Sjögren-like pluriglandular exocrine insufficiency after drug-induced toxic epidermal necrolysis

Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.

Stevens - Johnson Syndrome and Toxic Epidermal Necrolysis; Extensive Review of Reports of Drug-Induced Etiologies, and Possible Therapeutic Modalities

Stevens - Johnson Syndrome and Toxic Epidermal Necrolysis are adverse hypersensitivity reactions that affect the skin and mucous membranes. They are characterised by erythematous macules and hemorrhagic erosions of the mucous membranes. Epidermal detachments of varying degrees of severity also occur in these conditions. Various aetiologies are associated with these conditions, with adverse drug reaction being the most common. Though the worldwide incidence of these conditions is recorded as low, diverse types of medication are being observed to lead to these conditions. This review compiles information on the details of Stevens-Johnson syndrome and Toxic Epidermal Necrolysis, the pathophysiology, therapeutic management, and largely considers the drug-induced etiologies associated with these conditions.

Toxic epidermal necrolysis and Stevens-Johnson syndrome

Toxic epidermal necrolysis (TEN) and Stevens Johnson Syndrome (SJS) are severe adverse cutaneous drug reactions that predominantly involve the skin and mucous membranes. Both are rare, with TEN and SJS affecting approximately 1or 2/1,000,000 annually, and are considered medical emergencies as they are potentially fatal. They are characterized by mucocutaneous tenderness and typically hemorrhagic erosions, erythema and more or less severe epidermal detachment presenting as blisters and areas of denuded skin. Currently, TEN and SJS are considered to be two ends of a spectrum of severe epidermolytic adverse cutaneous drug reactions, differing only by their extent of skin detachment. Drugs are assumed or identified as the main cause of SJS/TEN in most cases, but Mycoplasma pneumoniae and Herpes simplex virus infections are well documented causes alongside rare cases in which the aetiology remains unknown. Several drugs are at "high" risk of inducing TEN/SJS including: Allopurinol, Trimethoprim-sulfamethoxazole and other sulfonamide-antibiotics, aminopenicillins, cephalosporins, quinolones, carbamazepine, phenytoin, phenobarbital and NSAID's of the oxicam-type. Genetic susceptibility to SJS and TEN is likely as exemplified by the strong association observed in Han Chinese between a genetic marker, the human leukocyte antigen HLA-B*1502, and SJS induced by carbamazepine. Diagnosis relies mainly on clinical signs together with the histological analysis of a skin biopsy showing typical full-thickness epidermal necrolysis due to extensive keratinocyte apoptosis. Differential diagnosis includes linear IgA dermatosis and paraneoplastic pemphigus, pemphigus vulgaris and bullous pemphigoid, acute generalized exanthematous pustulosis (AGEP), disseminated fixed bullous drug eruption and staphyloccocal scalded skin syndrome (SSSS). Due to the high risk of mortality, management of patients with SJS/TEN requires rapid diagnosis, evaluation of the prognosis using SCORTEN, identification and interruption of the culprit drug, specialized supportive care ideally in an intensive care unit, and consideration of immunomodulating agents such as high-dose intravenous immunoglobulin therapy. SJS and TEN are severe and life-threatening. The average reported mortality rate of SJS is 1-5%, and of TEN is 25-35%; it can be even higher in elderly patients and those with a large surface area of epidermal detachment. More than 50% of patients surviving TEN suffer from long-term sequelae of the disease.

Ocular features and histopathologic changes during follow-up of toxic epidermal necrolysis

OBJECTIVE

To evaluate ocular surface histopathologic changes and ocular sequelae in the follow-up of patients with toxic epidermal necrolysis (TEN).

DESIGN

Prospective, consecutive, comparative, interventional case series.

PARTICIPANTS

Eleven patients (22 eyes) with TEN that developed after drug treatment and 33 normal subjects as the control group.

METHODS

Toxic epidermal necrolysis diagnosis was based on data obtained from medical records. Only patients with ocular involvement in the acute stage were included. Patients and controls underwent a complete ophthalmic assessment, including tear film evaluation and corneal and conjunctival impression cytology. These were performed at the beginning of the study (∼1 month after TEN) and 6 and 12 months later. Tear film production and stability were evaluated by break-up time, Schirmer's test with anesthesia, rose bengal, and fluorescein staining pattern. Conjunctival retraction was determined by studying the vanishing point in eye abduction of the lacunar folds.

MAIN OUTCOME MEASURES

Break-up time, Schirmer's test, fluorescein and rose bengal stain, corneal and conjunctival epithelial squamous metaplasia, conjunctival retraction, and ocular sequelae.

RESULTS

Mild or moderate ocular involvement was present in 73% of patients in the acute stage. Ocular involvement was not related to TEN severity, area of skin involvement, or drug etiology. One-year follow-up, ocular manifestations, slit-lamp findings, and epithelial cell squamous metaplasia were related to ocular involvement severity in the acute phase. We found pathologic conjunctival retraction in 86.4% of patients. Decreased levels of break-up time and Schirmer's test were found in patients with TEN. Conjunctival cytology showed a marked decrease in goblet cell density. No patients died, and there were no recurrences of TEN during the study.

CONCLUSIONS

Ocular involvement in the acute stage was not related to TEN severity or etiology. Ocular sequelae were related to ocular involvement severity in the acute phase. Early ophthalmic assessment and frequent follow-up are helpful because ocular involvement represents the first long-term complication in patients with TEN. Impression cytology and measurement of conjunctival retraction can be useful tools in the assessment of dynamic ocular changes in patients with TEN.

Allergic cholestatic hepatitis and exanthema induced by metamizole: verification by lymphocyte transformation test

We report about a 66-year-old-male patient who was hospitalized with generalized exanthema and increase of liver enzymes after intake of metamizole because of flue-like symptoms. Despite initial high dose steroids, disease activity persisted, and therefore liver biopsy was performed. Histology revealed acute hepatitis with perivenular non-bridging confluent necrosis and granuloma formation consistent with drug-induced hepatitis. A metamizole-induced process was suspected. Lymphocyte transformation test confirmed the sensitization of the patient's lymphocytes to metamizole and three of its four metabolites (4-methylaminoantipyrine, 4-acetylaminoantipyrine and 4-formylaminoantipyrine). Other drugs could be excluded with high probability. In the follow-up, the general condition of the patient improved, and liver enzymes decreased under treatment with steroids. Thus, we conclude that in this patient metamizole has induced an allergic reaction not only of the skin but also of the liver. To our knowledge, an allergic cholestatic hepatitis caused by metamizole has been reported only once in literature.

Amniotic membrane in the surgical management of acute toxic epidermal necrolysis

OBJECTIVE

To report a new surgical technique to manage severe acute toxic epidermal necrolysis.

DESIGN

Two interventional case reports.

PARTICIPANTS

Two patients. Case 1: A 6-year-old boy had severe toxic epidermal necrolysis develop after being treated with trimethoprim and sulfamethoxazole for chronic otitis media. Both eyes and eyelids were affected. He underwent bilateral lysis of symblepharon and all adhesions and bilateral amniotic membrane transplantation to the entire ocular surface except the cornea. Loss of eyelid skin required transplantation of amniotic membrane to all four eyelids and strips of amniotic membrane at the eyelid margins. Case 2: An 8-year-old girl with severe toxic epidermal necrolysis associated with mycoplasma pneumonia had bilateral, diffuse keratoconjunctivitis, diffuse corneal epithelial defects, and bilateral symblepharon. Amniotic membrane transplantation was performed bilaterally, using a symblepharon ring in the left eye.

INTERVENTION

Amniotic membrane transplantation.

MAIN OUTCOME MEASURES

Preservation of normal ocular and eyelid surfaces and prevention of blindness.

RESULTS

Case 1: Thirty-six months after bilateral ocular surgery, there is no symblepharon, good ocular surface wetting, and an uncorrected bilateral vision of 20/20. Case 2: Amniotic membrane transplantation protected both ocular surfaces and prevented conjunctival contracture without adhesion of the eyelids to the ocular surface. The central vision was preserved. There was minimal peripheral corneal vascularization and mild conjunctival scarring of the tarsal conjunctival surface 34 months postoperatively.

CONCLUSIONS

These are the first cases of acute toxic epidermal necrolysis treated with amniotic membrane transplantation and the first use of the procedure on external eyelid surfaces with good healing of the eyelids. This new treatment for acute toxic epidermal necrolysis preserves normal ocular and eyelid surfaces and may prevent blindness.

Toxic epidermal necrolysis. A study of the sweat glands

Toxic epidermal necrolysis (TEN) is a rare dermatological emergency which is caused by drugs and results in a high morbidity and a mortality rate of 20-30%. Ten confirmed cases of TEN were retrieved and the sweat glands were examined. Abnormalities of the sweat duct were found in all the cases and included basal vaculopathy, increased lymphocytic infiltration, basal apoptosis, basal cell hyperplasia and necrosis of the duct. Destruction and loss of the distal duct was present in 40% of the cases and was accompanied by dilatation of the proximal duct. In all cases, the proximal duct was involved to a lesser degree and in continuity with the distal duct, supporting the possibility of cytokine action. The secretory gland was normal. The presence of a significant reduction of sweat ducts in a disease process that involves 30-100% of the total body surface area is of clinical importance.