[Factors associated with the severity of acute ocular involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis in sub-Saharan Africa]

AIM

The purpose of this study was to identify risk factors associated with the severity of acute ocular involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) in sub-Saharan Africa.

PATIENTS AND METHOD

A retrospective study was carried out at the dermatology department in collaboration with the ophthalmology department for SJS/TEN patients between January 2000 and December 2016 in Lomé (Togo). The severity of acute ocular involvement was evaluated using the Power classification, and the drug eruption score was assessed using de Bastuji-Garin classification.

RESULTS

A total of 107 cases of SJS/TEN (84 cases of SJS, 20 cases of TEN and 3 cases of overlap syndrome) were analyzed. There were 71 women and 36 men, with an average age of 32.3±12.5 years (range: 5 to 75 years). Sulfonamides (37.4%) were the most commonly used drugs followed by nevirapine (22.4%). HIV serology was positive in 46 (58.2%) of the 79 patients tested. A total of 54 (50.5%) patients had acute ocular involvement, which was mild in 29.9% of patients, moderate in 13.1% and severe in 7.5%. In multivariate analysis, exposure to sulfadoxine was the sole factor associated with moderate or severe acute ocular involvement in SJS/TEN (adjusted odds ratio=3.3; 95% CI=[1.1; 10.2]).

CONCLUSION

Exposure to sulfadoxine was identified in our study as a risk factor associated with the severity of acute ocular involvement in SJS/TEN. Multicenter studies should be conducted in sub-Saharan Africa to confirm this associated risk factor.

[Lethal Lyell's syndrome induced by fusidic acid]

BACKGROUND

Herein, we report the first case of toxic epidermal necrosis due to oral fusidic acid having a fatal outcome.

PATIENTS AND METHODS

An 82-year-old woman was referred to our dermatology department for generalized bullous skin eruption. Clinical examination showed fever, oral and ocular ulcerations, and epidermal detachment involving more than 70 % of her body surface area together with a positive Nikolsky sign. Lyell's syndrome was diagnosed. Cutaneous histology showed total epidermal necrosis and a normal dermis. Oral fusidic acid had been prescribed 12 days earlier for a chronic sacral pressure sore. No other treatment had been introduced during the previous two months. The outcome was fatal within 24 hours.

DISCUSSION

Fusidic acid is commonly used topically by dermatologists for limited staphylococcal skin infections. Oral treatment is rare and is recommended only for skin, bone or joint infections. This is the first reported case of toxic epidermal necrolysis due to oral fusidic acid. The French national drug safety monitoring register contains only one case in which fusidic acid was a possible culprit.

CONCLUSION

Fusidic acid must be considered a potential source of serious cutaneous adverse reactions, particularly toxic epidermal necrolysis.

[Severe cutaneous drug reactions to misused griseofulvin: 2 cases]

BACKGROUND

Griseofulvin is an antifungal drug known to cause drug rash. However, it is widely prescribed outside its classic indications. Herein, we describe 2 cases in which griseofulvin was prescribed for off-label indications.

PATIENTS AND METHODS

Case No. 1. A 51-year-old woman was referred to the department of internal medicine for management of Stevens-Johnson Syndrome (SJS). The symptoms appeared 17 days after she had taken griseofulvin for inguinal intertrigo. Case No. 2. A 19-year-old female patient consulted for toxic epidermal necrolysis (TEN) affecting 30% of her body surface, with a positive Nikolsky sign and severe mucosal lesions. These symptoms appeared 9 days after she began taking griseofulvin, which had initially been prescribed for her husband for mycosis.

DISCUSSION

Toxic epidermal necrolysis, a condition chiefly of drug-related origin, is a severe mucocutaneous syndrome characterized by massive keratinocytic apoptosis. Although there are few scientific publications referring to griseofulvin-induced drug eruption, they deserve to be mentioned since this drug is widely used for purposes other than the approved indications and can cause life-threatening reactions.

CONCLUSION

We report two cases of toxic epidermal necrolysis related to the misuse of griseofulvin. It is important to bear in mind the precautions for use of oral antifungal drugs, which are strictly reserved for use against resistant or diffuse forms of mucocutaneous fungal infections.

[Systemic lupus erythematosus presenting as Stevens-Johnson syndrome]

Stevens-Johnson syndrome and toxic epidermal necrolysis are life-threatening dermatological conditions. Their most common cause is medication. However, in a small proportion of patients these dermatological conditions could be the first presentation of systemic lupus erythematosus. We now describe a 34-year-old patient who presented with manifestations of Stevens-Johnson as a first feature of systemic lupus erythematosus. Systemic lupus erythematosus reveled by Stevens-Johnson syndrome has been infrequently reviewed in the previous literature. This diagnosis should be considered when cutaneous adverse drug reactions occur without clear drug causality.

[Vemurafenib-induced toxic epidermal necrolysis]

BACKGROUND

Herein we report the first case of toxic epidermal necrolysis (TEN) occurring with use of vemurafenib.

PATIENTS AND METHODS

A 75-year-old female patient was being treated with vemurafenib for stage IV melanoma with BRAF V600E mutation. She suddenly presented fever, diffuse pruriginous maculopapular erythema, palpebral edema, palmar bulla, conjunctivitis, cheilitis and mucosal ulceration. The condition progressed towards detachment affecting 50% of the skin area. Cutaneous biopsy revealed lichenoid dermatosis, chiefly vesicular with numerous eosinophils. Direct immunofluorescence (IFD) was negative. Vemurafenib was the only drug to which the reaction was ascribable and we concluded on vemurafenib-induced TEN.

DISCUSSION

To our knowledge, this is the first reported case of vemurafenib-induced TEN, but this adverse effect, although already described in the BRIM-3 study, appears rare in clinical practice. Other severe skin reactions have been described in the literature. These include a case of Stevens-Johnson syndrome in a female patient treated with vemurafenib and previously receiving ipilimumab. A more common occurrence is cutaneous reactions involving efflorescence of benign hyperkeratotic lesions, occasionally accompanied by authentic epidermal carcinoma or keratoacanthoma, and requiring regular dermatological monitoring of patients treated with vemurafenib.

CONCLUSION

If maculopapular exanthema occurs under vemurafenib, continuation of this treatment should be reassessed since the risk of progression to a more serious condition such as TEN, as seen in the present case, cannot be ruled out.