1
|
van Nispen C, Long B, Koyfman A. High risk and low prevalence diseases: Stevens Johnson syndrome and toxic epidermal necrolysis. Am J Emerg Med 2024; 81:16-22. [PMID: 38631147 DOI: 10.1016/j.ajem.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/04/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are serious conditions that carry a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of SJS/TEN, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION SJS/TEN is a rare, delayed hypersensitivity reaction resulting in de-epithelialization of the skin and mucous membranes. The majority of cases are associated with medication or infection. Clinicians should consider SJS/TEN in any patient presenting with a blistering mucocutaneous eruption. Evaluation of the skin, mucosal, pulmonary, renal, genital, and ocular systems are essential in the diagnosis of SJS/TEN, as well as in the identification of complications (e.g., sepsis). Laboratory and radiological testing cannot confirm the diagnosis in the ED setting, but they may assist in the identification of complications. ED management includes stabilization of airway and breathing, fluid resuscitation, and treatment of any superimposed infections with broad-spectrum antibiotic therapy. All patients with suspected SJS/TEN should be transferred and admitted to a center with burn surgery, critical care, dermatology, and broad specialist availability. CONCLUSIONS An understanding of SJS/TEN can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
Collapse
Affiliation(s)
- Christiaan van Nispen
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| |
Collapse
|
2
|
Glasson N, De Sandre C, Pantet O, Reinhard A, Lambercy K, Sandu K, Gorostidi F. Oropharyngolaryngeal manifestations in severe toxic epidermal necrolysis: a single-center's retrospective case series. Int J Dermatol 2023; 62:1384-1390. [PMID: 37767642 DOI: 10.1111/ijd.16858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/26/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Toxic epidermal necrolysis is a rare and life-threatening mucocutaneous disease. Although mucosal ear, nose, and throat (ENT) involvement is common, little is known about the characteristics, treatment modalities, and outcomes of these lesions. The aim of this study was to evaluate ENT mucosal lesions in severe toxic epidermal necrolysis patients and analyze their characteristics, treatment modalities, and outcomes, as well as proposing a management algorithm to prevent long-term debilitating sequalae of these lesions. METHODS This is a retrospective review of toxic epidermal necrolysis cases treated at the tertiary burns unit of the Lausanne University Hospital CHUV, Switzerland, between 2006 and 2019. RESULTS Out of 19 patients with severe toxic epidermal necrolysis, 17 (89%) underwent a complete ENT examination at admission and 14 (82%) had ENT mucosal involvement. Five (26.3%) patients died during the stay in the intensive care unit. Of the 16 patients who received maximal care, 13 (81%) required orotracheal intubation for a median time of 16 (IQR: 14) days. Out of the 14 patients who survived, four (29%) had long-term ENT complications consisting of synechiaes necessitating subsequent endoscopic procedures. Those four patients all required mechanical ventilation with an orotracheal tube and suffered from hypopharyngeal synechiaes as well as oral and endonasal synechiaes in individual cases. CONCLUSION This study suggests a high prevalence of ENT synechiaes in patients with severe toxic epidermal necrolysis and requiring orotracheal intubation. Periodic ENT examination could prevent mature synechiae formation in these patients. We propose an algorithm to prevent long-term sequalae in ENT mucosal involvement.
Collapse
Affiliation(s)
- Nicolas Glasson
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| | - Cécile De Sandre
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| | - Olivier Pantet
- Department of Adult Intensive Care, CHUV, Lausanne, Switzerland
| | - Antoine Reinhard
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| | - Karma Lambercy
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| | - Kishore Sandu
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| | - François Gorostidi
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| |
Collapse
|
3
|
Matsumoto K, Ueta M, Inatomi T, Fukuoka H, Mieno H, Tamagawa-Mineoka R, Katoh N, Kinoshita S, Sotozono C. Topical Betamethasone Treatment of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis with Ocular Involvement in the Acute Phase. Am J Ophthalmol 2023; 253:142-151. [PMID: 37182731 DOI: 10.1016/j.ajo.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/24/2023] [Accepted: 05/06/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE To clarify the importance of administering topical steroids for the treatment of Stevens-Johnson syndrome (SJS) / toxic epidermal necrolysis (TEN) with ocular involvement in the acute phase. DESIGN Retrospective case series. METHODS Using the medical records of acute SJS/TEN patients treated at the Kyoto Prefectural University of Medicine Hospital, Kyoto, Japan, between July 2006 and July 2017, the ocular findings, topical steroid dosage, systemic steroid dosage, and ocular sequelae were retrospectively examined. The level of cytokines in tear fluid and serum samples was also analyzed. RESULTS This study involved 13 cases. In 10 cases in whom the clinical courses were recorded before the start of steroid therapy, the mean acute ocular severity score (AOSS: 3 = very severe; 2 = severe; 1 = mild; 0 = none) was 2.8 ± 0.4 points in the severest phase. The mean systemic steroid dose after steroid pulse therapy was 694 ± 386 mg and the mean topical steroid (0.1% betamethasone eye drop and ointment) dose was 13.4 ± 3.3 times daily in the severest phase. Analysis of cytokine levels of 4 cases showed that a cytokine storm occurred in the tear fluid after the steroid pulse therapy. At final follow-up, 16 eyes of 8 patients had a logMAR visual acuity of ≤0, and no serious ocular sequelae were observed. CONCLUSIONS In patients with SJS/TEN, ocular surface inflammation remains strong even after systemic inflammation has improved post steroid pulse therapy, thus suggesting that both systemic and topical steroid therapy should be administered appropriately.
Collapse
Affiliation(s)
- Kaori Matsumoto
- From the Department of Ophthalmology, Kyoto Prefectural University of Medicine (K.M., M.U., H.F., H.M., C.S.), Kyoto
| | - Mayumi Ueta
- From the Department of Ophthalmology, Kyoto Prefectural University of Medicine (K.M., M.U., H.F., H.M., C.S.), Kyoto
| | - Tsutomu Inatomi
- Department of Ophthalmology, National Center for Geriatrics and Gerontology (T.I.), Aichi
| | - Hideki Fukuoka
- From the Department of Ophthalmology, Kyoto Prefectural University of Medicine (K.M., M.U., H.F., H.M., C.S.), Kyoto
| | - Hiroki Mieno
- From the Department of Ophthalmology, Kyoto Prefectural University of Medicine (K.M., M.U., H.F., H.M., C.S.), Kyoto
| | - Risa Tamagawa-Mineoka
- Department of Dermatology, Kyoto Prefectural University of Medicine (R.T-M., N.K.), Kyoto, Japan
| | - Norito Katoh
- Department of Dermatology, Kyoto Prefectural University of Medicine (R.T-M., N.K.), Kyoto, Japan
| | - Shigeru Kinoshita
- Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine (S.K.), Kyoto, Japan
| | - Chie Sotozono
- From the Department of Ophthalmology, Kyoto Prefectural University of Medicine (K.M., M.U., H.F., H.M., C.S.), Kyoto.
| |
Collapse
|
4
|
Lian BSY, Lee HY. Managing the ADR of Stevens-Johnson syndrome/toxic epidermal necrolysis. Expert Opin Drug Saf 2022; 21:1039-1046. [PMID: 35878014 DOI: 10.1080/14740338.2022.2106367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening adverse drug reactions that are collectively known as epidermal necrolysis. The abrupt detachment of the skin and mucositis results in systemic complications such as fluid and electrolyte disturbances, hypothermia, sepsis, organ failure, and death. Management is multidisciplinary and complex. AREAS COVERED This present article reviews the principles and best practices in the care of patients with epidermal necrolysis. These include having prompt admissions to optimal care facilities, coordinated specialized care during the acute phase, as well as long-term follow-up to manage chronic sequelae. EXPERT OPINION Patients with epidermal necrolysis should be managed in specialized/reference centers that are experienced with the management of the disease. Multi-disciplinary supportive care remains the cornerstone. Current evidence precludes definitive recommendation on any immunomodulatory agent as treatment. Long-term follow-up is required in order to diagnose and treat any chronic sequelae.
Collapse
Affiliation(s)
| | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital Singapore, Singapore.,Allergy Centre, Singapore General Hospital Singapore, Singapore.,Duke-NUS Medical School, Medicine Academic Clinical Programme, Singapore
| |
Collapse
|
5
|
Vittetoe KL, Landeen KC, Gelbard A. A Rare Laryngeal Presentation of Stevens-Johnson Syndrome. Laryngoscope 2021; 131:2519-2522. [PMID: 33942909 DOI: 10.1002/lary.29598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/23/2021] [Indexed: 11/06/2022]
Abstract
Stevens-Johnson syndrome (SJS) is a rare but severe mucocutaneous epidermolysis commonly triggered by medications. SJS is characterized by mucocutaneous lesions of the trunk, face, and limbs, as well as the oral cavity, gastrointestinal tract, and respiratory tract. Although uncommon, laryngeal involvement in SJS can lead to severe respiratory, phonatory and deglutitive complications. Providers caring for patients with SJS should maintain a high index of suspicion for laryngeal involvement and low threshold to solicit Otolaryngology consultation. Laryngeal complications can be more expediently managed when anticipated early in the course of disease. Laryngoscope, 2021.
Collapse
Affiliation(s)
- Kelly L Vittetoe
- Department of Otolaryngology - Head & Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Kelly C Landeen
- Department of Otolaryngology - Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Alexander Gelbard
- Department of Otolaryngology - Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| |
Collapse
|
6
|
Brüggen MC, Le ST, Walsh S, Toussi A, de Prost N, Ranki A, Didona B, Colin A, Horváth B, Brezinova E, Milpied B, Moss C, Bodemer C, Meyersburg D, Salavastru C, Tiplica GS, Howard E, Bequignon E, Bouwes Bavinck JN, Newman J, Gueudry J, Nägeli M, Zaghbib K, Pallesen K, Bygum A, Joly P, Wolkenstein P, Chua SL, Le Floch R, Shear NH, Chu CY, Hama N, Abe R, Chung WH, Shiohara T, Ardern-Jones M, Romanelli P, Phillips EJ, Stern RS, Cotliar J, Micheletti RG, Brassard A, Schulz JT, Dodiuk-Gad RP, Dominguez AR, Paller AS, Seminario-Vidal L, Mostaghimi A, Noe MH, Worswick S, Tartar D, Sheridan R, Kaffenberger BH, Shinkai K, Maverakis E, French LE, Ingen-Housz-Oro S. Supportive care in the acute phase of Stevens-Johnson syndrome and toxic epidermal necrolysis: an international, multidisciplinary Delphi-based consensus. Br J Dermatol 2021; 185:616-626. [PMID: 33657677 DOI: 10.1111/bjd.19893] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Supportive care is the cornerstone of management of adult and paediatric Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, consensus on the modalities of supportive care is lacking. OBJECTIVES Our aim in this international multicentric Delphi exercise was to establish a multidisciplinary expert consensus to standardize recommendations regarding supportive care in the acute phase of SJS/TEN. METHODS Participants were sent a survey via the online tool SurveyMonkey, consisting of 103 statements organized into 11 topics: multidisciplinary team composition, suspect drug management, infection prevention, fluid resuscitation and prevention of hypothermia, nutritional support, pain and psychological distress management, management of acute respiratory failure, local skincare, ophthalmological management, management of other mucosa, and additional measures. Participants evaluated the level of appropriateness of each statement on a scale of 1 (extremely inappropriate) to 9 (extremely appropriate). The results were analysed according to the RAND/UCLA Appropriateness Method. RESULTS Forty-five participants from 13 countries (on three continents) participated. After the first round, a consensus was obtained for 82.5% of the 103 initially proposed statements. After the second round, a final consensus was obtained for 102 statements. CONCLUSIONS We have reached an international Delphi-based consensus on best supportive care practice for SJS/TEN. Our expert consensus should help guide physicians in treating patients with SJS/TEN and thereby improve short-term prognosis and the risk of sequelae.
Collapse
Affiliation(s)
- M-C Brüggen
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Christine Kühne Center for Allergy Research and Education, Davos, Switzerland.,ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France
| | - S T Le
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - S Walsh
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Department of Dermatology, King's College Hospital, London, UK
| | - A Toussi
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - N de Prost
- Intensive Care Unit, AP-HP, Henri Mondor Hospital, Créteil, France.,Toxic Bullous Dermatoses TOXIBUL Reference Centre, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France
| | - A Ranki
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Department of Skin and Allergic Diseases, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - B Didona
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,First Dermatology Division, Institute Dermopatico dell'Immacolata (I.D.I.) - IRCCS, Via Monti di Creta 104, Rome, 00167, Italy
| | - A Colin
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Toxic Bullous Dermatoses TOXIBUL Reference Centre, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France.,Dermatology Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - B Horváth
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Department of Dermatology, Center for Blistering Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - E Brezinova
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Department of Dermatovenereology, St Ann's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - B Milpied
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Toxic Bullous Dermatoses TOXIBUL Reference Centre, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France.,Department of Dermatology, CHU Bordeaux, Bordeaux, France
| | - C Moss
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Birmingham Children's Hospital and University of Birmingham, Birmingham, UK
| | - C Bodemer
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Toxic Bullous Dermatoses TOXIBUL Reference Centre, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France.,Department of Dermatology, AP-HP, Necker Hospital, Paris, France
| | - D Meyersburg
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Department of Dermatology and Allergology, University Hospital Salzburg of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - C Salavastru
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Department of Paediatric Dermatology, Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - G-S Tiplica
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Department of Dermatology II, Colentina Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - E Howard
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Birmingham Children's Hospital and University of Birmingham, Birmingham, UK
| | - E Bequignon
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Department of Otorhinolaryngology and Head and Neck Surgery, AP-HP, Henri Mondor Hospital, Créteil, France
| | - J N Bouwes Bavinck
- Department of Dermatology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Newman
- Macmillan Skin Cancer CNS, Normanby Building, Denmark Hill, London, UK
| | - J Gueudry
- Toxic Bullous Dermatoses TOXIBUL Reference Centre, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France.,Ophthalmology Department, Hospital Charles Nicolle, EA7510, UFR Santé, Rouen University, Rouen, France
| | - M Nägeli
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - K Zaghbib
- Toxic Bullous Dermatoses TOXIBUL Reference Centre, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France.,Department of Psychiatry, AP-HP, Henri Mondor-Albert Chenevier Hospitals, Cr, France
| | - K Pallesen
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Department of Dermatology, Aarhus University Hospital, Palle Juul-Jensens, Aarhus, Denmark
| | - A Bygum
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Clinical Institute, University of Southern Denmark, Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - P Joly
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Toxic Bullous Dermatoses TOXIBUL Reference Centre, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France.,Department of Dermatology, CHU Charles, Nicolle, Rouen, France
| | - P Wolkenstein
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Toxic Bullous Dermatoses TOXIBUL Reference Centre, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France.,Dermatology Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - S-L Chua
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Le Floch
- Toxic Bullous Dermatoses TOXIBUL Reference Centre, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France.,Réanimation Chirurgicale et des Brûlés, PTMC, CHU Nantes, Nantes, France
| | - N H Shear
- Division of Clinical Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - C-Y Chu
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - N Hama
- Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - R Abe
- Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - W-H Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - T Shiohara
- Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan
| | - M Ardern-Jones
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - P Romanelli
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - E J Phillips
- Department of Medicine & Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - R S Stern
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - R G Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - A Brassard
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - J T Schulz
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - R P Dodiuk-Gad
- Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A R Dominguez
- Department of Dermatology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - A S Paller
- Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - L Seminario-Vidal
- Department of Dermatology, University of South Florida, Cutaneous Oncology Program, Moffitt Cancer Center, Tampa, FL, USA
| | - A Mostaghimi
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - M H Noe
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - S Worswick
- Keck-USC School of Medicine, Los Angeles, CA, USA
| | - D Tartar
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - R Sheridan
- Burn Surgery Service, Shriners Burns Hospital, Sumner Redstone Burn Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - B H Kaffenberger
- Division of Dermatology, Department of Internal Medicine, Ohio State University, Columbus, OH, USA
| | - K Shinkai
- Department of Dermatology, University of California, San Francisco, CA, USA
| | - E Maverakis
- Department of Dermatology, University of California, Davis, Sacramento, CA, USA
| | - L E French
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Department of Dermatology and Allergy, University Hospital of Munich, LMU, Munich, Germany
| | - S Ingen-Housz-Oro
- ToxiTEN Group, European Reference Network for Rare Skin Diseases (ERN-skin), Paris, France.,Toxic Bullous Dermatoses TOXIBUL Reference Centre, Filière FIMARAD, AP-HP, Henri Mondor Hospital, Créteil, France.,Dermatology Department, AP-HP, Henri Mondor Hospital, Créteil, France.,Universit, EpiDermE, Créteil, France
| |
Collapse
|
7
|
Neill BC, Seger EW, Ferguson JE, Hooton T, Rickstrew JJ, Rajpara A. SJS/TENN: A Mnemonic for Early Clinical Diagnosis of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Kans J Med 2021; 14:114-115. [PMID: 33903813 PMCID: PMC8060068 DOI: 10.17161/kjm.vol1414842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/28/2021] [Indexed: 11/17/2022] Open
Abstract
Steven Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are dermatologic emergencies that are more likely to be encountered by primary care providers rather than dermatologists. Thus, it is essential for all clinicians to be familiar with common signs associated with SJS/TEN, so as not to miss or delay the diagnosis. We designed the simple mnemonic “SJS/TENN” which describes the most frequently seen clinical characteristics in these conditions to aid in the initial diagnosis.
Collapse
Affiliation(s)
- Brett C Neill
- Department of Internal Medicine, Division of Dermatology, University of Kansas Medical Center, Kansas City, KS
| | - Edward W Seger
- Department of Internal Medicine, Division of Dermatology, University of Kansas Medical Center, Kansas City, KS
| | - Jessica E Ferguson
- Department of Internal Medicine, Division of Dermatology, University of Kansas Medical Center, Kansas City, KS
| | - Tyler Hooton
- Department of Internal Medicine, Division of Dermatology, University of Kansas Medical Center, Kansas City, KS
| | - Jace J Rickstrew
- Department of Internal Medicine, Division of Dermatology, University of Kansas Medical Center, Kansas City, KS
| | - Anand Rajpara
- Department of Internal Medicine, Division of Dermatology, University of Kansas Medical Center, Kansas City, KS
| |
Collapse
|
8
|
Brandt C, McGuire L, Uetrecht J. Severe cutaneous adverse reaction associated with antiseizure medications: Diagnosis, management, and prevention. Epilepsy Behav 2021; 117:107844. [PMID: 33639435 DOI: 10.1016/j.yebeh.2021.107844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 02/06/2023]
Abstract
Severe cutaneous adverse reactions (SCARs) are potentially life-threatening, with considerable morbidity and mortality. They are nonimmediate hypersensitivity reactions that occur in specifically predisposed patients with delayed T-cell-mediated hypersensitivity reaction. Antiseizure medications (ASMs) are among the drugs that can induce SCAR. Increased awareness of SCAR among clinicians treating patients with ASMs is critically important for early recognition of symptoms, prompt identification and removal of the causal drug, and early intervention to reduce SCAR-related acute and long-term morbidity and mortality. The diagnosis, management, and prevention of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) are reviewed, along with the current understanding of the pathomechanisms and role of genetics in SCAR development. Supportive care and immunomodulating treatments for SCAR are discussed.
Collapse
Affiliation(s)
- Christian Brandt
- Department of General Epileptology, Bethel Epilepsy Centre, Mara Hospital, Bielefeld, Germany.
| | - Lynanne McGuire
- MedVal Scientific Information Services, LLC, Princeton, NJ, USA
| | - Jack Uetrecht
- Department of Pharmacology & Toxicology, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| |
Collapse
|
9
|
Xue DD, Zhou L, Yang Y, Ma SY. Autologous scalp skin grafting to treat toxic epidermal necrolysis in a patient with a large skin injury: A case report. World J Clin Cases 2021; 9:1646-1653. [PMID: 33728308 PMCID: PMC7942035 DOI: 10.12998/wjcc.v9.i7.1646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/26/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Toxic epidermal necrolysis (TEN) is often associated with skin wounds affecting large areas. Healing of this type of wound is difficult because of pressure, infection and other factors. It can increase the length of hospital stay and result in wound sepsis and even death.
CASE SUMMARY A 49-year-old woman developed a skin lesion covering 80% of the total body surface area after using a kind of Chinese medicinal ointment on a burn wound on her back; she developed life-threatening wound sepsis and septic shock. Methicillin-resistant Staphylococcus aureus, carbapenem-resistant Acinetobacter baumannii, carbapenem-resistant Pseudomonas aeruginosa and other bacteria were cultured from wound tissue, deep venous catheter and blood samples. Imipenem cilastatin sodium, tigecycline and teicoplanin were used for anti-infection therapy. Finally, the patient was transferred to the burn department because of severe wound sepsis. In the burn intensive care unit, pain-free dressing changes and autologous scalp skin grafting were performed to heal the wound in addition to reasonable and effective antibacterial treatment according to microbial susceptibility test results. After three operations within 2 wk, the wound healed and sepsis resolved.
CONCLUSION TEN patients with large areas of skin injury may develop wound infection and life-threatening wound sepsis. Autologous scalp skin grafting may be beneficial for rapid wound healing and reducing the risk of sepsis in TEN patients, and it leaves no scar at the donor site.
Collapse
Affiliation(s)
- Dong-Dong Xue
- Southwest Hospital, Institute of Burn Research, Chongqing 400038, China
| | - Ling Zhou
- Southwest Hospital, Institute of Burn Research, Chongqing 400038, China
| | - Yong Yang
- Southwest Hospital, Institute of Burn Research, Chongqing 400038, China
| | - Si-Yuan Ma
- Southwest Hospital, Institute of Burn Research, Chongqing 400038, China
| |
Collapse
|
10
|
Shanbhag SS, Chodosh J, Fathy C, Goverman J, Mitchell C, Saeed HN. Multidisciplinary care in Stevens-Johnson syndrome. Ther Adv Chronic Dis 2020; 11:2040622319894469. [PMID: 32523661 PMCID: PMC7236394 DOI: 10.1177/2040622319894469] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/12/2019] [Indexed: 12/17/2022] Open
Abstract
Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are potentially fatal mucocutaneous diseases that can involve many organ systems. Manifestations of SJS/TEN outside of the skin, eyes, and oral mucosa are not well defined or well recognized, and, therefore, are often not addressed clinically. As supportive care improves and mortality from SJS/TEN decreases, chronic complications in affected organ systems are becoming more prevalent. Recognition of the manifestations of SJS/TEN in the acute phase is critical to optimal care. In this review, we review the organ systems that may be involved in SJS/TEN, provide an overview of their management, and propose a list of items that should be communicated to the patient and family upon discharge. The organ systems discussed include the pulmonary, gastrointestinal/hepatic, oral, otorhinolaryngologic, gynecologic, genitourinary, and renal systems. In addition, the significant psychosocial, nutritional, and pain consequences and management of SJS/TEN are discussed.
Collapse
Affiliation(s)
- Swapna S Shanbhag
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Cherie Fathy
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeremy Goverman
- Department of Surgery, Massachusetts General Hospital, Sumner Redstone Burn Center, Boston, MA, USA
| | - Caroline Mitchell
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - Hajirah N Saeed
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114, USA
| |
Collapse
|
11
|
Seminario-Vidal L, Kroshinsky D, Malachowski SJ, Sun J, Markova A, Beachkofsky TM, Kaffenberger BH, Ergen EN, Mauskar M, Bridges A, Calhoun C, Cardones AR, Chen ST, Chodosh J, Cotliar J, Davis MDP, DeNiro KL, Dominguez AR, Eljure-Téllez J, Femia A, Fox LP, Guda A, Mitchell C, Mostaghimi A, Ortega-Loayza AG, Owen C, Pasieka H, Rahnama-Moghadam S, Saeed HN, Saunderson RB, Shanbhag S, Sharon VR, Strowd L, Venkatesh S, Wanat KA, Wetter DA, Worswick S, Micheletti RG. Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults. J Am Acad Dermatol 2020; 82:1553-1567. [PMID: 32151629 DOI: 10.1016/j.jaad.2020.02.066] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/04/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.
Collapse
Affiliation(s)
- Lucia Seminario-Vidal
- Department of Dermatology, University of South Florida, Morsani College of Medicine, Tampa, Florida; Cutaneous Oncology Program, H. Lee Moffitt Cancer Center, Tampa, Florida.
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen J Malachowski
- Department of Internal Medicine, Medical College of Wisconsin Affiliated Hospitals, St. Joseph's Hospital, Milwaukee, Wisconsin
| | - James Sun
- Cutaneous Oncology Program, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Alina Markova
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Elizabeth N Ergen
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melissa Mauskar
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alina Bridges
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Cody Calhoun
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Adela R Cardones
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Steven T Chen
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James Chodosh
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Cotliar
- Division of Dermatology, Harbor-University of California, Los Angeles Medical Center, Los Angeles, California
| | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | | | - Arturo R Dominguez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Juliana Eljure-Téllez
- Department of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - Alisa Femia
- Ronald O. Perelman Department of Dermatology, New York University Langone Health, New York, New York
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | - Anisha Guda
- University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas
| | - Caroline Mitchell
- Vincent Center for Reproductive Biology, Department of Obstetrics, Gynecology & Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Cindy Owen
- Division of Dermatology, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Helena Pasieka
- Department of Dermatology, MedStar Washington Hospital Center, Washington, DC
| | | | - Hajirah N Saeed
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Rebecca B Saunderson
- Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Swapna Shanbhag
- Tej Kohli Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, India
| | - Victoria R Sharon
- Department of Dermatology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Lindsay Strowd
- Department of Dermatology, Wake Forest University School of Medicine, Wake Forest, North Carolina
| | - Samantha Venkatesh
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Karolyn A Wanat
- Department of Dermatology, University of Southern California, Los Angeles, California
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Scott Worswick
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert G Micheletti
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
12
|
Chaby G, Maldini C, Haddad C, Lebrun‐Vignes B, Hemery F, Ingen‐Housz‐Oro S, Gonzalez‐Chiappe S, Wolkenstein P, Chosidow O, Mahr A, Fardet L. Incidence of and mortality from epidermal necrolysis (Stevens–Johnson syndrome/toxic epidermal necrolysis) in France during 2003–16: a four‐source capture–recapture estimate. Br J Dermatol 2019; 182:618-624. [DOI: 10.1111/bjd.18424] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2019] [Indexed: 12/14/2022]
Affiliation(s)
- G. Chaby
- EA 7379 EpiDermE Université Paris Est Créteil France
| | - C. Maldini
- Department of Internal Medicine Hôpital Saint Louis, AP‐HP Paris France
| | - C. Haddad
- EA 7379 EpiDermE Université Paris Est Créteil France
- Regional Center of Pharmacovigilance Hôpital Pitié‐Salpêtrière, AP‐HP Paris France
| | - B. Lebrun‐Vignes
- EA 7379 EpiDermE Université Paris Est Créteil France
- Regional Center of Pharmacovigilance Hôpital Pitié‐Salpêtrière, AP‐HP Paris France
| | - F. Hemery
- Department of Medical InformaticsHôpital Henri‐Mondor, AP–HP Créteil France
| | - S. Ingen‐Housz‐Oro
- EA 7379 EpiDermE Université Paris Est Créteil France
- Department of Dermatology and Reference Center for Toxic Bullous Diseases Hôpital Henri‐Mondor, AP–HP Créteil France
| | | | - P. Wolkenstein
- EA 7379 EpiDermE Université Paris Est Créteil France
- Department of Dermatology and Reference Center for Toxic Bullous Diseases Hôpital Henri‐Mondor, AP–HP Créteil France
| | - O. Chosidow
- EA 7379 EpiDermE Université Paris Est Créteil France
- Department of Dermatology and Reference Center for Toxic Bullous Diseases Hôpital Henri‐Mondor, AP–HP Créteil France
- INSERM Centre d'Investigation Clinique 1430 Créteil France
| | - A. Mahr
- Department of Internal Medicine Hôpital Saint Louis, AP‐HP Paris France
| | - L. Fardet
- EA 7379 EpiDermE Université Paris Est Créteil France
- Department of Dermatology and Reference Center for Toxic Bullous Diseases Hôpital Henri‐Mondor, AP–HP Créteil France
| |
Collapse
|
13
|
Bhullar HK, Aung AK, Graudins L, Ihle J, Gin D, Cleland H, Mei Teh B. Upper airway involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis. Burns 2019; 46:682-686. [PMID: 31591001 DOI: 10.1016/j.burns.2019.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/27/2019] [Accepted: 09/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening hypersensitivity conditions associated with epidermal detachment and mucositis. The indication for flexible nasoendoscopy (FNE) and overall predictive factors for early intubation are unclear. OBJECTIVES To describe the incidence of airway involvement and the key indicators for intubation in our SJS or TEN patient cohort. To determine the association between FNE findings and early intubation. METHODS A retrospective review of 45 patients with biopsy proven SJS or TEN admitted to an Australian tertiary burns centre from 2010 to 2017. RESULTS Thirty-five patients were diagnosed with TEN (77.8%), followed by overlap syndrome (SJS-TEN) (n = 6, 13.3%) and SJS (n = 4, 8.9%). Twenty (44.4%) patients were intubated; and all 20 had a diagnosis of TEN (100.0%) (p < 0.05). Intubated patients had a higher increase in total body surface area percentage(%) from day 1-3 [10.0% (IQR 0.0-23.8%)] and a longer length of stay [26.0 days (IQR 12.5-34.0)], compared to non-intubated patients [0.0% (IQR 0.0-4.0%)], [10.0 days (IQR 6.0-14.0)] (p < 0.05) respectively. The main indications for intubation were to facilitate operative and dressing management (47.4%) followed by airway involvement (26.3%). FNE was performed on 32 patients (71.1%), however FNE findings did not significantly influence intubation rates. CONCLUSION More than half (n = 20, 57.1%) of the 35 patients diagnosed with TEN underwent intubation, mainly to facilitate operative and dressing management. FNE was performed on most patients, however there was no clear association between FNE findings and early intubation.
Collapse
Affiliation(s)
- Harmeet K Bhullar
- Ear, Nose and Throat Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; Central Clinical School, Monash University, Victoria, Australia.
| | - Ar Kar Aung
- Department of General Medicine, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; School of Public Health and Preventative Medicine, Monash University, Victoria, Australia.
| | - Linda Graudins
- Pharmacy Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Josh Ihle
- School of Public Health and Preventative Medicine, Monash University, Victoria, Australia; Intensive Care Unit, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Douglas Gin
- Department of Dermatology, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Heather Cleland
- Central Clinical School, Monash University, Victoria, Australia; Victorian Adult Burns Services, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Bing Mei Teh
- Ear, Nose and Throat Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia; Department of Surgery, Monash University, Victoria, Australia.
| |
Collapse
|
14
|
Tran AK, Sidhu S. Stevens Johnson syndrome and toxic epidermal necrolysis – an Australian analysis of treatment outcomes and mortality. J DERMATOL TREAT 2019; 30:718-723. [DOI: 10.1080/09546634.2019.1568380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | - Shireen Sidhu
- Department of Dermatology, Royal Adelaide Hospital, Adelaide, Australia
| |
Collapse
|
15
|
Omran S, Kiakojuri K, Armaki M, Rajabnia R, Pournajaf A, Karami M. Acute middle ear Aspergillus niger infection in a patient with Stevens-Johnson syndrome: a case report. JOURNAL OF ACUTE DISEASE 2019. [DOI: 10.4103/2221-6189.263711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
16
|
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a delayed-type hypersensitivity reaction to drugs. They represent true medical emergencies and an early recognition and appropriate management is decisive for the survival. SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms. The difference between SJS, SJS/TEN overlap, and TEN is defined by the degree of skin detachment: SJS is defined as skin involvement of < 10%, TEN is defined as skin involvement of > 30%, and SJS/TEN overlap as 10-30% skin involvement. The diagnosis of different degrees of epidermal necrolysis is based on the clinical assessment in conjunction with the corresponding histopathology. The mortality rates for SJS and TEN have decreased in the last decades. Today, the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is available for SJS/TEN severity assessment. Drugs with a high risk of causing SJS/TEN are anti-infective sulfonamides, anti-epileptic drugs, non-steroidal anti-inflammatory drugs of the oxicam type, allopurinol, nevirapine, and chlormezanone. Besides conventional drugs, herbal remedies and new biologicals should be considered as causative agents. The increased risk of hypersensitivity reactions to certain drugs may be linked to specific HLA antigens. Our understanding of the pathogenesis of SJS/TEN has improved: drug-specific T cell-mediated cytotoxicity, genetic linkage with HLA- and non-HLA-genes, TCR restriction, and cytotoxicity mechanisms were clarified. However, many factors contributing to epidermal necrolysis still have to be identified, especially in virus-induced and autoimmune forms of epidermal necrolysis not related to drugs. In SJS/TEN, the most common complications are ocular, cutaneous, or renal. Nasopharyngeal, esophageal, and genital mucosal involvement with blisters, erosions as well as secondary development of strictures also play a role. However, in the acute phase, septicemia is a leading cause of morbidity and fatality. Pulmonary and hepatic involvement is frequent. The acute management of SJS/TEN requires a multidisciplinary approach. Immediate withdrawal of potentially causative drugs is mandatory. Prompt referral to an appropriate medical center for specific supportive treatment is of utmost importance. The most frequently used treatments for SJS/TEN are systemic corticosteroids, immunoglobulins, and cyclosporine A.
Collapse
|
17
|
Ingen-Housz-Oro S, Duong TA, de Prost N, Colin A, Fardet L, Lebrun-Vignes B, Barbaud A, Chosidow O, Wolkenstein P. Traitement des toxidermies graves. Ann Dermatol Venereol 2018; 145:454-464. [DOI: 10.1016/j.annder.2018.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/13/2018] [Accepted: 02/14/2018] [Indexed: 12/17/2022]
|
18
|
Ingen-Housz-Oro S, Duong TA, Bensaid B, Bellon N, de Prost N, Lu D, Lebrun-Vignes B, Gueudry J, Bequignon E, Zaghbib K, Royer G, Colin A, Do-Pham G, Bodemer C, Ortonne N, Barbaud A, Fardet L, Chosidow O, Wolkenstein P. Epidermal necrolysis French national diagnosis and care protocol (PNDS; protocole national de diagnostic et de soins). Orphanet J Rare Dis 2018; 13:56. [PMID: 29636107 PMCID: PMC5894129 DOI: 10.1186/s13023-018-0793-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 03/22/2018] [Indexed: 12/18/2022] Open
Abstract
Epidermal necrolysis (EN) encompasses Stevens-Johnson syndrome (SJS, < 10% of the skin affected), Lyell syndrome (toxic epidermal necrolysis, TEN, with ≥30% of the skin affected) and an overlap syndrome (10 to 29% of the skin affected). These rare diseases are caused, in 85% of cases, by pharmacological treatments, with symptoms occurring 4 to 28 days after treatment initiation. Mortality is 20 to 25% during the acute phase, and almost all patients display disabling sequelae (mostly ocular impairment and psychological distress). The objective of this French national diagnosis and care protocol (protocole national de diagnostic et de soins; PNDS), based on a critical literature review and on a multidisciplinary expert consensus, is to provide health professionals with an explanation of the optimal management and care of patients with EN. This PNDS, written by the French National Reference Center for Toxic Bullous Dermatoses was updated in 2017 (https://www.has-sante.fr/portail/jcms/c_1012735/fr/necrolyse-epidermique-syndromes-de-stevens-johnson-et-de-lyell). The cornerstone of the management of these patients during the acute phase is an immediate withdrawal of the responsible drug, patient management in a dermatology department, intensive care or burn units used to dealing with this disease, supportive care and close monitoring, the prevention and treatment of infections, and a multidisciplinary approach to sequelae. Based on published data, it is not currently possible to recommend any specific immunomodulatory treatment. Only the culprit drug and chemically similar molecules must be lifelong contraindicated.
Collapse
Affiliation(s)
- Saskia Ingen-Housz-Oro
- Dermatology Department, AP-HP, Henri Mondor Hospital, 51 avenue du maréchal de Lattre de Tassigny, 94000, Créteil, France. .,French National Reference Center for Toxic Bullous Dermatoses, Créteil, France. .,EA7379 EpiDermE (Epidemiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France.
| | - Tu-Anh Duong
- Dermatology Department, AP-HP, Henri Mondor Hospital, 51 avenue du maréchal de Lattre de Tassigny, 94000, Créteil, France.,French National Reference Center for Toxic Bullous Dermatoses, Créteil, France
| | - Benoit Bensaid
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Dermatology Department, Edouard Herriot Hospital, Lyon, France
| | - Nathalia Bellon
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Dermatology Department, AP-HP, Necker Hospital, Paris, France
| | - Nicolas de Prost
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Intensive Care Unit, AP-HP, Henri Mondor Hospital, Créteil, France.,Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
| | - Dévy Lu
- Dermatology Department, AP-HP, Henri Mondor Hospital, 51 avenue du maréchal de Lattre de Tassigny, 94000, Créteil, France.,French National Reference Center for Toxic Bullous Dermatoses, Créteil, France
| | - Bénédicte Lebrun-Vignes
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Pharmacovigilance Department, AP-HP, La Pitié Salpêtrière Hospital, Paris, France
| | - Julie Gueudry
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Ophthalmology Department, Charles Nicolle Hospital, Rouen, France
| | - Emilie Bequignon
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Ear Nose and Throat Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Karim Zaghbib
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Psychiatry Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Gérard Royer
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Ophthalmology Department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Audrey Colin
- Dermatology Department, AP-HP, Henri Mondor Hospital, 51 avenue du maréchal de Lattre de Tassigny, 94000, Créteil, France.,French National Reference Center for Toxic Bullous Dermatoses, Créteil, France
| | - Giao Do-Pham
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Dermatology Department, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Christine Bodemer
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Dermatology Department, AP-HP, Necker Hospital, Paris, France
| | - Nicolas Ortonne
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Pathology Department, AP-HP, Henri Mondor Hospital, Créteil, France.,Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
| | - Annick Barbaud
- French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,Dermatology Department, AP-HP, Tenon Hospital, Paris, France
| | - Laurence Fardet
- Dermatology Department, AP-HP, Henri Mondor Hospital, 51 avenue du maréchal de Lattre de Tassigny, 94000, Créteil, France.,French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,EA7379 EpiDermE (Epidemiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
| | - Olivier Chosidow
- Dermatology Department, AP-HP, Henri Mondor Hospital, 51 avenue du maréchal de Lattre de Tassigny, 94000, Créteil, France.,French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,EA7379 EpiDermE (Epidemiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France.,Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
| | - Pierre Wolkenstein
- Dermatology Department, AP-HP, Henri Mondor Hospital, 51 avenue du maréchal de Lattre de Tassigny, 94000, Créteil, France.,French National Reference Center for Toxic Bullous Dermatoses, Créteil, France.,EA7379 EpiDermE (Epidemiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France.,Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
| | | |
Collapse
|
19
|
Lebrun-Vignes B, Guy C, Jean-Pastor MJ, Gras-Champel V, Zenut M. Is acetaminophen associated with a risk of Stevens-Johnson syndrome and toxic epidermal necrolysis? Analysis of the French Pharmacovigilance Database. Br J Clin Pharmacol 2017; 84:331-338. [PMID: 28963996 DOI: 10.1111/bcp.13445] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 09/20/2017] [Indexed: 12/24/2022] Open
Abstract
AIM Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but severe mostly drug-induced cutaneous reactions. Acetaminophen is an over-the-counter drug used worldwide to treat pain and reduce fever. In 2013, the US Food and Drug Administration informed the public that acetaminophen was associated with a rare risk of SJS/TEN. The aim of the present retrospective study was to analyse reports of acetaminophen as a possible suspect in the development of SJS/TEN from the French Pharmacovigilance Database (FPDB). METHODS Cases of TEN/SJS with acetaminophen as a suspect drug registered in the FPDB, collected from January 2002 to December 2013, were analysed by an expert group. The algorithm of drug causality for epidermal necrolysis (ALDEN) was used as a reference tool for SJS/TEN to assess the causality of each suspect drug. RESULTS After exclusion of 16 nonvalidated cases, 112 cases (47 TEN, 51 SJS, 14 SJS/TEN overlaps) involving 574 suspected drugs (5⋅1/case) were analysed. In 80 cases, the acetaminophen ALDEN score was inferior or equal to that of other drugs, associated with a higher suspicion for causality. In 32 cases, acetaminophen had the highest score but matched with a 'very unlikely' or 'unlikely' causality in 12 cases. For the 20 remaining cases with a 'possible' or ' probable' causality, a protopathic or a confounding bias was likely in 14 cases. CONCLUSIONS After analysis of the French pharmacovigilance data using the ALDEN algorithm, we found no obvious SJS/TEN risk related to the use of acetaminophen in this large national series.
Collapse
Affiliation(s)
- Bénédicte Lebrun-Vignes
- Centre Régional de Pharmacovigilance, Hôpitaux Universitaires Pitié-Salpêtrière Charles-Foix, AP-HP, 47-83, Boulevard de l'Hôpital, 75651 Cedex 13, Paris, France
| | - Claire Guy
- Centre Régional de Pharmacovigilance, CHU - Hôpital Nord, Avenue Albert Raimond, 42055 Cedex 02, Saint-Etienne, France
| | - Marie-Josèphe Jean-Pastor
- Centre Régional de Pharmacovigilance Marseille - Provence - Corse, Hôpital Sainte-Marguerite, AP-HM, 270 Boulevard de Saint-Marguerite, 13009 Cedex 9, Marseille, France
| | - Valérie Gras-Champel
- Centre Régional de Pharmacovigilance, CHU Amiens Sud, 80054 Cedex 1, Amiens, France
| | - Marie Zenut
- Centre Régional de Pharmacovigilance, CHU - Centre de Biologie, EA 4681 PEPRADE, Université d'Auvergne, 58 Rue Montalembert -BP 69, 63003 Cedex 1, Clermont-Ferrand, France
| | | |
Collapse
|
20
|
Abstract
During the past decade, major advances have been made in the accurate diagnosis of severe cutaneous adverse reactions (SCARs) to drugs, management of their manifestations, and identification of their pathogenetic mechanisms and at-risk populations. Early recognition and diagnosis of SCARs are key in the identification of culprit drugs. SCARS are potentially life threatening, and associated with various clinical patterns and morbidity during the acute stage of Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reactions with eosinophilia and systemic symptoms, and acute generalised exanthematous pustulosis. Early drug withdrawal is mandatory in all SCARs. Physicians' knowledge is essential to the improvement of diagnosis and management, and in the limitation and prevention of long-term sequelae. This Seminar provides the tools to help physicians in their clinical approach and investigations of SCARs.
Collapse
Affiliation(s)
- Tu Anh Duong
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France.
| | - Laurence Valeyrie-Allanore
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France
| | - Pierre Wolkenstein
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France; EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val-de-Marne, Créteil, France
| | - Olivier Chosidow
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, Créteil, France; Centre de Référence des Dermatoses Bulleuses Toxiques, Créteil, France; EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques), Université Paris-Est Créteil Val-de-Marne, Créteil, France; French Satellite of the Cochrane Skin Group, Créteil, France; INSERM, Centre d'Investigation Clinique 1430, Créteil, France
| |
Collapse
|
21
|
Lee H, Walsh S, Creamer D. Long-term complications of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN): the spectrum of chronic problems in patients who survive an episode of SJS/TEN necessitates multidisciplinary follow-up. Br J Dermatol 2017; 177:924-935. [DOI: 10.1111/bjd.15360] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2017] [Indexed: 12/14/2022]
Affiliation(s)
- H.Y. Lee
- Department of Dermatology; Singapore General Hospital; Singapore
| | - S.A. Walsh
- Department of Dermatology; King's College Hospital; London U.K
| | - D. Creamer
- Department of Dermatology; King's College Hospital; London U.K
| |
Collapse
|