Acute pancreatic injuries: A complication of Stevens-Johnson syndrome/toxic epidermal necrolysis associated with cytotoxic immunocell activation

Exosomal miR-375-3p mediated lipid metabolism, ferritinophagy and CoQ-dependent pathway contributes to the ferroptosis of keratinocyte in SJS/TEN

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) manifest life-threatening cutaneous adverse drug reactions characterized by keratinocyte death. Previous studies have indicated that apoptosis and necroptosis are implicated in SJS/TEN pathogeneses. However, other forms of cell death involved in this process remain unidentified. Ferroptosis, cell death driven by iron-dependent lipid peroxidation, has been implicated in various human diseases. In this study, the identification of ferroptosis and the potential effects of ferroptosis on SJS/TEN were investigated. We demonstrated that the skin lesions and plasma of SJS/TEN patients show increased levels of lipid peroxidation and iron. The biomarkers of ferroptosis correlated positively with the disease severity in SJS/TEN patients. Besides, plasma exosomes derived from patients with SJS/TEN exhibited elevated levels of cellular oxidized polyunsaturated fatty acids (PUFAs) and phospholipids phosphatidylethanolamine (PE), the key phospholipids that drive cells towards ferroptotic death. miR-375-3p, enriched in plasma-derived exosomes from SJS/TEN patients, was observed reduce both ferritin heavy chain 1 (FTH1) and ferroptosis suppressor protein 1 (FSP1) expression. Parallelly, exosomal miR-375-3p overexpression increased the level of lipid peroxidation but decreased the coenzyme Q10 (CoQ10), thus enhancing the ferroptosis rate of keratinocyte. Above all, we concluded that ferritinophagy-mediated ferroptosis, lipid metabolism, and the FSP1-CoQ-dependent pathway in ferroptosis are critical mechanisms contributing to SJS/TEN. Targeting ferroptosis in keratinocyte may be a therapeutic strategy for preventing SJS/TEN in the future.

Serum Concentrations of IL-18, IL-21, IL-22, IL-23, IL-27, and IL-31 in Patients With Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Their Correlation With Disease Severity

Background

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions marked by extensive epidermal necrolysis and skin sloughing.

Objective

The study aimed to assess the serum levels of specific proinflammatory interleukins (IL-18, -21, 22, -23, -27, and -31) and their relationship with the severity of SJS/TEN within the Vietnamese population.

Methods

This descriptive cross-sectional study was conducted from 2018 to 2020. Serum levels of IL-18, -21, -22, -23, -27, and -31 were measured using the fluorescence covalent microbead immunosorbent assay.

Results

The study included 61 patients (29 males and 32 females; 21 with SJS and 40 with TEN), with a median age of 51 years (interquartile range: 37-58), and 20 healthy controls. The median lesional area covered 45% of the body surface area (interquartile range: 8-70%). The most frequently identified medications were traditional medicine (19 patients; 31.15%), allopurinol (9 patients; 14.75%), and carbamazepine (8 patients; 13.11%). In the TEN group, the serum level of IL-18 was significantly elevated compared to the healthy control group. A correlation was found between serum levels of IL-18 and IL-27 and the lesional area in SJS/TEN patients, as well as between serum levels of IL-18 and IL-31 and the lesional area in TEN patients.

Conclusion

Serum levels of IL-18 were increased in TEN group. Additionally, serum concentrations of IL-18, IL-27, and IL-31 were associated with disease severity as indicated by the lesional area. These interleukins may play an important role in the pathogenesis of SJS/TEN.

5-Fluorouracil and actinomycin D lead to erythema multiforme drug eruption in chemotherapy of invasive mole: Case report and literature review

RATIONALE

5-Fluorouracil (5-FU) and actinomycin D (ActD) are often used in chemotherapy for various cancers. Side effects are more common in bone marrow suppression, liver function impairment, and gastrointestinal responses. Skin effects are rare and easy to be ignored by doctors and patients, which can lead to life-threatening consequence.

PATIENT CONCERNS

We reported a 45-year-old woman patient developed skin erythema and fingernail belt in chemotherapy of 5-FU and ActD.

DIAGNOSIS

Erythema multiforme drug eruption.

INTERVENTIONS

Laboratory tests including blood and urine routine, liver and kidney function, electrolytes and coagulation function and close observation.

OUTCOMES

The rash was gone and the nail change returned.

LESSONS

Delays in diagnosis or treatment may lead to serious consequence. We should pay attention to the dosage of 5-FU and ActD, monitor adverse reactions strictly, to reduce occurrence of skin malignant events.

Inhibition of tumor necrosis factor improves conventional steroid therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis in a cohort of patients

BACKGROUND

Systemic steroid therapies for Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) have been challenged because of their limited benefits. Whether additional tumor necrosis factor (TNF) α inhibition provides an optimized approach remains unexplored.

OBJECTIVE

To investigate the efficacy of TNF-α inhibition combined with a steroid to treat SJS/TEN and to identify potential biomarkers.

METHODS

Twenty-five patients with SJS/TEN were recruited and divided into 2 groups: 10 patients received methylprednisolone and 15 patients received etanercept plus methylprednisolone. Serum levels of granzyme B, perforin, interferon-γ, interleukin (IL) 6, IL-15, IL-18, macrophage inflammatory protein 1α, macrophage inflammatory protein 1β, and TNF-α were measured by multiplex cytokine analysis kits during the acute and resolution phases.

RESULTS

Compared with the steroid monotherapy, the combination therapy significantly shortened the course of the initial steroid treatment and the duration of the acute stage, hospitalization stay, and skin re-epithelialization. Although both therapies significantly reduced IL-15 levels; the combination therapy also decreased IL-6 and IL-18 levels. While the level of IL-15 was positively correlated with skin re-epithelialization time in both groups, the level of IL-6 served as an additional marker for the course of the disease in the combination therapy group.

LIMITATIONS

The cohort size is relatively small.

CONCLUSION

Additional TNF-α inhibition to steroid treatment appeared to improve outcomes for SJS/TEN.