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Ozhathil DK, Powell CM, Corley CV, Golovko G, Song J, El Ayadi A, Wolf SE, Kahn SA. A retrospective analysis of mortality risk and immunosuppressive therapy for Stevens-Johnson Syndrome and toxic epidermal necrolysis syndrome using the TriNetX research network. Burns 2024; 50:75-86. [PMID: 37734977 DOI: 10.1016/j.burns.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/17/2023] [Accepted: 08/16/2023] [Indexed: 09/23/2023]
Abstract
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) exist on a spectrum of autoimmune conditions which cause epidermal detachment and keratinocyte necrosis. Due to the rare incidence of these conditions, a dramatic heterogeneity in treatment algorithms exists. To better appreciate pharmacologic immunosuppressive therapies' impact on survival, the authors queried a multi-institutional data network. Data for this study was extracted from TriNetX Research Network, a platform that contains ICD-9/ICD-10 coding data from a consortium of international healthcare organizations. Seventy-one institutions were queried to identify adult patients diagnosed with SJS, TEN or SJS-TEN Overlap. Cohorts were created based on the therapy received: systemic steroids (SS), diphenhydramine (DH), cyclosporine (CS), intravenous immunoglobulin (IVIG), tumor necrosis factor alpha inhibitors (TNFαi), or a combination of treatments. Cohorts were then propensity matched with patients who received supportive care. Patients who only received one of the above treatments showed no significant reduction in 90-day mortality. Patients who received CS or IVIG as part of their multitherapy showed a significantly increased risk of death when compared to supportive care (CS: RR = 1.583, 95% CI [1.119, 2.240]; IVIG: RR = 2.132, 95% CI [1.485, 3.059]). Despite their frequent utilization, this study's analysis suggests that none of these therapies confer significant 90-day mortality survival over supportive care alone. These results highlight the heterogeneity of therapies and emphasize the need for critical prospective appraisal of their outcomes in SJS and TEN.
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Affiliation(s)
- Deepak K Ozhathil
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA.
| | - Carter M Powell
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA
| | - Caroline V Corley
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA
| | - George Golovko
- 301 University Boulevard, Department of Pharmacology, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Juquan Song
- 301 University Boulevard, Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Amina El Ayadi
- 301 University Boulevard, Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Steven E Wolf
- 301 University Boulevard, Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Steven A Kahn
- Department of Surgery, Medical University of South Carolina, 96 Jonathen Lucas Street CSB 420 MSC 613, Charleston, SC 29425, USA
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Saito Y, Abe R. New insights into the diagnosis and management of Stevens-Johnson syndrome and toxic epidermal necrolysis. Curr Opin Allergy Clin Immunol 2023; 23:271-278. [PMID: 37284785 DOI: 10.1097/aci.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE OF REVIEW Recent studies have been clarifying the pathogenesis and early diagnostic markers of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Additionally, the efficacy of tumor necrosis factor alpha inhibitors is attracting attention. This review provides) recent evidence for the diagnosis and management of SJS/TEN. RECENT FINDINGS Risk factors for the development of SJS/TEN have been identified, particularly the association between HLA and the onset of SJS/TEN with specific drugs, which has been intensively studied. Research on the pathogenesis of keratinocyte cell death in SJS/TEN has also progressed, revealing the involvement of necroptosis, an inflammatory cell death, in addition to apoptosis. Diagnostic biomarkers associated with these studies have also been identified. SUMMARY The pathogenesis of SJS/TEN remains unclear and effective therapeutic agents have not yet been established. As the involvement of innate immunity, such as monocytes and neutrophils, in addition to T cells, has become clear, a more complex pathogenesis is predicted. Further elucidation of the pathogenesis of SJS/TEN is expected to lead to the development of new diagnostic and therapeutic agents.
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Affiliation(s)
- Yuki Saito
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Lehloenya RJ. Disease severity and status in Stevens–Johnson syndrome and toxic epidermal necrolysis: Key knowledge gaps and research needs. Front Med (Lausanne) 2022; 9:901401. [PMID: 36172538 PMCID: PMC9510751 DOI: 10.3389/fmed.2022.901401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022] Open
Abstract
Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are on a spectrum of cutaneous drug reactions characterized by pan-epidermal necrosis with SJS affecting < 10% of body surface area (BSA), TEN > 30%, and SJS/TEN overlap between 10 and 30%. Severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is a validated tool to predict mortality rates based on age, heart rate, BSA, malignancy and serum urea, bicarbonate, and glucose. Despite improved understanding, SJS/TEN mortality remains constant and therapeutic interventions are not universally accepted for a number of reasons, including rarity of SJS/TEN; inconsistent definition of cases, disease severity, and endpoints in studies; low efficacy of interventions; and variations in treatment protocols. Apart from mortality, none of the other endpoints used to evaluate interventions, including duration of hospitalization, is sufficiently standardized to be reproducible across cases and treatment centers. Some of the gaps in SJS/TEN research can be narrowed through international collaboration to harmonize research endpoints. A case is made for an urgent international collaborative effort to develop consensus on definitions of endpoints such as disease status, progression, cessation, and complete re-epithelialization in interventional studies. The deficiencies of using BSA as the sole determinant of SJS/TEN severity, excluding internal organ involvement and extension of skin necrosis beyond the epidermis, are discussed and the role these factors play on time to healing and mortality beyond the acute stage is highlighted. The potential role of artificial intelligence, biomarkers, and PET/CT scan with radiolabeled glucose as markers of disease status, activity, and therapeutic response is also discussed.
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Affiliation(s)
- Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Combined Drug Allergy Clinic, Groote Schuur Hospital, Cape Town, South Africa
- *Correspondence: Rannakoe J. Lehloenya, ; orcid.org/0000-0002-1281-1789
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Naik PP. A contemporary snippet on clinical presentation and management of toxic epidermal necrolysis. Scars Burn Heal 2022; 8:20595131221122381. [PMID: 36118413 PMCID: PMC9476246 DOI: 10.1177/20595131221122381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Toxic epidermal necrolysis (TEN) is one of the most severe cutaneous adverse reactions with a mortality rate of 30%. Due to a lack of consensus regarding the treatment and management of TEN, therapy is individualized on a case-to-case basis. Purpose The scientific literature about Stevens-Johnson Syndrome (SJS) and TEN is summarized and assessed to aid and assist in determining the optimal course of treatment. Methods PubMed and Google Scholar, among others, were searched with the keywords: “Toxic Epidermal Necrolysis”, “corticosteroids”, “cyclosporine”, “etanercept”, “intravenous immunoglobulin”, “Stevens-Johnson syndrome” and filtered by year. The research articles generated by the search, and their references, were reviewed. Results TEN is a severe dermatological condition that is mainly caused by medicines. World-wide guidelines differ in care plans. As there is no consensus on the management of TEN, this article aims to summarize the efficacy and feasibility of the management aspect of TEN from previous studies. Supportive care is highly accepted, along with early discontinuation of all medicines (hydration & electrolytes). Corticosteroids and cyclosporine have been used in therapy. Intravenous immunoglobulin (IVIG) is currently being administered; however, their efficacy by themselves and in combination remains uncertain. Conclusion Current evidence predominantly from retrospective studies suggests no individual treatment has sufficient efficacy and a multi-faceted regimen stands to be favored. Therapeutic regimens from corticosteroids to IVIG are under constant evaluation. The life-threatening nature of TEN warrants further confirmation with more extensive, robust randomized, controlled trials. Lay Summary Toxic epidermal necrolysis (TEN) is a serious skin reaction with a 30% chance of mortality. Commonly TEN is caused by medicines and results in a burn like appearance and sensation in patients. Usually administered medicine is cleared effectively by the human body but when the clearance of few metabolites from medicine is disrupted due to few genes, it leads to an ominous response by the body. This response involves several intermediate chemicals that primarily attack skin cells. Treatment guidelines differ globally. Supportive care is highly accepted, along with early discontinuation of all medicine. Currently, a multi-faceted treatment regimen is favored. Treatments like corticosteroids to immunoglobulins are under constant evaluation. Identification of the perfect combination of treatment needs confirmation from robust randomized controlled trials.
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Affiliation(s)
- Piyu Parth Naik
- Department of Dermatology, Saudi German Hospital and Clinic, Dubai, United Arab Emirates
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Patel TK, Patel PB, Thakkar S. Comparison of effectiveness of interventions in reducing mortality in patients of toxic epidermal necrolysis: A network meta-analysis. Indian J Dermatol Venereol Leprol 2021; 87:628-644. [PMID: 33871208 DOI: 10.25259/ijdvl_605_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/01/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Limited evidence is available about effectiveness and choice of immunomodulating treatment modalities for toxic epidermal necrolysis (TEN). AIMS To compare the effectiveness of interventions to reduce mortality in patients of toxic epidermal necrolysis through network meta-analysis. METHODS Studies were retrieved using PubMed, Google Scholar and Cochrane Database of Systematic Reviews from inception to September 18, 2018. Only English language articles were considered. Observational and randomized controlled studies having ≥ 5 TEN patients in each intervention arm were included. Two investigators independently extracted study characteristics, intervention details and mortality data. Bayesian network meta-analysis was performed using the Markov chain Monte Carlo (MCMC) approach through the random effect model. The ranking analysis was done to provide a hierarchy of interventions. The consistency between direct and indirect evidence was assessed through node spit analysis. The primary outcome was to compare the mortality [Odds ratio OR (95% credibility interval CrI)] among all treatment modalities of TEN. RESULTS Twenty-four studies satisfying the selection criteria were included. The network analysis showed improved survival with cyclosporine as compared to supportive care [OR- 0.19 (95% CrI: 0.05, 0.59)] and intravenous immunoglobulin [OR- 0.21 (95% CrI: 0.05, 0.76)]. The hierarchy of treatments based on "surface under the cumulative ranking curves" (SUCRA) value were cyclosporine (0.93), steroid+intravenous immunoglobulin (0.76), etanercept (0.59), steroids (0.46), intravenous immunoglobulin (0.40), supportive care (0.34) and thalidomide (0.02). No inconsistencies between direct and indirect estimates were observed for any of the treatment pairs. LIMITATIONS Evidence is mainly based on retrospective studies. CONCLUSION The use of cyclosporine can reduce mortality in TEN patients. Other promising immunomodulators could be steroid+intravenous immunoglobulin combination and etanercept.
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Affiliation(s)
- Tejas K Patel
- Department of Pharmacology, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India
| | - Parvati B Patel
- Department of Pharmacology, GMERS Medical College, Gotri, Gujarat, India
| | - Sejal Thakkar
- Department of Dermatology, GMERS Medical College and Hospital, Gotri, Vadodara, Gujarat, India
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Borilova Linhartova P, Gachova D, Lipovy B. Responsiveness to i.v. immunoglobulin therapy in patients with toxic epidermal necrolysis: A novel pharmaco-immunogenetic concept. J Dermatol 2020; 47:1236-1248. [PMID: 32935409 DOI: 10.1111/1346-8138.15583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 12/15/2022]
Abstract
Toxic epidermal necrolysis (TEN) represents a rare drug-induced autoimmune reaction with delayed-type hypersensitivity that initiates the process of developing massive keratinocyte apoptosis, dominantly in the dermoepidermal junction. Although the etiopathophysiology has not yet been fully elucidated, the binding of Fas ligand (FasL, CD95L) to the Fas receptor (CD95) was shown to play a key role in the induction of apoptosis in this syndrome. The knowledge of the role of immunoglobulin G (IgG) in inhibition of Fas-mediated apoptosis contributed to the introduction of i.v. Ig (IVIg) in the therapy of TEN patients. Despite great enthusiasm for this therapy at the end of the 1990s, subsequent studies in various populations and meta-analyses could not unequivocally confirm the efficacy of the IVIg-based treatment concept. Today, therefore, we are faced with the dilemmas of how to adjust therapy of TEN patients most effectively, which patients could benefit from IVIg therapy and what dose of the preparation should be administrated. The ground-breaking question is: do the host genetic profiles influence the responsiveness and side-effects of IVIg therapy in TEN patients? Based on recent pharmacological, immunological and genetic findings, we suggest that the variability of IVIg therapy outcomes in TEN patients may be related to functional variants in Fas, FasL and Fc-γ receptor genes. This novel concept could lead to improved quality of care for patients with TEN, facilitating personalized therapy to reduce mortality.
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Affiliation(s)
- Petra Borilova Linhartova
- Institute of Medical Genetics, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Pathophysiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Clinic of Stomatology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Molecular Pharmacy, Faculty of Pharmacy, Masaryk University, Brno, Czech Republic.,Clinic of Maxillofacial Surgery, Institution shared with University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Daniela Gachova
- Department of Pathophysiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Bretislav Lipovy
- Department of Burns and Plastic Surgery, Institution shared with University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Torres‐Navarro I, Briz‐Redón Á, Botella‐Estrada R. Systemic therapies for Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis: a SCORTEN‐based systematic review and meta‐analysis. J Eur Acad Dermatol Venereol 2020; 35:159-171. [DOI: 10.1111/jdv.16685] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/11/2020] [Indexed: 12/20/2022]
Affiliation(s)
- I. Torres‐Navarro
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
| | - Á. Briz‐Redón
- Department of Statistics and Operations Research Universitat de València València Spain
| | - R. Botella‐Estrada
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
- Department of Medicine Universitat de València València Spain
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8
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Hasegawa A, Abe R. Recent advances in managing and understanding Stevens-Johnson syndrome and toxic epidermal necrolysis. F1000Res 2020; 9. [PMID: 32595945 PMCID: PMC7308994 DOI: 10.12688/f1000research.24748.1] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 12/15/2022] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening diseases characterized by detachment of the epidermis and mucous membrane. SJS/TEN are considered to be on the same spectrum of diseases with different severities. They are classified by the percentage of skin detachment area. SJS/TEN can also cause several complications in the liver, kidneys, and respiratory tract. The pathogenesis of SJS/TEN is still unclear. Although it is difficult to diagnose early stage SJS/TEN, biomarkers for diagnosis or severity prediction have not been well established. Furthermore, optimal therapeutic options for SJS/TEN are still controversial. Several drugs, such as carbamazepine and allopurinol, are reported to have a strong relationship with a specific human leukocyte antigen (HLA) type. This relationship differs between different ethnicities. Recently, the usefulness of HLA screening before administering specific drugs to decrease the incidence of SJS/TEN has been investigated. Skin detachment in SJS/TEN skin lesions is caused by extensive epidermal cell death, which has been considered to be apoptosis via the Fas-FasL pathway or perforin/granzyme pathway. We reported that necroptosis, i.e. programmed necrosis, also contributes to epidermal cell death. Annexin A1, released from monocytes, and its interaction with the formyl peptide receptor 1 induce necroptosis. Several diagnostic or prognostic biomarkers for SJS/TEN have been reported, such as CCL-27, IL-15, galectin-7, and RIP3. Supportive care is recommended for the treatment of SJS/TEN. However, optimal therapeutic options such as systemic corticosteroids, intravenous immunoglobulin, cyclosporine, and TNF-α antagonists are still controversial. Recently, the beneficial effects of cyclosporine and TNF-α antagonists have been explored. In this review, we discuss recent advances in the pathophysiology and management of SJS/TEN.
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Affiliation(s)
- Akito Hasegawa
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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9
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Torres‐Navarro I, Briz‐Redón Á, Botella‐Estrada R. Accuracy of SCORTEN to predict the prognosis of Stevens‐Johnson syndrome/toxic epidermal necrolysis: a systematic review and meta‐analysis. J Eur Acad Dermatol Venereol 2020; 34:2066-2077. [DOI: 10.1111/jdv.16137] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/21/2019] [Indexed: 12/13/2022]
Affiliation(s)
- I. Torres‐Navarro
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
| | - Á. Briz‐Redón
- Department of Statistics and Operations Research Universitat de València València Spain
| | - R. Botella‐Estrada
- Dermatology Department Hospital Universitario y Politécnico la Fe València Spain
- Department of Medicine Universitat de València València Spain
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Krajewski A, Mazurek MJ, Mlynska-Krajewska E, Piorun K, Knakiewicz M, Markowska M. Toxic Epidermal Necrolysis Therapy with TPE and IVIG-10 Years of Experience of the Burns Treatment Center. J Burn Care Res 2019; 40:652-657. [PMID: 31032516 DOI: 10.1093/jbcr/irz073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a potentially life-threatening, exfoliative disease. It is described as idiosyncratic, severe, skin reaction to drugs. With Stevens-Johnson's Syndrome, it presents as a continuum of a disease being categorized relating to the percentage of affected skin. Without any multicenter trials comparing TEN treatment modalities, there is dearth of strong evidence-based guidelines of care. Total plasma exchange with intravenous immunoglobulin (IVIG) is one among plethora of possible treatment strategies. In our 10-year experience, we have observed 21 patients admitted to our burns center due to TEN. All of them were placed under intensive care with daily plasmapheresis (TPE) and IVIG. We have observed 52% mortality, with observed severe concomitant diseases in every patient in nonsurvivor group (average Acute Physiology and Chronic Health Evaluation II score at admission: 31.5%). We consider that TPE with IVIG might be of use in selected group of patients with TEN without any severe comorbidities. However, further multicenter trials are needed because in some cases it may raise mortality.
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Affiliation(s)
| | | | | | - Krzysztof Piorun
- West Pomeranian Burns and Plastic Surgery Center, Gryfice, Poland
| | | | - Marta Markowska
- West Pomeranian Burns and Plastic Surgery Center, Gryfice, Poland
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11
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Chateau AV, Dlova NC, Dawood H, Aldous C. Outcomes of Stevens-Johnson syndrome and toxic epidermal necrolysis in HIV-infected patients when using systemic steroids and/or intravenous immunoglobulins in Pietermaritzburg, South Africa. South Afr J HIV Med 2019; 20:944. [PMID: 31308970 PMCID: PMC6620497 DOI: 10.4102/sajhivmed.v20i1.944] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/13/2019] [Indexed: 11/23/2022] Open
Abstract
Background Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe life-threatening mucocutaneous reactions. There is an ongoing controversy regarding the use of systemic corticosteroids and intravenous immunoglobulin (IVIG) in SJS/TEN and their utility in HIV-infected patients. Objectives The objective was to assess the outcome of a combination of intensive supportive care with oral corticosteroids in SJS and a combination of systemic steroids and IVIG for 3 consecutive days in HIV-infected patients with TEN. In addition, we assessed management in a general dermatology ward without implementing wound debridement. Methods This was a retrospective cohort study of 36 HIV-infected adults with SJS/TEN admitted to a tertiary dermatology unit between 1st January 2010 and 31st July 2011. Standard-of-care protocols included identification and elimination of the possible causative drug, meticulous wound care without debridement, initiation of oral prednisone (1 mg/kg/day) on admission for 3 consecutive days, and the addition of IVIG (1 g/kg/day) for 3 consecutive days to those with TEN. Results Of the 36 patients in the study, 32 were female. Nevirapine was the commonest drug implicated. A diagnosis of tuberculosis did not increase the case fatality rate. Complications included infections, anaemia, drug-induced hepatitis, ocular involvement, renal impairment, deep vein thrombosis, respiratory distress, Leucopenia, gastritis and hypernatremia. The overall survival rate was 97%. Conclusion HIV-infected SJS and TEN patients were treated in a tertiary dermatology ward with a treatment plan of skin care, and a combination of systemic corticosteroids and IVIG respectively had a survival rate of 97%.
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Affiliation(s)
- Antoinette V Chateau
- Department of Dermatology, School of Clinical Medicine Greys Hospital, University of Kwa-Zulu Natal, KwaZulu-Natal, South Africa
| | - Ncoza C Dlova
- Department of Dermatology, School of Clinical Medicine Greys Hospital, University of Kwa-Zulu Natal, KwaZulu-Natal, South Africa
| | - Halima Dawood
- Department Medicine, Infectious Disease Unit, Greys Hospital and Caprisa, University of Kwa-Zulu Natal, KwaZulu-Natal, South Africa
| | - Colleen Aldous
- Department of General Medicine, School of Clinical Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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Al-Kathiri L, Mercyamma V, Al-Najjar T. A Case of Toxic Epidermal Necrolysis Successfully Treated with Low Dose Intravenous Immunoglobulins and Systemic Corticosteroid. Oman Med J 2018; 33:356-359. [PMID: 30038738 DOI: 10.5001/omj.2018.65] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Toxic epidermal necrolysis (TEN), a severe form of Stevens-Johnson syndrome, is an acute life-threatening adverse drug reaction with a mortality rate of approximately 30%. Primary treatment of TEN is usually supportive. The use of intravenous immunoglobulin (IVIG) and corticosteroids are still uncertain, as there are only a limited number of studies comparing the usefulness of these treatments. We report a case of a Filipino male patient who developed TEN, most likely due to one of the medications he received during his course of illness. The patient was admitted to Sultan Qaboos Hospital, Salalah, with fever and diffuse painful maculopapular eruption, which became vesicular and bullous after few days, followed by shedding of large sheets of the epidermis. The patient was admitted initially under medical care, and a diagnosis of TEN was considered later. All unnecessary drugs were discontinued, and the patient was shifted to the burns unit. In addition to standard supportive treatment, a combination therapy of systemic steroid and a low-dose IVIG (1.2 g/kg) divided over three days was administered. This low-dose regimen of IVIG has a pharmacoeconomic benefit compared with the previous cumulative dose (3 g/kg), which is usually given by dermatologists in other institutions to patients with TEN. The outcome was excellent, and the condition recovered almost completely two weeks after starting the treatment without sequelae.
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Affiliation(s)
- Lutfi Al-Kathiri
- Department of Dermatology, Sultan Qaboos Hospital, Salalah, Oman
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13
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White KD, Abe R, Ardern-Jones M, Beachkofsky T, Bouchard C, Carleton B, Chodosh J, Cibotti R, Davis R, Denny JC, Dodiuk-Gad RP, Ergen EN, Goldman JL, Holmes JH, Hung SI, Lacouture ME, Lehloenya RJ, Mallal S, Manolio TA, Micheletti RG, Mitchell CM, Mockenhaupt M, Ostrov DA, Pavlos R, Pirmohamed M, Pope E, Redwood A, Rosenbach M, Rosenblum MD, Roujeau JC, Saavedra AP, Saeed HN, Struewing JP, Sueki H, Sukasem C, Sung C, Trubiano JA, Weintraub J, Wheatley LM, Williams KB, Worley B, Chung WH, Shear NH, Phillips EJ. SJS/TEN 2017: Building Multidisciplinary Networks to Drive Science and Translation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:38-69. [PMID: 29310768 PMCID: PMC5857362 DOI: 10.1016/j.jaip.2017.11.023] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 12/17/2022]
Abstract
Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a life-threatening, immunologically mediated, and usually drug-induced disease with a high burden to individuals, their families, and society with an annual incidence of 1 to 5 per 1,000,000. To effect significant reduction in short- and long-term morbidity and mortality, and advance clinical care and research, coordination of multiple medical, surgical, behavioral, and basic scientific disciplines is required. On March 2, 2017, an investigator-driven meeting was held immediately before the American Academy of Dermatology Annual meeting for the central purpose of assembling, for the first time in the United States, clinicians and scientists from multiple disciplines involved in SJS/TEN clinical care and basic science research. As a product of this meeting, this article summarizes the current state of knowledge and expert opinion related to SJS/TEN covering a broad spectrum of topics including epidemiology and pharmacogenomic networks; clinical management and complications; special populations such as pediatrics, the elderly, and pregnant women; regulatory issues and the electronic health record; new agents that cause SJS/TEN; pharmacogenomics and immunopathogenesis; and the patient perspective. Goals include the maintenance of a durable and productive multidisciplinary network that will significantly further scientific progress and translation into prevention, early diagnosis, and management of SJS/TEN.
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Affiliation(s)
- Katie D White
- Vanderbilt University Medical Center, Nashville, Tenn
| | - Riichiro Abe
- Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | | | - Thomas Beachkofsky
- Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, San Antonio, Texas
| | | | - Bruce Carleton
- University of British Columbia, Vancouver, British Columbia, Canada; B.C. Children's Hospital, British Columbia, Vancouver, British Columbia, Canada
| | - James Chodosh
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass
| | - Ricardo Cibotti
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Md
| | - Robert Davis
- University of Tennessee Health Sciences, Memphis, Tenn
| | | | - Roni P Dodiuk-Gad
- Emek Medical Center, Technion-Institute of Technology, Afula, Israel; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - James H Holmes
- Wake Forest Baptist Medical Center, Winston-Salem, NC; Wake Forest University School of Medicine, Winston-Salem, NC
| | | | | | | | - Simon Mallal
- Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Teri A Manolio
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Md; F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md
| | | | | | - Maja Mockenhaupt
- Medical Center and Medical Faculty-University of Freiburg, Freiburg, Germany
| | | | - Rebecca Pavlos
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | | | - Elena Pope
- University of Toronto, Toronto, Ontario, Canada; Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alec Redwood
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | | | | | | | | | - Hajirah N Saeed
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass
| | - Jeffery P Struewing
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Md
| | | | | | - Cynthia Sung
- Duke-NUS Medical School, Singapore, Singapore; Health Sciences Authority, Singapore, Singapore
| | - Jason A Trubiano
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | | | - Lisa M Wheatley
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | | | | | | | - Neil H Shear
- Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia.
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Treatments for Severe Cutaneous Adverse Reactions. J Immunol Res 2017; 2017:1503709. [PMID: 29445753 PMCID: PMC5763067 DOI: 10.1155/2017/1503709] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 11/16/2017] [Indexed: 12/17/2022] Open
Abstract
Severe cutaneous adverse reaction (SCAR) is life-threatening. It consists of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), and generalized bullous fixed drug eruptions (GBFDE). In the past years, emerging studies have provided better understandings regarding the pathogenesis of these diseases. These diseases have unique presentations and distinct pathomechanisms. Therefore, theoretically, the options of treatments might be different among various SCARs. However, due to the rarity of these diseases, sufficient evidence is still lacking to support the best choice of treatment for patients with SCAR. Herein, we will provide a concise review with an emphasis on the characteristics and treatments of each SCAR. It may serve as a guidance based on the current best of knowledge and may shed light on the directions for further investigations.
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Improving mortality outcomes of Stevens Johnson syndrome/toxic epidermal necrolysis: A regional burns centre experience. Burns 2017; 44:603-611. [PMID: 29029855 DOI: 10.1016/j.burns.2017.09.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/25/2017] [Accepted: 09/15/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Stevens Johnson Syndrome/toxic epidermal necrolysis (SJS/TEN) are rare, potentially fatal desquamative disorders characterised by large areas of partial thickness skin and mucosal loss. The degree of epidermal detachment that occurs has led to SJS/TEN being described as a burn-like condition. These patients benefit from judicious critical care, early debridement and meticulous wound care. This is best undertaken within a multidisciplinary setting led by clinicians experienced in the management of massive skin loss and its sequelae. In this study, we examined the clinical outcomes of SJS/TEN overlap & TEN patients managed by our regional burns service over a 12-year period. We present our treatment model for other burn centres treating SJS/TEN patients. METHODS A retrospective case review was performed for all patients with a clinical diagnosis of TEN or SJS/TEN overlap admitted to our paediatric and adult burns centre between June 2004 and December 2016. Patient demographics, percentage total body surface area (%TBSA), mucosal involvement, causation, severity of illness score (SCORTEN), length of stay and survival were appraised with appropriate statistical analysis performed using Graph Pad Prism 7.02 Software. RESULTS During the study period, 42 patients (M26; F: 16) with TEN (n=32) and SJS/TEN overlap (n=10) were managed within our burns service. Mean %TBSA of cutaneous involvement was 57% (range 10-100%) and mean length of stay (LOS) was 27 days (range 1-144 days). We observed 4 deaths in our series compared to 16 predicted by SCORTEN giving a standardised mortality ratio (SMR) of 24%. CONCLUSION Management in our burns service with an aggressive wound care protocol involving debridement of blistered epidermis and wound closure with synthetic and biological dressings seems to have produced benefits in mortality when compared to predicted outcomes.
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Cartotto R. Burn Center Care of Patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Clin Plast Surg 2017; 44:583-595. [DOI: 10.1016/j.cps.2017.02.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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17
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Creamer D, Walsh SA, Dziewulski P, Exton LS, Lee HY, Dart JKG, Setterfield J, Bunker CB, Ardern-Jones MR, Watson KMT, Wong GAE, Philippidou M, Vercueil A, Martin RV, Williams G, Shah M, Brown D, Williams P, Mohd Mustapa MF, Smith CH. U.K. guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016. Br J Dermatol 2017; 174:1194-227. [PMID: 27317286 DOI: 10.1111/bjd.14530] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 12/11/2022]
Affiliation(s)
- D Creamer
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - S A Walsh
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - P Dziewulski
- St Andrews Centre for Plastic Surgery and Burns, Mid Essex Hospital Services NHS Trust, Chelmsford, CM1 7ET, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - H Y Lee
- Dermatology Unit, Singapore General Hospital, Singapore
| | - J K G Dart
- Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, U.K
| | - J Setterfield
- Mucosa and Salivary Biology, Dental Institute, King's College London, Guy's Campus, Great Maze Pond, London, SE1 9RT, U.K
| | - C B Bunker
- University College Hospital, London, NW1 2BU, U.K
| | - M R Ardern-Jones
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, U.K
| | - K M T Watson
- Department of Dermatology, Orpington Hospital, Orpington, Kent, BR6 9JU, U.K
| | - G A E Wong
- Department of Dermatology, University Hospital of South Manchester NHS Foundation Trust, Manchester, M23 9LT, U.K
| | - M Philippidou
- Department of Histopathology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - A Vercueil
- Intensive Care Medicine, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - R V Martin
- St Andrews Centre for Plastic Surgery and Burns, Mid Essex Hospital Services NHS Trust, Chelmsford, CM1 7ET, U.K
| | - G Williams
- Late of the Burns Centre, Chelsea and Westminster NHS Foundation Trust, London, SW10 9NH, U.K
| | - M Shah
- Department of Burns and Plastic Surgery, University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, M23 9LT, U.K
| | - D Brown
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
| | - P Williams
- Department of Dermatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London, W1T 5HQ, U.K
| | - C H Smith
- St John's Institute of Dermatology, Guy's and St Thomas NHS Foundation Trust, London, SE1 9RT, U.K
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Schneider JA, Cohen PR. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Concise Review with a Comprehensive Summary of Therapeutic Interventions Emphasizing Supportive Measures. Adv Ther 2017; 34:1235-1244. [PMID: 28439852 PMCID: PMC5487863 DOI: 10.1007/s12325-017-0530-y] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are two of the most severe dermatologic conditions occurring in the inpatient setting. There is a lack of consensus regarding appropriate management of SJS and TEN. PURPOSE The scientific literature pertaining to SJS and TEN (subsequently referred to as SJS/TEN) is summarized and assessed. In addition, an interventional approach for the clinician is provided. METHODS PubMed was searched with the key words: corticosteroids, cyclosporine, etanercept, intravenous immunoglobulin, Stevens-Johnson syndrome, and toxic epidermal necrolysis. The papers generated by the search, and their references, were reviewed. RESULTS Supportive care is the most universally accepted intervention for SJS/TEN. Specific guidelines differ from the care required for patients with thermal burns. Adjuvant therapies are utilized in most severe cases, but the data are thus far underwhelming and underpowered. Using systemic corticosteroids as sole therapy is not supported. A consensus regarding combined corticosteroids and intravenous immunoglobulin (IVIG) has not been reached. Data regarding IVIG, currently the standard of care for most referral centers, is conflicting. Newer studies regarding cyclosporine and tumor necrosis factor inhibitors are promising, but not powered to provide definitive evidence of efficacy. Data regarding plasmapheresis is equivocal. Thalidomide increases mortality. CONCLUSION Clinicians who manage SJS/TEN should seek to employ interventions with the greatest impact on their patients' condition. While supportive care measures may seem an obvious aspect of SJS/TEN patient care, providers should understand that these interventions are imperative and that they differ from the care recommended for other critically ill or burn patients. While adjuvant therapies are frequently discussed and debated for hospitalized patients with SJS/TEN, a standardized management approach is not yet clear based on the current data. Therefore, until further data are available, decisions regarding such treatments should be made on a case-by-case basis.
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Affiliation(s)
- Jeremy A Schneider
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA
| | - Philip R Cohen
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA.
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Ye LP, Zhang C, Zhu QX. The Effect of Intravenous Immunoglobulin Combined with Corticosteroid on the Progression of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Meta-Analysis. PLoS One 2016; 11:e0167120. [PMID: 27902746 PMCID: PMC5130247 DOI: 10.1371/journal.pone.0167120] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 11/09/2016] [Indexed: 01/04/2023] Open
Abstract
Background Intravenous immunoglobulin (IVIG) treatment is commonly used to treat Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) with controversial therapeutic effect. Methods We conducted a comprehensive meta-analysis through combining the published eligible studies to evaluate the effectiveness of IVIG on SJS and TEN treatment. Results A total of 26 studies were selected from public available databases. The combination of IVIG and corticosteroid markedly reduced the recovery time (by 1.63 days, 95% CI: 0.83–2.43, P < 0.001), compared with solo corticosteroid group. The favorable effects were greater in Asian (2.19, 95% CI: 1.41–2.97, P < 0.001), TEN (2.56, 95% CI: 0.35–4.77, P = 0.023) and high-dose IVIG treated individuals (1.78, 95% CI: 0.42–3.14, P = 0.010). The hospitalization length reduced by 3.19 days (95% CI: 0.08–6.30, P = 0.045), though the outcome was proven to be unstable. We found heterogeneities, which sources were probably regional factors. Besides, IVIG was inclined to decrease SJS/TEN mortality (SMR: 0.84, 95% CI: 0.66–1.08, P = 0.178). This impact was possibly more profound when patients were treated with high dose IVIG (SMR: 0.74, 95% CI: 0.50–1.08, P = 0.116), or when patients were diagnosed as TEN (SMR: 0.68, 95% CI: 0.45–1.01, P = 0.058). Conclusions Our current meta-analysis suggests that IVIG combined with corticosteroid could reduce recovery time for SJS and TEN. This effect is greater among Asian patients. Whereas, its impact on reducing mortality is not significant.
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Affiliation(s)
- Liang-ping Ye
- Institute of Dermatology and Department of Dermatology at No.1 Hospital, Anhui Medical University, Hefei, Anhui, China
- Physical Examination Centre, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Cheng Zhang
- Department of Occupational and Environmental Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Qi-xing Zhu
- Institute of Dermatology and Department of Dermatology at No.1 Hospital, Anhui Medical University, Hefei, Anhui, China
- Department of Occupational and Environmental Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
- * E-mail: . (QXZ)
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20
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are a spectrum of T-cell mediated immune disorders. While the contributory mechanisms leading to the apoptosis of epidermal cells in SJS/TEN remain unproven, the keratinocyte apoptosis seen in SJS/TEN is thought to occur through the T-cell mediated Fas-Fas ligand (FasL), perforin/granzyme B, and other immune mediators. Most recently, emphasis has been placed on the granulysin pathway as being the primary mediator of apoptosis and widespread epidermal necrosis in SJS/TEN. This article aims to review the proposed mechanisms by which these pathways work and the immunomodulatory therapies that have been developed in an attempt to target them.
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Affiliation(s)
- Hajirah N Saeed
- a Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School , Boston , Massachusetts , USA
| | - James Chodosh
- a Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School , Boston , Massachusetts , USA
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Bai M, Yu Y, Huang C, Liu Y, Zhou M, Li Y, Ma F, Jing R, Zhao L, Li L, Wang P, He L, Sun S. Continuous venovenous hemofiltration combined with hemoperfusion for toxic epidermal necrolysis: a retrospective cohort study. J DERMATOL TREAT 2016; 28:353-359. [PMID: 27653468 DOI: 10.1080/09546634.2016.1240326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM The current treatments of toxic epidermal necrolysis (TEN) are limited to the discontinuation of a suspect medication and supportive measures. We conducted a retrospective study to evaluate the efficacy of adding continuous venovenous hemofiltration (CVVH) and hemoperfusion (HP) to the conventional treatment for TEN. METHODS TEN patients who were admitted to our center between January 2008 and May 2016 were considered as candidates. The included patients were divided into the CVVH&HP group (n = 34) and the conventional group (n = 34) according to their accepted therapies during hospital stay. RESULTS The patients in the conventional group had a significantly reduced 28-day survival proportion compared with patients in the CVVH&HP group (73.5 versus 91.2%, p = .047). The adjusted results demonstrated that the conventional group had a significantly higher risk of 28-day mortality as well. Moreover, patients in the CVVH&HP group were associated with significantly shorter hospital stay, rash, fever, and antibiotic durations. However, the addition of CVVH&HP to conventional treatment did not significantly increase the in-hospital cost. CONCLUSIONS In conclusion, CVVH&HP might be a safe and effective adjuvant therapy for TEN. Further well-designed studies are warranted to obtain robust evidence.
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Affiliation(s)
- Ming Bai
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Yan Yu
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Chen Huang
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Yirong Liu
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Meilan Zhou
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Yangping Li
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Feng Ma
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Rui Jing
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Lijuan Zhao
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Li Li
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Pengbo Wang
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Lijie He
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
| | - Shiren Sun
- a Department of Nephrology , Xijing Hospital, the Fourth Military Medical Univerisity , Shaanxi , China
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22
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe dermatologic reactions with mucocutaneous involvement that carry elevated mortality rates. They differ along a spectrum of severity based upon body surface area affected. These conditions, usually caused by a drug or infection, are believed to result from cell-mediated and often drug-specific cytotoxic reactions against keratinocytes, leading to widespread dermal-epidermal detachment. Studies attempting to identify potential curative therapies such as intravenous immune globulin (IVIG) and corticosteroids remain inconclusive. However, improved outcomes have been demonstrated by early withdrawal of offending medications, early transfer to an intensive care unit or burn unit, and aggressive supportive care. Due to the rare incidence of SJS and TEN, its recurrence among survivors hints at future vulnerability for these patients, and notorious offending medications should thus be avoided. This clinical review will highlight the diagnostic and therapeutic challenges posed by SJS and TEN, while emphasizing the need to maintain them high on the emergency medicine physician's differential. The review will also detail the supportive measures to take for preventing the rapid progression of mucocutaneous complications and subsequent sepsis-related mortality.
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23
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UK guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults 2016. J Plast Reconstr Aesthet Surg 2016; 69:e119-e153. [DOI: 10.1016/j.bjps.2016.01.034] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/14/2016] [Indexed: 12/13/2022]
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Jain R, Sharma N, Basu S, Iyer G, Ueta M, Sotozono C, Kannabiran C, Rathi VM, Gupta N, Kinoshita S, Gomes JAP, Chodosh J, Sangwan VS. Stevens-Johnson syndrome: The role of an ophthalmologist. Surv Ophthalmol 2016; 61:369-99. [PMID: 26829569 DOI: 10.1016/j.survophthal.2016.01.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 01/22/2016] [Accepted: 01/25/2016] [Indexed: 01/03/2023]
Abstract
Stevens-Johnson syndrome (SJS) is an acute blistering disease of the skin and mucous membranes. Acute SJS leads to the acute inflammation of the ocular surface and chronic conjunctivitis. If not properly treated, it causes chronic cicatricial conjunctivitis and cicatricial lid margin abnormalities. Persistent inflammation and ulceration of the ocular surface with cicatricial complications of the lids leads to chronic ocular sequelae, ocular surface damage, and corneal scarring. The destruction of the glands that secrete the tear film leads to a severe form of dry eye that makes the management of chronic SJS difficult. The option that is routinely used for corneal visual rehabilitation, keratoplasty, is best avoided in such cases. We describe the management strategies that are most effective during the acute and chronic stages of SJS. Although treatments for acute SJS involve immunosuppressive and immunomodulatory therapies, amniotic membrane transplantation is also useful. The options for visual rehabilitation in patients with chronic SJS are undergoing radical change. We describe the existing literature regarding the management of SJS and highlight recent advances in the management of this disorder.
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Affiliation(s)
- Rajat Jain
- Cornea, Ocular Surface and Anterior Segment Services, Department of Ophthalmology, drishtiCONE Eye Care, New Delhi, India
| | - Namrata Sharma
- Cornea and Refractive Surgery Services, Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Sayan Basu
- Cornea and Anterior Segment Services, Department of Ophthalmology, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Geetha Iyer
- C J Shah Cornea Services, Department of Ophthalmology, Dr. G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, Chennai, India
| | - Mayumi Ueta
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Ophthalmology, Doshisha University, Kyotanabe, Japan
| | - Chie Sotozono
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Chitra Kannabiran
- Department of Ophthalmology, Kallam Anji Reddy Molecular Genetics Laboratory, L V Prasad Eye Institute (LVPEI), Hyderabad, Telangana, India
| | - Varsha M Rathi
- Cornea Services, Department of Ophthalmology, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Nidhi Gupta
- Department of Ophthalmology, Dr. Shroff Charity Eye Hospital, Delhi, India
| | - Shigeru Kinoshita
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - José A P Gomes
- Cornea and External Disease Service, Department of Ophthalmology, Federal University of Sao Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil; Advanced Ocular Surface Center (CASO), Department of Ophthalmology, Federal University of Sao Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Virender S Sangwan
- Department of Ophthalmology, Srujana Center for Innovation, L V Prasad Eye Institute, Hyderabad, Telangana, India.
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Williams R, Hodge J, Ingram W. Indications for intubation and early tracheostomy in patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Am J Surg 2016; 211:684-688.e1. [PMID: 26860621 DOI: 10.1016/j.amjsurg.2015.12.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) result in epidermal sloughing and mucositis. There are no published guidelines for intubation and early tracheostomy in this patient population. METHODS A retrospective chart review of 40 patients admitted from 2010 to 2015 with SJS and TEN was conducted. Descriptive statistics and significance were calculated. RESULTS Of the 43% of patients who underwent early tracheostomy, 100% had oral involvement while the initial total body surface area (TBSA) was 70% or more in 41% of patients (P < .05). TBSA progressed 15% or more in 53% of patients with 6% having airway involvement and a neurologic diagnosis mandating intubation. Mortality was 17%. CONCLUSIONS Indications for intubation and early tracheostomy for SJS and TEN are documented oral involvement plus one of the following: initial TBSA 70% or more; progression of TBSA involved from hospital day 1 to hospital day 3, 15% TBSA or more; underlying neurologic diagnosis preventing airway protection; and documented airway involvement on direct laryngoscopy.
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Affiliation(s)
- Rachael Williams
- Emory University School of Medicine and Grady Health System, 69 Jesse Hill Jr. Drive, SE, Atlanta, GA, 30303, USA.
| | - Juvonda Hodge
- Emory University School of Medicine and Grady Health System, 69 Jesse Hill Jr. Drive, SE, Atlanta, GA, 30303, USA
| | - Walter Ingram
- Emory University School of Medicine and Grady Health System, 69 Jesse Hill Jr. Drive, SE, Atlanta, GA, 30303, USA
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Kohanim S, Palioura S, Saeed HN, Akpek EK, Amescua G, Basu S, Blomquist PH, Bouchard CS, Dart JK, Gai X, Gomes JAP, Gregory DG, Iyer G, Jacobs DS, Johnson AJ, Kinoshita S, Mantagos IS, Mehta JS, Perez VL, Pflugfelder SC, Sangwan VS, Sippel KC, Sotozono C, Srinivasan B, Tan DTH, Tandon R, Tseng SCG, Ueta M, Chodosh J. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis--A Comprehensive Review and Guide to Therapy. I. Systemic Disease. Ocul Surf 2015; 14:2-19. [PMID: 26549248 DOI: 10.1016/j.jtos.2015.10.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 09/01/2015] [Accepted: 10/15/2015] [Indexed: 01/06/2023]
Abstract
The intent of this review is to comprehensively appraise the state of the art with regard to Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to the ocular surface complications and their management. SJS and TEN represent two ends of a spectrum of immune-mediated, dermatobullous disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. The widespread keratinocyte death seen in SJS/TEN is rapid and irreversible, and even with early and aggressive intervention, morbidity is severe and mortality not uncommon. We have divided this review into two parts. Part I summarizes the epidemiology and immunopathogenesis of SJS/TEN and discusses systemic therapy and its possible benefits. We hope this review will help the ophthalmologist better understand the mechanisms of disease in SJS/TEN and enhance their care of patients with this complex and often debilitating disease. Part II (April 2016 issue) will focus on ophthalmic manifestations.
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Affiliation(s)
- Sahar Kohanim
- Vanderbilt Eye Institute, Vanderbilt University School of Medicine, Nashville, TN
| | - Sotiria Palioura
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Hajirah N Saeed
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | - Esen K Akpek
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Guillermo Amescua
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Sayan Basu
- LV Prasad Eye Institute, Hyderabad, India
| | | | | | - John K Dart
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - Xiaowu Gai
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | | | - Darren G Gregory
- Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, Aurora, CO
| | - Geetha Iyer
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, India
| | - Deborah S Jacobs
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA; Boston Foundation for Sight, Boston, MA
| | | | | | | | - Jodhbir S Mehta
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
| | - Victor L Perez
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | - Chie Sotozono
- Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Bhaskar Srinivasan
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, Sankara Nethralaya, India
| | - Donald T H Tan
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore
| | - Radhika Tandon
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Delhi, India
| | - Scheffer C G Tseng
- Ocular Surface Center, Ocular Surface Research & Education Foundation, Miami, FL
| | - Mayumi Ueta
- Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - James Chodosh
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.
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Aihara M, Kano Y, Fujita H, Kambara T, Matsukura S, Katayama I, Azukizawa H, Miyachi Y, Endo Y, Asada H, Miyagawa F, Morita E, Kaneko S, Abe R, Ochiai T, Sueki H, Watanabe H, Nagao K, Aoyama Y, Sayama K, Hashimoto K, Shiohara T. Efficacy of additional i.v. immunoglobulin to steroid therapy in Stevens-Johnson syndrome and toxic epidermal necrolysis. J Dermatol 2015; 42:768-77. [PMID: 25982480 DOI: 10.1111/1346-8138.12925] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/25/2015] [Indexed: 01/11/2023]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and life-threatening cutaneous adverse drug reactions. While there is no established therapy for SJS/TEN, systemic corticosteroids, plasma exchange and i.v. immunoglobulin (IVIG) have been used as treatment. The efficacy of IVIG is still controversial because total doses of IVIG used vary greatly from one study to another. The aim of this study was to evaluate the efficacy of IVIG, administrated for 5 days consecutively, in an open-label, multicenter, single-arm study in patients with SJS or TEN. IVIG (400 mg/kg per day) administrated for 5 days consecutively was performed as an additional therapy to systemic steroids in adult patients with SJS or TEN. Efficacy on day 7 of IVIG was evaluated. Parameters to assess clinical outcome were enanthema including ophthalmic and oral lesions, cutaneous lesions and general condition. These parameters were scored and recorded before and after IVIG. We enrolled five patients with SJS and three patients with TEN who did not respond sufficiently to systemic steroids before IVIG administration. All of the patients survived and the efficacy on day 7 of the IVIG was 87.5% (7/8 patients). Prompt amelioration was observed in skin lesions and enanthema in the patients in whom IVIG therapy was effective. Serious side-effects from the use of IVIG were not observed. IVIG (400 mg/kg per day) administrated for 5 days consecutively seems to be effective in patients with SJS or TEN. IVIG administrated together with steroids should be considered as a treatment modality for patients with refractory SJS/TEN. Further studies are needed to define the therapeutic efficacy of IVIG.
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Affiliation(s)
- Michiko Aihara
- Department of Dermatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yoko Kano
- Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Hiroyuki Fujita
- Department of Dermatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Takeshi Kambara
- Department of Dermatology, Yokohama City University Medical Center, Yokohama, Japan
| | - Setsuko Matsukura
- Department of Dermatology, Yokohama City University Medical Center, Yokohama, Japan
| | - Ichiro Katayama
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Azukizawa
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Miyachi
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuichiro Endo
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hideo Asada
- Department of Dermatology, Nara Medical University, Kashihara, Japan
| | - Fumi Miyagawa
- Department of Dermatology, Nara Medical University, Kashihara, Japan
| | - Eishin Morita
- Department of Dermatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Sakae Kaneko
- Department of Dermatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Riichiro Abe
- Department of Dermatology, Hokkaido University School of Medicine, Sapporo, Japan
| | - Toyoko Ochiai
- Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hirohiko Sueki
- Department of Dermatology, Showa University School of Medicine, Tokyo, Japan
| | - Hideaki Watanabe
- Department of Dermatology, Showa University School of Medicine, Tokyo, Japan
| | - Keisuke Nagao
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yumi Aoyama
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Sayama
- Department of Dermatology, Ehime University School of Medicine, Ehime, Japan
| | - Koji Hashimoto
- Ehime Prefectural University of Health Sciences, Ehime, Japan
| | - Tetsuo Shiohara
- Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan
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Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis. CUTANEOUS DRUG ERUPTIONS 2015. [PMCID: PMC7121137 DOI: 10.1007/978-1-4471-6729-7_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Erythema multiforme in its most extreme form has traditionally been divided between toxic epidermal necrolysis and Stevens-Johnson Syndrome. These two life-threatening skin diseases are now considered part of the same spectrum of disease. They can be differentiated by clinical and histological criteria. We can also now predict which patients are apt to have the most guarded prognosis. Treatment by multiple agents is imperfect, but offers a better chance of a good outcome than ever before.
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Sun J, Liu J, Gong QL, Ding GZ, Ma LW, Zhang LC, Lu Y. Stevens-Johnson Syndrome and toxic epidermal necrolysis: a multi-aspect comparative 7-year study from the People's Republic of China. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:2539-47. [PMID: 25548516 PMCID: PMC4271784 DOI: 10.2147/dddt.s71736] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Stevens–Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but severe cutaneous drug reactions. They are differentiated based on the fraction of the body surface area affected. Optimal therapy for SJS and TEN is a controversial issue. Objective We compared the treatments given to and the clinical outcomes of 39 cases of SJS and 48 cases of TEN seen at a single institution between January 2007 and December 2013 for better understanding of the clinical characteristics and development of the two conditions. Methods Demographic data, clinical characteristics, treatments given, and therapeutic responses observed were retrospectively collected. Results The incidence rates of hypoproteinemia and secondary infections are significantly higher in TEN than in SJS (P=0.001 and P=0.002, respectively). The corticosteroid dose did not influence the time from the initiation of therapy to control of the lesions in SJS, but increasing the dosage of corticosteroids progressively decreased the time from the initiation of therapy to control of the lesions in TEN. With increases in the utilization ratio of intravenous immunoglobulin (IVIG), the length of the hospital stay became shorter, whereas the time from the initiation of therapy to control of the lesions remained the same in SJS. However, for TEN, both the length of the hospital stay and the time from the initiation of therapy to control of the lesions became shorter with increases in the utilization ratio of IVIG. Conclusion SJS and TEN are two variants of the same spectrum, and they differ from each other not only in the severity of epidermal detachment but also in other clinical parameters and their distinct clinical courses. Thus, differential treatment of both conditions may have benefits for their prognosis.
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Affiliation(s)
- Jie Sun
- Department of Dermatology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, People's Republic of China
| | - Jin Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu Province, People's Republic of China
| | - Qing-Li Gong
- Department of Dermatology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, People's Republic of China
| | - Gao-Zhong Ding
- Department of Dermatology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, People's Republic of China
| | - Li-Wen Ma
- Department of Dermatology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, People's Republic of China
| | - Li-Chao Zhang
- Department of Dermatology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, People's Republic of China
| | - Yan Lu
- Department of Dermatology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, People's Republic of China
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Kim DH, Yoon KC, Seo KY, Lee HS, Yoon SC, Sotozono C, Ueta M, Kim MK. The role of systemic immunomodulatory treatment and prognostic factors on chronic ocular complications in Stevens-Johnson syndrome. Ophthalmology 2014; 122:254-64. [PMID: 25262319 DOI: 10.1016/j.ophtha.2014.08.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 06/24/2014] [Accepted: 08/04/2014] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To compare the effect of early systemic immunomodulatory treatment and to identify prognostic factors of chronic ocular complications in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) patients. DESIGN Retrospective, comparative, multicenter study. PARTICIPANTS Forty-three patients admitted to 1 of 3 University Hospitals (Seoul National University Hospital, Chonnam National University Hospital, and Yonsei University Hospital) with a diagnosis of SJS or TEN who were followed up for at least 6 months in Korea. METHODS Patients were divided into 5 groups according to systemic immunomodulatory treatment received: systemic steroids (S), intravenous immunoglobulin (IVIG), combined S plus IVIG, systemic pulse steroids (PS), and supportive care only (C). Best-corrected visual acuity (BCVA) and chronic ocular surface complications score (COCS; range, 0-15) at final follow-up were compared among the 5 groups. Prognostic factors at onset (age, gender, causative drugs, initial visual acuities, acute ocular involvement score [range, 0-3], acute systemic involvement score [range, 0-16], systemic steroid dose, IVIG dose, and amniotic membrane transplantation [AMT]) were analyzed to predict final BCVA or COCS using logistic regression or linear regression analysis. MAIN OUTCOME MEASURES Best-corrected visual acuity and COCS at final follow-up. RESULTS The mean age and follow-up period of the patients was 30.5±21.0 years and 29.1±30.4 months, respectively. The acute systemic involvement score in the IVIG, S plus IVIG, and PS groups was significantly higher than that in the S and C groups (P < 0.001). However, final BCVA and COCS were not significantly different between groups, even after statistical adjustment. High COCS (≥8 points) was associated with female gender (P = 0.012) and AMT at the acute stage (P = 0.040). High acute ocular and systemic involvement scores were associated with worse COCS (P < 0.001), and COCS showed good correlation with final BCVA (R(2) = 0.7101; P < 0.0001). CONCLUSIONS There were no therapeutic benefits of systemic immunomodulatory treatments in final visual outcome and COCS in SJS and TEN patients. Female gender and acute ocular and systemic involvement scores may be prognostic factors predicting chronic ocular complications.
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Affiliation(s)
- Dong Hyun Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea; Laboratory of Ocular Regenerative Medicine and Immunology, Seoul Artificial Eye Center, Seoul National University Hospital Clinical Research Institute, Seoul, Korea
| | - Kyung Chul Yoon
- Department of Ophthalmology, Chonnam National University Medical School, Gwangju, Korea
| | - Kyoung Yul Seo
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea.
| | - Hyo Seok Lee
- Department of Ophthalmology, Chonnam National University Medical School, Gwangju, Korea
| | - Sang Chul Yoon
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
| | - Chie Sotozono
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mayumi Ueta
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mee Kum Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea; Laboratory of Ocular Regenerative Medicine and Immunology, Seoul Artificial Eye Center, Seoul National University Hospital Clinical Research Institute, Seoul, Korea.
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Roujeau JC, Bastuji-Garin S. Systematic review of treatments for Stevens-Johnson syndrome and toxic epidermal necrolysis using the SCORTEN score as a tool for evaluating mortality. Ther Adv Drug Saf 2014; 2:87-94. [PMID: 25083204 DOI: 10.1177/2042098611404094] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Epidermal necrolysis, whether involving limited, that is, Stevens-Johnson syndrome (SJS), or large, that is, toxic epidermal necrolysis (TEN), areas of the skin surface, is associated with high mortality. A specific prognosis score (SCORTEN) accurately predicts mortality. Management of SJS and TEN mainly relies on supportive care but several treatments have been proposed, particularly corticosteroids and intravenous immunoglobulins (IVIG), to block the progression of the disease. The aim of this study was a pooled analysis of published series addressing the question of treatment efficacy by comparing the mortality observed to the mortality predicted by the SCORTEN score. A literature search was carried out through PubMed from January 2001 to December 2009. It found 47 original series including at least 10 patients. Among these, 13 containing a clear description of treatment(s) and an evaluation of SCORTEN score were analyzed allowing the calculation of a mortality ratio (MR) for each series and a pooled MR with 95% confidence interval (CI) for each treatment. The analyzed series comprised a total of 439 patients. Supportive care was used only in 199 patients with a pooled MR of 0.89 (CI 0.67-1.16, p = 0.43), corticosteroids were administered to 78 patients with a pooled MR of 0.92 (CI 0.53-1.48, p = 0.84), and IVIG in 162 with a pooled MR of 0.82 (CI 0.58-1.12, p = 0.23). In conclusion, even though this analysis had some limitations, it strongly suggested that neither corticosteroids nor IVIG provide any important reduction in the risk of dying from SJS and TEN.
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Affiliation(s)
- Jean-Claude Roujeau
- Laboratoire d'Investigation Clinique, Université Paris Est Créteil (UPEC), 94010 Créteil Cedex, France
| | - Sylvie Bastuji-Garin
- Laboratoire d'Investigation Clinique, Université Paris Est Créteil (UPEC), EA 4393, and Pôle Recherche Clinique - Santé Publique, Hôpital Henri-Mondor, 94010 Créteil Cedex, France
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Paradisi A, Abeni D, Bergamo F, Ricci F, Didona D, Didona B. Etanercept therapy for toxic epidermal necrolysis. J Am Acad Dermatol 2014; 71:278-83. [PMID: 24928706 DOI: 10.1016/j.jaad.2014.04.044] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/13/2014] [Accepted: 04/15/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Toxic epidermal necrolysis (TEN) is a severe and potentially lethal drug reaction for which no standard treatment is available. OBJECTIVE To describe a case series of patients with TEN treated with a single dose of etanercept. METHODS We observed 10 consecutive patients with TEN. For each patient, we recorded the presence of comorbidities and all the drugs recently started (ie, in the last month). In all cases, 50 mg of etanercept was administered in a single subcutaneous injection. The clinical severity of disease was computed using the SCORe of Toxic Epidermal Necrosis (SCORTEN) scale. Using the probabilities of death linked to each level of SCORTEN score, we calculated the expected probability of death in our patients. Healing was defined as complete reepithelialization, and a time to healing curve was then obtained using the Kaplan-Meier method. RESULTS All patients promptly responded to treatment, reaching complete reepithelialization without complications or side effects. The median time to healing was 8.5 days. LIMITATIONS This is a small, uncontrolled case series. CONCLUSION These preliminary results suggest the possibility that tumor necrosis factor-alfa may be an effective target for control of TEN, a dangerous skin condition for which no effective cure has yet been found.
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Affiliation(s)
| | - Damiano Abeni
- Health Services Research Unit, IDI-IRCCS, Rome, Italy
| | | | - Francesco Ricci
- Department of Dermatology, Catholic University of the Sacred Heart, Rome, Italy
| | - Dario Didona
- Department of Dermatology, "La Sapienza" University, Rome, Italy
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Barron SJ, Del Vecchio MT, Aronoff SC. Intravenous immunoglobulin in the treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis: a meta-analysis with meta-regression of observational studies. Int J Dermatol 2014; 54:108-15. [PMID: 24697283 DOI: 10.1111/ijd.12423] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe disorders with significant morbidity and mortality. The therapeutic use of intravenous immunoglobulin (IVIG) is based on limited data. OBJECTIVES This systematic review evaluates the existing literature to determine if IVIG impacts the standardized mortality rate (SMR) in patients with SJS or TEN. METHODS The MEDLINE database was searched for the period 1966-2011 for pertinent studies. The bibliographies of selected references were also reviewed for additional studies. Inclusion criteria required the studies to refer to patients who received IVIG for SJS or TEN, the severity of which was determined using the SCORTEN system. Thirteen studies were used in the final analysis. Demographic data, IVIG dosing, SCORTEN score, and mortality rates were extracted. RESULTS Of the 13 studies, eight included a control group. Meta-analysis revealed that differences in SMRs were not significant (-0.322, 95% confidence interval [CI] -0.766 to 0.122; P = 0.155). The overall SMR point estimate for all 13 studies was 0.814 (95% CI 0.617-1.076). Meta-regression demonstrated a strong inverse correlation between IVIG dosage and SMRs (slope: -0.59, 95% CI -0.14 to -1.03; P = 0.009). CONCLUSIONS Intravenous IG at dosages of ≥2 g/kg appears to significantly decrease mortality in patients with SJS or TEN.
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Affiliation(s)
- Stacy J Barron
- Department of Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
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Mahar PD, Wasiak J, Hii B, Cleland H, Watters DA, Gin D, Spinks AB. A systematic review of the management and outcome of toxic epidermal necrolysis treated in burns centres. Burns 2014; 40:1245-54. [PMID: 24685065 DOI: 10.1016/j.burns.2014.02.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 12/20/2013] [Accepted: 02/11/2014] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Toxic epidermal necrolysis (TEN) is a rare condition characterised by mucocutaneous exfoliation of greater than 30% total body surface area (%TBSA), increasingly being treated in burns centres. The rate of mortality varies significantly in the literature, with recent prospective studies in non-burns centres reporting percentage mortality of approximately 45%. We undertook a systematic review of published studies that included TEN patients treated specifically in burns centres to determine a cumulative mortality rate. METHODS Electronic searches of MEDLINE, EMBASE and The Cochrane Library (Issue 4, 2010) databases from 1966 onwards were used to identify English articles related to the treatment of TEN in burns centres. RESULTS The systematic literature search identified 20 studies which specifically described patients with TEN grater than 30% %TBSA. Treatment regimens varied amongst studies, as did mortality. The overall percentage mortality of the combined populations was 30%. Risk factors commonly described as associated with mortality included age, %TBSA and delay to definitive treatment. CONCLUSION The review highlights the variation between principles of treatment and mortality amongst burns centres. It offers a standard that burns centre can use to internationally compare their mortality rates. The review supports the ongoing reporting of outcomes in TEN patients with epidermal detachment greater than 30%.
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Affiliation(s)
- Patrick D Mahar
- Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Dermatology, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, School of Medicine, Faculty of Health, Deakin University, Victoria, Australia.
| | - Jason Wasiak
- Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Belinda Hii
- Department of Plastic and Reconstructive Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Heather Cleland
- Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Central and Eastern Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - David A Watters
- Department of Surgery, School of Medicine, Faculty of Health, Deakin University, Victoria, Australia
| | - Douglas Gin
- Department of Dermatology, The Alfred Hospital, Melbourne, Victoria, Australia
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Trent JT, Ma F, Kerdel F, Fien S, French LE, Romanelli P, Kirsner RS. Dose of intravenous immunoglobulin and patient survival in SJS and toxic epidermal necrolysis. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.2.3.299] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cytotoxic proteins and therapeutic targets in severe cutaneous adverse reactions. Toxins (Basel) 2014; 6:194-210. [PMID: 24394640 PMCID: PMC3920257 DOI: 10.3390/toxins6010194] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 12/20/2013] [Accepted: 12/27/2013] [Indexed: 11/16/2022] Open
Abstract
Severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN), are rare but life-threatening conditions induced mainly by a variety of drugs. Until now, an effective treatment for SJS/TEN still remains unavailable. Current studies have suggested that the pathobiology of drug-mediated SJS and TEN involves major histocompatibility class (MHC) I-restricted activation of cytotoxic T lymphocytes (CTLs) response. This CTLs response requires several cytotoxic signals or mediators, including granulysin, perforin/granzyme B, and Fas/Fas ligand, to trigger extensive keratinocyte death. In this article, we will discuss the cytotoxic mechanisms of severe cutaneous adverse reactions and their potential applications on therapeutics for this disease.
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Schwartz RA, McDonough PH, Lee BW. Toxic epidermal necrolysis: Part II. Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment. J Am Acad Dermatol 2013; 69:187.e1-16; quiz 203-4. [PMID: 23866879 DOI: 10.1016/j.jaad.2013.05.002] [Citation(s) in RCA: 174] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/06/2013] [Accepted: 05/10/2013] [Indexed: 02/01/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a life-threatening, typically drug-induced, mucocutaneous disease. TEN has a high mortality rate, making early diagnosis and treatment of paramount importance. New but experimental diagnostic tools that measure serum granulysin and high-mobility group protein B1 (HMGB1) offer the potential to differentiate early TEN from other, less serious drug reactions, but these tests have not been validated and are not readily available. The mainstay of treatment for TEN involves discontinuation of the offending drug, specialized care in an intensive care unit or burn center, and supportive therapy. Pharmacogenetic studies have clearly established a link between human leukocyte antigen allotype and TEN. Human leukocyte antigen testing should be performed on patients of East Asian descent before the initiation of carbamezapine and on all patients before the initiation of abacavir. The effectiveness of systemic steroids, intravenous immunoglobulins, plasmapheresis, cyclosporine, biologics, and other agents is uncertain.
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Affiliation(s)
- Robert A Schwartz
- Dermatology, Preventive Medicine, and Pathology, Rutgers University New Jersey Medical School, Newark, New Jersey 07103-2714, USA.
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Ramasamy SN, Korb-Wells CS, Kannangara DRW, Smith MWH, Wang N, Roberts DM, Graham GG, Williams KM, Day RO. Allopurinol Hypersensitivity: A Systematic Review of All Published Cases, 1950–2012. Drug Saf 2013; 36:953-80. [DOI: 10.1007/s40264-013-0084-0] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Das S, Roy AK, Biswas I. A six-month prospective study to find out the treatment outcome, prognosis and offending drugs in toxic epidermal necrolysis from an urban institution in kolkata. Indian J Dermatol 2013; 58:191-3. [PMID: 23723468 PMCID: PMC3667280 DOI: 10.4103/0019-5154.110826] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Toxic epidermal necrolysis is the life-threatening dermatological emergency, most often an adverse cutaneous drug reaction with high mortality. A 6-month prospective study was conducted in our institution to find out the offending drugs, to assess the prognosis on admission using SCORTEN: Severity of illness score and to find out the treatment outcome. Anticonvulsants, NSAIDs and sulphonamides are the common offending agents; but in our study, 2 were due to homeopathic medicines. Out of 20 patients, on the date of admission SCORTEN prognostic score was 2 in 11 patients, 3 in 8 patients and 4 in 1 patient. Eighteen patients were treated with dexamethasone intramuscular injection and 2 patients got intravenous immunoglobulin (IVIG). All patients survived without any mortality. Though improvement was slightly faster with IVIG, early administration of corticosteroids was also of encouraging efficacy and should be considered in developing countries due to low cost. No mortality in our study suggests need to validate the SCORTEN index in our country in a large number of patients.
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Affiliation(s)
- Sudip Das
- Department of Dermatology, NRS Medical College, Kolkata, West Bengal, India
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Novaretti MCZ, Dinardo CL. Clinical applications of immunoglobulin: update. Rev Bras Hematol Hemoter 2012; 33:221-30. [PMID: 23049300 PMCID: PMC3415732 DOI: 10.5581/1516-8484.20110058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 03/28/2011] [Indexed: 11/27/2022] Open
Abstract
Human immunoglobulin is the most used blood product in the clinical practice. Immunoglobulin applications have increased quickly since the elucidation of its immunomodulatory and antiinflammatory properties which turned this blood product into a precious tool in the treatment of numerous diseases that present with humoral immune deficiency or that cause immune system dysfunction. Currently, the approved indications for Ig are: primary immunodeficiencies, secondary immunodeficiencies (multiple myeloma or chronic lymphoid leukemia), Kawasaki syndrome, immune thrombocytopenic purpura, Guillain Barré syndrome, graft-versus-host disease following bone marrow transplantation and repeat infections in HIV children. On the other hand, there are numerous "off-label" indications of immunoglobulin, which represent 20-60% of all clinical applications of this drug. It is important to study all these indications and, above all, the scientific evidence for its use, in order to provide patients with a new therapeutic option without burdening the health system. This review results from a wide selection of papers identified in the Pubmed and Lilacs scientific electronic databases. A group of descriptors were used from human immunoglobulin to the names of each disease that immunoglobulin is clinically applied. Our main objective is to list the numerous indications of immunoglobulin, both authorized and "off-label" and to analyze these indications in the light of the most recent scientific evidence.
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Huang YC, Li YC, Chen TJ. The efficacy of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis: a systematic review and meta-analysis. Br J Dermatol 2012; 167:424-32. [DOI: 10.1111/j.1365-2133.2012.10965.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Toxic epidermal necrolysis: Review of pathogenesis and management. J Am Acad Dermatol 2012; 66:995-1003. [DOI: 10.1016/j.jaad.2011.09.029] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 09/17/2011] [Accepted: 09/24/2011] [Indexed: 12/29/2022]
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Kim HI, Kim SW, Park GY, Kwon EG, Kim HH, Jeong JY, Chang HH, Lee JM, Kim NS. Causes and treatment outcomes of Stevens-Johnson syndrome and toxic epidermal necrolysis in 82 adult patients. Korean J Intern Med 2012; 27:203-10. [PMID: 22707893 PMCID: PMC3372805 DOI: 10.3904/kjim.2012.27.2.203] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 12/05/2011] [Accepted: 01/09/2012] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are predominantly known as medication-induced diseases. However, at our institution, we have experienced more cases of non-drug-related SJS and TEN than expected. Therefore, we studied the difference between non-drug-related and drug-related SJS and TEN in terms of clinical characteristics and prognoses. METHODS The etiologies, clinical characteristics, and treatment outcomes for 82 adult patients with SJS and TEN were retrospectively reviewed. RESULTS A total of 71 patients (86.6%) were classified as having SJS, and the other 11 patients (13.4%) were classified as having TEN. Drug-related cases were more common (43, 52.4%) than non-drug-related cases (39, 47.6%). Anticonvulsants (12/82, 14.6%) and antibiotics (9/82, 11%) were the most common causative medications. Anemia (p = 0.017) and C-reactive protein of ≥ 5 mg/dL (p = 0.026) were more common in the drug-related cases than in the non-drug-related cases. Intravenous steroid therapy was used as the main treatment regimen (70/82, 85.4%). Of the 82 patients, 8 (9.8%) died during the clinical course. A univariate analysis for mortality showed statistical significance for the following: kidney function abnormality, pneumonia, hemoglobin of < 10 g/dL, and combined underlying diseases. In a multivariate analysis, only pneumonia was statistically significant (odds ratio, 25.79; p = 0.009). CONCLUSIONS Drugs were the most frequent cause of these diseases. However, non-drug-related causes also contributed to a significant proportion of cases. Physicians should keep this in mind when documenting patient history. In addition, early recognition and treatment may be important for better outcomes.
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Affiliation(s)
- Hye-In Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Shin-Woo Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ga-Young Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Eu-Gene Kwon
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyo-Hoon Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ju-Young Jeong
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyun-Ha Chang
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jong-Myung Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Neung-Su Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Mockenhaupt M. The current understanding of Stevens-Johnson syndrome and toxic epidermal necrolysis. Expert Rev Clin Immunol 2012; 7:803-13; quiz 814-5. [PMID: 22014021 DOI: 10.1586/eci.11.66] [Citation(s) in RCA: 196] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Stevens-Johnson syndrome has long been considered to resemble erythema multiforme with mucosal involvement, but is now thought to form a single disease entity with toxic epidermal necrolysis. Although Stevens-Johnson syndrome is less severe, etiology, genetic susceptibility and pathomechanism are the same for Stevens-Johnson syndrome/toxic epidermal necrolysis. The condition is mainly caused by drugs, but also by infections and probably other risk factors not yet identified. Identification of the cause is important for the individual patient and in cases of drug-induced disease withdrawal of the inducing drug(s) has an impact on the patient's prognosis. If an infectious cause is suspected, adequate anti-infective treatment is needed. Besides this, supportive management is crucial to improve the patient's state, probably more than specific immunomodulating treatments. Despite all of the therapeutic efforts, mortality is high and increases with disease severity, patients' age and underlying medical conditions. Survivors may suffer from long-term sequelae such as strictures of mucous membranes including severe eye problems.
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Affiliation(s)
- Maja Mockenhaupt
- The German Registry on Severe Skin Reactions, Department of Dermatology, University of Freiburg, Freiburg, Germany.
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Abstract
OBJECTIVES The aims of this review are to summarize the definitions, causes, and clinical course as well as the current understanding of the genetic background, mechanism of disease, and therapy of toxic epidermal necrolysis and Stevens-Johnson syndrome. DATA SOURCES PubMed was searched using the terms toxic epidermal necrolysis, Stevens-Johnson syndrome, drug toxicity, drug interaction, and skin diseases. DATA SYNTHESIS Toxic epidermal necrolysis and Stevens-Johnson syndrome are acute inflammatory skin reactions. The onset is usually triggered by infections of the upper respiratory tract or by preceding medication, among which nonsteroidal anti-inflammatory agents, antibiotics, and anticonvulsants are the most common triggers. Initially the diseases present with unspecific symptoms, followed by more or less extensive blistering and shedding of the skin. Complete death of the epidermis leads to sloughing similar to that seen in large burns. Toxic epidermal necrolysis is the most severe form of drug-induced skin reaction and includes denudation of >30% of total body surface area. Stevens-Johnson syndrome affects <10%, whereas involvement of 10%-30% of body surface area is called Stevens-Johnson syndrome/toxic epidermal necrolysis overlap. Besides the skin, mucous membranes such as oral, genital, anal, nasal, and conjunctival mucosa are frequently involved in toxic epidermal necrolysis and Stevens-Johnson syndrome. Toxic epidermal necrolysis is associated with a significant mortality of 30%-50% and long-term sequelae. Treatment includes early admission to a burn unit, where treatment with precise fluid, electrolyte, protein, and energy supplementation, moderate mechanical ventilation, and expert wound care can be provided. Specific treatment with immunosuppressive drugs or immunoglobulins did not show an improved outcome in most studies and remains controversial. The mechanism of disease is not completely understood, but immunologic mechanisms, cytotoxic reactions, and delayed hypersensitivity seem to be involved. CONCLUSION Profound knowledge of exfoliative skin diseases is needed to improve therapy and outcome of these life-threatening illnesses.
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Zajicek R, Pintar D, Broz L, Suca H, Königova R. Toxic epidermal necrolysis and Stevens-Johnson syndrome at the Prague Burn Centre 1998-2008. J Eur Acad Dermatol Venereol 2011; 26:639-43. [DOI: 10.1111/j.1468-3083.2011.04143.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Worswick S, Cotliar J. Stevens-Johnson syndrome and toxic epidermal necrolysis: a review of treatment options. Dermatol Ther 2011; 24:207-18. [DOI: 10.1111/j.1529-8019.2011.01396.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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