germany
| | | | - Michael A. Norcross
- Laboratory of Immunology, Division of Biotechnology
Review and Research III (DBRR III), Office of Biotechnology Products (OBP), Office
of Pharmaceutical Quality (OPQ), Center for Drug Evaluation and Research (CDER),
FDA, Silver Spring, MD, USA
| | - Douglas Oboh
- Stevens-Johnson Syndrome Foundation, Westminster, CO,
USA
| | - Cristina Olteanu
- Division of Dermatology, Department of Medicine,
University of Alberta, Edmonton, AB, Canada
| | - Helena B. Pasieka
- Department of Der matology, MedStar Washington Hospital
Center, Washington, DC, USA
| | - Jonathan Peter
- Division of Allergy and Clinical Immunology, Department
of Medicine, University of Cape Town, Cape Town, South Africa
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology,
University of Liverpool, Liverpool, UK
| | - Michael Rieder
- Department of Paediatrics, Children’s
Hospital/London Health Sciences Centre, Schulich School of Medicine & Dentistry,
Western University, London, ON, Canada
| | - Hajirah N. Saeed
- Massachusetts Eye and Ear, Harvard Medical School, Boston,
MA, USA
| | - Neil H. Shear
- Sunnybrook Health Sciences Centre, University of Toronto,
ON, Canada
| | - Christine Shieh
- Department of Ophthalmology, Vanderbilt Eye Institute,
Nashville, TN, USA
| | - Sabine Straus
- Dutch Medicines Evaluation Board, Pharmacovigilance Risk
Assessment Committee, European Medicines Agency, Utrecht, Netherlands
| | | | - Cynthia Sung
- Health Products Regulation Group, Health Sciences
Authority Singapore, Duke-NUS Medical School, Singapore
| | - Jason A. Trubiano
- Department of Infectious Diseases, Austin Health,
Heidelberg, Germany,Department of Medicine, University of Melbourne,
Victoria, Australia
| | | | - Mayumi Ueta
- Department of Frontier Medical Science and Technology for
Ophthalmology, Kyoto Pre fectural University of Medicine, Kyoto, Japan
| | - Simona Volpi
- National Human Genome Research Institute, NIH, Bethesda,
ML, USA
| | - Chen Wan
- Genome British Columbia, Vancouver, BC, Canada
| | - Hongsheng Wang
- Institute of Dermatology, Chinese Academy of Medical
Sciences, National Center for STD and Leprosy Control, China CDC, Nanjing,
China
| | | | - Jessica Weintraub
- Division of Pharmacovigilance I, Office of Surveillance
and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug
Administration, USA
| | | | - Lisa M. Wheatley
- National Institute of Allergy and Infectious Diseases,
NIH, Bethesda, ML, USA
| | | | - Kristina B. Williams
- Department of Pathology, Microbiology and Immunology,
Vanderbilt University Medical Center, Nashville, TN, USA
| | - Galen Wright
- Division of Translational Therapeutics, Department of
Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC,
Canada
| | - Sonia N. Yeung
- Department of Ophthalmology and Visual Sciences,
University of British Columbia, Vancouver General Hospital Eye Care Center,
Vancouver, BC, Canada
| | - Li Zhou
- Division of General Internal Medicine and Primary Care,
Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical
and Research Center, Chang Gung Memorial Hospital, Linkou, Taipei, Keelung, Taoyuan,
Taiwan,Cancer Vaccine and Immune Cell Therapy Core Laboratory,
Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, Taoyuan,
Taiwan,College of Medicine, Chang Gung University, Taoyuan,
Taiwan,Whole-Genome Research Core Laboratory of Human Diseases,
Chang Gung Memorial Hospital, Keelung, Taiwan,Department of Dermatology, Xiamen Chang Gung Hospital,
Xiamen, China
| | - Elizabeth J. Phillips
- Department of Pathology, Microbiology and Immunology,
Vanderbilt University Medical Center, Nashville, TN, USA,Institute for Immunology and Infectious Diseases, Murdoch
University, Murdoch, Australia,Division of Infectious Diseases, Department of Medicine,
Vanderbilt University Medical Center, Nashville, TN, USA,Department of Pharmacology, Vanderbilt University Medical
Center, Nashville, TN, USA
| | - Bruce C. Carleton
- Division of Translational Therapeutics, Department of
Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC,
Canada,British Columbia Children’s Hospital Research
Institute, Vancouver, BC, Canada
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9
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Lehloenya RJ, Isaacs T, Nyika T, Dhana A, Knight L, Veenstra S, Peter J. Early high-dose intravenous corticosteroids rapidly arrest Stevens Johnson syndrome and drug reaction with eosinophilia and systemic symptoms recurrence on drug re-exposure. J Allergy Clin Immunol Pract 2020; 9:582-584.e1. [PMID: 32835874 DOI: 10.1016/j.jaip.2020.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Rannakoe J Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa.
| | - Thuraya Isaacs
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Tonderai Nyika
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
| | - Ashar Dhana
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
| | - Lauren Knight
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
| | - Simon Veenstra
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jonny Peter
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa; Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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10
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Knight LK, Lehloenya RJ, Sinanovic E, Pooran A. Cost of managing severe cutaneous adverse drug reactions to first-line tuberculosis therapy in South Africa. Trop Med Int Health 2019; 24:994-1002. [PMID: 31173430 DOI: 10.1111/tmi.13275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To compare the cost of managing treatment-limiting cutaneous adverse drug reactions (CADRs) to first-line anti-tuberculosis drugs to an alternative strategy of immediate treatment initiation using second-line drugs in a South African setting. METHODS Clinical and cost data were retrospectively collected from patients presenting with a first-line anti-tuberculosis therapy-associated CADR. Costs (2016 US$) were estimated using an ingredient's approach from a healthcare provider perspective. The per-patient and total cost of drug rechallenge, the current management strategy for severe CADR, was calculated. Alternative strategies involving second-line treatment were derived from literature and expert clinical advice. RESULTS Drug rechallenge costs US $5831 (95% CI: 5134-6527) per patient. Hospitalisation accounted for 62% of this cost. Alternative CADR management strategies using regimens containing rifabutin, bedaquiline and/or delamanid cost 44%-55% less than drug rechallenge (US $2651-US $3276/patient). In univariate sensitivity analyses, drug rechallenge and alternative strategies were most sensitive to hospitalisation and tuberculosis drug costs, respectively. CONCLUSION Cutaneous adverse drug reactions to anti-tuberculosis treatment represent a significant economic burden. An alternate strategy of outpatient-initiated second-line therapy is economically feasible but requires clinical validation to assess effectiveness.
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Affiliation(s)
- Lauren K Knight
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rannakoe J Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Combined Drug Allergy Clinic, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Edina Sinanovic
- Health Economics Division, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Anil Pooran
- Department of Medicine & Lung Institute, Centre for Lung Infection and Immunity, University of Cape Town, Cape Town, South Africa
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11
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Abstract
PURPOSE OF REVIEW Immune-mediated adverse drug reactions (IM-ADRs) are many times more common in HIV-infected patients. Usual offending drugs include antiretroviral and antiinfectives, but the burden of specific drug IM-ADRs is population-specific; changing as new and fixed dose combinations enter the market, and drug-resistance patterns demand. This review considers recent literature on epidemiology, mechanisms, clinical management and prevention of IM-ADRs amongst persons living with HIV/AIDS. RECENT FINDINGS Epidemiological studies continue to describe high rates of delayed hypersensitivity to known offenders, as well as similar reactions in preexposure prophylaxis. IM-ADRs to oral and injectable integrase strand transfer inhibitors are reported with expanding use. The clinical spectrum and management of IM-ADRs occurring in HIV-infected populations is similar to uninfected; with exceptions such as a recently described severe delayed efavirenz DILI with high mortality. Furthermore, the context can be unique, such as the lower than expected mortality in a Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) cohort from a HIV/TB high burden setting. Programmatic data showing the near complete elimination of Abacavir drug hypersensitivity syndrome following implementation of HLA-B57:01 screening is a stellar example of how prevention is possible with mechanistic insight. SUMMARY IM-ADRs remain a challenge in persons living with HIV. The complexities posed by polypharmacy, overlapping drug toxicities, drug interactions, overlap of IM-ADRs with other diseases, limited alternative drugs, and vulnerable patients with advanced immunosuppression with high mortality, necessitate increased use of drug provocation testing, treat-through and desensitization strategies. There is an urgent need for improved diagnostics and predictive biomarkers for prevention, or to guide treat-through, rechallenge and desensitization approaches.
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Affiliation(s)
- Jonny Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
| | - Phuti Choshi
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Rannakoe J. Lehloenya
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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12
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Lehloenya RJ, Haitembu N, Basera W, Peter J. Lower-than-predicted mortality in a predominantly HIV-infected population with epidermal necrolysis regardless of HIV status: implications and challenges for interventional studies. J Allergy Clin Immunol Pract 2018; 7:1653-1655. [PMID: 30448502 DOI: 10.1016/j.jaip.2018.10.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 10/01/2018] [Accepted: 10/29/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Rannakoe J Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa.
| | - Niita Haitembu
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Wisdom Basera
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Jonny Peter
- Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa; Division of Allergology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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13
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White KD, Abe R, Ardern-Jones M, Beachkofsky T, Bouchard C, Carleton B, Chodosh J, Cibotti R, Davis R, Denny JC, Dodiuk-Gad RP, Ergen EN, Goldman JL, Holmes JH, Hung SI, Lacouture ME, Lehloenya RJ, Mallal S, Manolio TA, Micheletti RG, Mitchell CM, Mockenhaupt M, Ostrov DA, Pavlos R, Pirmohamed M, Pope E, Redwood A, Rosenbach M, Rosenblum MD, Roujeau JC, Saavedra AP, Saeed HN, Struewing JP, Sueki H, Sukasem C, Sung C, Trubiano JA, Weintraub J, Wheatley LM, Williams KB, Worley B, Chung WH, Shear NH, Phillips EJ. SJS/TEN 2017: Building Multidisciplinary Networks to Drive Science and Translation. J Allergy Clin Immunol Pract 2018; 6:38-69. [PMID: 29310768 PMCID: PMC5857362 DOI: 10.1016/j.jaip.2017.11.023] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 12/17/2022]
Abstract
Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a life-threatening, immunologically mediated, and usually drug-induced disease with a high burden to individuals, their families, and society with an annual incidence of 1 to 5 per 1,000,000. To effect significant reduction in short- and long-term morbidity and mortality, and advance clinical care and research, coordination of multiple medical, surgical, behavioral, and basic scientific disciplines is required. On March 2, 2017, an investigator-driven meeting was held immediately before the American Academy of Dermatology Annual meeting for the central purpose of assembling, for the first time in the United States, clinicians and scientists from multiple disciplines involved in SJS/TEN clinical care and basic science research. As a product of this meeting, this article summarizes the current state of knowledge and expert opinion related to SJS/TEN covering a broad spectrum of topics including epidemiology and pharmacogenomic networks; clinical management and complications; special populations such as pediatrics, the elderly, and pregnant women; regulatory issues and the electronic health record; new agents that cause SJS/TEN; pharmacogenomics and immunopathogenesis; and the patient perspective. Goals include the maintenance of a durable and productive multidisciplinary network that will significantly further scientific progress and translation into prevention, early diagnosis, and management of SJS/TEN.
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Affiliation(s)
- Katie D White
- Vanderbilt University Medical Center, Nashville, Tenn
| | - Riichiro Abe
- Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | | | - Thomas Beachkofsky
- Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, San Antonio, Texas
| | | | - Bruce Carleton
- University of British Columbia, Vancouver, British Columbia, Canada; B.C. Children's Hospital, British Columbia, Vancouver, British Columbia, Canada
| | - James Chodosh
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass
| | - Ricardo Cibotti
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Md
| | - Robert Davis
- University of Tennessee Health Sciences, Memphis, Tenn
| | | | - Roni P Dodiuk-Gad
- Emek Medical Center, Technion-Institute of Technology, Afula, Israel; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - James H Holmes
- Wake Forest Baptist Medical Center, Winston-Salem, NC; Wake Forest University School of Medicine, Winston-Salem, NC
| | | | | | | | - Simon Mallal
- Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Teri A Manolio
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Md; F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md
| | | | | | - Maja Mockenhaupt
- Medical Center and Medical Faculty-University of Freiburg, Freiburg, Germany
| | | | - Rebecca Pavlos
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | | | - Elena Pope
- University of Toronto, Toronto, Ontario, Canada; Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alec Redwood
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | | | | | | | | | - Hajirah N Saeed
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass
| | - Jeffery P Struewing
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Md
| | | | | | - Cynthia Sung
- Duke-NUS Medical School, Singapore, Singapore; Health Sciences Authority, Singapore, Singapore
| | - Jason A Trubiano
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | | | - Lisa M Wheatley
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | | | | | | | - Neil H Shear
- Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia.
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14
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Lehloenya RJ, Dlamini S, Muloiwa R, Kakande B, Ngwanya MR, Todd G, Dheda K. Therapeutic Trial of Rifabutin After Rifampicin-Associated DRESS Syndrome in Tuberculosis-Human Immunodeficiency Virus Coinfected Patients. Open Forum Infect Dis 2016; 3:ofw130. [PMID: 27419190 PMCID: PMC4942758 DOI: 10.1093/ofid/ofw130] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/14/2016] [Indexed: 11/12/2022] Open
Abstract
Elimination of a rifamycin from the treatment regimen for tuberculosis negatively impacts outcomes. Cross-reactivity between the rifamycins after drug eruptions is unclear. We report 6 consecutive human immunodeficiency virus-infected patients with rifampicin-associated drug rash with eosinophilia and systemic symptoms (DRESS) syndrome confirmed on diagnostic rechallenge. The patients subsequently tolerated rifabutin. These data inform clinical management of tuberculosis-associated drug reactions.
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Affiliation(s)
| | - Sipho Dlamini
- Division of Infectious Disease and HIV Medicine, Department of Medicine
| | - Rudzani Muloiwa
- Department of Paediatrics and Child Health , University of Cape Town , South Africa
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15
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van Zyl-Smit RN, Lehloenya RJ, Meldau R, Dheda K. Impact of correcting the lymphocyte count to improve the sensitivity of TB antigen-specific peripheral blood-based quantitative T cell assays (T-SPOT.(®)TB and QFT-GIT). J Thorac Dis 2016; 8:482-9. [PMID: 27076944 PMCID: PMC4805805 DOI: 10.21037/jtd.2016.02.65] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/27/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND The standardized blood-based TB antigen-specific T cell assay, T-SPOT.(®)TB, is ~10% more sensitive than QuantiFERON(®)-TB-GIT (QFT-GIT) in detecting presumed latent TB infection (LTBI). Whilst T-SPOT.(®)TB uses a fixed number of lymphocytes per well, QFT-GIT uses a fixed volume of blood (~1 mL). However, the person-to-person lymphocyte count can vary by 2 to 3 fold. We hypothesized that this variability could explain the reduced sensitivity of QFT-GIT. The findings could have potential implications for improving case detection. METHODS T-SPOT.(®)TB was compared to QFT-GIT readouts before and after normalization of lymphocyte count (by adjusting the blood volume or lymphocyte enrichment within a fixed 1 mL volume) to an arbitrary value of 2.5×10(6) cells/mL. Within-test variability was evaluated to meaningfully interpret results. RESULTS In patient-specific optimization experiments IFN-γ concentrations significantly increased when QFT-GIT positive samples were enriched with increasing concentrations of lymphocytes (1×10(6) vs. 2.5×10(6) cells/mL). However, for the group as a whole lymphocyte enrichment whilst maintaining a ~1 mL volume, compared to un-enriched samples, did not significantly increase IFN-γ [median (range): 0.03 (0-4.41) vs. 0.20 (0-2.40) IU/mL; P=0.64]. There was also no increase in IFN-γ readouts when QFT-GIT lymphocyte numbers were corrected (to 2.5×10(6) lymphocytes/mL) using volume adjustment. Interestingly, adjusted values were significantly lower than unadjusted ones [median (range): 0.02 (0-12.93) vs. 0.09 (0-14.23) IU/mL; P=0.008]. CONCLUSIONS In QFT-GIT negative subjects lymphocyte enrichment did not increase QFT-GIT positivity rates. The reduced clinical sensitivity of the QFT-GIT assay, compared to T-SPOT.(®)TB, is likely to be due to factors other than lymphocyte count alone. Further studies are required to clarify these findings.
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Affiliation(s)
- Richard N van Zyl-Smit
- 1 Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, 2 Division of Dermatology, Department of Medicine, 3 Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa ; 4 Department of Infection, University College London Medical School, London, UK
| | - Rannakoe J Lehloenya
- 1 Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, 2 Division of Dermatology, Department of Medicine, 3 Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa ; 4 Department of Infection, University College London Medical School, London, UK
| | - Richard Meldau
- 1 Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, 2 Division of Dermatology, Department of Medicine, 3 Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa ; 4 Department of Infection, University College London Medical School, London, UK
| | - Keertan Dheda
- 1 Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, 2 Division of Dermatology, Department of Medicine, 3 Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa ; 4 Department of Infection, University College London Medical School, London, UK
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16
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Knight L, Todd G, Muloiwa R, Matjila M, Lehloenya RJ. Stevens Johnson Syndrome and Toxic Epidermal Necrolysis: Maternal and Foetal Outcomes in Twenty-Two Consecutive Pregnant HIV Infected Women. PLoS One 2015; 10:e0135501. [PMID: 26267659 PMCID: PMC4534424 DOI: 10.1371/journal.pone.0135501] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 07/22/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) form a spectrum of a rare and life-threatening cutaneous drug reaction. SJS/TEN in pregnancy poses largely unknown risk factors and outcomes for both the mother and foetus compared to the general population. Methods We conducted a study of consecutive pregnant women admitted to single tertiary referral centre in South Africa with SJS/TEN over a 3 year period. They were all managed by the same medical team using the same protocols. We evaluated their underlying illnesses, offending drugs and the course of pregnancy and outcomes to determine factors influencing maternal and foetal outcomes. Results We identified twenty-two women who developed SJS/TEN while pregnant, all of them HIV-infected. Their median age was 29 years. The majority 16/22 (73%) had SJS, the milder variant of the disease affecting < 10% body surface area. Nevirapine was the offending drug in 21/22 (95%) cases. All 22 of the mothers survived with 3/22 (14%) developing postpartum sepsis. Pregnancy outcomes were known in 18/22 women and 9/18 (50%) babies were delivered by caesarean section. There were 2 foetal deaths at 21 and 31 weeks respectively and both were associated with post-partum sepsis. Postnatal complications occurred in 5 cases, 3 involving the respiratory system and the other two being low birth weight deliveries. Eight placentae and one foetus were sent for histology and none showed macroscopic or microscopic features of SJS/TEN. On follow-up, only 12/20 children were tested for HIV at 6 weeks post-delivery and none of them were HIV-infected. All had received prophylactic ARVs including nevirapine. Conclusions TEN, the severe form of the disease, was associated with poorer foetal outcomes. SJS/TEN-associated mortality is not increased in HIV-infected pregnant women. Maternal SJS/TEN does not seem to commonly manifest in the foetus.
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Affiliation(s)
- Lauren Knight
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gail Todd
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Mushi Matjila
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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Lehloenya RJ, Muloiwa R, Dlamini S, Gantsho N, Todd G, Dheda K. Lack of cross-toxicity between isoniazid and ethionamide in severe cutaneous adverse drug reactions: a series of 25 consecutive confirmed cases. J Antimicrob Chemother 2015; 70:2648-51. [PMID: 26142408 DOI: 10.1093/jac/dkv158] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/25/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Isoniazid and ethionamide are important first- and second-line anti-TB drugs (FLDs and SLDs), respectively. Ethionamide is a structural analogue of isoniazid and the two drugs share other similarities, including their metabolism, therapeutic targets, hepato-toxicity patterns and drug resistance. As a result, there has always been concern about possible cross-reactivity between them. METHODS Among 69 patients with drug rash with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) to FLDs, FLDs were stopped and SLDs added when the skin and laboratory parameters had settled. This was followed by sequential and additive rechallenge with FLDs. We report 25 consecutive cases that developed confirmed cutaneous adverse drug reactions (CADRs) to isoniazid or ethionamide used as FLD and SLD, respectively. RESULTS Sixty-nine participants who developed CADRs on FLDs were enrolled in the study. Twenty developed a rechallenge reaction to isoniazid and five reacted to ethionamide. Four of the 20 isoniazid cases were patch test positive, 3/20 were skin prick test positive and 13/20 reacted to oral rechallenge. All seven cases that were patch and skin prick test positive were associated with systemic reactions. Twenty of the 25 cases had DRESS and 5 had SJS/TEN. Twenty-three of the 25 cases with rechallenge reactions were HIV infected. Importantly, none of the cases that reacted to ethionamide during the rechallenge reacted to isoniazid and none who subsequently reacted to isoniazid reacted to ethionamide. CONCLUSIONS Our findings strongly suggest that the risk of cross-reactivity of isoniazid and ethionamide in DRESS syndrome and SJS/TEN is low. These findings have implications for clinical management.
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Affiliation(s)
- Rannakoe J Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa Lung Infection and Immunity Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Sipho Dlamini
- Division of Infectious Disease and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nomphelo Gantsho
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gail Todd
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Knight L, Muloiwa R, Dlamini S, Lehloenya RJ. Factors associated with increased mortality in a predominantly HIV-infected population with Stevens Johnson syndrome and toxic epidermal necrolysis. PLoS One 2014; 9:e93543. [PMID: 24695805 PMCID: PMC3973591 DOI: 10.1371/journal.pone.0093543] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 03/05/2014] [Indexed: 01/20/2023] Open
Abstract
Introduction Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening drug reactions with a higher incidence in HIV-infected persons. SJS/TEN are associated with skin and mucosal failure, predisposing to systemic bacterial infection (BSI), a major cause of death. There are limited data on risk factors associated with BSI and and mortality in HIV-infected people with SJS/TEN. Methods We conducted a retrospective study of patients admitted to a university hospital with SJS/TEN over a 3 year period. We evaluated their underlying illnesses, eliciting drugs, predictive value of bacterial skin cultures and other factors associated with mortality and BSI in a predominantly HIV-infected population by comparing characteristics of the patients who demised and those who survived. Results We admitted 86 cases during the study period and 67/86(78%) were HIV-infected. Tuberculosis was the commonest co-morbidity, diagnosed in 12/86(14%) cases. Skin cultures correlated with BSI by the same organism in 7/64(11%) cases and 6/7 were Gram-negative. Two of the 8 cases of Gram-negative BSI had an associated Gram-negative skin culture, although not always the same organism. All 8 fatalities had >30% epidermal detachment, 7 were HIV-infected, 6 died of BSI and 6 had tuberculosis. Conclusions Having >30% epidermal detachment in SJS/TEN carries an increased risk of BSI and mortality. Tuberculosis and BSI are associated with higher risk of death in SJS/TEN. Our data suggests there may be an association between Gram-negative BSI and Gram-negative skin infection.
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Affiliation(s)
- Lauren Knight
- Medical Intern, Groote Schuur Hospital, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Sipho Dlamini
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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Shebe K, Ngwanya MR, Gantsho N, Lehloenya RJ. Severe recurrence of drug rash with eosinophilia and systemic symptoms syndrome secondary to rifampicin patch testing in a human immunodeficiency virus-infected man. Contact Dermatitis 2014; 70:125-7. [DOI: 10.1111/cod.12155] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 08/08/2013] [Accepted: 09/11/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Khadija Shebe
- Division of Dermatology, Department of Medicine; University of Cape Town; Cape Town 7925 South Africa
| | - Mzudumile R. Ngwanya
- Division of Dermatology, Department of Medicine; University of Cape Town; Cape Town 7925 South Africa
| | - Nomphelo Gantsho
- Division of Dermatology, Department of Medicine; University of Cape Town; Cape Town 7925 South Africa
| | - Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine; University of Cape Town; Cape Town 7925 South Africa
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Isaacs T, Ngwanya MR, Dlamini S, Lehloenya RJ. Annular erythema and photosensitivity as manifestations of efavirenz-induced cutaneous reactions: a review of five consecutive cases. J Antimicrob Chemother 2013; 68:2871-4. [PMID: 23852540 DOI: 10.1093/jac/dkt287] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES In HIV-infected persons, a rash is the most common manifestation of drug hypersensitivity reactions. Non-nucleotide reverse transcriptase inhibitors are a major cause of cutaneous reactions. While the characteristics of nevirapine-associated cutaneous adverse drug reactions (CADRs) have been well described, there are limited data on efavirenz-associated CADRs. The objective of this study was to characterize the clinical features of consecutive cases of efavirenz-associated CADRs in a single referral centre diagnosed over a 3 year period. METHODS We retrospectively reviewed the clinical records of 231 patients admitted with CADRs to a tertiary dermatology ward in Cape Town, South Africa. RESULTS In 42/231(18%) cases, there had been exposure to efavirenz in the preceding 8 weeks. Of these, 5/42 (12%) patients were diagnosed with probable efavirenz-associated CADRs based on the Naranjo score. The median exposure to efavirenz before the onset of the rash was 12 days (range 2-48). All the patients were female, with a median age of 31 years and a median CD4 cell count of 300 cells/mm(3) (range 81-887). Four had a photo-distributed eruption and one had a confluent indurated erythema affecting the face, trunk and limbs. In three out of five cases, there were annular plaques with raised erythematous edges and dusky centres, which were photo-distributed. Two patients had a mild transaminitis and another a mild eosinophilia. Histological features were non-specific, with perivascular lymphocytes the only consistent feature. In all five cases, efavirenz was withdrawn and potent topical steroid was the only CADR-specific intervention. The eruptions resolved on discharge from hospital, with no sequelae except for residual post-inflammatory hyperpigmentation. CONCLUSIONS Photo-distribution and annular erythema should alert clinicians to the possibility of efavirenz-associated CADRs.
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Affiliation(s)
- Thuraya Isaacs
- Division of Dermatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Lehloenya RJ, Esmail F, Christians SJ, Motsepe D, Todd G. Toxic epidermal necrolysis with failure of re-epithelialization. Could umbilical cord mesenchymal stem cell transplantation have a role? J Eur Acad Dermatol Venereol 2012; 27:923-5. [PMID: 22882345 DOI: 10.1111/j.1468-3083.2012.04667.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lehloenya RJ, Dheda K. Cutaneous adverse drug reactions to anti-tuberculosis drugs: state of the art and into the future. Expert Rev Anti Infect Ther 2012; 10:475-86. [PMID: 22512756 DOI: 10.1586/eri.12.13] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
First- and second-line anti-tuberculosis drugs are associated with a diverse presentation of cutaneous adverse drug reactions (CADR), ranging from mild to life threatening. An individual drug can cause multiple types of CADR, and a specific type of CADR can be due to any anti-tuberculosis drug, which can make the management of tuberculosis (TB) following CADR challenging. The higher incidence of TB and CADR in HIV-infected persons makes TB-associated CADR a burgeoning problem for clinicians, particularly in high HIV-prevalence settings. This review discusses the pathogenesis, epidemiology, clinical presentation, diagnosis and management of TB-associated CADR. Clinical controversies including its impact on treatment outcomes, challenges in restarting optimal anti-tuberculosis therapy and the timing of highly active antiretroviral therapy initiation in those with HIV coinfection are also discussed. Finally, gaps in the current knowledge of TB-associated CADR have been identified and a research agenda has been proposed.
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Affiliation(s)
- Rannakoe J Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Western Cape, South Africa
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Lehloenya RJ, Wallace J, Todd G, Dheda K. Multiple drug hypersensitivity reactions to anti-tuberculosis drugs: five cases in HIV-infected patients. Int J Tuberc Lung Dis 2012; 16:1260-4. [PMID: 22747953 DOI: 10.5588/ijtld.11.0187] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The paucity of effective anti-tuberculosis drugs often justifies rechallenge with first-line drugs following adverse drug reactions (ADR) to eliminate the offending drug from the regimen. Rechallenge is usually performed under cover of drugs the patient has not been exposed to previously. The occurrence of hypersensitivity reactions to both the first-line and cover drugs poses a therapeutic dilemma and makes it difficult to identify the offending drug(s). OBJECTIVE To characterise multiple drug hypersensitivity (MDH) in five human immunodeficiency virus (HIV) infected patients with previous tuberculosis (TB) associated ADR. DESIGN The series is part of an ongoing randomised controlled trial assessing rechallenge dosing following TB-associated cutaneous ADR. RESULTS The MDH was secondary to both first- and second-line anti-tuberculosis drugs. Itch, oedema, eosinophilia and fever were the most common features of MDH. Acute peripheral neuropathy associated with ethionamide, streptomycin (SM) and/or ofloxacin (OFX), to our knowledge not previously described in relation to MDH and these drugs, occurred in two patients. SM and OFX were associated with the most reactions. One patient had morphologically different reactions, namely Stevens Johnson syndrome/toxic epidermal necrolysis overlap and drug hypersensitivity syndrome, respectively to isoniazid and SM. CONCLUSION In a description of MDH in five HIV-TB co-infected patients, including acute peripheral neuropathy, SM and OFX were the most common offending drugs.
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Affiliation(s)
- R J Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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Lehloenya RJ, Todd G, Mogotlane L, Gantsho N, Hlela C, Dheda K. Lichenoid drug reaction to antituberculosis drugs treated through with topical steroids and phototherapy. J Antimicrob Chemother 2012; 67:2535-7. [PMID: 22687890 DOI: 10.1093/jac/dks225] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lehloenya RJ, Todd G, Badri M, Dheda K. Outcomes of reintroducing anti-tuberculosis drugs following cutaneous adverse drug reactions. Int J Tuberc Lung Dis 2012; 15:1649-57. [PMID: 22118173 DOI: 10.5588/ijtld.10.0698] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Data regarding outcomes of tuberculosis (TB) associated cutaneous adverse drug reactions (CADR) are limited. The re-introduction of first-line anti-tuberculosis drugs after CADR is controversial and management poorly defined. METHODS We retrospectively reviewed the records of 298 patients with CADR admitted to a tertiary dermatology ward in Cape Town, South Africa. RESULTS TB-associated CADR was diagnosed in 65 of 298 patients. Of these, 60/65 (92%) were human immunodeficiency virus (HIV) infected (median CD4 count 107 cells/mm (3)). Anti-tuberculosis drugs were reintroduced in 46/65 (71%) patients, of whom 23/46 (50%) developed re-introduction reactions. The most frequent re-introduction reactions were itch in 11/23 (48%) and hepatitis in 9/23 (39%) patients. Of the 23 re-introduction reactions, 13 (57%) were mild, six (26%) moderate and four (26%) severe. Among those with reintroduction reactions, rifampicin (RMP) was the offending drug in 13/23 (57%), isoniazid in 5/23(22%), pyrazinamide in 3/23 (13%), and ethambutol, streptomycin and ofloxacin each in 1/23 (4%) cases. Lack of previous TB treatment and re-challenge with RMP were independently associated with the likelihood of reintroduction reactions. CONCLUSIONS In this high TB burden setting, although re-introduction reactions are common, the majority are non-life-threatening. All first-line anti-tuberculosis drugs can cause CADR, and RMP is more commonly implicated than previously reported. These data guide the management of anti-tuberculosis drug-associated CADR in high HIV prevalence settings.
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Affiliation(s)
- R J Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Tomlinson GS, Cashmore TJ, Elkington PTG, Yates J, Lehloenya RJ, Tsang J, Brown M, Miller RF, Dheda K, Katz DR, Chain BM, Noursadeghi M. Transcriptional profiling of innate and adaptive human immune responses to mycobacteria in the tuberculin skin test. Eur J Immunol 2011; 41:3253-60. [PMID: 21805471 PMCID: PMC3258543 DOI: 10.1002/eji.201141841] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 07/06/2011] [Accepted: 07/25/2011] [Indexed: 12/24/2022]
Abstract
The tuberculin skin test (TST) is a model of integrated innate and adaptive human immune responses to Mycobacterium tuberculosis, but the component processes that are involved in this model have not previously been defined in vivo. We used transcriptional profiling to study these responses within the TST at molecular and system levels. Skin biopsies from TST injection sites were examined in subjects classified as TST+ or TST− by clinical and histological criteria. Genome-wide expression arrays showed evolution of immune responses reflecting T-cell activation and recruitment with uniquely Th1-polarized responses and cytotoxic T cells (CTLs). In addition, distinct innate immune and IFN-γ-stimulated gene expression signatures were identified, under the regulation of NF-κB and STAT1 transcriptional control. These were highly enriched for chemokines and MHC class II molecules providing a potential mechanism for paracrine amplification of inflammatory responses in the TST, by supporting cellular recruitment and enhancing antigen presentation. The same repertoire of innate and adaptive immune responses was evident in TST+ and TST− subjects alike, clinically positive TSTs being distinguished only by quantitatively greater differences. These data provide new insights into complex multifaceted responses within the TST, with much greater sensitivity than previous clinical or histological assessments.
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