Purpose To review the current progress in epidemiology, etiology, clinical manifestation, and pathophysiology of severe cutaneous adverse drug reactions （SCADRs）. Data sources Data were acquired by using Blackwell-S...Purpose To review the current progress in epidemiology, etiology, clinical manifestation, and pathophysiology of severe cutaneous adverse drug reactions （SCADRs）. Data sources Data were acquired by using Blackwell-Synergy, PubMed, original articles published in the main Chinese journals and related medical textbooks materials. Study selection and data extraction Throughout the literature review 49 articles were selected. Results SCADRs cases are rare, however, the implication is life threatening with significant mortality rates. Epidemiology studies have shown various incidences from different regions, gender, age, race and concurrent illness. There are typical signs and symptoms for each type of SCADRs, but this is not always so. Drugs associated with inducing SCADRs are anticonvulsants, antibiotics, NSAIDs and antirheumatic drugs. In some countries, especially in Asia, traditional drugs are often the cause of SCADRs. Genetic polymorphisms and viral infections are predisposition factors of SCADRs. Patients with certain genetic alleles and underlying diseases are vulnerable to SCADRs. The exact pathogenesis of SCADRs is not well defined. Nonetheless, recent study showed that reactive metabolites and immunological processes have a significant role in SCADRs. Conclusions The different SCADRs reactions are attributed by different intrinsic factors, such as genetic polymorphisms, gender, age and race as well as extrinsic factors, such as underlying diseases. Different regions and culprit drugs also play a role in the various types of SCADRs.展开更多
Background： Stevens-Johnson syndrome （SJS） and toxic epidennal necrolysis （TEN） are life-threatening diseases with high mortality rates. This study was designed to analyze the pathogenic factors, clinical manifes...Background： Stevens-Johnson syndrome （SJS） and toxic epidennal necrolysis （TEN） are life-threatening diseases with high mortality rates. This study was designed to analyze the pathogenic factors, clinical manifestations, complications, treatment, and prognosis of SJS/TEN and to explore the differences between surviving and deceased patients. Methods： SJS/TEN patients admitted to Beijing Friendship Hospital from January 2006 to December 2015 were included in the study. Patients＇ data were retrospectively analyzed. Comparative studies were performed on the survival group and the deceased group, and Fisher＇s exact probability test was used for statistical analysis. Results： Among the 88 patients included, 40 （45.5%） were male with a mean age of 45 - 18 years. Forty-eight （54.5%） had SJS, 34 （38.6%） had SJS/TEN, and 6 （6.8%） had TEN. Fifty-three （60.2%） cases were caused by medications, mainly antibiotics （n = 24） followed by traditional Chinese medicines 97 - 7）. Forty-two cases （47.7%） developed visceral damage. Eighty-two patients improved or recovered and were discharged from hospital, and six patients died. Comparative studies on the survival group and the deceased group showed that the presence of malignant tumor （Z2 = 27.969, P 〈 0.001）, connective tissue diseases （x^2 - 9.187, P = 0.002）, previous abnormal liver/kidney functions （x^2 = 6.006, P = 0.014）, heart rate 〉100 times/rain （x^2 = 6.347, P = 0.012）, detached skin area 〉20% （x^2 = 5.594, P = 0.018）, concurrent mucosal involvement at the mouth, eyes, and external genitals （Z2 = 4.945, P = 0.026）, subsequent accompanying liver/kidney damage （x^ = 11.839, P = 0.001, and x^2 = 36.302, P 〈 0.00 l, respectively）, and SCORTEN score 〉2 （x^2 = 37.148, P 〈 0.001 ） increased the risk of death. Conclusions： SJS/TEN is mainly caused by medications, and nearly half of patients develop visceral damage. Multiple factors increase the mortality risk.展开更多
BACKGROUND Stevens–Johnson syndrome and toxic epidermal necrolysis(SJS/TEN)are very serious skin allergies,with an etiology related to infections and medication.Since the coronavirus disease 2019(COVID-19)pandemic,se...BACKGROUND Stevens–Johnson syndrome and toxic epidermal necrolysis(SJS/TEN)are very serious skin allergies,with an etiology related to infections and medication.Since the coronavirus disease 2019(COVID-19)pandemic,severe acute respiratory syndrome coronavirus-2 has also been considered to cause SJS/TEN.CASE SUMMARY We report the case of a woman in her thirties who took acetaminophen after contracting COVID-19.After 3 d of fever relief,she experienced high fever and presented with SJS/TEN symptoms,accompanied by intrahepatic cholestasis.Three days of corticosteroid treatment did not alleviate the skin damage;therefore,double plasma molecular adsorption system(DPMAS)therapy was initiated,with treatment intervals of 48 h.Her skin symptoms improved gradually and were resolved after seven DPMAS treatments.CONCLUSION DPMAS therapy is beneficial for abrogating SJS/TEN because plasma adsorption and perfusion techniques reduce the inflammatory mediators(e.g.,tumor necrosis factor-alpha and interleukin-10 and-12)speculated to be involved in the pathology of the skin conditions.展开更多
Introduction:Toxic epidermal necrolysis(TEN)is a medical emergency that most commonly occurs as an adverse effect of certain drugs.Here,we describe a case of a 41-year-old man with no comorbid illness who developed TE...Introduction:Toxic epidermal necrolysis(TEN)is a medical emergency that most commonly occurs as an adverse effect of certain drugs.Here,we describe a case of a 41-year-old man with no comorbid illness who developed TEN.Case presentation:The patient had been prescribed ibuprofen for myalgia and developed skin lesions after the single dose.The lesions were erythematous papules and macules distributed all over the body after ibuprofen intake.TEN was diagnosed based on the patient’s clinical presentation and laboratory findings.He was treated with intravenous dexamethasone,intravenous immunoglobulin,and cyclosporine.Daily dressing changes and skin care was done with saline,chlorhexidine,and liquid paraffin.The patient was intubated and tracheostomized,and he gradually improved and survived.Later,he developed septicemia in the intensive care unit and was treated successfully.Discussion:The management of TEN includes cessation of the causative cause,multidisciplinary intensive care unit(ICU)care,prevention and early detection of sepsis,fluid and electrolyte balance,adequate analgesia and temperature control,proper organ support,aggressive nutritional management,and good psychological support.The pharmacological therapy for TEN includes corticosteroids,intravenous immunoglobulin,and cyclosporine.The key elements of management are aseptic care and proper dressing of the skin.Conclusion:TEN is associated with high mortality if not managed in a systemic and protocolized way.展开更多
BACKGROUND Toxic epidermal necrolysis(TEN)is a life-threatening dermatological emergency mainly induced by drug hypersensitivity reactions.Standard management includes discontinuation of culprit drug and application o...BACKGROUND Toxic epidermal necrolysis(TEN)is a life-threatening dermatological emergency mainly induced by drug hypersensitivity reactions.Standard management includes discontinuation of culprit drug and application of immunomodulatory therapy.However,mortality remains high due to complications like septic shock and multiorgan failures.Innovative approaches for skin care are crucial.This report introduces borneol-gypsum,a traditional Chinese drug but a novel dressing serving as an adjuvant of TEN therapy,might significantly improve skin conditions and patient outcomes in TEN.CASE SUMMARY A 38-year-old woman diagnosed with eosinophilic granulomatosis with polyangiitis experienced gangrenous complications and motor nerve involvement.After initial treatment of high-dose corticosteroids and cyclophosphamide,symptom of foot drop improved,absolute eosinophil counts decreased,while limb pain sustained.Duloxetine was added to alleviate her symptom.Subsequently,TEN developed.Additional topical application of borneol-gypsum dressing not only protected the skin lesions from infection but also significantly eased localized pain.This approach demonstrated its merit in TEN management by promoting skin healing and potentially reducing infection risks.CONCLUSION Borneol-gypsum dressing is a promising adjuvant that could significantly improve TEN management,skin regeneration,and patient comfort.展开更多
AIM To evaluate the utility of patch test and cross-sensitivity patterns in patients with adverse cutaneous drug reactions(ACDR) from common anticonvulsants. METHODS Twenty-four(M:F = 13:11) patients aged 18-75 years ...AIM To evaluate the utility of patch test and cross-sensitivity patterns in patients with adverse cutaneous drug reactions(ACDR) from common anticonvulsants. METHODS Twenty-four(M:F = 13:11) patients aged 18-75 years with ACDR from anticonvulsants were patch tested 3-27 mo after complete recovery using carbamazepine, phenytoin, phenobarbitone, lamotrigine, and sodium valproate in 10%, 20% and 30% conc. in pet. after informed consent. Positive reactions persisting on D3 and D4 were considered significant. RESULTS Clinical patterns were exanthematous drug rash with or without systemic involvement(DRESS) in 18(75%), Stevens-Johnsons syndrome/toxic epidermal necrolysis(SJS/TEN) overlap and TEN in 2(8.3%) patients each, SJS and lichenoid drug eruption in 1(4.2%) patient each, respectively. The implicated drugs were phenytoin in 14(58.3%), carbamazepine in 9(37.5%), phenobarbitone in 2(8.3%), and lamotrigine in 1(4.7%) patients,respectively. Twelve(50%) patients elicited positive reactions to implicated drugs; carbamazepine in 6(50%), phenytoin alone in 4(33.3%), phenobarbitone alone in 1(8.3%), and both phenytoin and phenobarbitone in 1(8.33%) patients, respectively. Cross-reactions occurred in 11(92%) patients. Six patients with carbamazepine positive patch test reaction showed cross sensitivity with phenobarbitone, sodium valproate and/or lamotrigine. Three(75%) patients among positive phenytoin patch test reactions had cross reactions with phenobarbitone, lamotrigine, and/or valproate. CONCLUSION Carbamazepine remains the commonest anticonvulsant causing ACDRs and cross-reactions with other anticonvulsants are possible. Drug patch testing appears useful in DRESS for drug imputability and cross-reactions established clinically.展开更多
Stevens-Johnson syndrome(SJS) or toxic epidermal necrolysis(TEN) is a severe adverse drug reaction associated with involvement of skin and mucosal membranes, and carries significant risk of mortality and morbidity. Mu...Stevens-Johnson syndrome(SJS) or toxic epidermal necrolysis(TEN) is a severe adverse drug reaction associated with involvement of skin and mucosal membranes, and carries significant risk of mortality and morbidity. Mucus membrane lesions usually involve the oral cavity, lips, bulbar conjunctiva and the anogenitalia. The oral/anal mucosa and liver are commonly involved in SJS or TEN. However, intestinal involvement is distinctly rare. We herein review the current literature regarding the gastrointestinal involvement in SJS or TEN. This review focuses mainly on the small bowel and colonic involvement in patients with SJS or TEN.展开更多
Stevens-Johnson syndrome(SJS)and toxic epidermal necrolysis(TEN)are rare but severe diseases.This study aimed to validate the predictive ability of risk models in patients with SJS/TEN and propose possible refinement ...Stevens-Johnson syndrome(SJS)and toxic epidermal necrolysis(TEN)are rare but severe diseases.This study aimed to validate the predictive ability of risk models in patients with SJS/TEN and propose possible refinement in China.Patients in the Department of Dermatology of Huashan Hospital from January 2008 to January 2019 were included.Results showed that the severity-of-illness score for TEN(SCORTEN)had a good discrimination(area under the receiver operating characteristic curve(AUC),0.78),and it was superior to auxiliary score(AS)and ABCD-10,which indicates age,bicarbonate level,cancer,dialysis,and 10%involved body surface area(AUC,0.69 and 0.68,respectively).The calibration of SCORTEN(Hosmer-Lemeshow goodness-of-fit test,P=0.69)was also better than that of AS(P=0.25)and ABCD-10(P=0.55).SCORTEN and ABCD-10 were similar(Brier score(BS),0.04 and 0.04)in terms of accuracy of predictions.In addition,the imaging appearance of pulmonary consolidation on computed tomography was associated with high mortality.Refined models were formed using the variables and this imaging appearance.The refined AS and ABCD-10 models were similar in discrimination compared with the original SCORTEN(0.74 vs.0.78,P=0.23;0.74 vs.0.78,P=0.30,respectively).Therefore,SCORTEN showed good discrimination performance,calibration,and accuracy,and refined AS or ABCD-10 model may be an option when SCORTEN variables are not available.展开更多
BACKGROUND Both programmed cell death-1(PD-1)inhibitors and lenvatinib,which have a synergistic effect,are promising drugs for tumor treatment.It is generally believed that combination therapy with a PD-1 inhibitor an...BACKGROUND Both programmed cell death-1(PD-1)inhibitors and lenvatinib,which have a synergistic effect,are promising drugs for tumor treatment.It is generally believed that combination therapy with a PD-1 inhibitor and lenvatinib is safe and effective.However,we report a case of toxic epidermal necrolysis(TEN),a grade 4 toxicity,after this combination therapy.CASE SUMMARY A 39-year-old male presented with erythema,blisters and erosions on the face,neck,trunk and limbs 1 wk after receiving combination therapy with lenvatinib and toripalimab,a PD-1 inhibitor.The skin injury covered more than 70%of the body surface area.He was previously diagnosed with liver cancer with cervical vertebra metastasis.Histologically,prominent necrotic keratinocytes,hyperkeratosis,liquefaction of basal cells and acantholytic bullae were observed in the epidermis.Blood vessels in the dermis were infiltrated by lymphocytes and eosinophils.Direct immunofluorescence staining was negative.Thus,the diagnosis was confirmed to be TEN(associated with combination therapy with toripalimab and lenvatinib).Full-dose and long-term corticosteroids,high-dose intravenous immunoglobulin and targeted antibiotic drugs were administered.The rashes gradually faded;however,as expected,the tumor progressed.Therefore, sorafenib and regorafenib were given in succession, and the patient was still alive at the10-mo follow-up.CONCLUSIONCautious attention should be given to rashes that develop after combination therapy with PD-1inhibitors and lenvatinib. Large-dose and long-course glucocorticoids may be crucial for thetreatment of TEN associated with this combination treatment.展开更多
<span style="font-family:Verdana;">Enzalutamide is a hormonal therapy that blocks the action of androgens, such as testosterone in the treatment of metastatic castration-resistant prostate cancer. <...<span style="font-family:Verdana;">Enzalutamide is a hormonal therapy that blocks the action of androgens, such as testosterone in the treatment of metastatic castration-resistant prostate cancer. </span><span style="font-family:Verdana;">Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) overlap and are part of an adverse drug reaction continuum of disease, in which there is a 10% - 30% involvement of the skin surface with mucositis, blisters, skin slough, and a macular rash. A 66-year-old male was treated with enzalutamide for metastatic prostate cancer and developed SJS/TEN overlap with 25% total body surface area skin involvement. The patient received a </span><span style="font-family:Verdana;">seven-day course of cyclosporine to which he responded by re-epithelialization </span><span style="font-family:Verdana;">but succumbed to multi-organ failure. While SJS/TEN has been reported with apalutamide, to our knowledge, this is the first case of SJS/TEN overlap with enzalutamide.</span>展开更多
Introduction: Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are adverse reaction to drugs whose manifestation affect the skin and mucous membranes whose outcomes may be life threatening and fatal...Introduction: Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are adverse reaction to drugs whose manifestation affect the skin and mucous membranes whose outcomes may be life threatening and fatal. Supportive management has been proven to be the mainstay with well executed nursing care resulting in quality clinical outcomes. The aim was to evaluate the nursing care interventions in management of patients with SJS/TEN in the dermatology unit. Methods: Qualitative design was used, data were collected through observation of nursing care activities, informant interviews and focus group discussion with the nurses. Qualitative data were recorded in audio tapes and transcribed. Qualitative content analysis was used for the analysis of the transcribed texts. Study was approved by KNH/ERC and informed written consent from participants. Funding was obtained from KNH through the Research and Programs department. Findings: 20 nurses participated in the study. The commonest nursing care interventions were described as routine tasks initiated at clinical diagnosis and routinely performed. They include aggressive skin care, wound care, mucosal and eye care, infection surveillance and prevention practices and general patient monitoring for complications. Skin and wound care were most challenging part of nursing care due to severe erosion or exfoliation. Nurses do not use any specific guidelines of care but consider their role a key in quality outcomes for patients with SJS/TEN in this hospital.展开更多
Toxic epidermal necrolysis(TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneum...Toxic epidermal necrolysis(TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneumatosis cystoides intestinalis(PCI) is a rare condition associated with a wide variety of underlying diseases, but to date no patient has presented with PCI associated with TEN. A 55-year-old man was admitted to intensive care unit for treatment of TEN caused by phenobarbital. On day 8 after admission, he presented with progressive abdominal distention and hypotension. Computed tomography(CT) showed gas in the superior mesenteric vein and air filled cysts in the walls of the small intestine. He was suspected of having septic shock due to PCI. As there were no indications of bowel ischemia or necrosis, the patient was managed conservatively with antibiotics and oxygen therapy. On day 10 after admission, he was weaned off catecholamines, with CT on day 11 showing complete resolution of gas in the superior mesenteric vein and air filled cysts. To our knowledge, this article describes the first patient presenting with PCI associated with TEN.展开更多
Toxic epidermal necrolysis （TEN） is a serious, usually drug-induced, dermatosis characterized by extensive erythema,necrosis, bullous detachment of the epidermis, constitutional symptoms, and visceral involvement. W...Toxic epidermal necrolysis （TEN） is a serious, usually drug-induced, dermatosis characterized by extensive erythema,necrosis, bullous detachment of the epidermis, constitutional symptoms, and visceral involvement. We report a 62-year-old man who was diagnosed TEN after percutaneous coronary intervention （PCI）. After consulting with a cardiologist, all pre-hospital medication was discontinued except clopidogrel. With supportive care, the patient recovered.展开更多
We describe a 6-year-old female patient who developed carbamazepine-associated toxic epidermal necrolysis.With active wound care,systemic methylprednisolone and intravenous immunoglobulin pulse therapies and multidisc...We describe a 6-year-old female patient who developed carbamazepine-associated toxic epidermal necrolysis.With active wound care,systemic methylprednisolone and intravenous immunoglobulin pulse therapies and multidisciplinary supportive care,the patient improved significantly.This case indicates that improving the management of Stevens-Johnson syndrome/Toxic epidermal necrolysis patients requires attention not only to the process of wound management but also to individual supportive care and active therapeutic intervention.Only through this can standardized care,including muco-cutaneous and visceral wound care,be delivered to provide high-quality care with improved clinical prognosis and quality of life.展开更多
Background:Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe life-threatening skin conditions.The most common cause of these manifestations is medications.Beside discontinued of the culpri...Background:Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe life-threatening skin conditions.The most common cause of these manifestations is medications.Beside discontinued of the culprit drug,systemic corticosteroids were used as a primary treatment option among pediatric population.This study aimed to explore causative drugs (drug group/ latent period),treaments,complications,and treatment outcome (morbidity,mortality,length of hospital stay) of SJS and TEN in children.Methods:A retrospective chart was reviewed during the period of 1992 to 2012 at Srinagarind Hospital,Faculty of Medicine,Khon Kaen University,Thailand.SJS and TEN were clinically diagnosed and confirmed by pediatric dermatologists.Other possible causes other than drug-induced SJS and TEN were excluded.Results:A total of 30 patients was recorded,including 24 (80%) SJS patients and 6 (20%) TEN patients.The mean age was 6.9 years (SD 4.4).Male to female ratio was 1.5:1.Antiepileptic drug group was the most common causative drug (n=18,60%),followed by antibiotic drug group (n=8,26.6%),and others (n=4,13.3%) which included nonsteroidal antiinflammtory drugs (NSAIDs) and chemotherapy drugs.Systemic corticosteroids were used in 29 patients (96.6%).Intravenous immunoglobulin was used in one TEN patient (3.3%).There was a medium correlation between time to treatment (systemic corticosteroids) and the length of hospital stay (Spearman correlation coefficient=0.63,P=0.005).Two TEN patients (6.6%) died.Conclusions:Carbamazepine was the most common causative drug of SJS and TEN in our study.The severity of skin detachment is not correlated to severity of ocular findings.However,the persistent of ocular complications up to one year is suggested for promptly appropriate ocular treatment in all SJS and TEN patients.Our data suggested that early administration of systemic corticosteroid may reduce the length of hospital stay and should be considered for the treatment of pediatric drug-induced SJS and TEN.展开更多
BACKGROUND Toxic epidermal necrolysis and Stevens-Johnson syndrome are acute lifethreatening skin reactions.AZD9291 has been developed as a third-generation epidermal growth factor receptor(EGFR)-tyrosine kinase inhib...BACKGROUND Toxic epidermal necrolysis and Stevens-Johnson syndrome are acute lifethreatening skin reactions.AZD9291 has been developed as a third-generation epidermal growth factor receptor(EGFR)-tyrosine kinase inhibitor(TKI)with activity against T790M mutation.CASE SUMMARY Herein we report a 68-year-old woman who developed a large area of skin necrosis and was diagnosed with toxic epidermal necrolysis after AZD-9291 ingestion.To the best of our knowledge,this is the first case reported in patients with EGFR T790M mutation in non-small cell lung cancer(NSCLC).Cabozantinib combined with erlotinib had clinically meaningful effectiveness,with additional toxicity that was generally manageable.CONCLUSION Treatment with AZD-9261 is effective in regressing the growth of the NSCLC and can bring some hope to despairing patients.We hope that more research will be carried out on the association between severe rashes and EGFR-TKIs,and more safe and effective drugs can be developed.展开更多
The development of immune checkpoint inhibitors,such as those targeting programmed cell death protein 1(PD-1),represents a major breakthrough in cancer therapy.Although immune checkpoint blockade therapy has a favorab...The development of immune checkpoint inhibitors,such as those targeting programmed cell death protein 1(PD-1),represents a major breakthrough in cancer therapy.Although immune checkpoint blockade therapy has a favorable risk/benefit ratio,it causes significant immune-related adverse events(irAEs),such as cutaneous reactions,in particular,severe bullous skin reactions and toxic epidermal necrolysis.Here,we report a case of a 51-year-old woman with malignant thymoma who developed a severe bullous skin reaction(characterized by a systemic rash,bullae,epidermal desquamation,and Stevens-Johnson syndrome)as a result of treatment with the PD-1 inhibitor toripalimab.The patient was treated with high doses of glucocorticoid,intravenous immunoglobulin,and intensive care,and eventually recovered from the severe irAEs.The intravenous injection of anti-PD-1 antibodies induces cutaneous reactions,which are associated with higher mortality rates.High doses of glucocorticoid combined with intravenous immunoglobulin are effective in alleviating such irAEs.Thus,improving the level of care and preventing skin infections can effectively reduce the risk of death.展开更多
BACKGROUND Preterm birth accounts for about 12%of all pregnancies worldwide and is the leading cause of neonatal morbidity and mortality.In order to avoid premature birth and prolong gestational age,tocolytics are the...BACKGROUND Preterm birth accounts for about 12%of all pregnancies worldwide and is the leading cause of neonatal morbidity and mortality.In order to avoid premature birth and prolong gestational age,tocolytics are the first and the best choice.Ritodrine is the most commonly used tocolytic medication.However,side effects such as pulmonary edema,hypokalemia,and hyperglycemia are known.Here we report a rare but serious side effect–toxic epidermal necrolysis(TEN)–caused by ritodrine.CASE SUMMARY A woman(31 years,gravida 4,para 2)was hospitalized because of premature contractions at 27+6 wk of gestation.A skin rash with pruritus appeared at 32+3 wk of gestation after administration of ritodrine,indomethacin,and dexamethasone,and it spread throughout the whole body in 3 d,particularly the four limbs.After 11 d’treatment,she was diagnosed with TEN.An emergency cesarean section was performed immediately to deliver the baby and intensive symptomatic treatment was promptly commenced after delivery.She recovered from the severe condition without any sequelae except for slight pigmentation after symptomatic treatment.CONCLUSION When a skin rash appears during the administration of ritodrine,we are supposed to consider the risk of TEN.展开更多
BACKGROUND: To explore the clinical manifestations, diagnosis, and treatment of patients with acquired immunodeficiency syndrome(AIDS) complicated with drug-induced erythroderma.METHODS: The clinical data of 12 AIDS p...BACKGROUND: To explore the clinical manifestations, diagnosis, and treatment of patients with acquired immunodeficiency syndrome(AIDS) complicated with drug-induced erythroderma.METHODS: The clinical data of 12 AIDS patients with drug-induced erythroderma in our hospital were retrospectively analyzed. The general information, offending medications, complications, modified severity-of-illness score for toxic epidermal necrolysis(SCORTEN) scores, and disease outcome spectrums were analyzed.RESULTS: Drug-induced erythroderma was mostly caused by antiviral drugs, antituberculosis drugs, antibiotics, traditional Chinese medicine, and immune checkpoint inhibitors. The spectrum of sensitizing drugs was broad, the clinical situation was complex, and infections were common. The affected areas were greater than 40% body surface area in all patients. The modified SCOTERN score averaged 3.01±0.99. All patients were treated with glucocorticoids, and nine patients were treated with intravenous immunoglobulin(IVIG) pulse therapy at the same time. The average time to effectiveness was 7.08±2.23 days, and the average hospital stay was 17.92±8.46 days. Eleven patients were cured, and one patient died of secondary multiple infections, who had a modified SCORTEN score of 5 points. The mortality rate in this study was 8.3%.CONCLUSIONS: The clinical situation of AIDS patients with drug-induced erythroderma in hospitalized patients is complex and the co-infection rate is high. The use of modified SCORTEN score may objectively and accurately assess the conditions, and the use of glucocorticoid combined with IVIG therapy may improve the prognosis.展开更多
文摘Purpose To review the current progress in epidemiology, etiology, clinical manifestation, and pathophysiology of severe cutaneous adverse drug reactions （SCADRs）. Data sources Data were acquired by using Blackwell-Synergy, PubMed, original articles published in the main Chinese journals and related medical textbooks materials. Study selection and data extraction Throughout the literature review 49 articles were selected. Results SCADRs cases are rare, however, the implication is life threatening with significant mortality rates. Epidemiology studies have shown various incidences from different regions, gender, age, race and concurrent illness. There are typical signs and symptoms for each type of SCADRs, but this is not always so. Drugs associated with inducing SCADRs are anticonvulsants, antibiotics, NSAIDs and antirheumatic drugs. In some countries, especially in Asia, traditional drugs are often the cause of SCADRs. Genetic polymorphisms and viral infections are predisposition factors of SCADRs. Patients with certain genetic alleles and underlying diseases are vulnerable to SCADRs. The exact pathogenesis of SCADRs is not well defined. Nonetheless, recent study showed that reactive metabolites and immunological processes have a significant role in SCADRs. Conclusions The different SCADRs reactions are attributed by different intrinsic factors, such as genetic polymorphisms, gender, age and race as well as extrinsic factors, such as underlying diseases. Different regions and culprit drugs also play a role in the various types of SCADRs.
文摘Background： Stevens-Johnson syndrome （SJS） and toxic epidennal necrolysis （TEN） are life-threatening diseases with high mortality rates. This study was designed to analyze the pathogenic factors, clinical manifestations, complications, treatment, and prognosis of SJS/TEN and to explore the differences between surviving and deceased patients. Methods： SJS/TEN patients admitted to Beijing Friendship Hospital from January 2006 to December 2015 were included in the study. Patients＇ data were retrospectively analyzed. Comparative studies were performed on the survival group and the deceased group, and Fisher＇s exact probability test was used for statistical analysis. Results： Among the 88 patients included, 40 （45.5%） were male with a mean age of 45 - 18 years. Forty-eight （54.5%） had SJS, 34 （38.6%） had SJS/TEN, and 6 （6.8%） had TEN. Fifty-three （60.2%） cases were caused by medications, mainly antibiotics （n = 24） followed by traditional Chinese medicines 97 - 7）. Forty-two cases （47.7%） developed visceral damage. Eighty-two patients improved or recovered and were discharged from hospital, and six patients died. Comparative studies on the survival group and the deceased group showed that the presence of malignant tumor （Z2 = 27.969, P 〈 0.001）, connective tissue diseases （x^2 - 9.187, P = 0.002）, previous abnormal liver/kidney functions （x^2 = 6.006, P = 0.014）, heart rate 〉100 times/rain （x^2 = 6.347, P = 0.012）, detached skin area 〉20% （x^2 = 5.594, P = 0.018）, concurrent mucosal involvement at the mouth, eyes, and external genitals （Z2 = 4.945, P = 0.026）, subsequent accompanying liver/kidney damage （x^ = 11.839, P = 0.001, and x^2 = 36.302, P 〈 0.00 l, respectively）, and SCORTEN score 〉2 （x^2 = 37.148, P 〈 0.001 ） increased the risk of death. Conclusions： SJS/TEN is mainly caused by medications, and nearly half of patients develop visceral damage. Multiple factors increase the mortality risk.
文摘BACKGROUND Stevens–Johnson syndrome and toxic epidermal necrolysis(SJS/TEN)are very serious skin allergies,with an etiology related to infections and medication.Since the coronavirus disease 2019(COVID-19)pandemic,severe acute respiratory syndrome coronavirus-2 has also been considered to cause SJS/TEN.CASE SUMMARY We report the case of a woman in her thirties who took acetaminophen after contracting COVID-19.After 3 d of fever relief,she experienced high fever and presented with SJS/TEN symptoms,accompanied by intrahepatic cholestasis.Three days of corticosteroid treatment did not alleviate the skin damage;therefore,double plasma molecular adsorption system(DPMAS)therapy was initiated,with treatment intervals of 48 h.Her skin symptoms improved gradually and were resolved after seven DPMAS treatments.CONCLUSION DPMAS therapy is beneficial for abrogating SJS/TEN because plasma adsorption and perfusion techniques reduce the inflammatory mediators(e.g.,tumor necrosis factor-alpha and interleukin-10 and-12)speculated to be involved in the pathology of the skin conditions.
文摘Introduction:Toxic epidermal necrolysis(TEN)is a medical emergency that most commonly occurs as an adverse effect of certain drugs.Here,we describe a case of a 41-year-old man with no comorbid illness who developed TEN.Case presentation:The patient had been prescribed ibuprofen for myalgia and developed skin lesions after the single dose.The lesions were erythematous papules and macules distributed all over the body after ibuprofen intake.TEN was diagnosed based on the patient’s clinical presentation and laboratory findings.He was treated with intravenous dexamethasone,intravenous immunoglobulin,and cyclosporine.Daily dressing changes and skin care was done with saline,chlorhexidine,and liquid paraffin.The patient was intubated and tracheostomized,and he gradually improved and survived.Later,he developed septicemia in the intensive care unit and was treated successfully.Discussion:The management of TEN includes cessation of the causative cause,multidisciplinary intensive care unit(ICU)care,prevention and early detection of sepsis,fluid and electrolyte balance,adequate analgesia and temperature control,proper organ support,aggressive nutritional management,and good psychological support.The pharmacological therapy for TEN includes corticosteroids,intravenous immunoglobulin,and cyclosporine.The key elements of management are aseptic care and proper dressing of the skin.Conclusion:TEN is associated with high mortality if not managed in a systemic and protocolized way.
文摘BACKGROUND Toxic epidermal necrolysis(TEN)is a life-threatening dermatological emergency mainly induced by drug hypersensitivity reactions.Standard management includes discontinuation of culprit drug and application of immunomodulatory therapy.However,mortality remains high due to complications like septic shock and multiorgan failures.Innovative approaches for skin care are crucial.This report introduces borneol-gypsum,a traditional Chinese drug but a novel dressing serving as an adjuvant of TEN therapy,might significantly improve skin conditions and patient outcomes in TEN.CASE SUMMARY A 38-year-old woman diagnosed with eosinophilic granulomatosis with polyangiitis experienced gangrenous complications and motor nerve involvement.After initial treatment of high-dose corticosteroids and cyclophosphamide,symptom of foot drop improved,absolute eosinophil counts decreased,while limb pain sustained.Duloxetine was added to alleviate her symptom.Subsequently,TEN developed.Additional topical application of borneol-gypsum dressing not only protected the skin lesions from infection but also significantly eased localized pain.This approach demonstrated its merit in TEN management by promoting skin healing and potentially reducing infection risks.CONCLUSION Borneol-gypsum dressing is a promising adjuvant that could significantly improve TEN management,skin regeneration,and patient comfort.
文摘AIM To evaluate the utility of patch test and cross-sensitivity patterns in patients with adverse cutaneous drug reactions(ACDR) from common anticonvulsants. METHODS Twenty-four(M:F = 13:11) patients aged 18-75 years with ACDR from anticonvulsants were patch tested 3-27 mo after complete recovery using carbamazepine, phenytoin, phenobarbitone, lamotrigine, and sodium valproate in 10%, 20% and 30% conc. in pet. after informed consent. Positive reactions persisting on D3 and D4 were considered significant. RESULTS Clinical patterns were exanthematous drug rash with or without systemic involvement(DRESS) in 18(75%), Stevens-Johnsons syndrome/toxic epidermal necrolysis(SJS/TEN) overlap and TEN in 2(8.3%) patients each, SJS and lichenoid drug eruption in 1(4.2%) patient each, respectively. The implicated drugs were phenytoin in 14(58.3%), carbamazepine in 9(37.5%), phenobarbitone in 2(8.3%), and lamotrigine in 1(4.7%) patients,respectively. Twelve(50%) patients elicited positive reactions to implicated drugs; carbamazepine in 6(50%), phenytoin alone in 4(33.3%), phenobarbitone alone in 1(8.3%), and both phenytoin and phenobarbitone in 1(8.33%) patients, respectively. Cross-reactions occurred in 11(92%) patients. Six patients with carbamazepine positive patch test reaction showed cross sensitivity with phenobarbitone, sodium valproate and/or lamotrigine. Three(75%) patients among positive phenytoin patch test reactions had cross reactions with phenobarbitone, lamotrigine, and/or valproate. CONCLUSION Carbamazepine remains the commonest anticonvulsant causing ACDRs and cross-reactions with other anticonvulsants are possible. Drug patch testing appears useful in DRESS for drug imputability and cross-reactions established clinically.
文摘Stevens-Johnson syndrome(SJS) or toxic epidermal necrolysis(TEN) is a severe adverse drug reaction associated with involvement of skin and mucosal membranes, and carries significant risk of mortality and morbidity. Mucus membrane lesions usually involve the oral cavity, lips, bulbar conjunctiva and the anogenitalia. The oral/anal mucosa and liver are commonly involved in SJS or TEN. However, intestinal involvement is distinctly rare. We herein review the current literature regarding the gastrointestinal involvement in SJS or TEN. This review focuses mainly on the small bowel and colonic involvement in patients with SJS or TEN.
基金This research was supported by a grant from the National Natural Science Foundation of China(No.81673060).
文摘Stevens-Johnson syndrome(SJS)and toxic epidermal necrolysis(TEN)are rare but severe diseases.This study aimed to validate the predictive ability of risk models in patients with SJS/TEN and propose possible refinement in China.Patients in the Department of Dermatology of Huashan Hospital from January 2008 to January 2019 were included.Results showed that the severity-of-illness score for TEN(SCORTEN)had a good discrimination(area under the receiver operating characteristic curve(AUC),0.78),and it was superior to auxiliary score(AS)and ABCD-10,which indicates age,bicarbonate level,cancer,dialysis,and 10%involved body surface area(AUC,0.69 and 0.68,respectively).The calibration of SCORTEN(Hosmer-Lemeshow goodness-of-fit test,P=0.69)was also better than that of AS(P=0.25)and ABCD-10(P=0.55).SCORTEN and ABCD-10 were similar(Brier score(BS),0.04 and 0.04)in terms of accuracy of predictions.In addition,the imaging appearance of pulmonary consolidation on computed tomography was associated with high mortality.Refined models were formed using the variables and this imaging appearance.The refined AS and ABCD-10 models were similar in discrimination compared with the original SCORTEN(0.74 vs.0.78,P=0.23;0.74 vs.0.78,P=0.30,respectively).Therefore,SCORTEN showed good discrimination performance,calibration,and accuracy,and refined AS or ABCD-10 model may be an option when SCORTEN variables are not available.
基金Supported by Guangdong Provincial Key Laboratory of Chinese Medicine for Prevention and Treatment of Refractory Chronic Diseases,No. 2018B030322012
文摘BACKGROUND Both programmed cell death-1(PD-1)inhibitors and lenvatinib,which have a synergistic effect,are promising drugs for tumor treatment.It is generally believed that combination therapy with a PD-1 inhibitor and lenvatinib is safe and effective.However,we report a case of toxic epidermal necrolysis(TEN),a grade 4 toxicity,after this combination therapy.CASE SUMMARY A 39-year-old male presented with erythema,blisters and erosions on the face,neck,trunk and limbs 1 wk after receiving combination therapy with lenvatinib and toripalimab,a PD-1 inhibitor.The skin injury covered more than 70%of the body surface area.He was previously diagnosed with liver cancer with cervical vertebra metastasis.Histologically,prominent necrotic keratinocytes,hyperkeratosis,liquefaction of basal cells and acantholytic bullae were observed in the epidermis.Blood vessels in the dermis were infiltrated by lymphocytes and eosinophils.Direct immunofluorescence staining was negative.Thus,the diagnosis was confirmed to be TEN(associated with combination therapy with toripalimab and lenvatinib).Full-dose and long-term corticosteroids,high-dose intravenous immunoglobulin and targeted antibiotic drugs were administered.The rashes gradually faded;however,as expected,the tumor progressed.Therefore, sorafenib and regorafenib were given in succession, and the patient was still alive at the10-mo follow-up.CONCLUSIONCautious attention should be given to rashes that develop after combination therapy with PD-1inhibitors and lenvatinib. Large-dose and long-course glucocorticoids may be crucial for thetreatment of TEN associated with this combination treatment.
文摘<span style="font-family:Verdana;">Enzalutamide is a hormonal therapy that blocks the action of androgens, such as testosterone in the treatment of metastatic castration-resistant prostate cancer. </span><span style="font-family:Verdana;">Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) overlap and are part of an adverse drug reaction continuum of disease, in which there is a 10% - 30% involvement of the skin surface with mucositis, blisters, skin slough, and a macular rash. A 66-year-old male was treated with enzalutamide for metastatic prostate cancer and developed SJS/TEN overlap with 25% total body surface area skin involvement. The patient received a </span><span style="font-family:Verdana;">seven-day course of cyclosporine to which he responded by re-epithelialization </span><span style="font-family:Verdana;">but succumbed to multi-organ failure. While SJS/TEN has been reported with apalutamide, to our knowledge, this is the first case of SJS/TEN overlap with enzalutamide.</span>
文摘Introduction: Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are adverse reaction to drugs whose manifestation affect the skin and mucous membranes whose outcomes may be life threatening and fatal. Supportive management has been proven to be the mainstay with well executed nursing care resulting in quality clinical outcomes. The aim was to evaluate the nursing care interventions in management of patients with SJS/TEN in the dermatology unit. Methods: Qualitative design was used, data were collected through observation of nursing care activities, informant interviews and focus group discussion with the nurses. Qualitative data were recorded in audio tapes and transcribed. Qualitative content analysis was used for the analysis of the transcribed texts. Study was approved by KNH/ERC and informed written consent from participants. Funding was obtained from KNH through the Research and Programs department. Findings: 20 nurses participated in the study. The commonest nursing care interventions were described as routine tasks initiated at clinical diagnosis and routinely performed. They include aggressive skin care, wound care, mucosal and eye care, infection surveillance and prevention practices and general patient monitoring for complications. Skin and wound care were most challenging part of nursing care due to severe erosion or exfoliation. Nurses do not use any specific guidelines of care but consider their role a key in quality outcomes for patients with SJS/TEN in this hospital.
文摘Toxic epidermal necrolysis(TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneumatosis cystoides intestinalis(PCI) is a rare condition associated with a wide variety of underlying diseases, but to date no patient has presented with PCI associated with TEN. A 55-year-old man was admitted to intensive care unit for treatment of TEN caused by phenobarbital. On day 8 after admission, he presented with progressive abdominal distention and hypotension. Computed tomography(CT) showed gas in the superior mesenteric vein and air filled cysts in the walls of the small intestine. He was suspected of having septic shock due to PCI. As there were no indications of bowel ischemia or necrosis, the patient was managed conservatively with antibiotics and oxygen therapy. On day 10 after admission, he was weaned off catecholamines, with CT on day 11 showing complete resolution of gas in the superior mesenteric vein and air filled cysts. To our knowledge, this article describes the first patient presenting with PCI associated with TEN.
文摘Toxic epidermal necrolysis （TEN） is a serious, usually drug-induced, dermatosis characterized by extensive erythema,necrosis, bullous detachment of the epidermis, constitutional symptoms, and visceral involvement. We report a 62-year-old man who was diagnosed TEN after percutaneous coronary intervention （PCI）. After consulting with a cardiologist, all pre-hospital medication was discontinued except clopidogrel. With supportive care, the patient recovered.
基金National Natural Science Foundation of China(Grant no.81602754)%Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding(code:ZYLX201601)%Project of Excellent Talents in Beijing City(code:2013A003034000013)
文摘We describe a 6-year-old female patient who developed carbamazepine-associated toxic epidermal necrolysis.With active wound care,systemic methylprednisolone and intravenous immunoglobulin pulse therapies and multidisciplinary supportive care,the patient improved significantly.This case indicates that improving the management of Stevens-Johnson syndrome/Toxic epidermal necrolysis patients requires attention not only to the process of wound management but also to individual supportive care and active therapeutic intervention.Only through this can standardized care,including muco-cutaneous and visceral wound care,be delivered to provide high-quality care with improved clinical prognosis and quality of life.
文摘Background:Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe life-threatening skin conditions.The most common cause of these manifestations is medications.Beside discontinued of the culprit drug,systemic corticosteroids were used as a primary treatment option among pediatric population.This study aimed to explore causative drugs (drug group/ latent period),treaments,complications,and treatment outcome (morbidity,mortality,length of hospital stay) of SJS and TEN in children.Methods:A retrospective chart was reviewed during the period of 1992 to 2012 at Srinagarind Hospital,Faculty of Medicine,Khon Kaen University,Thailand.SJS and TEN were clinically diagnosed and confirmed by pediatric dermatologists.Other possible causes other than drug-induced SJS and TEN were excluded.Results:A total of 30 patients was recorded,including 24 (80%) SJS patients and 6 (20%) TEN patients.The mean age was 6.9 years (SD 4.4).Male to female ratio was 1.5:1.Antiepileptic drug group was the most common causative drug (n=18,60%),followed by antibiotic drug group (n=8,26.6%),and others (n=4,13.3%) which included nonsteroidal antiinflammtory drugs (NSAIDs) and chemotherapy drugs.Systemic corticosteroids were used in 29 patients (96.6%).Intravenous immunoglobulin was used in one TEN patient (3.3%).There was a medium correlation between time to treatment (systemic corticosteroids) and the length of hospital stay (Spearman correlation coefficient=0.63,P=0.005).Two TEN patients (6.6%) died.Conclusions:Carbamazepine was the most common causative drug of SJS and TEN in our study.The severity of skin detachment is not correlated to severity of ocular findings.However,the persistent of ocular complications up to one year is suggested for promptly appropriate ocular treatment in all SJS and TEN patients.Our data suggested that early administration of systemic corticosteroid may reduce the length of hospital stay and should be considered for the treatment of pediatric drug-induced SJS and TEN.
基金National Natural Science Foundation of China,No.81974570.
文摘BACKGROUND Toxic epidermal necrolysis and Stevens-Johnson syndrome are acute lifethreatening skin reactions.AZD9291 has been developed as a third-generation epidermal growth factor receptor(EGFR)-tyrosine kinase inhibitor(TKI)with activity against T790M mutation.CASE SUMMARY Herein we report a 68-year-old woman who developed a large area of skin necrosis and was diagnosed with toxic epidermal necrolysis after AZD-9291 ingestion.To the best of our knowledge,this is the first case reported in patients with EGFR T790M mutation in non-small cell lung cancer(NSCLC).Cabozantinib combined with erlotinib had clinically meaningful effectiveness,with additional toxicity that was generally manageable.CONCLUSION Treatment with AZD-9261 is effective in regressing the growth of the NSCLC and can bring some hope to despairing patients.We hope that more research will be carried out on the association between severe rashes and EGFR-TKIs,and more safe and effective drugs can be developed.
文摘The development of immune checkpoint inhibitors,such as those targeting programmed cell death protein 1(PD-1),represents a major breakthrough in cancer therapy.Although immune checkpoint blockade therapy has a favorable risk/benefit ratio,it causes significant immune-related adverse events(irAEs),such as cutaneous reactions,in particular,severe bullous skin reactions and toxic epidermal necrolysis.Here,we report a case of a 51-year-old woman with malignant thymoma who developed a severe bullous skin reaction(characterized by a systemic rash,bullae,epidermal desquamation,and Stevens-Johnson syndrome)as a result of treatment with the PD-1 inhibitor toripalimab.The patient was treated with high doses of glucocorticoid,intravenous immunoglobulin,and intensive care,and eventually recovered from the severe irAEs.The intravenous injection of anti-PD-1 antibodies induces cutaneous reactions,which are associated with higher mortality rates.High doses of glucocorticoid combined with intravenous immunoglobulin are effective in alleviating such irAEs.Thus,improving the level of care and preventing skin infections can effectively reduce the risk of death.
文摘BACKGROUND Preterm birth accounts for about 12%of all pregnancies worldwide and is the leading cause of neonatal morbidity and mortality.In order to avoid premature birth and prolong gestational age,tocolytics are the first and the best choice.Ritodrine is the most commonly used tocolytic medication.However,side effects such as pulmonary edema,hypokalemia,and hyperglycemia are known.Here we report a rare but serious side effect–toxic epidermal necrolysis(TEN)–caused by ritodrine.CASE SUMMARY A woman(31 years,gravida 4,para 2)was hospitalized because of premature contractions at 27+6 wk of gestation.A skin rash with pruritus appeared at 32+3 wk of gestation after administration of ritodrine,indomethacin,and dexamethasone,and it spread throughout the whole body in 3 d,particularly the four limbs.After 11 d’treatment,she was diagnosed with TEN.An emergency cesarean section was performed immediately to deliver the baby and intensive symptomatic treatment was promptly commenced after delivery.She recovered from the severe condition without any sequelae except for slight pigmentation after symptomatic treatment.CONCLUSION When a skin rash appears during the administration of ritodrine,we are supposed to consider the risk of TEN.
基金supported by National Natural Science Foundation of China (81972931)。
文摘BACKGROUND: To explore the clinical manifestations, diagnosis, and treatment of patients with acquired immunodeficiency syndrome(AIDS) complicated with drug-induced erythroderma.METHODS: The clinical data of 12 AIDS patients with drug-induced erythroderma in our hospital were retrospectively analyzed. The general information, offending medications, complications, modified severity-of-illness score for toxic epidermal necrolysis(SCORTEN) scores, and disease outcome spectrums were analyzed.RESULTS: Drug-induced erythroderma was mostly caused by antiviral drugs, antituberculosis drugs, antibiotics, traditional Chinese medicine, and immune checkpoint inhibitors. The spectrum of sensitizing drugs was broad, the clinical situation was complex, and infections were common. The affected areas were greater than 40% body surface area in all patients. The modified SCOTERN score averaged 3.01±0.99. All patients were treated with glucocorticoids, and nine patients were treated with intravenous immunoglobulin(IVIG) pulse therapy at the same time. The average time to effectiveness was 7.08±2.23 days, and the average hospital stay was 17.92±8.46 days. Eleven patients were cured, and one patient died of secondary multiple infections, who had a modified SCORTEN score of 5 points. The mortality rate in this study was 8.3%.CONCLUSIONS: The clinical situation of AIDS patients with drug-induced erythroderma in hospitalized patients is complex and the co-infection rate is high. The use of modified SCORTEN score may objectively and accurately assess the conditions, and the use of glucocorticoid combined with IVIG therapy may improve the prognosis.
