Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis

Prevention of toxic epidermal necrolysis by regulatory T cells

To analyze immunoregulation of autoreactive T cells specific for epidermal skin antigens, we crossed transgenic mice expressing ovalbumin selectively in keratinocytes under the keratin 5 promoter (K5-mOVA) with mice expressing a K(b)-restricted OVA-specific T cell receptor transgene (OT-I). In athymic double-transgenic mice, OT-I cells developed extrathymically and, at 8-12 weeks of age, initiated severe epidermal damage mimicking toxic epidermal necrolysis (TEN). In contrast, euthymic double-transgenic mice showed thymic deletion of OT-I cells, had few of these cells in the periphery, and never developed skin changes mimicking TEN. Adoptive transfer of OT-I cells isolated from euthymic double-transgenic mice induced TEN in athymic K5-mOVA single-transgenic mice. This spontaneous disease in athymic double-transgenic mice was prevented by transferring lymph node cells from euthymic mice, but was not prevented when CD4(+) or CD25(+) cells were depleted from this population. Although purified CD4(+)CD25(+) cells scarcely prevented the skin disease induced by adoptive transfer of OT-I cells, they efficiently prevented the disease when co-transferred with CD11c(+) dendritic cells. These results suggested that thymus-derived regulatory T cells cooperate with CD11c(+) dendritic cells to prevent life-threatening skin damage such as TEN.

Risk estimates for drugs suspected of being associated with Stevens-Johnson syndrome and toxic epidermal necrolysis: a case-control study

The purpose of this case-control study is to estimate the risks of Stevens-Johnson syndrome or toxic epidermal necrolysis associated with the use of specific drugs. The suspected cases were identified from the computerized hospital discharge file. We calculated crude relative risks and adjusted them for confounding by multivariate analysis. The analysis was based on 35 cases and 105 controls. This study showed that the use of carbamazepine, phenytoin and allopurinol is most associated with the risks in the oriental population.

Syndrome de Stevens-Johnson et nécrolyse épidermique toxique à Lomé (Togo)

INTRODUCTION

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous drug reactions, the prognosis of which largely depends on the quality of their treatment. The purpose of this study was to determine the evolutional and etiological profiles of SJS/TEN in a teaching hospital in Lome (Togo).

METHODS

The medical records of patients hospitalized in the departments of dermatology and intensive care of the university hospital center of Lome for SJS/TEN from 1992 to 2001 were reviewed retrospectively. The records of patients retained corresponded to the international classification criteria of SJS/TEN.

RESULTS

We collected 40 cases of SJS/TEN (27 cases of SJS, 12 cases of TEN and one overlap SJS/TEN). Patients' mean age was of 30 +/- 7 years. The sex ratio (male/female) was of 1.5 and the mean follow-up after hospitalization was of 2 months (range: 4 weeks to 8 months). The HIV serology was known in 20 cases (13 cases of SJS and 7 cases of TEN). It was positive in 10 cases (5 during TEN and 5 during SJS). Five of the 12 patients (41.7 p.cent) exhibiting NET died (all were HIV-infected) versus 2 of the 27 patients (7.4 p.cent) exhibiting SJS (2 patients were also HIV-infected). The principle drugs incriminated were: antibacterial sulphonamides (16 cases; 40 p.cent), rifampicin-isoniazid combination (7 cases; 17.9 p.cent), anti-epileptics (5 cases; 12.5 p.cent); amino-penicillin (4 cases; 10 p.cent) and non-steroidal anti-inflammatories (2 cases; 5 p.cent). Chinese drugs of undetermined nature were incriminated in 3 cases of SJS. No drug was formally identified in 3 cases of SJS.

DISCUSSION

This study confirms the rareness of SJS/NET. These affections are of poor prognosis, particularly in developing countries. The results of this study suggest that the concomitance of an opportunist infection due to HIV-immunodepression is of poor prognosis in the evolution of SJS/NET. Antibacterial sulphonamides and the rifampicin-isoniazid combination are frequently incriminated in Togo.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a review of the literature

OBJECTIVE

To perform a comprehensive review of Stevens-Johnson syndrome and toxic epidermal necrolysis.

DATA SOURCES

A MEDLINE search was performed for the years 1975 to 2003 using the keywords Stevens-Johnson syndrome and toxic epidermal necrolysis to identify relevant articles published in English in peer-reviewed journals.

STUDY SELECTION

All clinical studies that reported on 4 or more patients, review articles, and experimental studies that concerned disease mechanisms were selected and further analyzed. Clinical reports that included fewer than 4 patients were selected only if they were believed to carry a significant message about disease mechanism or therapy.

RESULTS

Stevens-Johnson syndrome and toxic epidermal necrolysis seem to be variants of the same disease with differing severities. A widely accepted consensus regarding diagnostic criteria and therapy does not exist at present. Despite the recent experimental studies, the pathogenic mechanisms of these diseases remain unknown. Although progress in survival through early hospitalization in specialized burn units has been made, the prevalence of life-long disability from the ocular morbidity of Stevens-Johnson syndrome and toxic epidermal necrolysis has remained unchanged for the past 35 years. Further progress depends on modification of the acute phase of the disease rather than continuation of supportive care. The available published evidence indicates that a principal problem in the pathogenesis is immunologic and that immunomodulatory intervention with short-term, high-dose intravenous steroids or intravenous immunoglobulin holds the most promise for effective change in survival and long-term morbidity.

CONCLUSIONS

The results of this review call for a widely accepted consensus on diagnostic criteria for Stevens-Johnson and toxic epidermal necrolysis and multicenter collaboration in experimental studies and clinical trials that investigate disease mechanisms and novel therapeutic interventions, respectively.

Probable vancomycin-associated toxic epidermal necrolysis

A 52-year-old man with no previous drug allergies or skin disorders developed a widespread papulovesicular rash while receiving an antimicrobial regimen of piperacillin-tazobactam, tobramycin, and vancomycin. Skin biopsy suggested leukocytoclastic vasculitis, which responded well to antibiotic discontinuation and steroid therapy. Fifteen days later, during steroid tapering, an additional course of vancomycin was begun for suspected line infection. The subsequent maculopapular rash that developed was diagnosed as toxic epidermal necrolysis (TEN) based on a second skin biopsy and clinical presentation. This case is consistent with previous reports of vancomycin-associated TEN. Any patient who develops TEN while receiving vancomycin therapy should be evaluated for possible vancomycin-induced TEN.

Human Immunodeficiency Virus, Pregnancy, and Stevens-Johnson Syndrome

BACKGROUND

Stevens-Johnson syndrome and toxic epidermal necrolysis are life-threatening dermatologic disorders that are more common in the setting of a compromised immune system. We present the case of a pregnant patient with known human immunodeficiency virus (HIV) infection who presented with Stevens-Johnson syndrome after treatment with antibiotics for a urinary tract infection.

CASE

A young woman at 33 4/7 weeks of gestation with known HIV infection presented to the emergency room with a chief complaint of rash, fever, blisters, and lower abdominal pain. Her symptoms were present for 2 days after ingestion of nitrofurantoin, prescribed for a urinary tract infection. She was diagnosed with preterm labor and possibly Stevens-Johnson syndrome. Due to active labor, HIV, and vaginal stenosis, a primary cesarean was performed. A skin biopsy performed at the time of admission confirmed the diagnosis of a drug-induced dermatosis (erythema multiforme), evidenced by subepidermal bullae, hemorrhage, and acantolated, dyskeratotic eosinophilic cells.

CONCLUSION

Stevens-Johnson syndrome and toxic epidermal necrolysis represent a spectrum of disease that has been long associated with multiple drugs, recently including many antiretroviral medications. It also seems that the incidence of these conditions is increased in immunocompromised patients. We speculate that the combination of HIV and pregnancy in addition to antibiotic treatment, such as with nitrofurantoin, may induce Stevens-Johnson syndrome in patients with severely altered immune systems.

Fatal toxic epidermal necrolysis due to lansoprazole

Toxic epidermal necrolysis (TEN) is a serious cutaneous reaction and is most commonly drug induced. It is associated with significant morbidity and mortality. We describe a patient who developed fatal TEN after re-exposure to lansoprazole. Three years previously he presented with erythema multiforme due to the same drug. To our knowledge this is the first published report of TEN occurring with lansoprazole.

Norfloxacin-Induced Toxic Epidermal Necrolysis

OBJECTIVE:

To report a case of toxic epidermal necrolysis (TEN) in a man who was treated with oral norfloxacin for prostatitis.

CASE SUMMARY:

A 40-year-old man presented with a severe skin reaction, which was diagnosed as TEN. He had received norfloxacin 800 mg/day over a 14-day period for prostatitis and, 10 days after finishing the treatment regimen, he developed cutaneous and mucous lesions typical of TEN. After a prolonged hospitalization and treatment with oral prednisolone therapy, fluid resuscitation, and wound dressing, the man recovered.

DISCUSSION:

TEN is an infrequent, yet often fatal, severe systemic and cutaneous disease that is most often an adverse drug reaction. There are few case reports of TEN induced by fluoroquinolones. A MEDLINE search (1966–February 2005) revealed no reports of toxic epidermal necrolysis, but one incidence of Stevens—Johnson syndrome due to norfloxacin therapy. An objective causality assessment suggests that TEN was probably related to norfloxacin in this patient.

CONCLUSIONS:

To our knowledge, this is the first case of TEN associated with the use of oral norfloxacin. We hope that this case report creates awareness that norfloxacin-induced TEN is possible.

Stevens-Johnson syndrome-toxic epidermal necrolysis (SJS-TEN) overlap associated with carbamazepine use

A benign pruritic rash occurs in 10%-15% of persons treated with carbamazepine. A small fraction of them may experience life-threatening dermatological syndromes such as exfoliative dermatitis, erythema multiforme, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). The case of an 18-year-old female suffering from bipolar affective disorder (mania) who was being treated with carbamazepine, lithium, chlorpromazine and benzhexol is presented. After 10 days of treatment, she developed high-grade fever and mucocutaneous manifestations of SJS-TEN overlap. She was treated in hospital with systemic corticosteroids, antibiotics, intravenous fluids and other supportive measures, and recovered after 3 weeks.

Novel Treatments for Drug-Induced Toxic Epidermal Necrolysis (Lyell’s Syndrome)

Drug-induced toxic epidermal necrolysis (TEN) is a life-threatening disease characterized by extensive destruction of the epidermis. It apparently results from the formation of specific toxic drug metabolites by the keratinocytes. The mortality rate which averages 25-30% is mainly due to secondary septicemia, and to ionic and metabolic disturbances following loss of epidermal integrity. Apoptosis is the likely mechanism leading to massive keratinocyte death in TEN. Dysregulations in the tumor necrosis factor-alpha (TNF-alpha) pathway, CD95 system (Fas ligand, CD95L; Fas receptor, CD95R) and calcium homeostasis in the epidermis are involved in this apoptotic process. An active role has also been ascribed to T lymphocytes, macrophages and factor XIIIa-positive dermal dendrocytes. Despite progress, treatment of TEN remains controversial. In the past, systemic glucocorticoids were used in order to target the inflammatory reaction in TEN. However, there was no evidence for improvement of the healing process, while corticosteroids worsened the prognosis by increasing the risk of septicemia. Only a few cases have been treated with other drugs including cyclophosphamide, pentoxyfilline, thalidomide, anti-TNF-alpha antibodies and cyclosporin A. In the recent past, some TEN patients were treated with intravenous human immunoglobulins (IVIG). The rationale for such a treatment was to block the CD95 system on keratinocytes. The early promising clinical results of IVIG treatment in TEN were subsequently challenged. This review compares the effectiveness and drawbacks of the major drugs presently used in TEN treatment. Some future prospects in TEN management are also discussed.

HLA-B*5801 allele as a genetic marker for severe cutaneous adverse reactions caused by allopurinol

Allopurinol, a commonly prescribed medication for gout and hyperuricemia, is a frequent cause of severe cutaneous adverse reactions (SCAR), which include the drug hypersensitivity syndrome, Stevens-Johnson syndrome, and toxic epidermal necrolysis. The adverse events are unpredictable and carry significant morbidity and mortality. To identify genetic markers for allopurinol-SCAR, we carried out a case-control association study. We enrolled 51 patients with allopurinol-SCAR and 228 control individuals (135 allopurinol-tolerant subjects and 93 healthy subjects from the general population), and genotyped for 823 SNPs in genes related to drug metabolism and immune response. The initial screen revealed strong association between allopurinol-SCAR and SNPs in the MHC region, including BAT3 (encoding HLA-B associated transcript 3), MSH5 (mutS homolog 5), and MICB (MHC class I polypeptide-related sequence B) (P < 10(-7)). We then determined the alleles of HLA loci A, B, C, and DRB1. The HLA-B*5801 allele was present in all (100%) 51 patients with allopurinol-SCAR, but only in 20 (15%) of 135 tolerant patients [odds ratio 580.3 (95% confidence interval, 34.4-9780.9); corrected P value = 4.7 x 10(-24)] and in 19 (20%) of 93 of healthy subjects [393.51 (23.23-6665.26); corrected P value = 8.1 x 10(-18)]. HLA alleles A*3303, Cw*0302, and DRB1*0301 were in linkage disequilibrium and formed an extended haplotype with HLA-B*5801. Our results indicated that allopurinol-SCAR is strongly associated with a genetic predisposition in Han Chinese. In particular, HLA-B*5801 allele is an important genetic risk factor for this life-threatening condition.

Lamotrigine in psychiatry: pharmacology and therapeutics

Following the introduction of lamotrigine in 1994 as a treatment for epilepsy in the United States, the drug has seen progressively greater application in psychiatry, particularly as a treatment for bipolar disorder. This review critically evaluates the support for lamotrigine use across a broad range of psychiatric disorders as well as discuss its pharmacology, side-effect profile, and interactions with other medications.

Erythema multiforme: a review and contrast from Stevens-Johnson syndrome/toxic epidermal necrolysis

Erythema multiforme and Stevens-Johnson syndrome/toxic epidermal necrolysis are separate diseases. Recent evidence suggests that they have different etiologies and require different treatments. This article provides an overview of the two conditions with emphasis on the differences between them. An outline of the diagnosis and management of the diseases is included.

Lyell syndrome revisited: analysis of 18 cases of severe bullous skin disease in a burns unit

Over the last few years, understanding of the pathophysiology of toxic epidermal necrolysis (TEN), or Lyell's disease, has substantially increased. However, differentiation of severe bullous skin disease remains a challenge for the clinician, and one that is often complicated by late patient referral. We performed a retrospective analysis of all patients with severe bullous skin disease, admitted between 1997 and 2002 to the Burn Centre, which is an integrated part of the Division for Plastic, Hand- and Reconstructive Surgery at the University Hospital of Zurich, Switzerland. We present an overview of our strategies and of the diagnostic and therapeutic difficulties encountered. The final diagnoses of the 18 patients referred to the unit were as follows: eight cases of TEN, one case of staphylococcal scalded-skin syndrome (SSSS), two cases of generalised drug eruption, one case of acute generalised exanthematic pustulosis and one case of febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta (PLEVA). In two cases, the diagnosis remained unclear. In three cases, paraneoplastic origins were suspected but not demonstrated. The overall mortality rate was 33% (six of 18 patients). Remarkably, all patients with histologically confirmed TEN survived. Six of these patients were successfully treated with intravenous immunoglobulins (IVIG). The most common single causative drug inducing TEN (four cases out of eight) was Phenytoin. Establishing an accurate diagnosis-based on a skin biopsy, harvested at an early stage-is more important than ever, because more specific and effective therapeutic modalities are available. As these potentially life-threatening bullous skin disorders are rare, we recommend, that care be provided by an experienced interdisciplinary team, comprising a dermatologist, or dermatopathologist, an intensive care specialist and a plastic surgeon.

Utilization of hospital and outpatient care for adverse cutaneous reactions to medications

PURPOSE

To quantify hospitalizations, visits to office based physicians, hospital clinics and emergency departments with primary diagnoses of skin conditions that are often due to drug reaction.

METHODS

I analyzed data from the National Hospital Discharge Summary (1997-2001), National Ambulatory Care Survey (1995-2000) and National Hospital Ambulatory Care Survey (1995-2000) to determine the number of hospitalizations and visits with primary diagnoses of skin conditions that are often attributed to drugs. Using statistical methods for surveys, I determined the demographic characteristics of patients with these diagnoses and compared them with patients seeking care for other reasons.

RESULTS

In the United States, there are about 5000 hospitalizations each year with a primary diagnosis of erythema multiform, Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis, of which 35% are specifically ascribed to drugs. Annually, there are more than 100,000 outpatient visits for these diagnoses and about two million visits for immediate hypersensitivity reactions that may be due to drugs. Outpatient visits for drug eruptions and drug allergies that include a skin component exceed 500,000 annually.

CONCLUSIONS

Skin conditions often attributed to drugs are frequent reasons for hospitalization and physician visits. Optimal care of the individual patients with these conditions requires careful attention to drugs as a possible cause.

Antibiotics do not reduce toothache caused by irreversible pulpitis. Are systematic antibiotics effective in providing pain relief in people who have irreversible pulpitis?

DATA SOURCES

Cochrane Oral Health Group Trials Register and the Pain, Palliative Care and Supportive Care Group Trials Register, the Cochrane Central Register of Controlled Trials, Medline and Embase.

STUDY SELECTION

Randomised controlled trials (RCT) were included that involved patients over the age of 18 years who had presented with a single tooth with a clinical diagnosis of irreversible pulpitis.

DATA EXTRACTION AND SYNTHESIS

Abstracts of studies were independently assessed by two reviewers. The primary outcome was patient-reported pain (intensity/duration) and pain relief measured on a categorical scale in the preoperative phase of irreversible pulpitis. Secondary outcomes were type, dose and frequency of medication required for pain relief. Only one trial was included so pooling of data from studies was not possible and a descriptive summary is presented.

RESULTS

One trial of 40 participants was included. There was a close parallel distribution of the pain ratings in both the intervention and placebo groups over the 7-day study period. The between-group differences in sum pain intensity differences for the penicillin group were 6.0+/-10.5, and for placebo 6.0+/-9.5 (P=0.776; differences assessed by Mann-Whitney-Wilcoxon test considered to be statistically significant at P=0.05). The sum pain percussion intensity differences for the penicillin group were 3.5+/-7.5 and placebo 2.0+/-7.0 (P=0.290). There was no significant difference in the mean total number of ibuprofen tablets (P=0.839) and acetaminophen tablets (P=0.325) taken for pain relief in either group over the study period. The administration of penicillin over placebo did not appear to significantly reduce the quantity of analgesic medication taken (P=0.05) for irreversible pulpitis.

CONCLUSIONS

This review based on one methodologically sound but low-powered small sample trial, provides some evidence that there is no significant difference in pain relief between individuals who had untreated irreversible pulpitis who did or did not take antibiotics in addition to analgesics.

Schwere Arzneimittelreaktionen der Haut

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are severe drug-induced bullous skin reactions. They are rare, but often life-threatening and have a high mortality rate. Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction, but after the suspected drug is withdrawn, the skin heals rapidly and mortality is low. The clinical pattern, histology and inducing drugs differ substantially between AGEP and the SJS/TEN group.

Toxic epidermal necrolysis as a complication of treatment with voriconazole

An 81-year-old female received voriconazole in a 7-day treatment course for a symptomatic Candida krusei urinary tract infection. Four days after the last dose, she developed toxic epidermal necrolysis. She was treated with intravenous immunoglobulin, and her symptoms promptly resolved.

Agranulocytosis associated with dipyrone (metamizol)

OBJECTIVES

Reported estimates of the risk of agranulocytosis associated with metamizol have varied by several orders of magnitude. We assessed this association in a large database for the surveillance of blood dyscrasias.

METHODS

Since 1980, all laboratory units of haematology in a defined area (3.3-4.1x10(6) inhabitants) contribute to the ascertainment of all cases of agranulocytosis meeting strict diagnostic criteria. These cases of patients with agranulocytosis and sex-, age-, hospital- and date-matched controls were interviewed using a structured questionnaire about previous drug exposures, and relative risks were calculated for several categories of exposure to metamizol.

RESULTS

After a total follow-up of 78.73x10(6) person-years, 273 community cases of agranulocytosis had been found--of which 96 were excluded for various reasons and 177 were included in the case-control analysis--and were compared with 586 matched controls. Thirty cases of agranulocytosis (16.9%) and nine controls (1.5%) had been exposed to metamizol during the week before the index day. The adjusted relative risk was 25.8 [95% confidence interval (CI), 8.4-79.1], and the attributable incidence was 0.56 (0.4-0.8) cases per million inhabitants and per year. The risk disappeared after more than 10 days since the last dose of metamizol, and it increased with duration of use. Those with agranulocytosis exposed to metamizol had taken the drug for longer periods than the exposed controls. Compared with the cases recently reported from Sweden, the duration of use of metamizol by our exposed cases was substantially shorter, and the use of concomitant medications potentially causing agranulocytosis was lower.

DISCUSSION

In our milieu, agranulocytosis attributable to metamizol is rare. Geographical disparities in its risk estimate can be partly explained by differences in its patterns of use, in terms of dose, duration and concomitant medications.

A case of rofecoxib-associated stevens-johnson syndrome with corneal and conjunctival changes

PURPOSE

To report a case of rofecoxib (Vioxx)-associated Stevens-Johnson syndrome with corneal and conjunctival changes.

DESIGN

Interventional case report.

METHODS

Case report of a 62-year-old woman with systemic lupus erythematosus (SLE) taking rofecoxib for arthritis for 3 weeks.

RESULTS

Stevens-Johnson syndrome after 3 weeks of rofecoxib therapy.

CONCLUSION

This case report suggests that oral rofecoxib may trigger Stevens-Johnson syndrome, potentially causing symblepharons, corneal neovascularization and cicatricial ectropions.

Separate and concomitant use of lamotrigine, lithium, and divalproex in bipolar disorders

Expert consensus emphasizes the need for better recognition and accurate diagnosis of bipolar disorder. Current research on lithium, divalproex, and lamotrigine provides new insight into the effective management of this illness. Advances in identifying the mechanism of action of mood stabilization has focused on signaling pathways within the cell that are associated with neurotrophic effects. Clinical research has led to confirmatory evidence of the efficacy of lithium in all phases of bipolar disorder, with the greatest effects seen in the treatment and prevention of mania. Compared to divalproex, lithium also has been found to have greater efficacy in the prevention of suicide. Lamotrigine has emerged as a first line treatment for bipolar depression, which is an area of weakness for other mood stabilizers. Oral loading of divalproex leads to rapid stabilization of mania without imposing a greater adverse effect burden than conventional dosing. Because no agent is universally effective in all phases of the illness, combination therapy with two or more agents often is the best option.

Assessment and management of cutaneous reactions with amifostine administration: Findings of the ethyol (amifostine) cutaneous treatment advisory panel (ECTAP)

PURPOSE

To review reports of severe skin reactions during amifostine treatment.

METHODS AND MATERIAL

The expert panel reviewed postmarketing reports of skin reactions and discussed strategies for evaluation and management.

RESULTS

Between 1994 and April 2002, 35 events were classified as severe skin reactions worldwide: erythema multiforme (8), Stevens-Johnson syndrome (10), toxic epidermal necrolysis (11), toxicoderma (3), and bullae (3). Unadjusted incidences were 6-9 per 10,000 radiotherapy patients and 0.8-1 per 10,000 chemotherapy patients. In 10 patients (29%) amifostine was continued after cutaneous signs and symptoms appeared.

CONCLUSIONS

Practical recommendations for practicing clinicians were developed. Cutaneous evaluation for rash, ulceration, or lesions-particularly on lips/mucosa, palmar/plantar surfaces, and the trunk-should be performed before amifostine administration. Reactions can be classified as local injection site/radiation port reactions or non-injection site reactions; and non-injection site reactions with associated fever or constitutional symptoms must be differentiated from radiation-induced dermatitis or cutaneous reaction with another etiology. Amifostine should be permanently discontinued for severe skin reactions or reactions associated with constitutional symptoms not known to be due to any other etiology. Increased physician awareness, proper patient management, monitoring before administration, and early intervention/discontinuation for non-injection site reactions may reduce the incidence of cutaneous reactions and enhance amifostine safety.

Continuous pentobarbital infusion in children is associated with high rates of complications

PURPOSE

To evaluate the incidence and severity of complications related to continuous pentobarbital (PB) infusion for sedation in the Pediatric Intensive Care Unit (PICU).

MATERIALS AND METHODS

We conducted a retrospective, chart review study. All patients admitted to the PICU from January 1997 through June 1998 who received continuous IV PB infusion for sedation (n = 8) were included.

RESULTS

All patients were intubated and mechanically ventilated prior to PB infusion. PB was used only as a second line sedative after a combination of an opioid and benzodiazepine failed to achieve adequate sedation. After initiation of PB, we were able to decrease or discontinue benzodiazepines and/or opioid doses and discontinue neuromuscular blocking drugs in all patients. We observed a high incidence of complications (62.5%) related to PB or the phenobarbital treatment used for barbiturate weaning, including blood pressure instability (25%), oversedation (12.5%), drug reaction (12.5%) and neurologic sequelae (12.5%). Discontinuation of the drug was required in 25% of the cases.

CONCLUSIONS

We found continuous PB infusion to be an effective sedative for children when other drugs fail. However, we observed a high rate of clinically significant complications requiring discontinuation of the drug.

Clinical evaluation and management of drug hypersensitivity

Adverse drug reactions are a major health problem in the inpatient and outpatient clinical setting. Although all of the immune mechanisms of drug reactions are not well characterized, a detailed medication history, knowledge of the signs and symptoms associated with known immune mechanisms, and knowledge of the types of medications typically associated with distinct immune reactions are helpful in implicating the causative drug. Standardized testing for drug reactions is limited, especially for non-IgE-mediated reactions. Management consists of stopping the offending drug, treating the acute reaction, and making a determination concerning future use of the drug.

Reações cutâneas graves adversas a drogas - aspectos relevantes ao diagnóstico e ao tratamento - Parte I - Anafilaxia e reações anafilactóides, eritrodermias e o espectro clínico da síndrome de Stevens-Johnson & necrólise epidérmica tóxica (Doença de Lyell)

As reações cutâneas graves adversas a droga (RCGAD) são as que geralmente necessitam de internação hospitalar, por vezes em unidade de terapia intensiva ou de queimados, com observação minuciosa dos sinais vitais e da função de órgãos internos. O objetivo é descrever essas reações, facilitando seu reconhecimento e tratamento. Fazem parte desse grupo a anafilaxia, a síndrome de Stevens-Johnson (SSJ), a necrólise epidérmica tóxica (NET) e, dependendo do envolvimento sistêmico, as eritrodermias. Neste artigo, são abordados as características clínicas e o tratamento de algumas reações adversas a droga: anafilaxia, as eritrodermias, a síndrome de Stevens-Johnson (SSJ) e a necrólise epidérmica tóxica (NET).

Herbal medicine induced Stevens-Johnson syndrome: a case report

A severe form of Erythema multiforme (EM), diagnosed as Stevens-Johnson syndrome (SJS) was detected in a 10-year-old Indian male child who took herbal medication of plant origin prescribed by a traditional healer for remission of his fever. The child developed a severe and florid form of mucocutaneous oral ulceration, severe ocular manifestations, along with marked constitutional disturbances and dehydration. An extensive literature search revealed few previous reports of herbal drug induced EM and SJS. In India, traditional therapy with herbal preparation (Ayurvedic medicine) is not uncommon.

Fatal toxic epidermal necrolysis in autoimmune polyglandular syndrome type I

Autoimmune polyglandular syndrome Type I (APS I) is a disorder defined by the presence of at least two of the following diseases: Addison's disease, hypoparathyroidism, and chronic mucocutaneous candidiasis. We present the case of a 45-yr-old woman, affected by APS I, in chronic treatment with betamethasone. She was referred to a Division of General Medicine for jaundice, ascites and peripheral edema attributed to worsening of pre-existing autoimmune chronic hepatitis. During hospitalization, the following drugs were given: Amoxicillin/Clavulanic acid and Levofloxacin for bronchopneumonia, Furosemide and Canreonate for renal impairment, Pantoprazole for gastric protection, and Itraconazole for oral candidiasis. After about a month, she developed widespread, sheet-like, epidermal detachment, with painful lesions of the conjunctiva, lips and mouth. Toxic epidermal necrolysis (TEN) was diagnosed, and the patient was transferred to a Burn Center, where she died 10 days after the first onset of cutaneous rash. Autoptic and histopathological findings (epidermal necrosis and detachment, lymphomonocytic infiltration of the dermis) confirmed the clinical diagnosis. TEN is a usually drug-induced cutaneous inflammatory disorder characterized by extensive epidermal detachment and frequent mucosal involvement. It has also been associated with immuno-mediated disorders (HIV infection, graft-vs-host disease, systemic lupus erythematosus, mixed essential cryoglobulinemia), in keeping with immuno-mediated pathogenesis. We present, to our knowledge, the first report of TEN in a patient with APS I, and suggest that some pathogenetic mechanisms of APS I are shared with TEN. We stress how such a disease can occur in an autoimmune syndrome, even during corticosteroid treatment.

A marker for Stevens–Johnson syndrome

Stevens-Johnson syndrome and the related disease toxic epidermal necrolysis are life-threatening reactions of the skin to particular types of medication. Here we show that there is a strong association in Han Chinese between a genetic marker, the human leukocyte antigen HLA-B*1502, and Stevens-Johnson syndrome induced by carbamazepine, a drug commonly prescribed for the treatment of seizures. It should be possible to exploit this association in a highly reliable test to predict severe adverse reaction, as well as for investigation of the pathogenesis of Stevens-Johnson syndrome.

Pharmacokinetic and pharmacodynamic issues in the treatment of bacterial infectious diseases

This review outlines some of the many factors a clinician must consider when selecting an antimicrobial dosing regimen for the treatment of infection. Integration of the principles of antimicrobial pharmacology and the pharmacokinetic parameters of an individual patient provides the most comprehensive assessment of the interactions between pathogen, host, and antibiotic. For each class of agent, appreciation of the different approaches to maximize microbial killing will allow for optimal clinical efficacy and reduction in risk of development of resistance while avoiding excessive exposure and minimizing risk of toxicity. Disease states with special considerations for antimicrobial use are reviewed, as are situations in which pathophysiologic changes may alter the pharmacokinetic handling of antimicrobial agents.

Erythema multiforme associated with phenytoin and cranial radiation therapy: A report of three patients and review of the literature

BACKGROUND

Intracranial malignancies (primary and metastatic) are often complicated by seizure activity. Phenytoin (Dilantin) is typically employed as prophylactic anticonvulsant in this setting. Uncommonly, erythema multiforme (EM) can develop in such patients at the port site during or soon after cranial radiation and can rapidly progress to EM major. Herein, in addition to a comprehensive literature review of this entity, three additional patients are presented. The acronym 'EMPACT' is suggested (E: erythema; M: multiforme; associated with P: phenytoin; A: and; C: cranial, radiation; T: therapy) to best describe this disorder.

METHODS

An extensive review of the English medical literature through the National Library of Medicine (PUBMED) was performed to identify patients who had received or continued to receive radiation therapy while on phenytoin. A total of 24 patients were identified and clinical information of varying detail was available in all cases. Clinical and histological information on three additional patients seen at two institutions (Rochester Methodist Hospital, Rochester, MN, and Fairview-University Medical Center, Minneapolis, MN) by the authors were also compiled.

RESULTS

The mean age was 44 years (range: 23-67) and no sexual predisposition was noted. All patients had taken phenytoin for variable time periods (range 16-80 days; mean: 40) and were on the medication when the skin lesions first appeared. These lesions developed within the port site during the radiation treatments (11 cases) or soon after (nine cases) its completion (mean: 16 days; range: 2-35). Subsequent disease evolution to EM major occurred in all cases (Stevens-Johnsons syndrome developed in 73% of patients). No relationship was identified between the extent and the severity of the skin lesions with the phenytoin and radiation dosages and with the histologic type and origin of the intracranial malignancy. None of the patients demonstrated the requisite features of the 'Dilantin hypersensitivity syndrome'. Although, a systemic steroid taper was employed in 10 out of the 14 patients before the development of the skin lesions, the subsequent progression of the skin lesions was not influenced by the use of systemic steroid therapy. Complete recovery occurred in all but two patients typically within 1-8 weeks of discontinuation of phenytoin.

CONCLUSIONS

The need for prophylactic anticonvulsant therapy especially utilizing phenytoin in patients undergoing cranial radiation therapy should be assessed on a case by case basis. If anticonvulsants are employed, then they must be administered with caution, and all cutaneous reactions developing subsequently within the radiation site must be promptly evaluated with a high index of suspicion for erythema multiforme.

Evaluation of the Extent of Under-Reporting of Serious Adverse Drug Reactions

INTRODUCTION

Toxic epidermal necrolysis (TEN) is a life-threatening adverse drug reaction (ADR) that is primarily the result of drug exposure (incidence 0.4-1.3 per million person-years). Life-threatening ADRs such as TEN should be reported to ADR monitoring programmes, which collect reports for suspected ADRs and alert the public and medical practitioners to new drug hazards. In Canada, reports are made to the Canadian Adverse Drug Reaction Monitoring Program (CADRMP).

OBJECTIVE

To examine the extent of under-reporting for TEN in Canada.

DESIGN

A retrospective case series design was used to collect all TEN cases for the period January 1995 to December 2000.

METHODS

The CADRMP and 22 burn centres across Canada were contacted for all TEN patients treated during the specified time period. PATIENT GROUPS STUDIED: The study population consisted of patients admitted to burn treatment sites across Canada, patient cases reported to the CADRMP and patient cases recorded by the Canadian Institute for Health Information (CIHI) hospital discharge summaries as the International Classification of Diseases Version 9 Clinical Modification (ICD-9-CM) code 695.1.

RESULTS

Twenty-five TEN cases (six fatal) were reported to CADRMP from January 1995 to December 2000. During this period, 14 (63.6%) burn treatment sites reported admission of 250 TEN cases. Hospital discharge summaries using the ICD-9-CM code 695.1 indicated that 4349 cases were admitted to hospital during this time period and it was estimated that 15.5% (n = 674) of these cases were TEN. Using the burn facility data as the denominator, 10% (25 of 250) of TEN cases were reported to CADRMP. Using CIHI data as a denominator, only 4% (25 of 674) of TEN cases were reported to CADRMP.

CONCLUSIONS

There is serious under-reporting of TEN. Lack of reporting of life-threatening ADRs can compromise population safety. There is a need to increase awareness of ADR reporting programmes.

Fatal toxic epidermal necrolysis: A complication of vancomycin treatment for an infected hip arthroplasty

The incidence of MRSA or MRSE type infections involving hip prostheses is increasing. Treatment often involves removal of the prosthesis followed by a defined period of antibiotic treatment, prior to insertion of a second prosthesis. Vancomycin is often used in this setting. We report a fatal case of toxic epidermal necrolysis (TEN) in a patient receiving vancomycin following a first stage revision hip replacement. With the increasing use of vancomycin in revision arthroplasty cases, knowledge of this rare but commonly fatal side effect is important so that if it occurs, rapid and appropriate treatment may be commenced. (Hip International 2004; 14: 58-61).

Drug-Induced Hypersensitivity

Drug-induced hypersensitivity is an adverse reaction, characterised by damaging immune-mediated responses, initiated by medicine given at therapeutic doses for prevention, diagnosis or treatment. Immune-mediated drug hypersensitivity accounts for 6-10% of the adverse drug reactions, which rank between the fourth and sixth leading causes of death in the US. With <10% of all adverse drug reactions reported, the magnitude of the problem is significant, with estimates of costs >$US30 billion annually in the US (1995 value). In addition, the costs of not determining the potential of a drug to produce hypersensitivity in the pre-clinical phase of drug development can be substantial. It has been estimated that the pre-clinical phase and clinical phase I, phase II and phase III costs are approximately $US6 million, $US12 million, $US12 million and $US100 million per drug, respectively (1999 values). It is important that investigational drugs with the potential to produce hypersensitivity reactions be identified as early in the development process as possible. Some adverse reactions to drugs can be avoided if drug-drug interactions are known or if there is a structure-activity relationship established. However, these methods are inadequate. Appropriate animal models of drug-induced hypersensitivity are needed, especially because hypersensitivity has been cited as the leading reason for taking drugs off the market. It is of critical importance to be able to predict hypersensitivity reactions to drugs. Most anaphylactic reactions occur in atopic individuals. Similarly, patients who have experienced other hypersensitivity reactions are more likely to have recurrent reactions. Therefore, animal models should be considered that predispose the animal to the reaction, such as the use of appropriate adjuvants and species. Using known positive controls of varying strengths, the investigator can rank the reaction against the positive controls as standards. This approach might yield greater results in a shorter period of time than using novel models. For the greatest safety, use of well understood models that have been thoroughly validated is imperative.

Increased in Vitro Release of Interferon-Gamma from Ampicillin-Stimulated Peripheral Blood Mononuclear Cells in Stevens-Johnson Syndrome

Stevens-Johnson syndrome (SJS) was diagnosed in a 39-year-old woman, treated with ampicillin (4000-8000 mg daily), phenytoin (250 mg daily), and furosemide (20-40 mg daily) for 25, 21, and 20 d, respectively, before the appearance of the eruption. The lymphocyte stimulation test with the MTT [3-(4,5-dimethyl thiazol-2-yl)-2,5-diphenyl tetrazolium bromide] assay on ampicillin, phenytoin, and furosemide showed a low value of stimulation index, which indicated negative reactivity. An in vitro IFN-gamma release test was conducted on the patient with SJS and on two healthy controls. IFN-gamma release increased by 52% following the in vitro challenge of the patient's peripheral blood mononuclear cells (PBMCs) with 15 microg/ml of ampicillin, but not with phenytoin or furosemide. Neither of the controls experienced increased IFN-gamma release. In the present case, increased in vitro IFN-gamma release was observed on ampicillin-stimulated PBMCs, which may indicate the role of ampicillin as the drug responsible for the induction of SJS, and may imply the role of IFN-gamma in the pathogenesis of SJS.

Differential diagnosis of severe cutaneous drug eruptions

Adverse cutaneous reactions to drugs are frequent, mostly secondary to antibacterials, however, serious adverse cutaneous reactions are infrequent. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are a spectrum of the same disease. They are the more severe drug eruptions, with a mortality around 30% for TEN. The confusion between erythema multiforme major and SJS means that erythema multiforme major is the main differential diagnosis. Skin disorders involving desquamation, in particular after pustulosis, are also common differential diagnoses. Mechanical or autoimmune blistering are also potential misdiagnoses of TEN/SJS. Hypersensitivity Syndrome (HSS) or Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) is a severe cutaneous drug reaction with often a long duration of eruption and serious other organ involvement. Exfoliative dermatitis, whether caused by psoriasis, dermatitis or lymphoma, can be thought of as a differential diagnosis of DRESS/HSS. Angio-immunoblastic lymphadenopathy, viral eruption and vasculitis are other differential diagnoses of DRESS/HSS. Prompt recognition of a severe drug reaction and withdrawal of the culprit drug is often the most important therapeutic action. Alternatively, a delay in starting a specific treatment for a disease misdiagnosed as a drug eruption could be deleterious.

Stevens-Johnson syndrome associated with ciprofloxacin: a review of adverse cutaneous events reported in Sweden as associated with this drug

Stevens-Johnson syndrome is a severe mucocutaneous reaction, which can be elicited by various drugs. We present 2 cases with this syndrome associated with ciprofloxacin treatment and review the adverse cutaneous events reported as possibly related to ciprofloxacin treatment in Sweden between 1988 and 2000. Eight cases, excluding ours, of Stevens-Johnson syndrome, toxic epidermal necrolysis, and erythema multiforme were reported. This implies an annual incidence of these adverse cutaneous events of 0.045 per 100,000 treated patients (assuming an average treatment length of 10 days). One patient died, but ciprofloxacin was not considered to be the major cause of death. Together with previous data from the literature, our report supports the view that ciprofloxacin can cause severe adverse cutaneous events.

Photo-induced Stevens-Johnson syndrome due to sulfasalazine therapy

OBJECTIVE

To report a case of photo-induced Stevens-Johnson Syndrome (SJS) due to sulfasalazine therapy.

CASE SUMMARY

Photo-induced SJS associated with sulfasalazine therapy occurred in a 34-year-old white man diagnosed as having seronegative symmetrical polyarthritis with no predisposing factors. According to his medical record, the patient had received methotrexate, levofolinate calcium, deflazacort, and diclofenac sodium as needed. Two months prior to admission, methotrexate and diclofenac sodium were suspended and treatment with sulfasalazine was started. The patient presented to our emergency department because of severe erythema confined to sun-exposed areas; annular lesions on the extremities and the mucosa were affected. Nikolsky's sign was present. A skin biopsy was compatible with SJS, and the clinical diagnosis was SJS induced by sulfasalazine. Administration of sulfasalazine was suspended, which resulted in an improvement in the skin lesions and general state of health. The patient was discharged without further symptoms.

DISCUSSION

The observed reaction to sulfasalazine was considered phototoxic, as lesions appeared like a burn rash reaction in sun-exposed areas when sulfasalazine treatment was started and the reaction progressed to SJS. It seems that there was a correlation between the time course of the reaction and the administration of sulfasalazine. An objective causality assessment revealed that the adverse effect was possible.

CONCLUSIONS

To our knowledge, this is the first report of photo-induced SJS due to sulfasalazine therapy. Clinicians should be aware of this infrequent but severe reaction. If clinical evaluation leads to the suspicion of SJS, sulfasalazine should be discontinued immediately.

Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the cochrane collaboration

STUDY DESIGN

A systematic review of randomized and/or double-blinded controlled trials.

SUMMARY OF BACKGROUND DATA

The use of muscle relaxants in the management of nonspecific low back pain is controversial. It is not clear if they are effective, and concerns have been raised about the potential adverse effects involved.

OBJECTIVES

The aim of this review was to determine if muscle relaxants are effective in the treatment of nonspecific low back pain.

METHODS

A computer-assisted search of the Cochrane Library (Issue 2, 2002), MEDLINE (1966 up to October 2001), and EMBASE (1988 up to October 2001) was carried out. These databases were searched using the algorithm recommended by the Cochrane Back Review Group. References cited in the identified articles and other relevant literature were screened. Randomized and/or double-blinded controlled trials, involving patients diagnosed with nonspecific low back pain, treated with muscle relaxants as monotherapy or in combination with other therapeutic methods, were included for review. Two reviewers independently carried out the methodologic quality assessment and data extraction of the trials. The analysis comprised not only a quantitative analysis (statistical pooling) but also a qualitative analysis ("best evidence synthesis"). This involved the appraisal of the strength of evidence for various conclusions using a rating system based on the quality and outcomes of the studies included. Evidence was classified as "strong," "moderate," "limited," "conflicting," or "no" evidence.

RESULTS

Thirty trials met the inclusion criteria. Twenty-three trials (77%) were of high quality; 24 trials (80%) were on acute low back pain. Four trials studied benzodiazepines, 11 nonbenzodiazepines, and 2 antispasticity muscle relaxants in comparison with placebo. Results showed that there is strong evidence that any of these muscle relaxants are more effective than placebo for patients with acute low back pain on short-term pain relief. The pooled relative risk for nonbenzodiazepines versus placebo after 2 to 4 days was 0.80 (95% confidence interval: 0.71 to 0.89) for pain relief and 0.49 (95% confidence interval: 0.25 to 0.95) for global efficacy. Adverse events, however, with a relative risk of 1.50 (95% confidence interval: 1.14 to 1.98) were significantly more prevalent in patients receiving muscle relaxants and especially the central nervous system adverse effects (relative risk 2.04; 95% confidence interval: 1.23 to 3.37). The various muscle relaxants were found to be similar in performance.

CONCLUSIONS

Muscle relaxants are effective in the management of nonspecific low back pain, but the adverse effects require that they be used with caution. Trials are needed that evaluate if muscle relaxants are more effective than analgesics or nonsteroidal anti-inflammatory drugs.

Stevens-Johnson syndrome in a boy with nephrotic syndrome during prednisolone therapy

Stevens-Johnson syndrome (SJS) is a mucocutaneous disease that can be lethal. It can occur in association with altered immunological conditions and the administration of various drugs, including corticosteroids. We report a case of SJS in a 14-year-old male with nephrotic syndrome, who was treated with oral prednisolone for 6 weeks. He presented symptoms of fever, skin lesions consisting of multiple vesiculopapular rashes, pruritic maculae and bullae, and mucosal involvement of the eyes, lips, oral cavity, and anorectal junction. His condition improved without complications following the discontinuation of oral prednisolone and replacement with intravenous methylprednisolone. Following the improvement of the symptoms of SJS, he received alternate-day oral prednisolone without any cutaneous eruption.

The inventory of antibiotics in Russian home medicine cabinets

The objective of this study was to inventory the stock of antimicrobials in the home medicine cabinets (HMCs) of the general population in Russia and to find out for which indications people report that they would use antibiotics without a physician's recommendation. The research was performed in 9 Russian cities by physicians who visited households. An inventory of antibiotics in HMCs was made, and respondents were asked about instances in which they would choose automedication with antibiotics. We found that 83.6% of families had antibiotics for systemic use in HMCs. The most common antibiotics in HMCs were trimethoprim-sulfamethoxazole (46.3% of HMCs), ampicillin (45.1%), chloramphenicol (32.7%), erythromycin (25.5%), and tetracycline (21.8%). The major indications for automedication with antibiotics were acute viral respiratory tract infections (12.3% of total indications), cough (11.8%), intestinal disorders (11.3%), fever (9%), and sore throat (6.8%). According to this study, antibiotics are widely stocked among the general population in Russia, and people use antibiotics in an uncontrolled and imprudent manner.

Possible cefotaxime-induced Stevens-Johnson syndrome

OBJECTIVE

To report a case of possible cefotaxime-induced Stevens-Johnson syndrome (SJS).

CASE SUMMARY

A 72-year-old woman with an upper urinary tract infection developed erosions and blisters on the skin and the mucous membranes, as well as fever and prostration, soon after the administration of cefotaxime. This presentation is consistent with the features of SJS. Resolution of the clinical manifestations was observed after discontinuation of the drug; all other drugs, infections, or immunologic disorders that could have caused this syndrome were carefully excluded. An objective causality assessment revealed that SJS was possibly associated with the use of cefotaxime.

DISCUSSION

Although cephalosporins have been associated with an increased risk for SJS and cefotaxime has been suspected of being associated with SJS in a previous case-control study, this is the first full report for cefotaxime-related SJS in the literature. An immunologically mediated reaction may be the underlying mechanism.

CONCLUSIONS

Although cefotaxime administration seems to be the underlying cause of the SJS observed in our patient, establishment of a definite causal relationship requires additional cases and supportive data.

Establishing the dose of the oral NK1 antagonist aprepitant for the prevention of chemotherapy-induced nausea and vomiting

BACKGROUND

The neurokinin-1 antagonist aprepitant (EMEND; Merck Research Laboratories, West Point, PA) has been shown to reduce chemotherapy-induced nausea and vomiting when it is given with a 5-hydroxytryptamine-3 receptor antagonist and dexamethasone. The current study sought to define the most appropriate dose regimen of oral aprepitant.

METHODS

This multicenter, randomized, double-blind, placebo-controlled study was conducted in patients with cancer who were receiving initial cisplatin (> or = 70 mg/m(2)) and standard antiemetic therapy (intravenous ondansetron plus oral dexamethasone). Patients were randomized to receive standard therapy plus either aprepitant 375 mg on Day 1 and 250 mg on Days 2-5, aprepitant 125 mg on Day 1 and 80 mg on Days 2-5, or placebo. Due to an apparent interaction with dexamethasone suggested by pharmacokinetic data obtained while the study was ongoing, the aprepitant 375/250 mg dose was discontinued and replaced with aprepitant 40 mg on Day 1 and 25 mg on Days 2-5, and a new randomization schedule was generated. Patients recorded nausea and emesis in a diary. The primary endpoint was complete response (no emesis and no rescue therapy), which was analyzed using an intent-to-treat approach with data obtained after the dose adjustment. Treatment comparisons were made using logistic regression models. Tolerability was assessed by reported adverse events and physical and laboratory assessments, and included all available data.

RESULTS

The percentages of patients who achieved a complete response in the overall study period were 71.0% for the aprepitant 125/80-mg group (n = 131 patients), 58.8% for the aprepitant 40/25-mg group (n = 119 patients), and 43.7% for the standard therapy group (n = 126 patients; P < 0.05 for either aprepitant regimen vs. standard therapy). Rates for Day 1 were 83.2% for the aprepitant 125/80-mg group, 75.6% for aprepitant 40/25-mg group, and 71.4% for the standard therapy group (P < 0.05 for aprepitant 125/80 mg vs. standard therapy), and rates on Days 2-5 were 72.7% for the aprepitant 125/80-mg group, 63.9% for the aprepitant 40/25-mg group, and 45.2% for the standard therapy group (P < 0.01 for either aprepitant group vs. standard therapy). The efficacy of the aprepitant 375/250-mg regimen was similar to that of the aprepitant 125/80-mg regimen. The overall incidence of adverse events was generally similar across treatment groups: 85% in the aprepitant 375/250-mg group (n = 34 patients), 76% in the aprepitant 125/80-mg group (n = 214 patients), 71% in the aprepitant 40/25-mg group (n = 120 patients), and 72% in the standard therapy group (n = 212 patients), with the exception of a higher incidence of infection in the aprepitant 125/80-mg group (13%) compared with the standard therapy group (4%).

CONCLUSIONS

When it was added to a standard regimen of intravenous ondansetron and oral dexamethasone in the current study, aprepitant reduced chemotherapy-induced nausea and vomiting and was generally well tolerated, although increases in infection were noted that were assumed to be due to elevated dexamethasone levels as a result of the pharmacokinetic interaction. The aprepitant 125/80-mg regimen had the most favorable benefit:risk profile.

Management of toxic epidermal necrolysis in a 15-year-old girl

Toxic epidermal necrolysis, a life-threatening reaction to certain types of drugs, is characterised by epidermal sloughing of more than 30% of the total body surface area. Patient survival depends on prompt referral to a specialist burns unit.

Outbreak of Stevens-Johnson syndrome/toxic epidermal necrolysis associated with mebendazole and metronidazole use among Filipino laborers in Taiwan

OBJECTIVES

This study sought to identify the risk factors associated with an outbreak of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) among Filipino laborers in Taiwan.

METHODS

Forty-six SJS/TEN patients were matched to 92 controls according to month of arrival in Taiwan, sex, and age.

RESULTS

The odds ratio for development of SJS/TEN was 9.5 (95% confidence interval [CI] = 3.9, 23.9) among workers who had used both metronidazole and mebendazole sometime in the preceding 6 weeks. In addition, a gradient increase in the occurrence of SJS/TEN was found with an increasing level of exposure to metronidazole.

CONCLUSIONS

This outbreak highlights the risk of SJS/TEN resulting from the use of both metronidazole and mebendazole and the need for control measures.

Muscle relaxants for non-specific low back pain

BACKGROUND

The use of muscle relaxants in the management of non-specific low back pain is controversial. It is not clear if they are effective, and concerns have been raised about the potential adverse effects involved.

OBJECTIVES

The aim of this review was to determine if muscle relaxants are effective in the treatment of non-specific low back pain.

SEARCH STRATEGY

A computer-assisted search of the Cochrane Library (Issue 2, 2002), MEDLINE (1966 up to October 2001) and EMBASE (1988 up to October 2001) was carried out. These databases were searched using the algorithm recommended by the Cochrane Back Review Group. References cited in the identified articles and other relevant literature were screened.

SELECTION CRITERIA

Randomised and/or double-blinded controlled trials, involving patients diagnosed with non-specific low back pain, treated with muscle relaxants as monotherapy or in combination with other therapeutic modalities, were included for review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently carried out the methodological quality assessment and data extraction of the trials. The analysis comprised not only a quantitative analysis (statistical pooling) but also a qualitative analysis ("best evidence synthesis"). This involved the appraisal of the strength of evidence for various conclusions using a rating system based on the quality and outcomes of the studies included. Evidence was classified as "strong", "moderate", "limited", "conflicting" or "no" evidence.

MAIN RESULTS

Thirty trials met the inclusion criteria. Twenty-three trials (77%) were of high quality, 24 trials (80%) were on acute low back pain. Four trials studied benzodiazepines, 11 non-benzodiazepines and two antispasticity muscle relaxants in comparison with placebo. Results showed that there is strong evidence that any of these muscle relaxants are more effective than placebo for patients with acute LBP on short-term pain relief. The pooled RR for non-benzodiazepines versus placebo after two to four days was 0.80 [95% CI; 0.71 to 0.89] for pain relief and 0.49 [95% CI; 0.25 to 0.95] for global efficacy. Adverse events, however, with a relative risk of 1.50 [95% CI; 1.14 to 1.98] were significantly more prevalent in patients receiving muscle relaxants and especially the central nervous system adverse effects (RR 2.04; 95% CI; 1.23 to 3.37). The various muscle relaxants were found to be similar in performance.

REVIEWER'S CONCLUSIONS

Muscle relaxants are effective in the management of non-specific low back pain, but the adverse effects require that they be used with caution. Trials are needed that evaluate if muscle relaxants are more effective than analgesics or non-steroidal anti-inflammatory drugs.

Stevens-Johnson syndrome: a diagnostic challenge in the absence of skin lesions

We report a 14-year-old boy with Stevens-Johnson syndrome who presented with mucous membrane lesions but without skin lesions and discuss the differential diagnosis of oral mucous membrane lesions in childhood. Stevens-Johnson syndrome in children is most frequently caused by a Mycoplasma pneumoniae infection. The full clinical picture of Stevens-Johnson syndrome can be present before seroconversion of Mycoplasma antibodies is observed. One should keep in mind that one negative titer of Mycoplasma antibodies does not rule out M. pneumoniae infection.