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Irwin T, Yeung CCS, Shinohara MM. Desmoplakin I/II immunohistochemical staining may be a helpful tool in differentiating cutaneous graft versus host disease from the erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis spectrum disorders. J Cutan Pathol 2024; 51:76-82. [PMID: 37691139 DOI: 10.1111/cup.14513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 06/02/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023]
Abstract
Cutaneous graft versus host disease (cGVHD) has substantial clinical and histopathologic overlap with erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). This overlap can make it difficult to distinguish these disorders in patients who have received hematopoietic transplants. We sought to evaluate the utility of Dp I/II immunohistochemical stain in differentiating EM/SJS/TEN and cGVHD in a large cohort. Skin biopsy specimens from patients with cGVHD (n = 58) and EM/SJS/TEN (n = 60) were evaluated for Dp I/II expression by immunohistochemistry. We found a statistically significant difference in Dp I/II staining between cGVHD (all grades) and EM/SJS/TEN (mean scores 1.62 and 2.14, respectively; p < 0.005), as well as between Grades 2 + 3 cGVHD and EM/SJS/TEN (mean scores 2.26 and 1.62, respectively; p < 0.005), while we did not find a significant difference between Grade 4 cGVHD and EM/SJS/TEN (mean scores 1.69 and 1.62, respectively; p = 0.71). Dp I/II immunostain may be useful for differentiating EM/SJS/TEN from Grade 2 and Grade 3 cGVHD, especially in clinically ambiguous cases without extracutaneous GVHD.
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Affiliation(s)
- Trent Irwin
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Cecilia C S Yeung
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Michi M Shinohara
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, Washington, USA
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2
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Roy SF, Ghazawi FM, Alsarheed A, Savin E, Litvinov IV, Sasseville D. Poor prognosis of drug-induced and acute graft-versus-host disease-induced epidermal necrolysis in bone marrow/stem cell transplant recipients: a retrospective case series. J Eur Acad Dermatol Venereol 2020; 34:e506-e510. [PMID: 32255220 DOI: 10.1111/jdv.16421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/16/2020] [Indexed: 11/30/2022]
Affiliation(s)
- S F Roy
- Division of Pathology, University of Montréal, Montréal, Québec, Canada
| | - F M Ghazawi
- Division of Dermatology, University of Ottawa, Ottawa, Ontario, Canada
| | - A Alsarheed
- Division of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - E Savin
- Division of Dermatology, McGill University, Montréal, Québec, Canada
| | - I V Litvinov
- Division of Dermatology, McGill University, Montréal, Québec, Canada
| | - D Sasseville
- Division of Dermatology, McGill University, Montréal, Québec, Canada
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3
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Dermatologic Conditions of the Early Post-Transplant Period in Hematopoietic Stem Cell Transplant Recipients. Am J Clin Dermatol 2019; 20:55-73. [PMID: 30298481 DOI: 10.1007/s40257-018-0391-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hematopoietic stem cell transplants (HSCTs) are used to treat a variety of conditions, including hematologic malignancies, bone marrow failure syndromes, and immunodeficiencies. Over 60,000 HSCTs are performed annually worldwide, and the numbers continue to increase. Indeed, as new conditioning regimens develop, more and more individuals, including those of older age, will be eligible for transplants. Nevertheless, although HSCTs are clearly a life-saving and necessary treatment for thousands of patients per year, there is still substantial morbidity and mortality associated with the procedure. Of note, skin eruptions in the post-HSCT period are frequent and often significantly reduce quality of life in recipients. Moreover, these cutaneous findings sometimes herald an underlying systemic condition, presenting possible opportunities for timelier intervention. Dermatologists therefore play a vital role in distinguishing life-threatening conditions from benign issues and prompting recognition of critical complications earlier in their course. This article aims to review the major dermatologic conditions occurring in the early post-HSCT period.
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Naik H, Lockwood S, Saavedra A. A pilot study comparing histological and immunophenotypic patterns in stage 4 skin graft vs host disease from toxic epidermal necrolysis. J Cutan Pathol 2017. [PMID: 28626936 DOI: 10.1111/cup.12986] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stage 4 skin graft-versus-host disease (GVHD) is associated with poor prognosis and high mortality rates. Clinical and histologic similarities with toxic epidermal necrolysis (TEN) make it difficult to distinguish between these 2 life-threatening conditions. METHODS A retrospective cohort study was conducted from a tertiary referral center. Skin biopsies were obtained from 11 patients who developed stage 4 skin GVHD and 11 patients who developed TEN between 2005 and 2012. The CD8+/CD4+ T lymphocyte ratios were assessed in lesional skin specimens. RESULTS Average CD8+and CD4+ cell counts co-expressing CD3 were 126.29 (range 86.42-173.06) and 84.60 (29.87-197.20) for stage 4 skin GVHD patients, and 61.97 (45.79-146.67) and 7.65 (0.00-39.50) for TEN patients, respectively. Immunohistochemical studies of stage 4 skin GVHD and TEN skin demonstrated average CD8+/CD4+ ratios of 1.78 (range 0.69-3.09) and 7.33 (1.16-12.3), respectively (P = .013). CONCLUSIONS Stage 4 skin GVHD and TEN are processes with cytotoxic profiles. TEN is notable for a greater relative depletion of CD4+ T lymphocytes compared with stage 4 skin GVHD, while stage 4 skin GVHD tends to be more inflammatory than TEN. These data suggest an immunohistologic method by which these 2 entities may be distinguished.
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Affiliation(s)
- Haley Naik
- Department of Dermatology, University of California, San Francisco, California
| | - Stephen Lockwood
- Harvard Medical School, Boston, Massachusetts.,Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Arturo Saavedra
- Harvard Medical School, Boston, Massachusetts.,Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
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Extensive toxic epidermal necrolysis versus acute graft versus host disease after allogenic hematopoietic stem-cell transplantation: challenges in diagnosis and management. J Burn Care Res 2015; 35:e431-5. [PMID: 24476990 DOI: 10.1097/bcr.0000000000000040] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Toxic epidermal necrolysis (TEN) is a rare complication after allogeneic hematopoietic stem-cell transplantation and carries high mortality rates. Graft-vs-host disease (GVHD) is also a life-threatening complication, and potentially indistinguishable from TEN because of similar clinical symptoms. However, current therapeutic recommendations differ between these two conditions, thereby posing a diagnostic dilemma. The authors, herein, present a complicated postoperative course after bone marrow transplantation with concurrent gastrointestinal and hepatic GVHD, and extensive epidermolytic disease compatible with both severe cutaneous GVHD and TEN. An early consult to a specialized burn service, and prompt transfer to a burn intensive care unit with extensive supportive care and nursing are of paramount importance in the management of immunosuppressed patients with TEN. Better understanding of the pathogenesis of TEN and GVHD after hematopoietic stem-cell transplantation, further treatment strategies, and more advanced diagnostic techniques are still needed to achieve acceptable mortality rates.
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Erythema multiforme, Stevens Johnson syndrome, and toxic epidermal necrolysis syndrome in patients undergoing radiation therapy: a literature review. Am J Clin Oncol 2014; 37:506-13. [PMID: 22892429 DOI: 10.1097/coc.0b013e31825d5835] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Erythema multiforme (EM), Stevens Johnson syndrome (SJS), and toxic epidermal necrolysis syndrome (TENS) are exfoliative disorders that may present as complications in some patients undergoing radiotherapy. The purpose of this literature review was to determine the reported frequency of these exanthemata in irradiated patients. METHODS A comprehensive search from 1903 to 2011, identified 89 articles with 165 cases. RESULTS Of 151 evaluable cases, 57 (38%) described EM; 46 (30.5%) SJS; 14 (9%) SJS/TENS overlap; and 34 (22.5%) TENS. Ninety-three percent underwent radiotherapy for either a primary or metastatic malignancy. A majority of patients were simultaneously treated with medications known to precipitate these exanthemata. Of the 61 patients receiving antiepileptic medications during radiotherapy, 48 were treated prophylactically and 13 for seizures, most frequently with phenytoin or phenobarbital. Amifostine was the second most common medication associated with radiotherapy and these reactions. Fourteen (23%) patients on anticonvulsant medication, and 11 (38%) on other medications died compared with 3 (8%) patients treated with radiotherapy alone (P = 0.002). No deaths occurred among irradiated patients receiving amifostine. CONCLUSIONS EM, SJS, and TENS were rarely reported in patients undergoing radiotherapy alone. The majority of SJS and TENS occurred in irradiated patients with concomitant prescribed medications.
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Arvidson J, Kildal M, Linde T, Gedeborg R. Toxic epidermal necrolysis and hemolytic uremic syndrome after allogeneic stem-cell transplantation. Pediatr Transplant 2007; 11:689-93. [PMID: 17663696 DOI: 10.1111/j.1399-3046.2007.00743.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
TEN and HUS are challenging complications with excessive mortality after HSCT. We report the development of these two conditions in combination in a nine-yr-old boy after HSCT from an unrelated donor. TEN with skin detachment of more than 90% of body surface area developed after initial treatment for GvHD. Within a few days of admission to the burns unit, the patient developed severe hemolysis, hypertension, thrombocytopenia, and acute renal failure consistent with HUS, apparently caused by CSA. The management included intensive care in a burns unit, accelerated drug removal using plasmapheresis, and a dedicated multi-disciplinary team approach to balance immunosuppression and infections management in a situation with extensive skin detachment. The patient survived and recovered renal function but requires continued treatment for severe GvHD. Suspecting and identifying causative drugs together with meticulous supportive care in the burns unit is essential in the management of these patients and long-term survival is possible.
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Affiliation(s)
- Johan Arvidson
- Department of Women's and Children's Health and Pediatrics, Uppsala University Hospital, Uppsala, Sweden
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Paquet P, Jacob E, Damas P, Piérard GE. Recurrent fatal drug-induced toxic epidermal necrolysis (Lyell's syndrome) after putative beta-lactam cross-reactivity: Case report and scrutiny of antibiotic imputability. Crit Care Med 2002; 30:2580-3. [PMID: 12441773 DOI: 10.1097/00003246-200211000-00029] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A series of antibiotics may be responsible for toxic epidermal necrolysis. We report two successive episodes of toxic epidermal necrolysis in the same patient. Drug imputability criteria designate a cross-reactivity between two antibiotics of different chemical classes but sharing the beta-lactam ring in common. DESIGN Descriptive case report and review of the literature. SETTING Medical intensive care unit in a university medical center. PATIENT AND MAIN RESULTS: A 75-yr-old woman developed a first episode of toxic epidermal necrolysis (involving 40% of the body surface) after intake of cefotaxime, a third-generation cephalosporin. Perfusions of high-dose immunoglobulins rapidly improved the lesions, followed by partial reepithelialization in 5 days. Sepsis required the administration of meropenem, which is a carbapenem antibiotic. The epidermal destruction immediately recurred, with extension to previously uninvolved skin areas and fatal consequences. CONCLUSIONS The beta-lactam ring present in cephalosporins and carbapenems represents the putative chemical structure responsible for the presently reported cross-reactivity to two antibiotics of different classes. Drugs having any chemical similarity to the initial culprit compound should be strictly avoided when possible in the management of toxic epidermal necrolysis.
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Affiliation(s)
- Philippe Paquet
- Department of Dermatopathology, University Medical Center, University Medical Center, Sart Tilman, Belgium
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Paquet P, Arrese JE, Beguin Y, Piérard GE. Clinicopathological differential diagnosis of drug-induced toxic epidermal necrolysis (Lyell's syndrome) and acute graft-versus-host reaction. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 2001; 94:49-63. [PMID: 11443887 DOI: 10.1007/978-3-642-59552-3_3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- P Paquet
- Centre Hospitalier Universitaire de Liège, Service de Dermatopathologie, Institut de Pathologie, 1 er étage, 4000 Liège, Belgium
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10
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Buttoni U, Pulsoni A, Innocenzi D, Pranteda G, Latini A, Bonaccorsi P, Mandelli F, Calvieri S. Toxic epidermal necrolyis (TEN) in a patient with non-Hodgkin lymphoma: successful treatment with dexamethasone at high dosage. J Eur Acad Dermatol Venereol 2000; 14:140-2. [PMID: 10972103 DOI: 10.1046/j.1468-3083.2000.00037-2.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Cerny A, Pichler W. Allergy to antibacterials: the problem with beta-lactams and sulfonamides. Pharmacoepidemiol Drug Saf 1999. [DOI: 10.1002/(sici)1099-1557(199808)7:1+3.0.co;2-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Takeda H, Mitsuhashi Y, Kondo S, Kato Y, Tajima K. Toxic epidermal necrolysis possibly linked to hyperacute graft-versus-host disease after allogeneic bone marrow transplantation. J Dermatol 1997; 24:635-41. [PMID: 9375462 DOI: 10.1111/j.1346-8138.1997.tb02308.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a severe blistering skin disease of high mortality. TEN may occur after bone marrow transplantation (BMT). In such cases, TEN have been attributed to graft-versus-host disease (GVHD) or an adverse drug reaction. It is very difficult to distinguish the causes of TEN after BMT. We report a 21-year-old Japanese man who developed TEN eight days after BMT, evaluate the differential diagnosis of hyperacute GVHD and an adverse drug reaction, and deduce that hyperacute GVHD was the more likely pathogenesis of TEN in this patient.
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Affiliation(s)
- H Takeda
- Department of Dermatology, Yamagata University School of Medicine, Japan
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13
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Epstein ME, Amodio-Groton M, Sadick NS. Antimicrobial agents for the dermatologist. I. Beta-lactam antibiotics and related compounds. J Am Acad Dermatol 1997; 37:149-65; quiz 166-8. [PMID: 9270499 DOI: 10.1016/s0190-9622(97)80118-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We review the newer antimicrobial agents that are being employed by dermatologists with increased frequency as well as some of the more commonly used older agents. Particular emphasis is based on selection factors such as causative pathogens and their resistance profiles, routes of administration, toxicity, drug interactions, and dosing requirements. Emphasis in this review is on the newer classes of antimicrobials such as third- and fourth-generation cephalosporins; beta-lactam, beta-lactamase inhibitor combination agents; monobactams; carbapenems; macrolides; and fluoroquinolones. Dermatologic indications and treatment alternatives are highlighted; this will expand the practicing clinician's therapeutic armamentarium and enable him/her to make rational decisions concerning treatment approaches to infectious disease problems encountered in daily practice.
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Affiliation(s)
- M E Epstein
- Department of Medicine, North Shore University Hospital, Manhasset, New York, USA
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14
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Revuz JE, Roujeau JC. Advances in toxic epidermal necrolysis. SEMINARS IN CUTANEOUS MEDICINE AND SURGERY 1996; 15:258-66. [PMID: 9069594 DOI: 10.1016/s1085-5629(96)80039-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
On the basis of the clinicopathologic and causative characteristics, one can separate an erythema multiformis spectrum from a toxic epidermal necrolysis (TEN)-Stevens Johnson syndrome which is a drug induced disease. Despite a well-known clinical aspect, several cutaneous diseases may be mistaken for TEN. Responsible drugs are sulfonamides anticonvulsants, and nonsteroidal antiinflammatory drugs--patients infected with HIV are at a higher risk of developing TEN. Pathogenesis includes abnormal drug metabolism and cell mediated immune keratinocyte apoptosis. Treatment relies on symptomatic management and so-called specific treatments including steroids are probably harmful.
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Affiliation(s)
- J E Revuz
- Service de Dermatologie, Hôpital Henri Mondor, Université Paris XII, Créteil, France
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Affiliation(s)
- J C Roujeau
- Department of Dermatology, Henri Mondor Hospital, University of Paris XII, Creteil, France
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16
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Affiliation(s)
- J C Roujeau
- Dermatology Service, Henri Mondor Hospital, University of Paris XII, France
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