Histopathology of cutaneous changes in drug-induced coma

Cutaneous eccrine inflammation and necrosis: review of inflammatory disorders affecting the eccrine apparatus including new associations

Despite being frequently overlooked during the examination of histopathological sections, eccrine sweat glands can offer clues for diagnosing various skin conditions. They provide important functions and can lead to several diseases when inflamed or injured. This review article provides information regarding eccrine physiology as well as well-established and novel entities that occur in association with eccrine gland pathology.

Drug Overdose-Induced Coma Blisters: Pathophysiology and Clinical and Forensic Diagnosis

BACKGROUND

Coma blisters or coma bullae are bullous lesions that have been associated with cases of drug overdose-induced coma. Previous history of suicide attempt by administering benzodiazepines, barbiturates, ethanol, antipsychotics, antidepressants or opioids have been particularly implicated. Patients may present also painful deep skin and soft tissue involvement, edema and functional impairment. The pathophysiology remains unknown and lesions are usually self-limited and typically resolve without scarring.

OBJECTIVE

This work aims to fully review the state of the art regarding the causes pathophysiology, diagnosis and treatment of drug overdose-induced coma blisters.

CONCLUSION

Coma blisters are a benign, self-limiting condition that should be suspected in patients who develop pressure blisters several hours after an altered state of consciousness.

Coma Blisters, Peripheral Neuropathy, and Amitriptyline Overdose: A Brief Report

Background:

Coma blisters are most commonly associated with barbiturate and benzodiazepine overdose; however, they have also been described in association with many other substances, including amitriptyline.

Objective:

To review the literature on the clinical manifestations of coma blisters in the setting of amitriptyline overdose.

Methods:

Case report and literature review.

Results:

Coma blisters in association with amitriptyline overdose have rarely been documented in the literature. Of the few reported cases, peripheral neuropathy has been present two (including our case report) out of four times.

Conclusion:

Amitriptyline is known to impair endothelial cell tight junction integrity. Thus, individuals with amitriptyline overdose may be predisposed to microvascular damage during the compression imposed from a comatose state. This may help to explain the tendency for patients to present with the interesting triad of coma, blisters, and neuropathy.

Pressure ulcers induced by drug administration: A new concept and report of four cases in elderly patients

Drug-induced akinesia is a potential cause of pressure ulcers. However, pressure ulcers that are caused by drug-induced akinesia are not considered an adverse drug reaction (ADR). We propose that drug-induced pressure ulcers (DIPU) are pressure ulcers that are caused by an external force that is experienced after drug administration, and we considered resolution of these ulcers after drug discontinuation to be a supportive finding. In this report, we reviewed the medical records of pressure ulcer cases from a 300-bed hospital. Among 148 patients, four patients with pressure ulcers met the criterion for DIPU. In these cases, the suspected DIPU were related to treatment with olanzapine, fluvoxamine, valproic acid, clotiazepam, triazolam and rilmazafone. These drugs were administrated to manage the patients' behavioral and psychological symptoms that accompanied dementia. The DIPU in these patients were categorized as stage IV according to the National Pressure Ulcer Advisory Panel criteria. Discontinuation of the causal drugs led to significant improvements or complete healing of the pressure ulcers, and the patients subsequently recovered their mobility. Therefore, we propose that DIPU are potential ADR that have been overlooked in clinical practice. Thus, recognition of DIPU as an ADR may be important in preventing and appropriately managing pressure ulcers among elderly patients.

Coma blisters in children: case report and review of the literature

Coma-induced blisters is a rare condition associated with prolonged impairment of conscious level, which is relatively well-known in adults following overdose with barbiturates. However, it has been very rarely described in children. A case of coma-bullae occurring in an 11-year-old child with meningoencephalitis is herein reported. The bullous lesions occurred on the limbs and trunks, and evolved into necrotic ulcers in a few days. No correlation with any drug overdosage was found. A skin biopsy revealed epidermal and eccrine sweat gland necrosis with abundant neutrophils, and thrombosis of the vessels in the lower dermis. A comprehensive review of the literature showed that only 5 cases of coma-bullae in children have been published so far. Coma blistering resolves spontaneously within days or weeks. Diagnosis of coma-bullae may require careful clinical-pathologic correlation to exclude other blistering diseases in children.

Immunohistochemical investigation of the coma blister and its pathogenesis

The erythematous patches and vesicles that are observed in coma patients, usually from an overdose of medication, are known as coma blisters. However, it is unknown whether the degenerated sweat gland is a necrosis or apoptosis. We immunohistochemically examined such skin lesions to investigate the characteristics and pathogenesis of the coma blister. Skin lesions were obtained from a forensic autopsy case, a woman in her thirties, of caffeine intoxication. Those lesions were observed in the left femoral, the lower left thigh, and the right knee. Histologically, the skin lesions showed that the keratinocytes had necrosed and the epidermis was thin in some areas. Eccrine sweat gland degeneration was observed. Obvious inflammatory cell infiltrations were not detected. Immunohistochemically, we stained each skin lesion against CD3, CD8, CD45RO, cytokeratin, 70 kD heat shock protein, ubiquitin, 150 kD oxygen regulated protein, and caspase-cleaved keratin 18 neo-epitope M30. They were also stained with an in situ apoptosis detection kit. Degenerated sweat glands featured CD45RO and M30 immunoreactivity. Immunohistochemical staining for CD45RO, CK-L, and M30 might be useful to observe sweat gland degeneration in the coma blister. Therefore, the apoptosis might be related to coma blisters and sweat gland degenerations.

Coma blisters after poisoning caused by central nervous system depressants: case report including histopathological findings

Blister formation and eccrine sweat gland necrosis is a cutaneous manifestation associated with states of impaired consciousness, most frequently reported after overdoses of central nervous system depressants, particularly phenobarbital. The case of a 45-year-old woman who developed "coma blisters" at six distinct anatomic sites after confirmed (laboratory) phenobarbital poisoning, associated with other central nervous system depressants (clonazepam, promethazine, oxcarbazepine and quetiapine), is presented. A biopsy from the left thumb blister taken on day 4 revealed focal necrosis of the epidermis and necrosis of sweat gland epithelial cells; direct immunofluorescence was strongly positive for IgG in superficial blood vessel walls but negative for IgM, IgA, C3 and C1q. The patient was discharged on day 21 with no sequelae.

Bullae and sweat gland necrosis in the differential diagnosis for Vibrio vulnificus infection in an alcoholic patient

Bullae and sweat gland necrosis remain rare cutaneous manifestation, and these conditions can be misdiagnosed as Vibrio vulnificus infections or other soft tissue infections because of their low index of suspicion. A 46-yr-old man with a history of continued alcohol consumption presented with erythematous and hemorrhagic bullous lesions on his left arm. The patient reported that after the ingestion of clams, he slept for 12 hr in a heavily intoxicated state. Then the skin lesions started as a reddish patch that subsequently became hemorrhagic bullae. V. vulnificus infection, cellulitis, and necrotizing fasciitis were considered in initial differential diagnosis. However, on the basis of sweat gland necrosis on histopathologic examinations and negative results on bacterial cultures, we made the diagnosis of bullae and sweat gland necrosis. Therefore, bullae and sweat gland necrosis should also be considered in chronic alcoholic patients who present with bullae and a previous history of unconsciousness.

Coma blisters in 2 children on anticonvulsant medication

Blister formation and eccrine sweat gland necrosis have been recognized to occur in states of impaired consciousness and were first reported following barbiturate intoxication. Their etiology is complex and cannot simply be explained by pressure effects. Now that barbiturates are less frequently used, clinicians are likely to be less aware of the phenomenon of coma blister formation; however, newer drugs have also been associated with the occurrence of coma blisters. We describe 2 new associations of coma blisters and anticonvulsants in children. In the first child, blisters recurred on multiple occasions along with obtundation and edema. Our aims are to alert clinicians to the occurrence of coma blisters in children sedated on anticonvulsant medications and to report the new finding of recurrent coma blisters.

Drug-induced sweat gland necrosis in a non-comatose patient: a case presentation

BACKGROUND

Coma-induced bullae and sweat gland necrosis is a rare clinicopathological entity often associated with drug-induced coma.

SUBJECT

We report a case with clinical and histopathologic findings characteristic of blisters and sweat gland necrosis occurring in a non-comatose patient.

CONCLUSIONS

Skin blisters with underlying sweat gland necrosis is an entity previously reported to occur in comatose patients, our findings open new questions about the role of the drugs in the pathogenesis of those conditions.

Coma blisters in a case of fatal theophylline intoxication

A case of fatal poisoning caused by theophylline toxicity (serum level 127 micro g/ml) is presented. At external examination, skin blisters on regions exposed to pressure were distinctive. Histologic examination demonstrated subepidermal bullae with eosinophilic necrosis of the eccrine sweat gland coil but no epidermal necrosis, vascular changes, or inflammatory infiltrate. To the authors' knowledge, this is the first description of coma blisters in a case of theophylline intoxication.

Coma-induced bullae and sweat gland necrosis following clobazam

Coma-induced bullae and sweat gland necrosis is a rare clinicopathological entity described in association with a variety of aetiopathological conditions all of which have resulted in an impairment of conscious level. We report the first case observed in association with clobazam, used as adjunctive therapy for resistant epilepsy in a 4-year old. The potential underlying mechanisms and previously reported associations are discussed.

Nonneoplastic disorders of the eccrine glands

Eccrine glands are uniquely susceptible to a variety of pathologic processes. Alteration in the rate of sweat secretion manifests as hypohidrosis and hyperhidrosis. Obstruction of the eccrine duct leads to miliaria. The excretion of drugs into eccrine sweat may be a contributory factor in neutrophilic eccrine hidradenitis (NEH), syringosquamous metaplasia (SSM), coma bulla, and erythema multiforme (EM). Alterations in the electrolyte composition of eccrine sweat can be observed in several systemic diseases, most notably cystic fibrosis. This article summarizes current knowledge of eccrine gland pathophysiology.

Panniculitis: recent developments and observations

Dermatopathologists rarely greet a biopsy of panniculitis with total confidence that a specific, definitive diagnosis will be rendered. As with many other areas in dermatopathology, our understanding of the pathogenesis of many forms of panniculitis is incomplete. This article examines a subset of panniculitis primarily from a pathogenetic standpoint, with the intention of providing a differential diagnosis for those cases in which ischemic changes are seen in the subcutis. The diverse group of conditions evoked by this approach also shares the distinction of having been the focus of nosologic and causative controversy, both historically and currently. In particular, stasis-associated sclerosing panniculitis, vascular calcification-cutaneous necrosis syndrome (calciphylaxis), oxalosis, and nodular vasculitis-erythema induratum are examined in depth. Erythema nodosum and variants, other granulomatous panniculitides, and panniculitides showing cytophagocytosis are also discussed with current perspectives.

Histopathology of cutaneous changes in non-drug-induced coma

To compare the histological features of non-drug-induced and drug-induced coma blister, we performed histopathological and immunopathological studies of four biopsy specimens from three patients with non-drug-induced coma. These results were compared with the previously well-documented histology of drug-induced coma. The findings of the present study of non-drug-induced coma included (a) a variable degree of epidermal cell degeneration, including vacuolation of basal cells, intraepidermal blister formation with pale cytoplasm, and extensive coagulation necrosis with pale nuclei; (b) alteration of the outer root sheath of telogen follicles, ranging from focal necrosis to total coagulation necrosis, and degeneration of sebaceous gland with disappearance of the germinative cell layer; (c) secretory eccrine cells with pyknotic nuclei, vacuolation of the cytoplasm, and intercellular edema, resulting in poorly defined cytoplasm, although the nuclei of the outer basal layer were partially preserved; (d) from slight edema of the vessel wall of the venules to fibrinoid, thrombosis and/or fibrinoid necrotic degeneration of arterioles and venules; and (e) deposits of immunoglobulins or complement as detected by direct immunofluorescent technique in all the three cases. One significant difference between non-drug-induced and drug-induced coma blister was the presence of fibrinoid thrombi in the lumina of non-drug-induced coma blisters. Since one of the three cases of non-drug-induced coma studied in the present report did not show thrombi in the lumina, this feature may not always be available for the differential diagnosis of these two conditions. However, fibrinoid thrombi may be a good marker for the differentiation of these two conditions, when the depth and duration of non-drug-induced coma are severe enough to induce these lesions.