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van Nispen C, Long B, Koyfman A. High risk and low prevalence diseases: Stevens Johnson syndrome and toxic epidermal necrolysis. Am J Emerg Med 2024; 81:16-22. [PMID: 38631147 DOI: 10.1016/j.ajem.2024.04.001] [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: 02/09/2024] [Revised: 03/04/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are serious conditions that carry a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of SJS/TEN, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION SJS/TEN is a rare, delayed hypersensitivity reaction resulting in de-epithelialization of the skin and mucous membranes. The majority of cases are associated with medication or infection. Clinicians should consider SJS/TEN in any patient presenting with a blistering mucocutaneous eruption. Evaluation of the skin, mucosal, pulmonary, renal, genital, and ocular systems are essential in the diagnosis of SJS/TEN, as well as in the identification of complications (e.g., sepsis). Laboratory and radiological testing cannot confirm the diagnosis in the ED setting, but they may assist in the identification of complications. ED management includes stabilization of airway and breathing, fluid resuscitation, and treatment of any superimposed infections with broad-spectrum antibiotic therapy. All patients with suspected SJS/TEN should be transferred and admitted to a center with burn surgery, critical care, dermatology, and broad specialist availability. CONCLUSIONS An understanding of SJS/TEN can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Christiaan van Nispen
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
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Green EA, Fogarty K, Ishmael FT. Penicillin Allergy: Mechanisms, Diagnosis, and Management. Med Clin North Am 2024; 108:671-685. [PMID: 38816110 DOI: 10.1016/j.mcna.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] [Indexed: 06/01/2024]
Abstract
Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.
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Affiliation(s)
- Estelle A Green
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Kelan Fogarty
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Faoud T Ishmael
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA; Mount Nittany Health, 1850 East Park Avenue, State College, PA 16803, USA.
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Erduran F, Adışen E, Emre S, Hayran Y, Başkan EB, Yazıcı S, Bilgiç A, Alpsoy E, Günaydın SD, Elmas L, Akyol M, Güner R, Arıca DA, Aypek Y, Ergun T, Karavelioğlu D, Yazıcı AC, Aydoğan K, Bayramgürler D, Kıran R, Erdoğan HK, Acer E, Aktaş A. Evaluation of the Factors Influencing Mortality in Patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Multicenter Study of 166 Patients. Dermatol Ther (Heidelb) 2024; 14:1547-1560. [PMID: 38758423 DOI: 10.1007/s13555-024-01180-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening acute mucocutaneous disorders usually triggered by drugs. In this study, we aimed to evaluate the factors affecting mortality in patients with SJS-TEN. METHODS Our study is a retrospective cohort study, analyzing data collected from a total of 12 tertiary care centers between April 2012 and April 2022. RESULTS The study included 59 males and 107 females, a total of 166 patients, with an average age of 50.91 ± 21.25 years. Disease classification was TEN in 50% of cases, SJS in 33.1%, and SJS-TEN overlap in 16.9%. The average SCORTEN within the first 24 h was 2.44 ± 1.42. Supportive care was provided to 99.4% of patients. The most commonly used systemic immunomodulatory treatments were systemic steroids (84.3%), IVIG (intravenous immunoglobulin) (49.3%), and cyclosporine (38.6%). Plasmapheresis was administered to five patients. While 66.3% of patients were discharged, 24.1% resulted in exitus. Our comparative analysis of survivors and deceased patients found no effect of systemic steroids, IVIG, and cyclosporine treatments on mortality. Univariate analysis revealed that the SCORTEN scores on days 1 and 3 as well as the rates of detachment at the onset and during follow-up were significantly higher in deceased patients compared to survivors. The rates of fever, positive blood cultures, and systemic antibiotic use were higher in deceased patients compared to survivors. The presence of comorbidities, diabetes, and malignancy were significantly more common in deceased patients. Multivariate regression analysis indicated that over SCORTEN 2, the mortality risk exponentially rose with each SCORTEN increment, culminating in an 84-fold increase in mortality at SCORTEN 5-6 (odds ratio [95% confidence interval]: 13.902-507.537, p < 0.001) compared to SCORTEN 0-1. Additionally, the utilization of plasmapheresis was associated with a 22-fold increase in mortality (odds ratio [95% confidence interval]: 1.96-247.2, p = 0.012). CONCLUSION Our study found that a high SCORTEN score within the first 24 h and the use of plasmapheresis were related to increased mortality, while systemic steroids, IVIG, and cyclosporine treatments had no impact on mortality. We believe that data gathered from one of the most comprehensive studies which we conducted on SJS-TEN will enrich the literature, although additional research is warranted.
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Affiliation(s)
- Funda Erduran
- Ankara Bilkent City Hospital, Department of Dermatology, Ankara, Turkey.
| | - Esra Adışen
- Department of Dermatology, Gazi University, Ankara, Turkey
| | - Selma Emre
- Department of Dermatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Yıldız Hayran
- Ankara Bilkent City Hospital, Department of Dermatology, Ankara, Turkey
| | | | - Serkan Yazıcı
- Department of Dermatology, Bursa Uludağ University, Bursa, Turkey
| | - Aslı Bilgiç
- Department of Dermatology, Akdeniz University, Antalya, Turkey
| | - Erkan Alpsoy
- Department of Dermatology, Akdeniz University, Antalya, Turkey
| | | | - Leyla Elmas
- Department of Dermatology, Hacettepe University, Ankara, Turkey
| | - Melih Akyol
- Department of Dermatology, Sivas Cumhuriyet University, Sivas, Turkey
| | - RukiyeYasak Güner
- Department of Dermatology, Sivas Cumhuriyet University, Sivas, Turkey
| | - Deniz Aksu Arıca
- Department of Dermatology, Karadeniz Technical University, Trabzon, Turkey
| | - Yağmur Aypek
- Department of Dermatology, Gazi University, Ankara, Turkey
| | - Tülin Ergun
- Department of Dermatology, Marmara University, Istanbul, Turkey
| | | | | | - Kübra Aydoğan
- Department of Dermatology, Mersin University, Mersin, Turkey
| | | | - Rebiay Kıran
- Department of Dermatology, Kocaeli University, Kocaeli, Turkey
| | - Hilal Kaya Erdoğan
- Department of Dermatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Ersoy Acer
- Department of Dermatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Akın Aktaş
- Department of Dermatology, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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Ge L, Chen W, Zhang G, Wei F. Camrelizumab-induced immune-related adverse events: Two case reports and literature review. Asian J Surg 2024; 47:2733-2734. [PMID: 38522994 DOI: 10.1016/j.asjsur.2024.03.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024] Open
Affiliation(s)
- Lingzhi Ge
- Department of Dermatology, The Second Affiliated Hospital of Shandong First Medical University, China
| | - Wenfang Chen
- Department of Dermatology, The Second Affiliated Hospital of Shandong First Medical University, China
| | - Ge Zhang
- Department of Emergency, The Second Affiliated Hospital of Shandong First Medical University, China
| | - Fangli Wei
- Department of Dermatology, The Second Affiliated Hospital of Shandong First Medical University, China.
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Diercks GFH, Meijer JM, Bolling MC, Scholtens-Jaegers SMHJ, Bremer J, Horvath B. Absence of Epidermal Antibodies in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Patients but Beware of Single Positive Results. Dermatol Res Pract 2024; 2024:5504462. [PMID: 38803350 PMCID: PMC11129901 DOI: 10.1155/2024/5504462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024] Open
Abstract
Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and potentially life-threatening mucocutaneous blistering diseases that clinically can resemble autoimmune bullous diseases. Moreover, it has been shown that autoantibodies against epidermal proteins are present in SJS/TEN. Objectives To establish the presence of antibodies against desmosomal and hemidesmosomal proteins in confirmed SJS/TEN patients. Methods Serum of SJS/TEN patients diagnosed based on clinical criteria, e.g., epidermal detachment with erosions and severe mucosal lesions, (suspicion of) a culprit drug, and matching histologic results was evaluated by various techniques, e.g., indirect immunofluorescence on monkey esophagus, salt split skin and rat bladder, immunoblotting (IB) and immunoprecipitation (IP), ELISAs against desmogleins and BP180, keratinocyte footprint assay, and keratinocyte binding assay. Results A total of 28 patients were included in this study, 15 men and 13 women with a mean age of 56 years. In most patients, none of the serological tests were positive. In two patients, an elevated DSG3 titer was found suspicious for pemphigus vulgaris. Three patients had elevated NC16a titers, suggesting bullous pemphigoid. However, in all these patients, no other tests were positive and in these patients, the biopsy for direct immunofluorescence showed no evidence for an autoimmune bullous disease. Three patients showed reactivity against rat bladder rat bladder; these were, however, completely negative for A2ML1, envoplakin, and periplakin in the IB as well as the IP. Conclusions Serological analysis for desmosomal and hemidesmosomal antibodies is reliable to rule an autoimmune bullous disease in patients with suspected SJS/TEN. However, one should not rely on one single test method since false positive results can occur. Moreover, this study also makes it less plausible that antibodies against desmosomal and/or hemidesmosomal components are involved in the pathogenesis of SJS/TEN.
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Affiliation(s)
- Gilles F. H. Diercks
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | - Joost M. Meijer
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | - Maria C. Bolling
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | | | - Jeroen Bremer
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
| | - Barbara Horvath
- University of Groningen, University Medical Center Groningen, Department of Dermatology, Center of Blistering Diseases, European Reference Networks-Skin Member, Groningen, Netherlands
- European Reference Networks (ERN)—SKIN Center, Paris, France
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Smaha KM, Prosser JD, Chan JT. Toxic Epidermal Necrolysis Secondary to Iodine Versus Methimazole in a Pediatric Patient With Complex Autoimmune Disease. Cureus 2024; 16:e57618. [PMID: 38707124 PMCID: PMC11069421 DOI: 10.7759/cureus.57618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
We report a case of a 17-year-old girl who developed toxic epidermal necrolysis (TEN) secondary to preoperative iodine administration before thyroidectomy for Graves' disease. Past medical history was significant for COVID-19 and multisystem inflammatory syndrome in Children (MISC-C), with subsequent diagnoses of type 1 diabetes mellitus (T1DM), Addison disease, and Graves' disease. Her Graves disease was initially managed with methimazole. While there are reported cases of Stevens-Johnson syndrome (SJS) and TEN due to methimazole, the patient had discontinued methimazole over one month prior. Therefore, she likely represents the first case of TEN reported secondary to potassium iodide solution in a pediatric patient. Given the rarity of TEN in pediatric patients, our case highlights the challenges in managing complex autoimmune conditions and underscores the importance of careful medication choices in such cases.
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Affiliation(s)
- Katlyn M Smaha
- Pediatric Endocrinology, Medical College of Georgia at Augusta University, Augusta, USA
| | - John D Prosser
- Pediatric Otolaryngology, Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, USA
| | - Jacqueline T Chan
- Pediatric Endocrinology, University of Utah Health, Salt Lake City, USA
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Akgun Z, Palamar M, Egrilmez S, Yagci A, Barut Selver O. Severity Classification of Limbal Stem Cell Failure Due to Steven Johnson Syndrome in the Light of the Classification Consensus of Limbal Stem Cell Deficiency. Eye Contact Lens 2024; 50:159-162. [PMID: 38305421 DOI: 10.1097/icl.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVES To examine and to understand the limbal stem-cell deficiency (LSCD) because of Steven-Johnson syndrome (SJS) in line with the new classification system for the first time in the literature. METHODS Medical records of patients with LSCD because of SJS were reviewed retrospectively. In addition to demographic data and ophthalmologic or systemic findings, anterior segment photographs of the patients were reviewed retrospectively. Limbal stem-cell deficiency severity was graded according to the classification published by the Limbal Stem Cell Working Group. RESULTS Twenty-four eyes of 14 patients with eye involvement secondary to SJS were included in the study. The mean age of the patients was 36.09±16.70 (9-58) years and the female-to-male ratio was 11:3. The anterior segment photographs of the patients were evaluated by two independent masked observers. Limbal stem-cell deficiency severity was graded according to the classification published by Deng et al. Corneal opacity was divided into three stages according to the area of involvement. Corneal opacity was classified as Stage I if the central 5 mm region of the cornea was not affected, as Stage II if the central 5 mm region of the cornea was affected, and as Stage III if the entire corneal surface was affected. Limbal involvement was classified as Stage A if it was below 50%, as Stage B if it was between 50% and 100%, and as Stage C if it was 100%. CONCLUSION This is the first study in the literature to describe and classify LSCD because of SJS, according to the new LSCD classification. Consistent with the results, LSCD follows a bimodal distribution. Most patients demonstrated severe (Stage III-32.14%) or mild (Stage IA-21.42%) LSCD.
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Affiliation(s)
- Zeynep Akgun
- Faculty of Medicine, Department of Ophthalmology, Ege University, Izmir, Turkey
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Sufiawati I, Amalia T, Dewi TS, Wisaksana R. The Association Between Oral Mucosal Lesions and Oral Health-Related Quality of Life Using the Validated Indonesian Version of OHIP-14 Among People Living with HIV/AIDS. HIV AIDS (Auckl) 2024; 16:9-16. [PMID: 38348377 PMCID: PMC10860594 DOI: 10.2147/hiv.s452154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/05/2024] [Indexed: 02/15/2024] Open
Abstract
Background Oral mucosal lesions in human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) patients, posing a concern for healthcare professionals, impact their oral health-related quality of life (OHRQoL). This study aimed to evaluate the association between oral mucosal lesions and OHRQoL as measured by the validated Indonesian version of the oral health impact profile-14 questionnaire (OHIP-14) among people living with HIV/AIDS (PLWHA). Methods A cross-sectional study was conducted at the Central Referral Hospital in West Java, Indonesia. The validity of OHIP-14 was evaluated in 30 PLWHA using inter-item corrected correlation, while reliability was assessed through Cronbach's alpha and kappa coefficient agreement. Subsequently, a consecutive sample of 110 PLWHA self-completed the validated Indonesian version of OHIP-14 and underwent an oral examination. The association between oral mucosal lesions and OHRQoL was analyzed using the chi-squared test. Results The validity test of the OHIP-14 questionnaire produced a rcount > 0.189, meaning that all question items were valid and could be used to describe OHRQoL. The reliability test of the OHIP-14 questionnaire produced a Cronbach's alpha value of 0.960 (> 0.7), which means that overall, the OHIP-14 questionnaire is reliable and feasible to be used to assess OHRQoL. Among the 110 enrolled participants, 61.8% were female and 38.2% were male, with the mean age 23.5 years old, the majority of them (59.1%) had been taking antiretrovirals (ARV), and (81.5%) had good QoL. There was a statistically significant relationship between oral lesions and quality of life (p<0.05), particularly acute pseudomembranous candidiasis, angular cheilitis, recurrent intraoral herpes, and Stevens-Johnson syndrome. Conclusion This study indicated a significant association between oral mucosal lesions and OHRQoL in PLWHA. The successfully validated Indonesian version of the OHIP-14 questionnaire serves as a reliable and effective tool for assessing OHRQoL among PLWHA.
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Affiliation(s)
- Irna Sufiawati
- Department of Oral Medicine, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
| | - Tuty Amalia
- Oral Medicine Residency Program, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
| | - Tenny Setiani Dewi
- Department of Oral Medicine, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
| | - Rudi Wisaksana
- Department of Internal Medicine, Dr. Hasan Sadikin Central General Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
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Fu Y, Xiao Y, Gao T, Zhang J, Wang T. Etanercept Combined with Glucocorticoid and Gamma Globulin for Treating Children with Toxic Epidermal Necrolysis: A Case Report. Clin Cosmet Investig Dermatol 2024; 17:167-171. [PMID: 38283797 PMCID: PMC10821656 DOI: 10.2147/ccid.s440476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/29/2023] [Indexed: 01/30/2024]
Abstract
Toxic epidermal necrolysis (TEN) is a type of drug eruption in dermatology emergencies that is rare in clinical practice but has a high mortality rate. The main causes are drug and viral infections. Unfortunately, no expert consensus on treating this disease exists, and a standard therapy is absent. Up to now, glucocorticoids combined with gamma globulin are commonly used in clinical practice, but their efficacy is highly controversial. This study reports on a 7-year-old girl with TEN who did not respond to traditional therapy, such as methylprednisolone combined with gamma globulin, but was finally cured with an additional low-dose etanercept. The results showed that etanercept therapy in paediatric TEN is safe, reliable and worth recommending.
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Affiliation(s)
- Yanhua Fu
- Department of Rheumatology, Baoding Hospital of Beijing Children’s Hospital, Baoding, 071000, People’s Republic of China
| | - Yuanyuan Xiao
- Department of Dermatology, National Center for Children’s Health (Beijing) Children’s Hospital Affiliated to Capital Medical University, Beijing, 100045, People’s Republic of China
| | - Tianji Gao
- Department of Rheumatology, Baoding Hospital of Beijing Children’s Hospital, Baoding, 071000, People’s Republic of China
| | - Junxiu Zhang
- Department of Dermatology, Baoding Hospital of Beijing Children’s Hospital, Baoding, 071000, People’s Republic of China
| | - Tianjiao Wang
- Department of Rheumatology, Baoding Hospital of Beijing Children’s Hospital, Baoding, 071000, People’s Republic of China
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Aoul AT, Al-Nasseri A, Hall C, He C, Abernathy J. Stevens-Johnson Syndrome in a Patient on Concomitant Treatment with Levetiracetam and Trimethoprim/Sulfamethoxazole. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e942982. [PMID: 38247161 PMCID: PMC10812293 DOI: 10.12659/ajcr.942982] [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: 10/25/2023] [Revised: 12/19/2023] [Accepted: 12/12/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Trimethoprim/sulfamethoxazole and levetiracetam are commonly prescribed medications in the treatment of infections and seizures, respectively. Despite their known efficacy, each has a reputation for triggering severe and sometimes life-threatening cutaneous adverse drug reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. Although the mechanism of such cutaneous adverse drug reactions cannot be fully explained, it is thought to be a type IV T cell and NK cells-mediated hypersensitivity reaction that leads to keratinocyte apoptosis and epidermal necrosis. It is also thought that cutaneous adverse drug reactions are also linked to a patient's genetic predispositions, especially the human leukocyte antigens profiles and the N-acetyl transferase 2 phenotypic variation. CASE REPORT We describe a case of Stevens-Johnson syndrome in a severely ill 51-year-old man who was treated in an outside health care facility simultaneously with Trimethoprim/sulfamethoxazole and levetiracetam. The patient presented to our Emergency Department with Stevens-Johnson syndrome believed to possibly be related to the combination of these 2 agents. CONCLUSIONS The concomitant use of Trimethoprim/sulfamethoxazole and levetiracetam might have been responsible for heightening the potential of these 2 medications to trigger an unfortunate adverse drug reaction, but no formal culprit was able to be identified and no in vivo study was performed, due to ethical considerations. Thus, through this case report we strive to increase awareness of the potential risk of simultaneously prescribing these 2 medications.
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Affiliation(s)
- Amel Tabet Aoul
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL, USA
| | - Abraheim Al-Nasseri
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL, USA
| | - Chase Hall
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL, USA
| | - Chun He
- Department of Pathology, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL, USA
| | - John Abernathy
- Department of Internal Medicine, HCA Healthcare Florida Citrus Hospital Florida, Inverness, FL, USA
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Lee AY. Immunological Mechanisms in Cutaneous Adverse Drug Reactions. Biomol Ther (Seoul) 2024; 32:1-12. [PMID: 38148549 PMCID: PMC10762274 DOI: 10.4062/biomolther.2023.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/10/2023] [Accepted: 10/23/2023] [Indexed: 12/28/2023] Open
Abstract
Adverse drug reactions (ADRs) are an inherent aspect of drug use. While approximately 80% of ADRs are predictable, immune system-mediated ADRs, often unpredictable, are a noteworthy subset. Skin-related ADRs, in particular, are frequently unpredictable. However, the wide spectrum of skin manifestations poses a formidable diagnostic challenge. Comprehending the pathomechanisms underlying ADRs is essential for accurate diagnosis and effective management. The skin, being an active immune organ, plays a pivotal role in ADRs, although the precise cutaneous immunological mechanisms remain elusive. Fortunately, clinical manifestations of skin-related ADRs, irrespective of their severity, are frequently rooted in immunological processes. A comprehensive grasp of ADR morphology can aid in diagnosis. With the continuous development of new pharmaceuticals, it is noteworthy that certain drugs including immune checkpoint inhibitors have gained notoriety for their association with ADRs. This paper offers an overview of immunological mechanisms involved in cutaneous ADRs with a focus on clinical features and frequently implicated drugs.
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Affiliation(s)
- Ai-Young Lee
- Department of Dermatology, Dongguk University Ilsan Hospital, Goyang 10326, Republic of Korea
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12
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Peng YT, Xiong JX, Wei B, Li H, Xu J, Chen AJ, Wang P. Tumor necrosis factor-α inhibitor for successful treatment of toxic epidermal necrolysis with severe infection: a case series. J Int Med Res 2024; 52:3000605231223059. [PMID: 38296223 PMCID: PMC10832423 DOI: 10.1177/03000605231223059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/11/2023] [Indexed: 02/03/2024] Open
Abstract
Toxic epidermal necrolysis (TEN) is a rare severe cutaneous adverse reaction that involves more than 30% of the body surface area. TEN can be accompanied by a series of systemic symptoms and has a high risk of death. Tumor necrosis factor (TNF)-α inhibitors such as adalimumab and etanercept have been shown to be safe and effective for the treatment of TEN in some cases. However, clinical data on the use of TNF-α inhibitors to treat TEN with severe systemic infection are scarce. In the present study, three adult patients who developed TEN with serious active infection were successfully treated with etanercept. One of the three patients had active open pulmonary tuberculosis, and the other two had septicemia and/or fungal sepsis. All patients' skin lesions significantly improved after several days, and none of the patients developed emerging or re-emerging infectious diseases, adverse reactions, or a similar rash during follow-up. TNF-α inhibitors may be an effective treatment choice for TEN with severe systemic infection. However, further studies with large samples are still required for validation because clinical experience is limited.
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Affiliation(s)
- Yu-Ting Peng
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian-Xia Xiong
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bin Wei
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hui Li
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Xu
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ai-Jun Chen
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ping Wang
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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13
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Aparcana-Choque WD, Pisconti-Palacios YM, Cordova-Tello I, Ausejo-Galarza J, Gomez-Gonzales W, Kochubei-Hurtado A, Arteaga-Livias K. Steven-Jonhson Syndrome in a Patient With Dengue Infection in Peru: A Case Report. J Investig Med High Impact Case Rep 2024; 12:23247096241242574. [PMID: 38546109 PMCID: PMC10981262 DOI: 10.1177/23247096241242574] [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: 10/25/2023] [Revised: 01/08/2024] [Accepted: 01/20/2024] [Indexed: 04/01/2024] Open
Abstract
Stevens-Johnson syndrome is an infrequent condition affecting the skin and mucous membranes, it involves cutaneous detachment with high mortality without adequate treatment. We present the case of a 40-year-old male with a history of epilepsy treated with valproic acid and lamotrigine, previously diagnosed with dengue. Evaluation showed erythematous blisters on skin and mucosa with bleeding and desquamation, covering 10% of the body surface. The patient progressed favorably with the medical care received. Stevens-Johnson syndrome should be studied in association with arboviral diseases.
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Affiliation(s)
| | | | - Ivan Cordova-Tello
- Universidad Privada San Juan Bautista, Lima, Perú
- Hospital Regional de Ica, Perú
| | - Jhon Ausejo-Galarza
- Universidad Privada San Juan Bautista, Lima, Perú
- Hospital Regional de Ica, Perú
| | | | | | - Kovy Arteaga-Livias
- Universidad Privada San Juan Bautista, Lima, Perú
- Universidad Nacional Hermilio Valdizán, Huánuco, Perú
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14
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Gomes Ferreira S, Fernandes L, Santos S, Ferreira S, Sequeira J. Dipyrone (Metamizole)-Induced Stevens-Johnson Syndrome. Cureus 2024; 16:e53122. [PMID: 38420072 PMCID: PMC10899118 DOI: 10.7759/cureus.53122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 03/02/2024] Open
Abstract
Stevens-Johnson Syndrome (SJS), a severe mucocutaneous hypersensitivity reaction primarily triggered by drugs, poses a low-incidence, high-mortality challenge. This report explores its clinical nuances and emphasizes supportive care as the mainstay of treatment. A 74-year-old female, burdened with a complex medical history, presented with a non-pruritic macular rash escalating to skin and oral mucosal involvement. A recent introduction of dipyrone (metamizole) implicated drug-induced SJS. Histopathological confirmation guided treatment involving supportive care, corticosteroids, and wound care, resulting in clinical improvement. The case underscores the significance of histopathological confirmation and thorough medication history in navigating SJS complexities, especially in patients with comorbidities like connective tissue disease. A successful multidisciplinary approach and the decision for post-discharge monitoring highlight the intricate management challenges. This case illuminates the intricate interplay of medication-induced hypersensitivity, comorbidities, and management challenges in SJS. Optimal outcomes require prompt diagnosis, trigger identification, and a multidisciplinary treatment approach, emphasizing ongoing research and clinical vigilance.
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Affiliation(s)
- Sérgio Gomes Ferreira
- Internal Medicine, Hospital São Sebastião, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, PRT
| | - Luís Fernandes
- Internal Medicine, Hospital São Sebastião, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, PRT
| | - Sara Santos
- Internal Medicine, Hospital São Sebastião, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, PRT
| | - Sofia Ferreira
- Internal Medicine, Hospital São Sebastião, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, PRT
| | - Joana Sequeira
- Internal Medicine, Hospital São Sebastião, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, PRT
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15
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Griffith V, Ramnot A, Resnik SR, Resnik BI. A case of Stevens-Johnson syndrome treated with oral cyclosporine. J Family Med Prim Care 2023; 12:3425-3428. [PMID: 38361872 PMCID: PMC10866270 DOI: 10.4103/jfmpc.jfmpc_1162_23] [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] [Received: 07/16/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 02/17/2024] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) can occur at any age and are commonly caused by adverse drug events. Rapid diagnosis of SJS/TEN is imperative, followed by immediate cessation of offending agent and induction of appropriate treatment. Cyclosporine, a calcineurin inhibitor, has been reported to have a promising therapeutic effect in SJS/TEN patients with few side effects. Diagnosis of SJS/TEN in children is especially challenging as many of the symptoms mimic that of an upper respiratory infection, or other viral entities such as cocksackie A, roseola, or herpes simplex virus. We recommend initiating cyclosporine modified treatment, especially in children, upon any suspicion of SJS/TEN in a patient in order to halt the disease progression as early as possible.
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Affiliation(s)
- Victoria Griffith
- Department of Graduate Medical Education, Memorial Healthcare, Pembroke Pines, FL, United States
| | - Amanda Ramnot
- Department of Internal Medicine, University of Miami/Jackson Health Systems, Miami, FL, United States
| | - Sydney R. Resnik
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Barry I. Resnik
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Department of Dermatology, Resnik Skin Institute, Aventura, FL, United States
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16
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Mortensen XM, Shenkute NT, Zhang AY, Banna H. Clinical Outcome of Amniotic Membrane Transplant in Ocular Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis at a Major Burn Unit. Am J Ophthalmol 2023; 256:80-89. [PMID: 37598739 DOI: 10.1016/j.ajo.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 07/28/2023] [Accepted: 07/30/2023] [Indexed: 08/22/2023]
Abstract
PURPOSE To analyze the clinical outcome of amniotic membrane transplantation in patients with ocular Stevens-Johnson syndrome/toxic epidermal necrolysis at a major burn unit. DESIGN Retrospective, non-randomized interventional study. METHODS A retrospective chart review from April 2014 to January 2022 of 43 patients (85 eyes) at a burn center who underwent amniotic membrane transplantation (AMT) for severe ocular Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), or SJS/TEN was performed. Data regarding the clinical course and outcome were obtained. A comparison between the use of cryopreserved AMT rings (cryoAMT) and dehydrated AMT (deAMT) was also assessed. RESULTS A total of 85 eyes in 43 patients underwent AMT for severe ocular SJS/TEN. Of the eyes, 72 received deAMT with symblepharon ring, whereas 13 received cryoAMT over the cornea surface. All patients had deAMT placed over the eyelid margins and palpebral conjunctivae and tucked into the fornices. The average best-corrected visual acuity (BCVA) on last follow-up examination was 20/33, 20/30, and 20/34 in all eyes, the cryoAMT group, and the deAMT group, respectively (no significant difference between groups). The most common suspected inciting agent was lamotrigine (17% of all cases). The average long-term complication score was 1.4, with no significant difference between the cryoAMT group (1.6) and the deAMT group (1.4, P = .5). Symblepharon formation was seen more in the cryoAMT group compared to the deAMT group (P < .05). CONCLUSION The use of AMTs in severe ocular SJS/TEN greatly mitigates long-term complications and improves visual outcome. The retrospective nature of this study limits substantial conclusions regarding any significant difference in outcome between AMT treatment methods. Nevertheless, the use of cryopreserved AMT rings has a similar outcome profile compared to use of dehydrated AMTs with symblepharon ring. Further research is needed to evaluate optimal AMT techniques.
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Affiliation(s)
- Xavier M Mortensen
- From the University of North Carolina Hospitals, Department of Ophthalmology, Chapel Hill, North Carolina, USA
| | - Nathan T Shenkute
- From the University of North Carolina Hospitals, Department of Ophthalmology, Chapel Hill, North Carolina, USA
| | - Alice Yang Zhang
- From the University of North Carolina Hospitals, Department of Ophthalmology, Chapel Hill, North Carolina, USA
| | - Hussam Banna
- From the University of North Carolina Hospitals, Department of Ophthalmology, Chapel Hill, North Carolina, USA.
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17
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Glasson N, De Sandre C, Pantet O, Reinhard A, Lambercy K, Sandu K, Gorostidi F. Oropharyngolaryngeal manifestations in severe toxic epidermal necrolysis: a single-center's retrospective case series. Int J Dermatol 2023; 62:1384-1390. [PMID: 37767642 DOI: 10.1111/ijd.16858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/26/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Toxic epidermal necrolysis is a rare and life-threatening mucocutaneous disease. Although mucosal ear, nose, and throat (ENT) involvement is common, little is known about the characteristics, treatment modalities, and outcomes of these lesions. The aim of this study was to evaluate ENT mucosal lesions in severe toxic epidermal necrolysis patients and analyze their characteristics, treatment modalities, and outcomes, as well as proposing a management algorithm to prevent long-term debilitating sequalae of these lesions. METHODS This is a retrospective review of toxic epidermal necrolysis cases treated at the tertiary burns unit of the Lausanne University Hospital CHUV, Switzerland, between 2006 and 2019. RESULTS Out of 19 patients with severe toxic epidermal necrolysis, 17 (89%) underwent a complete ENT examination at admission and 14 (82%) had ENT mucosal involvement. Five (26.3%) patients died during the stay in the intensive care unit. Of the 16 patients who received maximal care, 13 (81%) required orotracheal intubation for a median time of 16 (IQR: 14) days. Out of the 14 patients who survived, four (29%) had long-term ENT complications consisting of synechiaes necessitating subsequent endoscopic procedures. Those four patients all required mechanical ventilation with an orotracheal tube and suffered from hypopharyngeal synechiaes as well as oral and endonasal synechiaes in individual cases. CONCLUSION This study suggests a high prevalence of ENT synechiaes in patients with severe toxic epidermal necrolysis and requiring orotracheal intubation. Periodic ENT examination could prevent mature synechiae formation in these patients. We propose an algorithm to prevent long-term sequalae in ENT mucosal involvement.
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Affiliation(s)
- Nicolas Glasson
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| | - Cécile De Sandre
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| | - Olivier Pantet
- Department of Adult Intensive Care, CHUV, Lausanne, Switzerland
| | - Antoine Reinhard
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| | - Karma Lambercy
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| | - Kishore Sandu
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
| | - François Gorostidi
- Department of Otolaryngology-Head and Neck Surgery, CHUV, Lausanne, Switzerland
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18
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Paterno JM, Breslow Z, Mamo MA, Mercado E. A Multifactorial Case of Stevens-Johnson Syndrome With Atypical Features. Cureus 2023; 15:e49289. [PMID: 38143660 PMCID: PMC10748208 DOI: 10.7759/cureus.49289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/26/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) is a severe mucocutaneous reaction that has a broad spectrum of causes and risk factors that include medications and other infectious causes such as Mycoplasma. In this case report, a patient with multiple comorbidities that confounded the presentation of Stevens-Johnson syndrome is observed. The patient was a 29-year-old female with a past medical history of recurrent cerebrovascular accident (CVA) who presented for an evaluation of chest pain. After empiric vancomycin was started for suspicion of endocarditis, our patient developed altered mental status, mucositis, and a painful erythematous erosion on her chest concerning for vasculitis, but after treatment and pathological review, it was found to be Stevens-Johnson syndrome. It is important to not forget the wide variety of risk factors for developing Stevens-Johnson syndrome and some of its unique associated presenting symptoms.
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Affiliation(s)
- Jennifer M Paterno
- Family Medicine, Hospital Corporation of America (HCA) Florida St. Petersburg Hospital, St. Petersburg, USA
| | - Zach Breslow
- Internal Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Mufit A Mamo
- Family Medicine, Hospital Corporation of America (HCA) Florida St. Petersburg Hospital, St. Petersburg, USA
| | - Edgar Mercado
- Critical Care, Hospital Corporation of America (HCA) Florida St. Petersburg Hospital, St. Petersburg, USA
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19
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Jain A, Meshram RJ. Toxic Epidermal Necrolysis Following the Ingestion of Paracetamol in a Pediatric Patient: A Case Report. Cureus 2023; 15:e48216. [PMID: 38050528 PMCID: PMC10693832 DOI: 10.7759/cureus.48216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/03/2023] [Indexed: 12/06/2023] Open
Abstract
Paracetamol is considered to be a relatively safe drug, even in the pediatric age group, at the recommended doses. Here we present a case of a six-year-old male presenting with symptoms and signs of Steven Johnson syndrome/toxic epidermal necrosis (SJS/TEN) following the ingestion of paracetamol. Steven Johnson syndrome/toxic epidermal necrosis is a potentially life-threatening dermatological emergency requiring intensive treatment. The patient was initially misdiagnosed as a case of chickenpox and was administered paracetamol. However, upon attending a tertiary care facility, he was diagnosed with TEN and treated with immunosuppressants. He recovered fully without any complications and was discharged within a week.
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Affiliation(s)
- Aditya Jain
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences School of Epidemiology and Public Health, Wardha, IND
| | - Revat J Meshram
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences School of Epidemiology and Public Health, Wardha, IND
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20
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Schroeder JW, Caputo V, Guida S, Conte F, Paolino G, Bonoldi E, Baruffaldi Preis FW, Rongioletti F. Stevens-Johnson syndrome and toxic epidermal necrolysis: 11-year retrospective experience in a high-complexity tertiary hospital in Milan, Italy. Clin Dermatol 2023; 41:712-720. [PMID: 37716583 DOI: 10.1016/j.clindermatol.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe drug-induced hypersensitivity reactions characterized by widespread epidermal necrosis, mucous membrane erosions, and systemic findings. We have provided our 11-year experience from a Milan, Italy tertiary hospital managing SJS/TEN, evaluating the clinical and histopathologic features plus the impact on mortality. We retrospectively analyzed 28 patients diagnosed with SJS/TEN based on the clinical and histopathologic findings, according to the classification criteria of multiple studies. We assessed the dermatographics, comorbidities, drug history, lesion characteristics, clinical findings, treatments, blood tests, and outcomes. Severity scores (SCORTEN, Re-SCORTEN, ABCD-10) were used for treatment evaluation and mortality prediction. Data were statistically analyzed, and significant factors associated with mortality were identified. We found that among the 28 patients, 89.2% had comorbidities, mainly cardiovascular diseases, and 21.4% had autoimmune disorders. All patients had received systemic therapy (46.6% monotherapy, 53.6% combination therapy), with systemic steroids (71.4%) and intravenous immunoglobulins (67.8%) being common treatments. There were complications, including systemic infections (67.9%) and septic shock (10.7%). The overall mortality rate was 17.8%. The statistical analysis indicated that malignancy, a high ABCD-10 score, and a high neutrophil-to-lymphocyte ratio were significantly associated with mortality. The extent of affected body surface area did not correlate significantly with mortality. This study provides insights into SJS/TEN management, revealing factors influencing mortality in a high-complexity tertiary hospital setting.
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Affiliation(s)
- Jan W Schroeder
- Unit of Allergology and Immunology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Valentina Caputo
- Unit of Pathological Anatomy and Cytogenetics, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefania Guida
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Dermatology Clinic, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesca Conte
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Paolino
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Emanuela Bonoldi
- Unit of Pathological Anatomy and Cytogenetics, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Franco Rongioletti
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Dermatology Clinic, IRCCS San Raffaele Hospital, Milan, Italy.
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21
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Gedon NKY, Bizikova P, Olivry T, Mendoza-Kuznetsova E, Oberkirchner U, Robertson JB, Linder KE. Histopathological characterisation of trunk-dominant canine pemphigus foliaceus, and comparison with classic facial and insecticide-triggered forms. Vet Dermatol 2023; 34:425-440. [PMID: 37316895 DOI: 10.1111/vde.13174] [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: 01/14/2023] [Revised: 03/14/2023] [Accepted: 03/24/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND While the clinical features were described recently, the histopathological characterisation of trunk-dominant canine pemphigus foliaceus (PF) is lacking, and whether it differs from classic facial or insecticide-triggered PF is unknown. HYPOTHESIS/OBJECTIVES This study describes the histopathological findings of trunk-dominant PF, and compares the results to classic facial and insecticide-triggered PF. ANIMALS Skin biopsies from 103 dogs with clinically characterised trunk-dominant (n = 33), classic facial (n = 26) and insecticide-triggered PF (n = 44) were included. MATERIALS AND METHODS Histological sections, randomised and blinded, were scored for over 50 morphological parameters of pustules, epidermis, dermis, adnexa and crusts. Intact pustule area and width were measured by digital microscopy. RESULTS In trunk-dominant PF, 77 intact pustules were predominantly subcorneal (0.0019-1.940 mm2 area, 0.0470-4.2532 mm wide), and contained from one to over 100 acantholytic keratinocytes. Pustules had boat acantholytic cells, corneocytes, perinuclear eosinophilic rings, neutrophil rosettes, acantholytic cell necrosis, rafts, cling-ons and/or eosinophils. Peripustular epidermal spongiosis, necrosis and lymphocyte exocytosis occurred, as did follicular pustules. Mixed dermal inflammation often contained eosinophils. Trunk-dominant PF did not differ from the other PF groups except for few parameters, such as having fewer rafts (p = 0.003). Additional autoimmune inflammatory patterns occurred in all PF groups. CONCLUSIONS AND CLINICAL RELEVANCE Trunk-dominant PF and other canine PF variants are histologically similar, which indicates shared pathomechanisms. The identification of common boat acantholytic cells and corneocyte separation has implications for the mechanisms of acantholysis. The diversity of histopathological and polyautoimmunity features support complicated immune mechanisms. Finally, results indicate that diagnostic biopsies cannot differentiate between these PF variants in dogs.
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Affiliation(s)
| | - Petra Bizikova
- College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Thierry Olivry
- College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | | | | | | | - Keith Emerson Linder
- College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
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22
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Line J, Saville E, Meng X, Naisbitt D. Why drug exposure is frequently associated with T-cell mediated cutaneous hypersensitivity reactions. FRONTIERS IN TOXICOLOGY 2023; 5:1268107. [PMID: 37795379 PMCID: PMC10546197 DOI: 10.3389/ftox.2023.1268107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
Cutaneous hypersensitivity reactions represent the most common manifestation of drug allergy seen in the clinic, with 25% of all adverse drug reactions appearing in the skin. The severity of cutaneous eruptions can vastly differ depending on the cellular mechanisms involved from a minor, self-resolving maculopapular rash to major, life-threatening pathologies such as the T-cell mediated bullous eruptions, i.e., Stevens Johnson syndrome/toxic epidermal necrolysis. It remains a significant question as to why these reactions are so frequently associated with the skin and what factors polarise these reactions towards more serious disease states. The barrier function which the skin performs means it is constantly subject to a barrage of danger signals, creating an environment that favors elicitation. Therefore, a critical question is what drives the expansion of cutaneous lymphocyte antigen positive, skin homing, T-cell sub-populations in draining lymph nodes. One answer could be the heterologous immunity hypothesis whereby tissue resident memory T-cells that express T-cell receptors (TCRs) for pathogen derived antigens cross-react with drug antigen. A significant amount of research has been conducted on skin immunity in the context of contact allergy and the role of tissue specific antigen presenting cells in presenting drug antigen to T-cells, but it is unclear how this relates to epitopes derived from circulation. Studies have shown that the skin is a metabolically active organ, capable of generating reactive drug metabolites. However, we know that drug antigens are displayed systemically so what factors permit tolerance in one part of the body, but reactivity in the skin. Most adverse drug reactions are mild, and skin eruptions tend to be visible to the patient, whereas minor organ injury such as transient transaminase elevation is often not apparent. Systemic hypersensitivity reactions tend to have early cutaneous manifestations, the progression of which is halted by early diagnosis and treatment. It is apparent that the preference for cutaneous involvement of drug hypersensitivity reactions is multi-faceted, therefore this review aims to abridge the findings from literature on the current state of the field and provide insight into the cellular and metabolic mechanisms which may contribute to severe cutaneous adverse reactions.
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Affiliation(s)
| | | | | | - Dean Naisbitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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23
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X R, W M, W G, Z L, W X, C W, W C. Chemotherapy-induced toxic epidermal necrolysis in a patient with multiple myeloma, a case report and literature review. Front Oncol 2023; 13:1227448. [PMID: 37601673 PMCID: PMC10433741 DOI: 10.3389/fonc.2023.1227448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
Rationale and patient concerns Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are severe drug-induced skin reactions associated with a high mortality rate. The patient in this case report developed TEN after receiving the Velcade-lenalidomide-dexamethasone (VRD) regimen for the treatment of multiple myeloma (MM). The patient's concerns included the progression of the rash, pain, itching, and potential long-term complications. TEN is a life-threatening condition that requires prompt medical intervention and hospitalization. Interventions The treatment approach for the patient included discontinuation of the causative medication (lenalidomide) and comprehensive supportive therapy. Supportive measures included the administration of systemic corticosteroids (methylprednisolone), intravenous immunoglobulin infusion, pain relief medication (ebastine), antibiotic prophylaxis, laminar bed use, and regular dressing changes. The goal was to alleviate symptoms, promote skin and mucous membrane healing, and prevent complications such as infection. Diagnosis The patient was diagnosed with stage III A DS and stage III ISS MM, specifically of the immunoglobulin G (λ) type. Diagnostic procedures included CT and MRI scans, bone marrow testing through flow cytometry and morphology analysis, and laboratory tests to assess blood markers. The diagnosis of TEN was made based on the clinical presentation, skin biopsy, and exclusion of other potential causes. Outcomes With the implemented interventions, the patient's condition gradually improved, and the rash resolved without any residual scarring. The patient's skin and mucosa healed, blood markers improved, and bone pain was relieved. The patient was discharged within a month of receiving the final treatment with bortezomib and dexamethasone. The patient got partial response(PR) of multiple myeloma. Lessons Drug-induced SJS/TEN is more prevalent in Asian populations, potentially due to differences in human leukocyte antigen (HLA) alleles. The use of systemic corticosteroid therapy in SJS/TEN cases is controversial due to the potential risks of immune suppression and complications. Balancing the immune response to prevent SJS/TEN while maintaining an effective cytotoxic immune response for tumor control remains a challenge. Lenalidomide, an immunomodulatory agent, can enhance antitumor immune responses but also contribute to the pathogenesis of SJS/TEN. Increased awareness of HLA variations and frequently mutated genes in different malignancies can help prevent SJS/TEN and improve patient outcomes.
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Affiliation(s)
- Rui X
- Department of Hematology, Dongyang Hospital Affiliated with Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Meidan W
- Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Gongqiang W
- Department of Hematology, Dongyang Hospital Affiliated with Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Longyi Z
- Clinical Laboratory, Dongyang Hospital Affiliated to Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Xiaoxia W
- Department of Hematology, Dongyang Hospital Affiliated with Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Wei C
- Department of Hematology, Dongyang Hospital Affiliated with Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Chenhui W
- Department of Hematology, Dongyang Hospital Affiliated with Wenzhou Medical University, Dongyang, Zhejiang, China
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24
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Maghsoud Y, Dong C, Cisneros GA. Investigation of the Inhibition Mechanism of Xanthine Oxidoreductase by Oxipurinol: A Computational Study. J Chem Inf Model 2023. [PMID: 37319436 PMCID: PMC10405278 DOI: 10.1021/acs.jcim.3c00624] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Xanthine oxidoreductase (XOR) is an enzyme found in various organisms. It converts hypoxanthine to xanthine and urate, which are crucial steps in purine elimination in humans. Elevated uric acid levels can lead to conditions like gout and hyperuricemia. Therefore, there is significant interest in developing drugs that target XOR for treating these conditions and other diseases. Oxipurinol, an analogue of xanthine, is a well-known inhibitor of XOR. Crystallographic studies have revealed that oxipurinol directly binds to the molybdenum cofactor (MoCo) in XOR. However, the precise details of the inhibition mechanism are still unclear, which would be valuable for designing more effective drugs with similar inhibitory functions. In this study, molecular dynamics and quantum mechanics/molecular mechanics calculations are employed to investigate the inhibition mechanism of XOR by oxipurinol. The study examines the structural and dynamic effects of oxipurinol on the pre-catalytic structure of the metabolite-bound system. Our results provide insights on the reaction mechanism catalyzed by the MoCo center in the active site, which aligns well with experimental findings. Furthermore, the results provide insights into the residues surrounding the active site and propose an alternative mechanism for developing alternative covalent inhibitors.
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Affiliation(s)
- Yazdan Maghsoud
- Department of Chemistry and Biochemistry, The University of Texas at Dallas, Richardson, Texas 75080, United States
| | - Chao Dong
- Department of Chemistry and Physics, The University of Texas Permian Basin, Odessa, Texas 79762, United States
| | - G Andrés Cisneros
- Department of Chemistry and Biochemistry, The University of Texas at Dallas, Richardson, Texas 75080, United States
- Department of Physics, The University of Texas at Dallas, Richardson, Texas 75080, United States
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25
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McKinley BJ, Allen ME, Michels N. Photodistributed Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and proposal for a new diagnostic classification. Eur J Med Res 2023; 28:188. [PMID: 37303053 DOI: 10.1186/s40001-023-01142-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 05/15/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Ultraviolet radiation (UVR) exposure is commonly reported as a risk factor for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, minimal evaluation of photo-induced SJS/TEN has been conducted. Thus, this review identifies all cases of SJS/TEN that are linked to an acute exposure of UVR and outlines the unifying characteristics of these cases. Furthermore, the theoretical pathogenesis, differential diagnoses, and proposed diagnostic criteria are defined. METHODS PubMed, Google Scholar, and other databases and websites were searched from inception to September 2021 to identify studies that met inclusion criteria. The following keywords were utilized: "Stevens-Johnson syndrome" and "toxic epidermal necrolysis" with "ultraviolet," "photodistributed," "photo-induced," "photosensitivity," and "photo." One reviewer assessed study characteristics, with confirmation by a second. The risk of bias was assessed independently by another. RESULTS Thirteen patient cases were identified, all reporting ultraviolet radiation prior to rash onset and an underlying causal drug. Case classifications included 7/13 SJS and 6/13 TEN. All cases described the rash as photodistributed with UVR exposure prior to rash onset (delay of 1-3 days) and a causal drug. 10 cases provided evidence that the photodistributed rash lacked linear demarcation (as in a sunburn) with satellite target-like lesions. No cases described a flu-like prodrome. DISCUSSION Mucositis, palmar and plantar rash, a positive Nikolsky sign, and a prolonged disease course can help distinguish from photosensitive reactions, while a negative direct immunofluorescence test is important to distinguish from other photo-induced disorders. CONCLUSION Physicians should be aware that UVR may precipitate SJS/TEN in patients taking susceptible drugs. After a 24-h delay from UVR exposure, a non-distinct, photodistributed rash appears with no flu-like prodrome and progresses for at least 48 h to include vesiculobullous eruptions and mucous membrane involvement. Photodistributed SJS/TEN appears to be photo-drug-induced with a unique onset and rash presentation that should be recognized as a distinct diagnosis.
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Affiliation(s)
- Blake Jeffrey McKinley
- Department of Internal Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
| | - Mitchell Edger Allen
- Department of Primary Care, Rocky Vista University College of Osteopathic Medicine, Ivins, UT, 84738, USA
| | - Nicole Michels
- Department of Medical Humanities and Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine, 8401 S. Chambers Road, Parker, CO, 80134, USA.
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Dewi ST, Qomariah LN, Sarkowi WK, Puspitasari M, Khalidah M, Anggatama M, Rizkiani DA, Etnawati K, Febriana SA. Combination of cyclosporine A and methylprednisolone to treat pediatric Stevens-Johnson syndrome/toxic epidermal necrolysis overlap syndrome. Dermatol Reports 2023; 15:9656. [PMID: 37426373 PMCID: PMC10327664 DOI: 10.4081/dr.2023.9656] [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] [Received: 12/23/2022] [Accepted: 02/08/2023] [Indexed: 07/11/2023] Open
Abstract
The treatment of epidermal necrolysis in pediatric patients remains a major challenge. Cyclosporine A has emerged as a promising therapy for epidermal necrolysis in adults; however, its efficacy in children is unclear. We present the case of a boy with Stevens-Johnson syndrome/toxic epidermal necrolysis overlap syndrome who was initially resistant to methylprednisolone monotherapy but improved after receiving the combination of cyclosporine A and methylprednisolone. Published reports on the use of cyclosporine A for pediatric epidermal necrolysis are also briefly reviewed.
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Affiliation(s)
- Shinta Trilaksmi Dewi
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | | | | | - Monika Puspitasari
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | - Miya Khalidah
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | - Marcella Anggatama
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | - Dwinanda Almira Rizkiani
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | - Kristiana Etnawati
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
| | - Sri Awalia Febriana
- Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta
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Hou SW, Chen SJ, Shen JD, Chen HY, Wang SJ, Wang CH, Man KM, Liu PL, Tsai MY, Chen YH, Chen WC. Emodin, a Natural Anthraquinone, Increases Uric Acid Excretion in Rats with Potassium Oxonate-Induced Hyperuricemia. Pharmaceuticals (Basel) 2023; 16:789. [PMID: 37375737 DOI: 10.3390/ph16060789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/09/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
The treatment of hyperuricemia and gout is mostly based on lowering serum uric acid levels using drugs, such as allopurinol, or increasing urinary excretion of uric acid. However, some patients still experience adverse reactions to allopurinol and turn to Chinese medicine as an alternative. Therefore, it is crucial to design a preclinical study to obtain more convincing data on the treatment of hyperuricemia and gout with Chinese medicine. This study aimed to explore the therapeutic effect of emodin, a Chinese herbal extract, in a rat model of hyperuricemia and gout. In this study, we used 36 Sprague-Dawley rats, which were randomly divided into six groups for experimentation. Hyperuricemia was induced in rats by intraperitoneal injections of potassium oxonate. The efficacy of emodin in reducing serum uric acid levels was demonstrated by comparing the positive control group with groups treated with three different concentrations of emodin. The inflammatory profiles, including interleukin (IL)-1β, IL-6, and tumor necrosis factor-α levels, were unaffected by emodin treatment. In the experimental results, it was observed that the serum uric acid concentration in the vehicle control group was 1.80 ± 1.14, while the concentrations in the moderate and high concentration emodin groups were 1.18 ± 0.23 and 1.12 ± 0.57, resulting in no significant difference in uric acid concentration between these treatment groups and the control group, indicating that emodin has a therapeutic effect on hyperuricemia. The increase in the fractional excretion of uric acid (FEUA) demonstrated that emodin promoted urinary uric acid excretion without significantly affecting the inflammatory profile. Thus, emodin reduced the serum uric acid concentration to achieve effective treatment of hyperuricemia and gout by increasing urinary excretion. These results were supported by the measured serum uric acid and FEUA levels. Our data have potential implications for the treatment of gout and other types of hyperuricemia in clinical practice.
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Affiliation(s)
- Shen-Wei Hou
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University, Taichung 404, Taiwan
| | - Szu-Ju Chen
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Jing-Dung Shen
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University, Taichung 404, Taiwan
- Division of Urology, Department of Surgery, Taichung Armed Forces General Hospital, Taichung 411, Taiwan
- National Defense Medical Center, Taipei 114, Taiwan
| | - Huey-Yi Chen
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University, Taichung 404, Taiwan
- Department of Obstetrics and Gynecology, Department of Medical Research, Department of Urology, China Medical University Hospital, Taichung 404, Taiwan
| | - Shih-Jing Wang
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University, Taichung 404, Taiwan
| | - Chia-Han Wang
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University, Taichung 404, Taiwan
- Department of Chinese Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung 427, Taiwan
| | - Kee-Ming Man
- Department of Medicinal Botanicals and Health Applications, College of Biotechnology and Bioresources, Da Yeh University, Changhua 515, Taiwan
- Department of Anesthesiology, China Medical University Hsinchu Hospital, Hsinchu 302, Taiwan
| | - Po-Len Liu
- Department of Respiratory Therapy, College of Medicine, Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Ming-Yen Tsai
- Department of Chinese Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
- Kaohsiung Municipal Feng Shan Hospital-Under the Management of Chang Gung Medical Foundation, Kaohsiung 830, Taiwan
| | - Yung-Hsiang Chen
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University, Taichung 404, Taiwan
- Department of Obstetrics and Gynecology, Department of Medical Research, Department of Urology, China Medical University Hospital, Taichung 404, Taiwan
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung 413, Taiwan
| | - Wen-Chi Chen
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University, Taichung 404, Taiwan
- Department of Obstetrics and Gynecology, Department of Medical Research, Department of Urology, China Medical University Hospital, Taichung 404, Taiwan
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Mohamed Jiffry MZ, Carmona Pires F, Perozo MA, Rangsipat N, Tabares D. A Rare Case of Pertuzumab-Induced Toxic Epidermal Necrolysis. Cureus 2023; 15:e39797. [PMID: 37398793 PMCID: PMC10313340 DOI: 10.7759/cureus.39797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
Pertuzumab is a targeted therapy drug that is employed in the management of human epidermal growth factor receptor 2 (HER2)-positive breast cancer and works by blocking the ability of cancer cells to receive growth and proliferation signals. Toxic epidermal necrolysis (TEN) is a severe cutaneous manifestation characterized by widespread erythema, necrosis, and bullous detachment of the skin involving more than 10% of the body surface area (BSA) and may be precipitated by an immunologic response to the administration of certain medications. However, TEN development as a consequence of HER2 inhibitor therapy has not been described in the existing literature. A 44-year-old female with a history of metastatic breast cancer to the liver presented with a diffuse blistering rash following a first-time administration of pertuzumab three days prior. Her rash began as painful and pruritic blisters 12 hours after the last infusion of pertuzumab and progressed to involve her arms, chest, groin, and thighs with a positive Nikolsky sign. She was managed supportively with high-dose steroids and antihistamines, and although her hospital course was complicated by hypotension requiring pressor support, she gradually made a full recovery and was released to a rehabilitation facility.
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Affiliation(s)
| | | | | | - Napat Rangsipat
- School of Medicine, American University of the Caribbean, Cupecoy, SXM
| | - Daniel Tabares
- School of Medicine, American University of the Caribbean, Cupecoy, SXM
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29
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Wung CH, Wang CW, Lai KC, Chen CB, Chen WT, Hung SI, Chung WH. Current understanding of genetic associations with delayed hypersensitivity reactions induced by antibiotics and anti-osteoporotic drugs. Front Pharmacol 2023; 14:1183491. [PMID: 37180708 PMCID: PMC10169607 DOI: 10.3389/fphar.2023.1183491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023] Open
Abstract
Drug-induced delayed hypersensitivity reactions (DHRs) is still a clinical and healthcare burden in every country. Increasing reports of DHRs have caught our attention to explore the genetic relationship, especially life-threatening severe cutaneous adverse drug reactions (SCARs), including acute generalized exanthematous pustulosis (AGEP), drug reactions with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). In recent years, many studies have investigated the immune mechanism and genetic markers of DHRs. Besides, several studies have stated the associations between antibiotics-as well as anti-osteoporotic drugs (AOD)-induced SCARs and specific human leukocyte antigens (HLA) alleles. Strong associations between drugs and HLA alleles such as co-trimoxazole-induced DRESS and HLA-B*13:01 (Odds ratio (OR) = 45), dapsone-DRESS and HLA-B*13:01 (OR = 122.1), vancomycin-DRESS and HLA-A*32:01 (OR = 403), clindamycin-DHRs and HLA-B*15:27 (OR = 55.6), and strontium ranelate (SR)-SJS/TEN and HLA-A*33:03 (OR = 25.97) are listed. We summarized the immune mechanism of SCARs, update the latest knowledge of pharmacogenomics of antibiotics- and AOD-induced SCARs, and indicate the potential clinical use of these genetic markers for SCARs prevention in this mini review article.
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Affiliation(s)
| | - Chuang-Wei Wang
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei and Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
| | - Kuo-Chu Lai
- Department of Physiology and Pharmacology, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Hematology and Oncology, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City, Taiwan
| | - Chun-Bing Chen
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei and Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Ti Chen
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei and Keelung, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shuen-Iu Hung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei and Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Institute of Pharmacology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei and Keelung, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Dermatology, Beijing Tsinghua Chang Gung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
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Lootah S, Alshammari E, Alqanatish J. Complete Remission in a Child With Multisystem Inflammatory Syndrome and Stevens-Johnson Syndrome Treated With Infliximab. Cureus 2023; 15:e37076. [PMID: 37153258 PMCID: PMC10156146 DOI: 10.7759/cureus.37076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
COVID-19, caused by SARS-CoV-2, can present with various dermatological manifestations, including (albeit rarely) severe mucocutaneous manifestations such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis. In contrast, multisystem inflammatory syndrome in children (MIS-C) commonly presents with mucocutaneous manifestations. The presentation of SJS in a child with MIS-C deserves increased attention from clinicians because of its potential fatality. Here we describe a 10-year-old boy with a history of exposure to confirmed COVID-19 who presented with fever, bilateral subconjunctival hemorrhage, cracked and red lips, oral ulcers, and generalized hemorrhagic skin lesions with targetoid lesions. Laboratory tests revealed leukocytosis, neutrophilia, lymphopenia, elevated C-reactive protein, sedimentation rate, ferritin, and B-type natriuretic peptide. A skin biopsy revealed patchy vacuolar interface dermatitis with subepidermal edema and superficial and deep perivascular predominantly histiocytic infiltrates with scattered eosinophils, lymphocytes, and neutrophils suggestive of SJS. In addition to supportive treatment, he was treated with IV methylprednisolone, immunoglobulins, and infliximab, after which his symptoms improved and gradually resolved.
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31
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Shamloul G, Desai M, Laslett N. An Unusual Case of Stevens-Johnson/Toxic Epidermal Necrolysis Overlap Syndrome in HER2 (Human Epidermal Growth Factor Receptor 2)-Positive Breast Cancer Patient Treated With Docetaxel. Cureus 2023; 15:e37590. [PMID: 37193463 PMCID: PMC10183237 DOI: 10.7759/cureus.37590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/02/2023] [Indexed: 05/18/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening drug-induced hypersensitivity reactions existing as a disease continuum based on the area of skin detachment. Following three cycles of treatment with docetaxel, a 60-year-old female with early-stage human epidermal growth factor receptor 2 (HER2)-positive breast cancer presented to the hospital with a flu-like illness and black crusting of the bilateral orbits, navel, and perianal region. Nikolsky sign was positive, and the patient was subsequently transferred to a specialized burn center for treatment of SJS/TEN overlap syndrome. There are a small number of cases documenting SJS/TEN following docetaxel administration in cancer patients.
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Affiliation(s)
- Gelan Shamloul
- Oncology, Philadelphia College of Osteopathic Medicine, Philadelphia, USA
| | - Mehir Desai
- Internal Medicine, Christiana Care Health System, Newark, USA
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Chen X, Chen X, Xiao Z, Wu H, Hu L, Yu R. Platelet-to-lymphocyte ratio predicts the duration of glucocorticoid therapy in the treatment of cutaneous adverse drug reactions. Toxicol Appl Pharmacol 2023; 468:116498. [PMID: 37023865 DOI: 10.1016/j.taap.2023.116498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Glucocorticoid (GC) remains the mainstay of treatment for cutaneous adverse drug reactions (cADRs) but has been associated with side effects, emphasizing the importance of precisely managing the duration of high-dose GC treatment. Although the platelet-to-lymphocyte ratio (PLR) has been proven to be closely related to inflammatory disorders, its ability to predict the timing of GC dose reduction (Tr) during cADRs treatment remains obscure. METHODS Hospitalized patients diagnosed with cADRs treated with glucocorticoids were analyzed in the present study to evaluate the association between PLR values and Tr values using linear, locally weighted scatter plot smoothing (LOWESS) and Poisson regression. Subgroup and ROC curve analyses were conducted to identify confounding variables and assess the predictive performance, respectively. RESULTS A total of 308 patients were included in the study, with a median age of 47.0 (31.0-62.0) years old and a median incubation period of 4 days. Antibiotics (n = 113, 36.7%) were the most common cause of cADRs, followed by Chinese herbs (n = 76, 24.7%). PLR values were positively correlated with Tr values during linear regression (P < 0.001, r = 0.414) and LOWESS regression analyses. Poisson regression showed PLR was an independent risk factor for higher Tr values (the incidence rate ratio ranged from 1.016 to 1.070 and P < 0.05 for all). The area under the curve of PLR for predicting Tr < 7 days was 0.917. CONCLUSIONS PLR is a simple and convenient parameter with huge prospects for application as a biomarker to assist clinicians in optimally managing patients treated with glucocorticoid therapy for cADRs.
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Affiliation(s)
- Xiaoli Chen
- Department of Dermatology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China
| | | | - Zupeng Xiao
- Department of Dermatology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China
| | - Hanyi Wu
- Department of Dermatology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China
| | - Li Hu
- Department of Dermatology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China.
| | - Rentao Yu
- Department of Dermatology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China.
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Green EA, Fogarty K, Ishmael FT. Penicillin Allergy. Prim Care 2023; 50:221-235. [PMID: 37105603 DOI: 10.1016/j.pop.2022.11.002] [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: 02/27/2023]
Abstract
Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.
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Affiliation(s)
- Estelle A Green
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Kelan Fogarty
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Faoud T Ishmael
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA; Mount Nittany Health, 1850 East Park Avenue, State College, PA 16803, USA.
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Iliopoulos G, Daoussis D. FDA-APPROVED INDICATIONS OF ADRENOCORTICOTROPIC HORMONE (ACTH) AS A DRUG: DOES IT HAVE A PLACE IN DISEASE MANAGEMENT TODAY? CENTRAL ASIAN JOURNAL OF MEDICAL HYPOTHESES AND ETHICS 2022. [DOI: 10.47316/cajmhe.2022.3.4.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
ACTH is a pituitary hormone important for proper function of adrenal glands, cortisol production as well as human physiology in general. It is involved in the pathogenesis of several endocrine disorders like Cushing syndrome and can be a useful diagnostic tool for diseases like primary adrenal insufficiency. Although popular as a hormone in endocrine system physiology and testing, ACTH has been used as a drug since the 1950s. Except for steroid-releasing properties, its mechanism of action involves a steroid-independent anti-inflammatory and possible immune-modulatory effect. Pharmaceutic ACTH has a wide range of indications approved by FDA and usually comes in the form of subcutaneous injections. In this narrative review, we accumulated what we considered as important data from reviews, cases and trials involving the most basic FDA-approved ACTH indications. A special emphasis was given on rheumatologic indications of ACTH. More large data studies need to be performed to assess ACTH usefulness, efficacy, safety and cost-effectiveness as a drug.
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Ortega Beltrá N, Guallart Domenech F, Martínez Ruiz de Apodaca P, Pons Rocher F. Odynophagia as the first manifestation of toxic epidermal necrolysis. BMJ Case Rep 2022; 15:e250305. [PMID: 36423938 PMCID: PMC9693651 DOI: 10.1136/bcr-2022-250305] [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] [Indexed: 11/25/2022] Open
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are infrequent mucocutaneous diseases, rapidly progressive and life-threatening. The clinical aspects and the management of TEN are exposed following a case.A man in his 40s presented to the emergency department with severe odynophagia, poor general condition and fever. His medical history was significant for HIV stage AIDS, and the treatment was discontinued 5 years before the present diagnosis. He was admitted for cerebral toxoplasmosis and discharged the previous 14 days with sulfadiazine. Erythematous-bullous lesions in the oral cavity, diffuse erythematous maculopapular rashes over his neck and chest, acute bilateral conjunctivitis and purulent urethritis was observed. The diagnostic suspicion was SJS/TEN due to sulfadiazine in immunosuppressed patients.This entity is infrequent but is a life-threatening dermatological emergency that requires immediate medical attention. Its diagnosis is mainly clinical, with a new drug history, prodromal symptoms and characteristic cutaneous-mucous lesions. Early diagnosis and rapid withdrawal of the drug improve the prognosis.
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Affiliation(s)
| | | | - Paula Martínez Ruiz de Apodaca
- Otorhinolaryngology, Hospital Universitario Doctor Peset, Valencia, Spain
- Otorhinolaryngology, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Francisco Pons Rocher
- Otorhinolaryngology, Hospital Universitario Doctor Peset, Valencia, Spain
- Cirurgia (Otorhinolaryngology), Universitat de Valencia Facultat de Medicina i Odontologia, Valencia, Spain
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Ran D, Wang N, Bao F, Liu Y, Zhou G, Zhou S, Shi Z. Carbamazepine-induced follicular mucinosis-like drug eruption. Indian J Dermatol Venereol Leprol 2022; 88:826-828. [PMID: 35962486 DOI: 10.25259/ijdvl_136_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/01/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Delin Ran
- Department of Dermatology, Shandong Provincial Hospital for Skin Disease & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Shandong, China
| | - Na Wang
- Department of Dermatology, Shandong Provincial Hospital for Skin Disease & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Shandong, China
| | - Fangfang Bao
- Department of Dermatology, Shandong Provincial Hospital for Skin Disease & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Shandong, China
| | - Yongxia Liu
- Department of Dermatology, Shandong Provincial Hospital for Skin Disease & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Shandong, China
| | - Guizhi Zhou
- Department of Dermatology, Shandong Provincial Hospital for Skin Disease & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Shandong, China
| | - Shengji Zhou
- Department of Dermatology, Shandong Provincial Hospital for Skin Disease & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Shandong, China
| | - Zhongxiang Shi
- Department of Dermatology, Shandong Provincial Hospital for Skin Disease & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Shandong, China
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Sljivic S, Pogson K, Williams FN, Nizamani R, King BT. COVID-induced toxic epidermal necrolysis in a 4-year-old female: a case report and literature review. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2022; 12:204-209. [PMID: 36420101 PMCID: PMC9677226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/28/2022] [Indexed: 12/24/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are conditions characterized by an immune-mediated skin reaction that results in blistering and epidermal detachment. Most cases are caused by drug hypersensitivity; however, recently there have been many publications documenting the association between coronavirus disease 2019 (COVID-19) and SJS/TEN. Our objective is to explore a case of a 4-year-old female who presented with a papular rash on her thighs that progressively worsened and spread to her face, trunk, and genital area. The patient tested positive for COVID-19. She required treatment with intravenous immunoglobulin (IVIG) and IV methylprednisolone, but eventually made a full recovery. This case underscores the need for awareness of the wide spectrum of dermatologic presentations in COVID-19 patients.
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Affiliation(s)
- Sanja Sljivic
- Department of Surgery, University of North Carolina School of MedicineChapel Hill, NC, USA,North Carolina Jaycee Burn CenterChapel Hill, NC, USA
| | - Kaylyn Pogson
- University of North Carolina School of MedicineChapel Hill, NC, USA
| | - Felicia N Williams
- Department of Surgery, University of North Carolina School of MedicineChapel Hill, NC, USA,North Carolina Jaycee Burn CenterChapel Hill, NC, USA
| | - Rabia Nizamani
- Department of Surgery, University of North Carolina School of MedicineChapel Hill, NC, USA,North Carolina Jaycee Burn CenterChapel Hill, NC, USA
| | - Booker T King
- Department of Surgery, University of North Carolina School of MedicineChapel Hill, NC, USA,North Carolina Jaycee Burn CenterChapel Hill, NC, USA
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Nakamura R, Ochi F, Chisaka T, Jogamoto T, Eguchi M. Acetaminophen‐induced Stevens–Johnson syndrome with lethal lung injury: A case report. Clin Case Rep 2022; 10:e6294. [PMID: 36093460 PMCID: PMC9445262 DOI: 10.1002/ccr3.6294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/07/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022] Open
Abstract
Stevens–Johnson syndrome (SJS) with respiratory distress can lead to fatal outcomes. However, there are a few reports of drug‐induced lung injury with diffuse alveolar damage caused by acetaminophen, the most severe type. Here, we describe a fatal case of acetaminophen‐induced SJS in a child with irreversible lung lesions.
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Affiliation(s)
- Ryota Nakamura
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
| | - Fumihiro Ochi
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
- Department of PediatricsEhime Prefectural Niihama HospitalNiihamaEhimeJapan
| | - Toshiyuki Chisaka
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
| | - Toshihiro Jogamoto
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
| | - Mariko Eguchi
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
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Mitochondrial Autoantibodies and the Role of Apoptosis in Pemphigus Vulgaris. Antibodies (Basel) 2022; 11:antib11030055. [PMID: 36134951 PMCID: PMC9495650 DOI: 10.3390/antib11030055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
Pemphigus vulgaris (PV) is an IgG autoantibody-mediated, potentially fatal mucocutaneous disease manifested by progressive non-healing erosions and blisters. Beyond acting to inhibit adhesion molecules, PVIgGs elicit a unique process of programmed cell death and detachment of epidermal keratinocytes termed apoptolysis. Mitochondrial damage by antimitochondrial antibodies (AMA) has proven to be a critical link in this process. AMA act synergistically with other autoantibodies in the pathogenesis of PV. Importantly, absorption of AMA inhibits the ability of PVIgGs to induce blisters. Pharmacologic agents that protect mitochondrial function offer a new targeted approach to treating this severe immunoblistering disease.
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Wang L, Varghese S, Bassir F, Lo YC, Ortega CA, Shah S, Blumenthal KG, Phillips EJ, Zhou L. Stevens-Johnson syndrome and toxic epidermal necrolysis: A systematic review of PubMed/MEDLINE case reports from 1980 to 2020. Front Med (Lausanne) 2022; 9:949520. [PMID: 36091694 PMCID: PMC9449801 DOI: 10.3389/fmed.2022.949520] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening immunologic reactions. Prior studies using electronic health records, registries or reporting databases are often limited in sample size or lack clinical details. We reviewed diverse detailed case reports published over four decades. Methods Stevens-Johnson syndrome and toxic epidermal necrolysis-related case reports were identified from the MEDLINE database between 1980 and 2020. Each report was classified by severity (i.e., SJS, TEN, or SJS-TEN overlap) after being considered a “probable” or “definite” SJS/TEN case. The demographics, preconditions, culprit agents, clinical course, and mortality of the cases were analyzed across the disease severity. Results Among 1,059 “probable” or “definite” cases, there were 381 (36.0%) SJS, 602 (56.8%) TEN, and 76 (7.2%) SJS-TEN overlap cases, with a mortality rate of 6.3%, 24.4%, and 21.1%, respectively. Over one-third of cases had immunocompromised conditions preceding onset, including cancer (n = 194,18.3%), autoimmune diseases (n = 97, 9.2%), and human immunodeficiency virus (HIV) (n = 52, 4.9%). During the acute phase of the reaction, 843 (79.5%) cases reported mucous membrane involvement and 210 (19.8%) involved visceral organs. Most cases were drug-induced (n = 957, 90.3%). A total of 379 drug culprits were reported; the most frequently reported drug were antibiotics (n = 285, 26.9%), followed by anticonvulsants (n = 196, 18.5%), analgesics/anesthetics (n = 126, 11.9%), and antineoplastics (n = 120, 11.3%). 127 (12.0%) cases reported non-drug culprits, including infections (n = 68, 6.4%), of which 44 were associated with a mycoplasma pneumoniae infection and radiotherapy (n = 27, 2.5%). Conclusion An expansive list of potential causative agents were identified from a large set of literature-reported SJS/TEN cases, which warrant future investigation to understand risk factors and clinical manifestations of SJS/TEN in different populations.
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Affiliation(s)
- Liqin Wang
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
- *Correspondence: Liqin Wang,
| | - Sheril Varghese
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
| | - Fatima Bassir
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
| | - Ying-Chin Lo
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
| | - Carlos A. Ortega
- School of Medicine, Vanderbilt University, Nashville, TN, United States
| | - Sonam Shah
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
- Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Elizabeth J. Phillips
- Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States
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Varol F, Can YY, Sahin E, Durak C, Kilic A, Sahin C, Gursoy F, Akin T. The role of treatment with plasma exchange therapy in two pediatric toxic epidermal necrolysis cases related to
COVID
‐19. J Clin Apher 2022; 37:516-521. [PMID: 35792366 PMCID: PMC9350357 DOI: 10.1002/jca.21997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/03/2022] [Accepted: 06/17/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Fatih Varol
- Department of Pediatric Intensive Care University of Health Sciences Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital Istanbul Turkey
| | - Yasar Yusuf Can
- Department of Pediatric Intensive Care University of Health Sciences Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital Istanbul Turkey
| | - Ebru Sahin
- Department of Pediatric Intensive Care University of Health Sciences Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital Istanbul Turkey
| | - Cansu Durak
- Department of Pediatric Intensive Care University of Health Sciences Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital Istanbul Turkey
| | - Aziz Kilic
- Department of Pediatrics Ankara University Faculty of Medicine Ankara Turkey
| | - Ceyhan Sahin
- Department of Pediatric Surgery University of Health Sciences Umraniye Training and Research Hospital Istanbul Turkey
| | - Fatima Gursoy
- Department of Pathology University of Health Sciences Umraniye Training and Research Hospital Istanbul Turkey
| | - Tugba Akin
- Department of Dermatology Konya Numune State Hospital Konya Turkey
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Ao S, Gao X, Zhan J, Ai L, Li M, Su H, Tang X, Chu C, Han J, Wang F. Inhibition of tumor necrosis factor improves conventional steroid therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis in a cohort of patients. J Am Acad Dermatol 2022; 86:1236-1245. [PMID: 35121075 DOI: 10.1016/j.jaad.2022.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/04/2022] [Accepted: 01/19/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Systemic steroid therapies for Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) have been challenged because of their limited benefits. Whether additional tumor necrosis factor (TNF) α inhibition provides an optimized approach remains unexplored. OBJECTIVE To investigate the efficacy of TNF-α inhibition combined with a steroid to treat SJS/TEN and to identify potential biomarkers. METHODS Twenty-five patients with SJS/TEN were recruited and divided into 2 groups: 10 patients received methylprednisolone and 15 patients received etanercept plus methylprednisolone. Serum levels of granzyme B, perforin, interferon-γ, interleukin (IL) 6, IL-15, IL-18, macrophage inflammatory protein 1α, macrophage inflammatory protein 1β, and TNF-α were measured by multiplex cytokine analysis kits during the acute and resolution phases. RESULTS Compared with the steroid monotherapy, the combination therapy significantly shortened the course of the initial steroid treatment and the duration of the acute stage, hospitalization stay, and skin re-epithelialization. Although both therapies significantly reduced IL-15 levels; the combination therapy also decreased IL-6 and IL-18 levels. While the level of IL-15 was positively correlated with skin re-epithelialization time in both groups, the level of IL-6 served as an additional marker for the course of the disease in the combination therapy group. LIMITATIONS The cohort size is relatively small. CONCLUSION Additional TNF-α inhibition to steroid treatment appeared to improve outcomes for SJS/TEN.
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Affiliation(s)
- Suiting Ao
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Xuemei Gao
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Jipang Zhan
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Lu Ai
- Department of Laboratory Medicine, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Minyi Li
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Huilin Su
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Xuhua Tang
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Coco Chu
- Jill Roberts Institute for Research in Inflammatory Bowel Disease, Weill Cornell Medicine, Cornell University, New York, New York
| | - Jiande Han
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Fang Wang
- Department of Dermatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
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Biswas M, Ershadian M, Shobana J, Nguyen A, Sukasem C. Associations of
HLA
genetic variants with carbamazepine‐induced cutaneous adverse drug reactions: An updated meta‐analysis. Clin Transl Sci 2022; 15:1887-1905. [PMID: 35599240 PMCID: PMC9372413 DOI: 10.1111/cts.13291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 11/12/2022] Open
Abstract
Aggregated risk of carbamazepine (CBZ)‐induced cutaneous adverse drug reactions (cADRs) with different HLA variants are unclear and limited in terms of the power of studies. This study aimed to assess the aggregated risk of CBZ‐induced cADRs associated with carrying the following HLA variants: HLA‐B*15:02, HLA‐B*15:11, HLA‐B*15:21, HLA‐B*38:02, HLA‐B*40:01, HLA‐B*46:01, HLA‐B*58:01, HLA‐A*24:02, and HLA‐A*31:01. Literature was searched in different databases following PRISMA guidelines. The outcomes were measured as odds ratio (OR) using RevMan software by a random/fixed effects model, where p < 0.05 was set as statistical significance. In total, 46 case–control studies met the inclusion criteria and were included in this analysis consisting of 1817 cases and 6614 controls. It was found that case‐patients who carried the HLA‐B*15:02 allele were associated with a significantly increased risk of CBZ‐induced Stevens−Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) compared to controls (OR 26.01; 95% CI 15.88–42.60; p < 0.00001). The aggregated risk of cADRs was slightly higher in Asian compared to Caucasian patients (Asians: OR 14.84; 95% CI 8.95–24.61; p < 0.00001; Caucasians: OR 11.65; 95% CI 1.68–80.70; p = 0.01). Further, HLA‐B*15:11, HLA‐B*15:21, or HLA‐A*31:01 allele was also associated with significantly increased risk of CBZ‐induced cADRs (HLA‐B*15:11: OR 6.08; 95% CI 2.28–16.23; p = 0.0003; HLA‐B*15:21: OR 5.37; 95% CI 2.02–14.28; p = 0.0008; HLA‐A*31:01: OR 5.92; 95% CI 4.35–8.05; p < 0.00001). Other HLA variants were not found to have any significant associations with CBZ‐induced cADRs. Strong associations between the HLA‐B*15:02, HLA‐B*15:11, HLA‐B*15:21, or HLA‐A*31:01 allele with CBZ‐induced cADRs have been established in this analysis. Pharmacogenetic testing of particular HLA alleles before initiation of CBZ therapy may be beneficial to patients and may help to eradicate cADRs substantially.
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Affiliation(s)
- Mohitosh Biswas
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology Faculty of Medicine Ramathibodi Hospital, Mahidol University Bangkok Thailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC) Ramathibodi Hospital Bangkok Thailand
- Department of Pharmacy University of Rajshahi Rajshahi Bangladesh
| | - Maliheh Ershadian
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology Faculty of Medicine Ramathibodi Hospital, Mahidol University Bangkok Thailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC) Ramathibodi Hospital Bangkok Thailand
| | - John Shobana
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology Faculty of Medicine Ramathibodi Hospital, Mahidol University Bangkok Thailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC) Ramathibodi Hospital Bangkok Thailand
| | - Ai‐Hoc Nguyen
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology Faculty of Medicine Ramathibodi Hospital, Mahidol University Bangkok Thailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC) Ramathibodi Hospital Bangkok Thailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology Faculty of Medicine Ramathibodi Hospital, Mahidol University Bangkok Thailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC) Ramathibodi Hospital Bangkok Thailand
- Pharmacogenomics and Precision Medicine, The Preventive Genomics & Family Check‐up Services Center Bumrungrad International Hospital Bangkok Thailand
- Department of Pharmacology and Therapeutics, MRC Centre for Drug Safety Science, Institute of Systems, Molecular and Integrative Biology University of Liverpool Liverpool UK
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Drug Reaction with Eosinophilia and Systemic Symptoms (DReSS)/Drug-Induced Hypersensitivity Syndrome (DiHS)—Readdressing the DReSS. Biomedicines 2022; 10:biomedicines10050999. [PMID: 35625735 PMCID: PMC9138571 DOI: 10.3390/biomedicines10050999] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 12/17/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DReSS), also known as drug-induced hypersensitivity syndrome (DiHS), is a severe, systemic, T cell mediated drug reaction with combinations of cutaneous, hematologic, and internal organ involvement. Pathogenesis of DReSS is multi-factorial, involving drug-exposure, genetic predisposition through specific human leukocyte antigen (HLA) alleles and metabolism defects, viral reactivation, and immune dysregulation. Clinical features of this condition are delayed, stepwise, and heterogenous, making this syndrome challenging to recognize and diagnose. Two sets of validated diagnostic criteria exist that can be employed to diagnose DReSS/DiHS. Methods to improve early recognition of DReSS and predict disease severity has been a recent area of research focus. In vitro and in vivo tests can be employed to confirm the diagnosis and help identify culprit drugs. The mainstay treatment of DReSS is prompt withdrawal of the culprit drug, supportive treatment, and immunosuppression depending on the severity of disease. We present a comprehensive review on the most recent research and literature on DReSS, with emphasis on pathogenesis, clinical features, diagnosis, confirmatory testing modalities, and treatment. Additionally, this summary aims to highlight the differing viewpoints on this severe disease and broaden our perspective on the condition known as DReSS.
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Yu R, Chen S, Pan Y, Ma C, Hu L, Chen A, Wei B. Combined use of cyclosporine in the treatment of Stevens-Johnson syndrome/toxic epidermal necrolysis. J Dermatol 2022; 49:629-636. [PMID: 35437858 DOI: 10.1111/1346-8138.16369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/10/2022] [Accepted: 03/12/2022] [Indexed: 11/28/2022]
Abstract
The exact efficacy of cyclosporine in the treatment of Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) still needs evidence from more clinical data. This study was designed to compare the effectiveness and side-effects of combined use of cyclosporine in the treatment TEN with glucocorticoids (GC)/i.v. immunoglobulin G (IVIG). A total of 46 patients with SJS/TEN were enrolled and classified into two groups based on the therapeutic drugs used. Clinical characteristics, interventions, outcomes, and disease progressions were collected and compared between the two groups. In our cohort, seven patients eventually died and the overall fatality rate was 15.2%, but there was no difference between the two groups (p = 0.557). On discharge, the median SCORe of Toxic Epidermal Necrosis (SCORTEN) fell from 2.0 at admission to 1.0 and the median body surface area detached fell from 32.0% at admission to 9.5%. Patients in the cyclosporine group had a higher rate of re-epithelialized area than patients in the non-cyclosporine group (p < 0.05). Cyclosporine significantly reduced the length of stay (19.0 vs. 13.0 days, p = 0.019) and the rate of systemic infection (71.4% vs. 36.0%, p = 0.017) compared with the non-cyclosporine group. SCORTEN was the only significant risk factor for death and the risk ratio was 1.96 (1.17-3.31, p = 0.011). Conclusively, the combined use of cyclosporine could reduce the occurrence of systemic infection and accelerate the re-epithelialization.
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Affiliation(s)
- Rentao Yu
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuang Chen
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yun Pan
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chunrong Ma
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Hu
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Aijun Chen
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bin Wei
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Primisawitri PP, Mawardi P. The Correlation of Neutrophil-Lymphocyte Ratio and Eosinophil Count with SCORTEN in SJS/TEN. CLINICAL, COSMETIC AND INVESTIGATIONAL DERMATOLOGY 2022; 15:547-556. [PMID: 35387203 PMCID: PMC8978353 DOI: 10.2147/ccid.s356450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/15/2022] [Indexed: 11/29/2022]
Abstract
Introduction Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute severe cutaneous adverse reactions commonly caused by medication. Precise evaluation of disease severity in initial setting must be obtained to start appropriate treatment. Neutrophil and lymphocyte ratio (NLR) plays a role in displaying inflammatory reaction while eosinophils count (EC) influences immunological dysregulation including the proliferation of cytotoxic cells in early onset of SJS/TEN. Objective To evaluate whether NLR and EC serve as prognostic markers of disease severity in patients with SJS/TEN using SCORTEN. Methods A single center study with retrospective study included SJS/TEN patients at Dr. Moewardi General Hospital Surakarta in January 1st 2018–December 31st 2020. The required laboratory data was assessed at the beginning of the patient’s admission through medical records. The significance analysis were performed using one-way ANOVA and Spearman while the receiver-operator curve were used to evaluate the prognostic value of variables for severity in SJS/TEN patients. Results The total sample in this study was 24 patients with majority female (58%) and range from 25 to >50 years (54%). The results demonstrated of significant difference and positively correlated between NLR and EC with severity of SJS/TEN (p<0.01; r>0.05). The specificity and sensitivity of 51%;61% and 70%;60%, respectively. Conclusion NLR and EC can be used as prognosticators of severity in SJS/TEN while further research on other inflammatory markers with increased number of samples and study centers are needed to provide more actual data.
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Affiliation(s)
- Pratiwi Prasetya Primisawitri
- Department of Dermatology and Venereology Faculty of Medicine, Sebelas Maret University/Dr. Moewardi General Hospital Surakarta, Central Java, Indonesia
| | - Prasetyadi Mawardi
- Department of Dermatology and Venereology Faculty of Medicine, Sebelas Maret University/Dr. Moewardi General Hospital Surakarta, Central Java, Indonesia
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Eyer GC, Heidemeyer K, Exadaktylos A, Ziaka M. Fuchs Syndrome with Isolated Oral Mucosa Lesions due to Severe Herpes Simplex Cheilitis in a Patient with Idiopathic Thrombocytopenic Purpura. Eur J Case Rep Intern Med 2022; 9:003278. [PMID: 35520365 PMCID: PMC9067420 DOI: 10.12890/2022_003278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 11/29/2022] Open
Abstract
UNLABELLED Stevens-Johnson syndrome (SJS) is a severe dermatological disease classically characterized by erythematous target lesions and mucosal involvement. Fuchs syndrome is an incomplete presentation of SJS which has oral, conjunctival and genital manifestations but no skin lesions. To the best of our knowledge, our case of Fuchs syndrome in an 80-year-old man is the first such case related to herpes simplex virus (HSV)-1 infection to be described. Our patient quickly recovered following IVIG therapy, although specific treatment is still a topic of discussion. Research is required on this poorly understood dermatological disease to determine optimum therapy. LEARNING POINTS We report a case of Fuchs syndrome in an elderly man after HSV-1 cheilitis.Therapy always includes discontinuation of the causative drug.Specific therapy for Stevens-Johnson syndrome and Fuchs syndrome is still a topic of discussion, although we noted marked improvement following the administration of IVIG therapy.
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Affiliation(s)
| | - Kristine Heidemeyer
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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Singh R, Nutan F. The Successful Management of SJS/TEN secondary to enfortumab vedotin Therapy. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2022. [DOI: 10.1016/j.cpccr.2022.100162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Li Y, Fu R, Jiang T, Duan D, Wu Y, Li C, Li Z, Ni R, Li L, Liu Y. Mechanism of Lethal Skin Toxicities Induced by Epidermal Growth Factor Receptor Inhibitors and Related Treatment Strategies. Front Oncol 2022; 12:804212. [PMID: 35223483 PMCID: PMC8866822 DOI: 10.3389/fonc.2022.804212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/17/2022] [Indexed: 02/01/2023] Open
Abstract
Epidermal growth factor receptor (EGFR) inhibitors are widely used to treat various types of cancers such as non-small cell lung cancer, head and neck cancer, breast cancer, pancreatic cancer. Adverse reactions such as skin toxicity, interstitial lung disease, hepatotoxicity, ocular toxicity, hypomagnesemia, stomatitis, and diarrhea may occur during treatment. Because the EGFR signaling pathway is important for maintaining normal physiological skin function. Adverse skin reactions occurred in up to 90% of cancer patients treated with EGFR inhibitors, including common skin toxicities (such as papulopustular exanthemas, paronychia, hair changes) and rare fatal skin toxicities (e.g., Stevens–Johnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis). This has led to the dose reduction or discontinuation of EGFR inhibitors in the treatment of cancer. Recently, progress has been made about research on the skin toxicity of EGFR inhibitors. Here, we summarize the mechanism of skin toxicity caused by EGFR inhibitors, measures to prevent severe fatal skin toxicity, and provide reference for medical staff how to give care and treatment after adverse skin reactions.
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Affiliation(s)
- Yanping Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Ruoqiu Fu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Tingting Jiang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Dongyu Duan
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yuanlin Wu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Chen Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Ziwei Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Rui Ni
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Li Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yao Liu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
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Stevens-Johnson syndrome with vulvar involvement: A case report and literature review. Case Rep Womens Health 2022; 34:e00404. [PMID: 35340779 PMCID: PMC8942816 DOI: 10.1016/j.crwh.2022.e00404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/08/2023] Open
Abstract
Stevens-Johnson syndrome is a rare, life-threatening mucocutaneous condition causing necrosis and detachment of the epidermis. Vulvovaginal involvement, seen in up to 70% of affected women, can lead to painful chronic conditions such as adenosis, hematocolpos, and chronic pelvic pain. To date, there is no consensus regarding the optimal treatment of vulvovaginal involvement. In this case report, one case of Stevens-Johnson syndrome with vulvar and vaginal involvement is described, and the treatment options for this rare condition are reviewed. Up to 70% of patients with Stevens-Johnson syndrome may have vulvar involvement. The management of vulvar Stevens-Johnson syndrome should include high-potency topical steroids. Vaginal strictures may develop, in which case the use of vaginal dilators may be considered. Rolled gauze may be used to encourage labial separation when agglutination is seen.
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