Severe cutaneous adverse drug reactions

Impact of non-genetic factors on severe cutaneous adverse reactions and associated mortality in ESRD patients: Advancing clinical guidance

BACKGROUND

In end-stage renal disease (ESRD), reduced renal function affects medication response and clearance, increasing risk of adverse drug reactions. Renal disease is a risk factor for poor prognosis in severe cutaneous adverse reactions (SCARs). The effects of SCARs in ESRD patients are less understood.

METHODS

This retrospective analysis of the United States Renal Data System (USRDS) evaluated whether SCARs are an independent risk factor for mortality in ESRD patients, controlling for demographic and clinical factors, including malnutrition, sepsis, pneumonia, secondary autoimmune conditions and Charlson Comorbidity Index (CCI). We examined whether Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) or drug reaction with eosinophilia and systemic symptoms (DRESS) was associated with all-cause mortality in subjects enrolled in the USRDS from 2005 to 2018.

RESULTS

Patients with DRESS were more often female (OR = 1.37), with catheter (OR = 1.08) or graft (OR = = 1.15) access and a higher CCI (OR = 1.21). Those with SJS/TEN were more likely to be black (OR = 2.43) or other race (OR = 2.06) and female (OR = 1.55), with catheter access (OR = 1.36) and a higher CCI (OR = 1.18). DRESS and SJS/TEN were associated with higher risk of malnutrition (OR = 1.64, OR = 2.61), sepsis (OR = 1.93, OR = 3.38), pneumonia (OR = 1.82, OR = 1.80), and secondary autoimmune conditions (OR = 1.47, OR = 1.47). Patients with DRESS (HR = 2.05) or SJS/TEN (HR = 3.12) had increased mortality across 12 months following diagnosis. Increasing age (HR = 1.04), hemodialysis (HR = 1.76), catheter (HR = 2.58) or graft (HR = 1.52) access, malnutrition (HR = 1.07), and sepsis (HR = 1.26) increased mortality risk.

CONCLUSION

ESRD patients' risk for SCARs varied by age, race, sex, comorbidities, and dialysis modality. Patients with a SCAR had increased mortality across 12 months following diagnosis.

Drug-Induced Serious Cutaneous Reactions in Hospitalized Patients: A Cross-Sectional Study

Background: Serious adverse drug reactions (ADRs) can lead to hospital admission and can be fatal, but some of them are preventable. This study aimed to determine the types and frequencies of serious cutaneous ADRs and the methods employed to manage and prevent them, as well as to assess the factors related to their seriousness. Methods: A cross-sectional study was conducted retrospectively on inpatients and outpatients at a tertiary care hospital. All data were collected from the medical records database over a period of 3 years. Serious cutaneous ADRs were identified in the hospital database using the International Classification of Disease and Related Health Problems, 10th Revision (ICD-10). Results: A total of 2151 cases were retrieved using the ICD-10, and 436 patients were randomly selected for this study. Of these, 218 patients experienced ADRs (50.0%). The major clinical symptoms of the eight serious ADRs included anaphylaxis (38.5%) and urticaria (30.2%). The most commonly suspected drug group was antibiotics (45.0%). The main methods of ADR management were drug treatment (84.4%) and drug withdrawal (81.2%). The primary method of ADR prevention was patient drug allergy cards (52.3%). Factors affecting the severity of ADRs were having an underlying condition (p = 0.031) and the concomitant use of drugs (p = 0.044). Conclusions: Anaphylaxis was the most common serious ADR. Patients with underlying diseases and those taking concomitant drugs are more likely to present with serious ADRs. The prevention of serious ADRs should be promoted at all levels in hospitals to reduce harm and prevent their reoccurrence.

Spectrum of offending drugs and cutaneous adverse drug reactions requiring hospitalisation in a tertiary South African hospital in TB/HIV endemic setting

Introduction

Cutaneous immune-mediated adverse drug reactions are more prevalent in people with human immunodeficiency virus (PWH). Severe cutaneous adverse drug reactions (SCAR) are a life-threatening subset of cutaneous adverse drug reactions (CADRs) and a significant public health issue in settings endemic for human immunodeficiency virus and tuberculosis. However, limited data are available on CADR requiring hospitalisation in African settings. The aim of this study is to describe the epidemiology, offending drugs and outcomes of CADRs requiring admission to a South African tertiary dermatology service.

Methods

Retrospective folder review was conducted on all CADRs requiring hospitalisation at Nelson Mandela Academic Hospital in Mthatha, Eastern Cape, South Africa between 30 July 2015 and 15 December 2022. This data was compared to prospective inclusion of CADR admissions between 03 March 2021 and 09 April 2024 as part of the Immune-Mediated Adverse Drug Reactions (IMARI) Registry and Biorepository and AFRISCAR consortium. Where possible, phenotype and drug causality assessment was performed through RegiSCAR, or Naranjo and/or ALDEN scoring respectively.

Results

CADR admissions included 122 cases: 89 and 33 in the retrospective and prospective cohorts respectively. The commonest SCAR phenotype was Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) at 59.8% (73/122), although other validated SCAR phenotypes included drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP) and generalized fixed bullous drug eruption (GBFDE). Cutaneous presentations included typical and atypical SCAR features against a background Fitzpatrick skin tones of type IV and above. Amongst the retrospective cohort 16.9% (15/89) of phenotypes were unclassifiable due to lack of photographs. The overall median (IQR) age was 38 (25-50) years, 50.8% (62/122) were male and 60.7% (74/122) were PWH [median (IQR) CD4T-cell count of 267 (76-470) cells/mm3]. The commonest offending drugs included cotrimoxazole in 24.6% (30/122); and anti-retroviral therapy (ART) in 13.9% (17/122). No offending drug could be identified in 24.7% (22/89) of the retrospective cohort. The median (IQR) length of hospital stay for validated SCAR was 13 (8-21) days for the retrospective cohort and 19 (13-28) days for the prospective cohort (p = 0.03). The median (IQR) length of hospital stay for non-SCAR was 9 (5-13) days for the retrospective cohort and 11 (9-16) days for the prospective cohort.

Conclusion

Typical and atypical presentations of SCAR were represented in this vulnerable South African cohort of predominantly PWH. SJS/TEN was the commonest phenotype, and cotrimoxazole the most frequent offending drug. This data emphasises the need for prospective data collection across a diverse African population for valid SCAR phenotyping and drug causality assessment.

Signal mining study of severe cutaneous adverse events of valaciclovir or acyclovir based on the FAERS database

OBJECTIVE

This study aimed to explore a comprehensive empirical investigation and assess SCARs related to valaciclovir or acyclovir based on FAERS database from FDA, thus providing a theoretical foundation for the rational application of drugs in clinic.

METHODS

SCARs reports relevant to valaciclovir or acyclovir were searched in FAERS database from the 2004 Q1 to 2023 Q2. These data were further mined by a proportional analysis and Bayesian approach to detect signals of SCARs caused by two drugs. Meanwhile, the clinical characteristics, onset time, correlation, and stratification analysis of the two drugs in SCARs were analyzed.

RESULTS

Both drugs exhibited positive signals for drug reaction with DRESS, AGEP, TEN, SJS-TEN overlap and SJS. The median onset time of SCARs caused by valaciclovir or acyclovir was 30 days vs 10 day for DRESS, 11 days vs 9 days for AGEP, 17 days vs 12 days (TEN) and 12 days vs 8 days (SJS). Excluding the effect of combinational drugs, there was an association between the two antiviral drugs and SCARs.

CONCLUSION

By analyzing the FAERS database, the risk trends of SCARs caused by valaciclovir or acyclovir have been identified, providing valuable insights to recognize various types of SCARs in clinics.

Current understanding of genetic associations with delayed hypersensitivity reactions induced by antibiotics and anti-osteoporotic drugs

Drug-induced delayed hypersensitivity reactions (DHRs) is still a clinical and healthcare burden in every country. Increasing reports of DHRs have caught our attention to explore the genetic relationship, especially life-threatening severe cutaneous adverse drug reactions (SCARs), including acute generalized exanthematous pustulosis (AGEP), drug reactions with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). In recent years, many studies have investigated the immune mechanism and genetic markers of DHRs. Besides, several studies have stated the associations between antibiotics-as well as anti-osteoporotic drugs (AOD)-induced SCARs and specific human leukocyte antigens (HLA) alleles. Strong associations between drugs and HLA alleles such as co-trimoxazole-induced DRESS and HLA-B*13:01 (Odds ratio (OR) = 45), dapsone-DRESS and HLA-B*13:01 (OR = 122.1), vancomycin-DRESS and HLA-A*32:01 (OR = 403), clindamycin-DHRs and HLA-B*15:27 (OR = 55.6), and strontium ranelate (SR)-SJS/TEN and HLA-A*33:03 (OR = 25.97) are listed. We summarized the immune mechanism of SCARs, update the latest knowledge of pharmacogenomics of antibiotics- and AOD-induced SCARs, and indicate the potential clinical use of these genetic markers for SCARs prevention in this mini review article.

The Co-Existence of Agranulocytosis and Stevens-Johnson Syndrome (SJS) in Carbamazepine Therapy: A Case Report

The therapeutic significance of carbamazepine in individuals with trigeminal neuralgia, epilepsy, and bipolar disorder is well recognized. Although it has high effectiveness, it raises the patient's risk for some adverse effects. The relationship between carbamazepine usage and agranulocytosis is well-established. Agranulocytosis is characterized by an unusually low number of neutrophils. This disorder poses a grave hazard to the patient since they are more likely to get potentially lethal bacterial or fungal infections. Moreover, carbamazepine is one of the most common causes of Stevens-Johnson syndrome (SJS), a severe skin condition with a high mortality rate. In cases where agranulocytosis and Stevens-Johnson syndrome coexist, the prognosis is relatively poor. We report a rare case of a patient who developed agranulocytosis and Stevens-Johnson syndrome after taking carbamazepine. Neutrophils accounted for 2.1% of the patient's differential leukocyte count. Furthermore, Naranjo's scale found a score of 8 for Stevens-Johnson syndrome, placing it in the "probable" category, while a score of 9 for agranulocytosis indicated that it was a confirmed adverse reaction to carbamazepine.

Drug-Induced Severe Cutaneous Adverse Reactions: Insights Into Clinical Presentation, Immunopathogenesis, Diagnostic Methods, Treatment, and Pharmacogenomics

SCARs are rare and life-threatening hypersensitivity reactions. In general, the increased duration of hospital stays and the associated cost burden are common issues, and in the worst-case scenario, they can result in mortality. SCARs are delayed T cell-mediated hypersensitivity reactions. Recovery can take from 2 weeks to many months after dechallenging the culprit drugs. Genetic polymorphism of the HLA genes may change the selection and presentation of antigens, allowing toxic drug metabolites to initiate immunological reactions. However, each SCARs has a different onset latency period, clinical features, or morphological pattern. This explains that, other than HLA mutations, other immuno-pathogenesis may be involved in drug-induced severe cutaneous reactions. This review will discuss the clinical morphology of various SCARs, various immune pathogenesis models, diagnostic criteria, treatments, the association of various drug-induced reactions and susceptible alleles in different populations, and the successful implementation of pharmacogenomics in Thailand for the prevention of SCARs.

Clinical, Biochemical, Genetic, and Therapeutic Profile of Patients with Epidermal Necrolysis: A Descriptive Study

Background

Epidermal necrolysis (SJS/TEN) is a rare but acute severe drug reaction associated with high morbidity and mortality rates.

Aims

To describe the clinical, molecular, biochemical, and therapeutic profile of these patients.

Methods

A total of 24 acute SJS/TEN patients were recruited during their hospital stay and detailed clinical history and treatment course recorded. Blood samples collected were subjected to DNA and serum separation for molecular and biochemical analysis.

Results

Of 24 patients, 18 (75%) were females and six (25%) were males with six SJS, six SJS-TEN overlap, and 12 TEN cases. The inciting drugs were non-steroidal anti-inflammatory (87.50%; n = 21) followed by antibiotics (66.67%; n = 16), antiepileptics (37.50%; n = 9), and others (37.50%; n = 9). Seventeen patients (77.2%) showed skin eruptions within 7 days after drug intake. Different co-morbidities were observed in 22 (91.6%) and 20 (83.3%) patients showed ocular manifestations. Length of hospital stay ranged from 8 to 55 days, 20 (83.3%) patients were treated with corticosteroids, and four (16.6%) received antimicrobial therapy. Interleukin polymorphisms revealed significantly low frequency of IL-4 in the patients, HLA-A locus typing revealed higher frequency of HLA-A*3301 (20.8%), HLA-A*02 (25%), HLA-A*2402 (14.6%), and sera showed raised levels of granulysin and sFas L in the patients compared to controls.

Conclusions

The preliminary study illustrates the clinical, molecular, and biochemical features of acute SJS/TEN and provides a better understanding that helps to improve patient care at an earlier stage. It also highlights the use of corticosteroids and antimicrobial therapy for effective treatment of patients.

A Comprehensive Review of HLA and Severe Cutaneous Adverse Drug Reactions: Implication for Clinical Pharmacogenomics and Precision Medicine

Human leukocyte antigen (HLA) encoded by the HLA gene is an important modulator for immune responses and drug hypersensitivity reactions as well. Genetic polymorphisms of HLA vary widely at population level and are responsible for developing severe cutaneous adverse drug reactions (SCARs) such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), maculopapular exanthema (MPE). The associations of different HLA alleles with the risk of drug induced SJS/TEN, DRESS and MPE are strongly supportive for clinical considerations. Prescribing guidelines generated by different national and international working groups for translation of HLA pharmacogenetics into clinical practice are underway and functional in many countries, including Thailand. Cutting edge genomic technologies may accelerate wider adoption of HLA screening in routine clinical settings. There are great opportunities and several challenges as well for effective implementation of HLA genotyping globally in routine clinical practice for the prevention of drug induced SCARs substantially, enforcing precision medicine initiatives.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a 10-year experience in a burns unit

OBJECTIVE

Stevens-Johnson syndrome (SJS) and its more severe counterpart, toxic epidermal necrolysis (TEN), are skin hypersensitivity reactions defined by epidermal blistering and necrosis. The exact pathophysiology of SJS/TEN is yet to be deciphered, but a number of risk factors have been identified including adverse drug reactions. The diagnosis of SJS/TEN is made on a clinical basis, and treatment consists of supportive care and occasionally immunosuppressants, such as cyclosporin, high-dose intravenous immunoglobulins and/or corticosteroids. Mortality rates can reach 20-25% in adults but are reduced with early intervention. To identify optimal treatment regimens, to better understand the patient cohort affected, and to help identify key risk factors for mortality, we report our experience with the treatment and management of SJS/TEN patients.

METHODS

A retrospective review of consecutive patients with SJS and/or TEN admitted to a single burns centre in Germany, between 2008 and 2018, was conducted. The primary outcomes of demographics, clinical course, treatment and patient-reported outcomes were recorded and compared with a control group of patients with burns without a diagnosis of SJS/TEN.

RESULTS

A total of 23 patients with SJS/TEN met the inclusion criteria: 17 (74%) with TEN; four (17%) with SJS/TEN overlap; and two (9%) with SJS. Of the patients, 14 (61%) were female and nine (39%) were male. Patient age ranged from 32-78 years (mean: 52 years). A matched cohort of 23 patients with burns served as the control group. All patients received standard of care with a multidisciplinary team. Compared with the control group, SJS/TEN patients had higher mortality rates (n=6, 26% versus n=8, 35%, respectively). The average age of death was 69 years in SJS/TEN patients versus 63 years in control group patients. Age and SCORTEN scores were significant predictors of mortality.

CONCLUSIONS

SJS and TEN are rare but extreme reactions of the skin and mucosa, associated with high disease mortality rates. This 10-year single-centre retrospective review contributes to the bank of information for reviews evaluating the management of SJS/TEN patients.

Dermoscopic Aspects of Cutaneous Adverse Drug Reactions

Background

Little is known about the dermoscopic evaluation of cutaneous adverse drug reactions (CADRs).

Objectives

To evaluate the dermoscopic patterns of CADRs and identify those associated with severe cutaneous adverse reactions to drugs (SCARDs).

Patients and Methods

Patients included in this study from May 2015 to April 2016 had presented with CADRs. CADR presentation and classification were based on standard criteria. SCARDs included Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), overlap SJS/TEN, drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP). The dermoscopic features of CADRs were described and compared according to the severity of the reactions.

Results

Sixty-nine patients were included. Sixteen patients (23.2%) presented SCARDs. The main dermoscopic findings in SJS, overlap SJS/TEN and TEN were black dots or necrotic areas (100%). Erosion [respectively, 4/6 (66.7%), 3/3 (100%) and 1/1 (100%)], necrotic borders [respectively, 4/6 (66.7%), 3/3 (100%) and 1/1, (100%)] and epidermal detachment [respectively, 5/6 (83.3%); 2/3 (66.7%) and 1/1 (100%)] were also common among these reactions. Erythema and purpuric dots were the main dermoscopic findings [respectively, 5/6 (83.3%) and 4/6 (66.7%)] in DRESS. In non-severe reactions, the most prevalent structures were erythema and purpura in exanthema [respectively, 31/33 (93.9%) and 24/33 (72.7%)] and erythema and vascular structures in urticarial reactions [respectively, 6/6 (100%) and 3/6 (50%)]. Black dots or necrotic areas, epidermal detachment, necrotic borders and erosion were highly associated with SCARDs (P < 0.001).

Conclusions

Dermoscopy improves clinical recognition of SCARDs.

Quinolines derivatives as promising new antifungal candidates for the treatment of candidiasis and dermatophytosis

Fungal infections have emerged as a current serious global public health problem. The main problem involving these infections is the expansion of multidrug resistance. Therefore, the prospection of new compounds with efficacy antifungal becomes necessary. Thus, this study evaluated the antifungal profile and toxicological parameters of quinolines derivatives against Candida spp. and dermatophyte strains. As a result, a selective anti-dermatophytic action was demonstrated by compound 5 (geometric means (GM = 19.14 μg ml⁻¹)). However, compounds 2 (GM = 50 μg ml⁻¹) and 3 (GM = 47.19 μg ml⁻¹) have presented only anti-Candida action. Compounds 3 and 5 did not present cytotoxic action. Compound 5 did not produce dermal and mucosal toxicity. In addition, this compound showed the absence of genotoxic potential, suggesting safety for topical and systemic use. Quinolines demonstrated a potent anti-dermatophytic and anti-yeast action. Moreover, compound 5 presented an excellent toxicological profile, acting as a strong candidate for the development of a new effective and safe compound against dermatophytosis of difficult treatment.

Reliability and validity of the Thai Drug Hypersensitivity Quality of Life Questionnaire: a multi-center study

OBJECTIVE

To adapted the Drug Hypersensitivity Quality of Life (DrHy-Q) Questionnaire from Italian into Thai and assessed its validity and reliability.

DESIGN

Prospectively recruited during January 2012-May 2017.

SETTING

Multicenter; six Thai tertiary university hospitals.

STUDY PARTICIPANTS

Total of 306 patients with physician-diagnosed drug hypersensitivity.

INTERVENTIONS

Internal consistency and test-retest reliability were evaluated among 68 participants using Cronbach's ɑ and intra-class correlation coefficient (ICC). The validity of Thai DrHy-Q was assessed among 306 participants who completed World Health Organization Quality of Life-BREF (WHOQOL-BREF-THAI). Construct and divergent validities were assessed for Thai DrHy-Q. Known-groups validity assessing discriminating ability was conducted in Thai DrHy-Q and WHOQOL-BREF-THAI.

MAIN OUTCOME MEASURES

Validity; reliability; single vs. multiple drug allergy; non-severe cutaneous adverse reactions (SCAR) vs. SCAR.

RESULTS

Thai DrHy-Q showed good reliability (Cronbach's ɑ = 0.94 and ICC = 0.8). Unidimensional factor structure was established by confirmatory factor analysis (CFI&TLI = 0.999, RMSEA = 0.02). Divergent validity was confirmed by weak correlation between Thai DrHy-Q and WHOQOL-BREF-THAI domains (Pearson's r = -0.41 to -0.19). Known-groups validity of Thai DrHy-Q was confirmed with significant difference between patients with and without life-threatening SCAR (P = 0.02) and patients with multiple implicated drug classes vs. those with one class (P < 0.01); while WHOQOL-BREF-THAI could differentiate presence of life-threatening SCAR (P < 0.01) but not multiple-drug allergy.

CONCLUSIONS

Thai DrHy-Q was reliable and valid in evaluating quality of life among patients with drug hypersensitivity. Thai DrHy-Q was able to discriminate serious drug allergy phenotypes from non-serious manifestations in clinical practice and capture more specific drug-hypersensitivity aspects than WHOQOL-BREF-THAI.

[Cutaneous drug reactions]

Cutaneous drug reactions are a common reason for calls and visits. This term chiefly refers to hypersensitivity reactions ranging from benign rash without contraindication of treatment to severe life-threatening clinical pictures, such as anaphylactic shock and epidermal necrolysis. They should be carefully managed from the outset. Indeed, history taking and precise semiological description of the lesions are crucial to the formulation of recommendations for the patient. Allergological investigation of such reactions has developed greatly in recent decades and must now be carried out much more extensively. The arrival of new drug families such as biotherapies and the development of drug habituation protocols constitute the challenges of tomorrow for cutaneous drug reactions.

A classification framework for exploiting sparse multi-variate temporal features with application to adverse drug event detection in medical records

BACKGROUND

Adverse drug events (ADEs) as well as other preventable adverse events in the hospital setting incur a yearly monetary cost of approximately $3.5 billion, in the United States alone. Therefore, it is of paramount importance to reduce the impact and prevalence of ADEs within the healthcare sector, not only since it will result in reducing human suffering, but also as a means to substantially reduce economical strains on the healthcare system. One approach to mitigate this problem is to employ predictive models. While existing methods have been focusing on the exploitation of static features, limited attention has been given to temporal features.

METHODS

In this paper, we present a novel classification framework for detecting ADEs in complex Electronic health records (EHRs) by exploiting the temporality and sparsity of the underlying features. The proposed framework consists of three phases for transforming sparse and multi-variate time series features into a single-valued feature representation, which can then be used by any classifier. Moreover, we propose and evaluate three different strategies for leveraging feature sparsity by incorporating it into the new representation.

RESULTS

A large-scale evaluation on 15 ADE datasets extracted from a real-world EHR system shows that the proposed framework achieves significantly improved predictive performance compared to state-of-the-art. Moreover, our framework can reveal features that are clinically consistent with medical findings on ADE detection.

CONCLUSIONS

Our study and experimental findings demonstrate that temporal multi-variate features of variable length and with high sparsity can be effectively utilized to predict ADEs from EHRs. Two key advantages of our framework are that it is method agnostic, i.e., versatile, and of low computational cost, i.e., fast; hence providing an important building block for future exploitation within the domain of machine learning from EHRs.

A Study of Cutaneous Adverse Drug Reactions in a Tertiary Care Center in Punjab

CONTEXT

Cutaneous adverse drug eruptions are the most common adverse reactions attributed to drugs in which any type of skin reaction can be mimicked, induced, or aggravated.

AIMS

To study the pattern of various types of cutaneous adverse drug reactions (CADRs), to find out the causative drug(s) involved and to determine the response to treatment and outcome in patients with CADRs.

PATIENTS AND METHODS

This prospective study was done in the department of dermatology. Patients with suspected drug rash, of either sex and all age groups were included in the study.

STATISTICAL ANALYSIS

Frequencies and proportions were calculated using Chi-square test and t-test as the tests of significance. Data was analyzed using SPSS version 21.

RESULTS

A total of 258 patients were enrolled in the study. The most common CADR observed in the study was exanthematous drug eruption in 42.63% patients followed by drug induced urticaria in 21.32% patients. Antimicrobials were the most common offending drugs in 64.73% of patients, followed by non-steroidal anti-inflammatory drugs (NSAIDs) in 15.50% patients. In the study, 12 patients (4.65%) were found to have severe cutaneous adverse drug reactions (SCADRs). Stevens-Johnson syndrome (SJS) - Toxic epidermal necrolysis (TEN) was the most common SCADR (50%) and antituberculous drugs were the most common causative group of drugs causing SCADRs.

CONCLUSION

The most common CADR observed in the study was exanthematous drug eruption and antimicrobials were the most common causative drugs.

Drug-induced Stevens-Johnson syndrome and toxic epidermal necrolysis in vietnamese spontaneous adverse drug reaction database: A subgroup approach to disproportionality analysis

WHAT IS KNOWN AND OBJECTIVE

Despite the numerous studies investigating drug-induced Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), the understanding and quantitative data in developing countries remain limited. The study aimed to describe and quantify the drug-related risk of SJS/TEN in a resource-limited context using the Vietnamese spontaneous reporting database (VSRD) of adverse drug reactions.

METHODS

Spontaneous reports relating to medium- and late-onset severe cutaneous adverse reactions (MLOSCAR) and SJS/TEN recorded in the VSRD from 2010 to 2015 were retrospectively analysed. The demographic characteristics and drug information were described and compared between SJS/TEN and other MLOSCAR reports. The drug-induced SJS/TEN signals were estimated using subgrouped disproportionality analysis with calculation of the reporting odds ratio (ROR) and the respective 95% confidence interval (CI).

RESULTS

The VSRD received 2,849 MLOSCAR reports, 136 of which focus on SJS/TEN over a 6-year period. About 60% of SJS/TEN patients were male, and the majority of them were adults (mean age 42.5 ± 22.9). Up to 91.8% of drugs induced SJS/TEN within 1-28 days, and 45% SJS/TEN cases were evaluated as life-threatening. Positive signals were generated with carbamazepine (n = 25, ROR [95% CI] = 11.99 [7.07-19.92]), allopurinol (n = 15, ROR [95% CI] = 4.2 [2.20-7.59]), traditional/herbal medicines (n = 7, ROR [95% CI] = 2.76 [1.12-5.86]), colchicine (n = 4, ROR [95% CI] = 6.22 [1.69-18.72]), valproic acid (n = 3, ROR [95% CI] = 8.71 [1.89-30.19]) and meloxicam (n = 3, ROR [95% CI] = 7.09 [1.55-24.29]), which are well known for SJS/TEN. Cefixime (n = 5, ROR [95% CI] = 3.34 [1.13-8.00]) and paracetamol (n = 22, ROR [95% CI] = 5.23 [3.10-8.49]) also generated positive signals despite their popularity in Vietnam.

WHAT IS NEW AND CONCLUSION

This first Vietnamese population-based study has highlighted original characteristics and signals of drug-induced SJS/TEN, which are relatively consistent with other worldwide data and typical for a developing country.

Iatrogenesis: A review on nature, extent, and distribution of healthcare hazards

Modern medicine is given overarching importance to tackle disease in the human body than environmental determinants. Although, most of the literature confirms that the determinants of disease are there in the environment. Yet in the modern times what is being emphasized is highly limited and reductionist approach of curing ailments in the human body only, which is one of the desired interventions but is full of other side effects and risks leading to iatrogenic reactions. Most of the literature establishes that modern medicine is one of the major threats to the world health. Besides treating disease at the clinical level, rational, and well-thoughtout changes in the overall environment can positively impact the nature, extent, and distribution of disease.

Rapid and Reliable Genotyping of HLA-B*57:01 in Four Chinese Populations Using a Single-Tube Duplex Real-Time Polymerase Chain Reaction Assay

HLA-B*57:01 is strongly associated with severe adverse drug reaction induced by the anti-HIV drug abacavir (ABC) and antibiotic flucloxacillin. This study was dedicated to establishing a new method for HLA-B*57:01 genotyping and investigating the HLA-B*57:01 distribution pattern in four Chinese populations. A single-tube duplex real-time polymerase chain reaction (PCR) system was established by combining the amplification refractory mutation system and TaqMan probe. The reliability of this assay was validated by comparing the genotyping results with those by sequence-based typing. With this assay, the distribution of HLA-B*57:01 in 354 blood samples from four ethnic groups, namely, Han, Tibetan, Uighur, and Buyei, was determined. A 100% concordance was observed between the results of real-time PCR and sequence-based typing in 50 Uighur samples. As low as 0.016 ng DNA that carried HLA-B*57:01 could be detected with this assay. HLA-B*57:01 carriers identified in 100 Northern Han Chinese, 104 Buyeis, 100 Tibetans, and 50 Uighurs were 0, 1 (0.96%), 3 (3%), and 6 (12%), respectively. The carrier rate of HLA-B*57:01 in Uighur was significantly higher than those in Northern Han (p = .001) and Buyei (p = .005). The newly established real-time PCR assay provides a rapid and reliable tool for HLA-B*57:01 allele screening before the prescription of ABC and flucloxacillin in clinical practice.

Carbamazepine-induced Life-threatening Stevens-Johnson Syndrome and Agranulocytosis: The Maiden Case

Stevens-Johnson syndrome is one of the few dermatological emergencies in clinical practice. The syndrome is often secondary to the usage of drugs, of which allopurinol, penicillins, sulfa drugs, ibuprofen, sodium valproate, phenytoin, lamotrigine and carbamazepine are commonly implicated. Agranulocytosis is the existence of a clinically significant reduction in neutrophil count. This condition is a serious threat to the patient, as he/she is at a greater risk of contracting bacterial or fungal infections, which may prove to be fatal. The co-existence of Stevens-Johnson syndrome and agranulocytosis in the same patient further increases the risk of morbidity and mortality. To the best of our knowledge, there are no reports available in the existing literature, of cases that were reported with both these life-threatening conditions in a single patient, at the same point of time. This is a case narrative of a patient who presented with both Stevens-Johnson syndrome and agranulocytosis, following the administration of carbamazepine The patient's differential leucocyte count revealed a neutrophil proportion of 2.33%. A causality assessment done using Naranjo's algorithm showed that carbamazepine "definitely" caused Agranulocytosis and "probably" caused Stevens-Johnson syndrome.

Drug induced exfoliative dermatitis: state of the art

Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Erythema multiforme (EM), Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Overall, T cells are the central player of these immune-mediated drug reactions. Here we provide a systematic review on frequency, risk factors, pathogenesis, clinical features and management of patients with drug induced ED.

Management of Psychotropic Drug-Induced DRESS Syndrome: A Systematic Review

Drug rash with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous eruption that has been linked to several common drugs and drug categories, including antiepileptics, allopurinol, sulfonamides, and various antibiotics; however, because of a number of recent case reports linking psychotropic medications to this condition, DRESS is increasingly recognized among psychiatrists. We systematically reviewed all psychotropic drugs linked to DRESS syndrome, and this article summarizes the clinical management relevant to psychiatric professionals. A comprehensive search was performed using Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus, and Litt's Drug Eruption and Reaction Database for articles published in English during the past 20 years (1996-2015) using the search terms (1) psychotropic drugs OR serotonin uptake inhibitors AND DRESS or (2) psychotropic drugs AND drug reaction (or rash) eosinophilia systemic syndrome, and all article abstracts were screened for inclusion and exclusion criteria by 3 reviewers. Two independent reviewers examined the full text of 163 articles, of which 96 (25 original articles, 12 review articles, 55 case reports, and 4 letters to the editor) were included in the systematic review. We identified 1072 cases of psychotropic drug-induced DRESS, with carbamazepine, lamotrigine, phenytoin, valproate, and phenobarbital being the most implicated drugs. Based on our review of the literature, we outline management principles that include prompt withdrawal of the causative drug, hospitalization, corticosteroid therapy, and novel treatments, including intravenous immunoglobulin, cyclophosphamide, and cyclosporine, for corticosteroid-resistant DRESS. Finally, we outline strategies for treating comorbid psychiatric illness after a DRESS reaction to the psychotropic medication.

Severe adverse drug reactions

Severe cutaneous adverse reactions (SCARs) can present in a multitude of ways including Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, and acute generalised exanthematous pustulosis. While the prognosis and therapy for these conditions may vary, it is crucial that the culprit drug is identified and withheld early as this can influence patient outcome. Mainstay of management is by supportive therapy. In all SCARs, long-term sequelae which may not be apparent initially can be debilitating and cause lasting impact on the quality of life of survivors.

Stevens-Johnson syndrome and toxic epidermal necrolysis in Dr. Hasan Sadikin General Hospital Bandung, Indonesia from 2009-2013

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions (SCAR) with high mortality and have a significant public health impact because of high mortality and morbidity.

OBJECTIVE

To describe data the epidemiological features, etiology, and treatment of retrospectively reviewed data of all patients with SJS and TEN.

METHODS

Retrospective study was conducted in patients with SJS and TEN treated from January 1, 2009 to December 31, 2013 in Dr. Hasan Sadikin General Hospital Bandung, Indonesia.

RESULTS

A total of 57 patients were enrolled in the study. Thirty-nine cases of SJS (21 males and 18 females), 7 cases of SJS overlapping TEN (4 males and 3 females), and 11 cases of TEN (5 males and 6 females) were reported. All cases of SJS and TEN were caused by drugs, such as paracetamol (16.56%), carbamazepine (7%), amoxicillin (5.73%), ibuprofen (4.46%), rifampicin (3.18%), and trihexyphenidyl (3.18%). All cases were treated systemically with corticosteroid alone (100%). Seven from 57 patients (12,28%) died; 5 cases developed sepsis and 2 cases developed respiratory failure. The mortality rate was 7.69% in SJS, 0% in SJS/TEN overlap, and 36.36% in TEN.

CONCLUSION

The role of systemic corticosteroids in SJS and TEN are still controversial, but with a prompt and earlier treatment reduces mortality and improves outcomes of SJS and TEN patients.

Peripheral blood eosinophilia and hypersensitivity reactions among patients receiving outpatient parenteral antibiotics

BACKGROUND

Although drug-induced peripheral eosinophilia complicates antimicrobial therapy, little is known about its frequency and implications.

OBJECTIVE

We aimed to determine the frequency and predictors of antibiotic-induced eosinophilia and subsequent hypersensitivity reactions (HSRs).

METHODS

We evaluated a prospective cohort of former inpatients receiving intravenous antibiotic therapy as outpatients with at least 1 differential blood count. We used multivariate Cox proportional hazards models with time-varying antibiotic treatment indicators to assess the effect of demographic data and antibiotic exposures on eosinophilia and subsequent HSRs, including documented rash, renal injury, and liver injury. Possible drug rash with eosinophilia and systemic symptoms (DRESS) syndrome cases were identified and manually validated.

RESULTS

Of 824 patients (60% male; median age, 60 years; median therapy duration, 41 days), 210 (25%) had eosinophilia, with median peak absolute eosinophil counts of 726/mL (interquartile range, 594-990/mL). Use of vancomycin, penicillin, rifampin, and linezolid was associated with a higher hazard of having eosinophilia. There was a subsequent HSR in 64 (30%) of 210 patients with eosinophilia, including rash (n = 32), renal injury (n = 31), and liver injury (n = 13). Patients with eosinophilia were significantly more likely to have rash (hazard ratio [HR], 4.16; 95% CI, 2.54-6.83; P < .0001) and renal injury (HR, 2.13; 95% CI, 1.36-3.33; P = .0009) but not liver injury (HR, 1.75; 95% CI, 0.92-3.33; P = .09). Possible DRESS syndrome occurred in 7 (0.8%) of 824 patients; 4 (57%) were receiving vancomycin.

CONCLUSIONS

Drug-induced eosinophilia is common with parenteral antibiotics. Although most patients with eosinophilia do not have an HSR, eosinophilia increases the hazard rate of having rash and renal injury. DRESS syndrome was more common than previously described.

Generation of uniform polymer eccentric and core-centered hollow microcapsules for ultrasound-regulated drug release

Uniform polydimethylsiloxane microcapsules with eccentric and core-centered internal hollow structures show controlled-release behaviour for site-specific drug delivery under ultrasound regulation.