[Ocular involvement in Stevens-Johnson syndrome: treatment with amniotic membrane transplantation in the acute phase]

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are both part of a spectrum of serious mucocutaneous disorders, most often caused by drugs, with a high morbidity and mortality. In the acute stage, serious skin and mucocutaneous lesions with painful blistering, erosions and systemic involvement present the main focus of attention. The severity of skin manifestations in the acute stage, however, does not necessarily correlate with that of the mucosal lesions. Most feared are long-term sequelae, especially chronic eye involvement, which can be highly disabling. Here, we illustrate the importance of daily evaluation, early recognition and treatment of eye involvement in the acute stage of SJS/TEN, even when skin manifestations and/or initial eye involvement are relatively mild. Timely performed amniotic membrane transplantation in the acute stage can limit irreversible damage, caused by chronic inflammation, and therefore prevent cicatrisation at a later stage.

Clindamycin-induced acute generalised exanthematous pustulosis: five cases and a review of the literature

Acute generalised exanthematous pustulosis (AGEP) is a rare but serious cutaneous adverse drug reaction, often related to antibiotics such as beta-lactams or macrolides. However, it is rarely associated with clindamycin which belongs to the lincosamide antibiotics. The Netherlands Pharmacovigilance Centre Lareb received five reports of AGEP associated with the use of clindamycin. We present these five cases and provide support for this association from the Lareb database, the database of the WHO Collaborating Centre for International Drug Monitoring (Vigibase™), the database of the European Medicine Agency (Eudravigilance), and from a mini review of the literature.

Severe flucloxacillin-induced acute generalized exanthematous pustulosis (AGEP), with toxic epidermal necrolysis (TEN)-like features: does overlap between AGEP and TEN exist? Clinical report and review of the literature

Acute generalized exanthematous pustulosis (AGEP) and Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) are rare but severe cutaneous adverse drug reactions. Especially in TEN, large areas of the skin and mucosae may become detached. Although AGEP and SJS/TEN are distinct entities with a different clinical picture, pathogenesis, prognosis and treatment, they may share some features, raising the hypothesis of overlap between both entities. We present a severe case of AGEP, caused by flucloxacillin, clinically presenting with TEN-like features and pronounced systemic symptoms with haemodynamic and respiratory instability. Furthermore, we present a review of the literature on cases of AGEP with features resembling SJS/TEN or a supposed overlap with SJS/TEN.

Drug reaction with eosinophilia and systemic symptoms (DRESS): an original multisystem adverse drug reaction. Results from the prospective RegiSCAR study

BACKGROUND

Cases of severe drug hypersensitivity, demonstrating a variable spectrum of cutaneous and systemic involvement, are reported under various names, especially drug reaction with eosinophilia and systemic symptoms (DRESS). Case definition and overlap with other severe cutaneous adverse reactions (SCAR) are debated.

OBJECTIVES

To analyse the spectrum of signs and symptoms of DRESS and distribution of causative drugs in a large multicentre series.

PATIENTS AND METHODS

RegiSCAR, a multinational registry of SCAR, prospectively enrolled 201 potential cases from 2003 to mid-2009. Using a standardized scoring system, 117 cases were validated as showing probable or definite DRESS.

RESULTS

The male/female ratio was 0.80; females were borderline significantly younger than males. Next to the ubiquitous exanthema, the main features were eosinophilia (95%), visceral involvement (91%), high fever (90%), atypical lymphocytes (67%), mild mucosal involvement (56%) and lymphadenopathy (54%). The reaction was protracted in all but two patients; two patients died during the acute phase. Drug causality was plausible in 88% of cases. Antiepileptic drugs were involved in 35%, allopurinol in 18%, antimicrobial sulfonamides and dapsone in 12% and other antibiotics in 11%. The median time interval after drug intake was 22 days (interquartile range 17-31) for all drugs with (very) probable causality, with differences between drugs.

CONCLUSION

This prospective observational study supports the hypothesis that DRESS is an original phenotype among SCAR in terms of clinical and biological characteristics, causative drugs, and time relation. The diversity of causative drugs was rather limited, and mortality was lower than that suggested by prior publications.

Why you should ask your patients about their fishing hobbies

Patients who use immunosuppressive agents, in particular medication that blocks tumour necrosis factor-a, are at risk for mycobacterial infections. Besides the typical Mycobacterium tuberculosis infection, a lso a typical mycobacterial disease may occur. Here we demonstrate two patients with such atypical mycobacterial infection due to swimming and fishing water contact. We propose that patients, before starting with immunosuppressive therapy, are counselled about risk factors for mycobacterial disease.

Stevens-Johnson syndrome and toxic epidermal necrolysis in patients with lupus erythematosus: a descriptive study of 17 cases from a national registry and review of the literature

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions with high morbidity and mortality. Some expressions of lupus erythematosus (LE) may cause enormous difficulties in differentiating them from SJS and TEN by showing large areas of sheet-like epidermal necrosis.

OBJECTIVE

To evaluate clinically and histopathologically probable or definite cases of SJS/TEN with a history of systemic or other LE [(S)LE].

METHODS

This was a retrospective analysis of validated cases of SJS/TEN with a history of (S)LE, based on a large population-based national registry.

RESULTS

Among 1366 patients with SJS/TEN, 17 with a sufficiently documented history of (S)LE and representative histological material could be identified, suggesting a considerable over-representation of LE in patients with SJS/TEN. Eight of these showed clinically and/or histopathologically some LE-characteristic features interfering with the diagnosis of SJS/TEN. Differentiation could be elaborated on clinical and histopathological grounds: four patients were classified as SJS/TEN with a preceding (S)LE exacerbation and/or LE-typical histopathological features, and four as 'TEN-like' (S)LE.

CONCLUSION

Most patients with SJS/TEN and a history of (S)LE demonstrate clinical and histopathological properties allowing clear differentiation. However, occasionally acute cutaneous manifestations of (S)LE and SJS/TEN can be phenotypically similar, caused by extensive epidermal necrosis. Although no feature by itself is conclusive, a combination of recent (S)LE exacerbation, evident photodistribution, annular lesions and absent or only mild focal erosive mucosal involvement may favour LE over SJS/TEN clinically. Histopathologically, in particular, junctional vacuolar alteration, and the presence of solitary necrotic keratinocytes at lower epidermal levels, combined with moderate to dense periadnexal and perivascular lymphocytic infiltrates with a variable presence of melanophages, and mucin point to a LE-related origin.

Erlotinib-induced florid acneiform rash complicated by extensive impetiginization

Erlotinib (Tarceva) is an epidermal growth factor receptor (EGFR) inhibitor, a member of a new group of molecular targeted drugs that combine high efficacy against tumours with less, often self-limiting, toxicity, compared with traditional chemotherapeutics. It is used for treatment of solid-organ tumours, especially as second- or third-line therapy for non-small-cell lung cancer. Dose-related cutaneous side-effects and diarrhoea may be a significant obstacle to treatment compliance. We present two cases with long-lasting acneiform eruptions, complicated by significant impetiginization, resulting in hospitalization in one case. The other patient suffered from sleep-disturbing, itching crusts on the scalp. As the use of EGFR inhibitors is increasing, clinicians should be aware of their side-effects. Early and timely dermatological intervention may diminish adverse events for patients treated with these agents and improve quality of life.

[Periorbital swelling caused by carbasalate calcium]

A 61-year-old man presented with visual problems due to a marked two-sided periorbital swelling that had started three years earlier. There was no obvious underlying cause and he had persistent rhinoconjunctival symptoms. At the time the swelling started he was already suffering from xanthelasmata palpebrarum and chronic obstructive pulmonary disease. He had been taking simvastatin and salmeterol-fluticason for a year and carbasalate calcium for two years. There was marked periorbital swelling accompanied by xanthelasmata palpebrarum and slight chemosis and erythema of the eyelids. After exclusion of other potential causes for the swelling, acenocoumarol was prescribed in place of carbasalate calcium. This resulted in a quick recovery from the swelling and rhinoconjunctival symptoms. Provocation with acetyl salicylic acid led to renewed swelling of both eyelids. Periorbital angio-oedema, a relatively uncommonly reported side effect of acetyl salicylic acid and its derivates, can occur even after previous long-term medication use.

Successful dexamethasone pulse therapy in a toxic epidermal necrolysis (TEN) patient featuring recurrent TEN to oxazepam

A 62-year-old female patient is described who developed toxic epidermal necrolysis (TEN) after medication with phenytoin and oxazepam. Initially phenytoin was discontinued and dexamethasone pulse therapy (1.5 mg/kg on 3 consecutive days) was initiated on the tenth day of skin disease. This resulted in clinical improvement. Histologically re-epithelialization could be demonstrated below the necrotic epidermis. However, on the eighteenth day of skin disease (10 days after discontinuation of phenytoin and 8 days after the start of dexamethasone pulse therapy), a histologically verified rebound-TEN developed with a detachment of 95%. Oxazepam was stopped and a second series of dexamethasone pulse therapy was given. Re-epithelialization began within 24 h of the start of the second series of dexamethasone pulse therapy, and continued to almost complete recovery within 1 week.

[Epithelioid sarcoma as cause of ulcus cruris]

In two young men, 22 and 23 years old, with non-healing leg ulcers, epithelioid sarcoma was diagnosed. This malignancy may be mistaken for a benign process. Better awareness may result in earlier diagnosis and improved prognosis. Both patients developed lymphogenic metastases.

Increased urinary excretion of the histamine metabolite N tau-methylhistamine during acetylsalicylic acid provocation in chronic urticaria patients

Seventeen chronic urticaria patients with a history suggestive of acetylsalicylic acid (ASA, Aspirin)-intolerance were challenged with ASA; only 2 patients showed marked clinical reactions. These clinical reactions were accompanied by a significant increase in the urinary excretion of the most important histamine metabolite, N tau-methylhistamine, in comparison with 15 non-responders (p less than or equal to 0.05) and placebo test. These results suggest an involvement of histamine in the pathogenesis of ASA-intolerance in chronic urticaria patients.

[Immunomapping in localized bullous pemphigoid]

A 70-year-old Caucasian patient is described, who presented with a bullous dermatosis on an amputation stump. The bullous lesions had developed after practice with a Kondylen-Bettung-Münster (KBM) prosthesis. The lesions disappeared completely after prednisone therapy and replacement of the prosthesis with a Thomas splint. The patient has remained free of symptoms ever since, even though prednisone was completely withdrawn after 9 months. According to skin immunofluorescence criteria, the patient suffered from pemphigoid, rather than epidermolysis bullosa acquisita as strongly suggested by the anamnesis. In particular, the presence of linear IgG at the level of the lamina lucida of the epidermal basement membrane zone and the localization of laminin antigen at the blister floor are highly suggestive of pemphigoid.

Drug-induced pseudolymphomatous skin reactions

We present two patients with generalized and three with localized skin eruptions due to various non-anticonvulsant drugs, with a histological picture of a pseudolymphoma of the skin. Cessation of the causative drugs resulted in disappearance of the lesions in all cases.

Morphological studies on cellular detachment induced by antibody reactions directed against membrane associated antigens. An ultrastructural study

The skin explant model was used to determine the effect of antibody reactions against membrane associated antigens on normal human keratinocytes. Addition of specific allo-antibodies against HLA class I antigens induced characteristic changes in the cells on the outermost region of the explant-outgrowth. A disorganization of the filopodia of these cells occurred and the edges of the cellular border were lifted from the substratum. These signs of detachment were also found when pemphigus serum was added. In both experimental conditions the detachment of the cells was complement independent. After removing the antiserum a recovery took place, but the cells once lifted from the substratum remained recognizable as a ridge of cells. No changes were observed when the explants were incubated with antibodies against HLA class II antigens. Incubation with specific antibodies against HLA class I antigens not present on the explant had also no effect. We propose that antibody reactions against various membrane associated antigens can induce within a few hours characteristic changes of the cellular margins.

Model for detection of membrane-associated antigens on epithelial cells (HLA-A, -B, -C alloantigens and pemphigus antigens)

Incubation of skin explant culture with HLA-A, -B and -C alloantibodies results in detachment of cells at the periphery of the outgrowth. This detachment can be observed within 1 1/2 h, using the reflection contrast microscope. During the detachment of the epithelial cell, characteristic changes occur, such as disorganization of the filopodia and lifting up of the cell borders from the surface of the Petri dish. The same changes were seen using antibodies against pemphigus antigens.

Lack of beneficial effect of zinc sulphate in rheumatoid arthritis

Twenty-two patients with severe long-standing rheumatoid arthritis were treated with oral zinc sulphate in a prospective long-term open trial. Six patients had (only subjective) improvement during the first 6 months of treatment, but all deteriorated subsequently. The remaining 16 deteriorated or did not improve and these patients expressed a wish to stop taking the drug after a mean period of 5 months. In the whole group of 22 patients, neither the number of affected joints, the ARA grading, nor functional classification changed significantly, nor did ESR, haemoglobin, haematocrit, or platelet count. The unpleasant taste and nausea caused by zinc sulphate was the main side effect. Our study confirms that ZnSO4 has no long-lasting beneficial effect for patients severely affected with rheumatoid arthritis.