Necrólisis epidérmica tóxica debido a un fármaco a base de caléndula más acetilcisteína: presentación de caso / Toxic Epidermal Necrolysis Induced by a Drug Combination of Calendula and Acetylcysteine: A Case Report / Necrólise epidermal tóxica por medicamento à base de calêndula mais acetilcisteína: relato de caso

Introducción: la hipersensibilidad por fármacos es inducida por una respuesta aberrante del sistema inmune; por lo general, impredecible, dosis independiente y amenazante para la vida del paciente. Las reacciones de hipersensibilidad por fármacos con compromiso mucocutáneo se dan en alrededor del 2 %-3 % de los pacientes hospitalizados. Objetivo: describir un caso de necrólisis tóxica epidérmica por un fármaco a base de caléndula y acetilcisteína como los presuntos desencadenantes. Presentación del caso: hombre de 39 años, quien asistió a emergencias, por malestar general, artralgias, mialgias, astenia y adinamia de un día de evolución. Tres días después refirió la aparición de lesiones purpúricas progre-sivas que se extendieron por cara, extremidades y glúteos; delimitadas; no dolorosas, y sin desaparecer a la digitopresión, asociado con disnea, inestabilidad hemodinámica y cardiovascular. Al sexto día de hos-pitalización, se interrogó al paciente, quien se había automedicado un fármaco de origen desconocido, presuntamente de extracto herbal a base de caléndula más acetilcisteína para artralgias, osteomialgias y disfagia. A la mañana siguiente, presentó lesiones purpúricas y ulcerativas extensas. Se observaron lesiones purpúricas progresivas y ulcerativas en cara extremidades y glúteos. Mediante la sospecha clínica y la evaluación histopatológica, se confirmó la necrólisis tóxica epidérmica. Conclusiones: las reacciones adversas medicamentosas severas que amenazan la vida del paciente son relativamente raras, pero representan un verdadero desafío diagnóstico y terapéutico. Es necesario profundizar en la investigación para esclarecer la causa de este tipo de reacción medicamentosa.

Introduction: Drug hypersensitivity is induced by an aberrant response from the immune system. It is usually unpredictable, dose-independent, and can be life-threatening to the patient. Drug-induced hypersensitivity reactions with mucocutaneous involvement occur in approximately 2­3% of hospitalized patients. However, Toxic Epidermal Necrolysis is a rare case. Aim: To describe a case of drug-induced toxic epidermal necrolysis triggered by Calendula officinalis and acetylcysteine. Case report: A 39-year-old male was pre-sented to the emergency room with malaise, arthralgia, myalgia, asthenia, and adynamia since day one. Three days later, he developed progressive purpuric lesions that spread to the face, extremities, and buttocks. These lesions were painless, not delineate, and did not blanch under pressure. They were asso-ciated with dyspnea and hemodynamic and cardiovascular instability. On the sixth day of hospitaliza-tion, the patient admitted to self-medicating with an unknown drug, presumably a herbal extract based on calendula and acetylcysteine, for arthralgia, myalgia, and dysphagia. The morning after the drug consumption, the patient developed extensive purpuric and ulcerative lesions. A diagnosis of toxic epi-dermal necrolysis was made based on clinical suspicion and histopathological confirmation. Conclusion:Severe adverse drug reactions that threaten a patient's life are relatively rare. However, they represent a real diagnostic and therapeutic challenge when they do occur

Introdução: a hipersensibilidade a drogas é induzida por uma resposta aberrante do sistema imunoló-gico; geralmente imprevisível, independente da dose e com risco de vida para o paciente. As reações de hipersensibilidade a drogas com comprometimento mucocutâneo estão em torno dos 2-3% dos pacien-tes hospitalizados. Objetivo: descrever um caso de necrólise epidérmica tóxica causada por uma droga à base de Calendula officinalis e acetilcisteína como os supostos desencadeantes. Apresentação do caso:homem, 39 anos, deu entrada no pronto-socorro manifestando mal-estar, artralgia, mialgia, astenia e adinamia há um dia. Posteriormente, três dias depois, relatou o aparecimento de lesões purpúricas pro-gressivas que se espalharam para a face, extremidades e nádegas; que são delimitadas, não dolorosas e não desaparecem com a acupressão associada a dispnéia, instabilidade hemodinâmica e cardiovascular. No sexto dia de internação, o paciente foi questionado, y disse que tinha se automedicado com uma droga de origem desconhecida, presumivelmente extrato de ervas à base de calêndula mais acetilcis-teína para artralgia, osteomialgia e disfagia. Na manhã seguinte, apresentou extensas lesões purpúricas e ulcerativas. Observam-se lesões purpúricas progressivas e ulcerativas que se estendem à face, extre-midades e nádegas. Pela suspeita clínica e confirmação histopatológica, confirma-se a necrólise epidér-mica tóxica. Conclusões: reações adversas graves a medicamentos que ameaçam a vida do paciente são relativamente raras, mas quando ocorrem representam um verdadeiro desafio a nível diagnóstico e terapêutico. São precisas mais pesquisas para esclarecer a causa desse tipo de reação medicamentosa.

Síndrome Stevens Jonhson: reporte de caso clínico / Stevens Johnson syndrome: clinical case report

Resumen Introducción: El síndrome Stevens Johnson (SSJ) es una dermatosis potencialmente fatal caracterizada por una extensa necrosis epidérmica y de mucosas que se acompaña de ataque al estado general, y junto con la necrólisis epidérmica tóxica (NET) se consideran reacciones de hipersensibilidad tipo IV, relacionadas con ciertos fármacos en 60% de los casos, siendo uno de los diagnósticos pocos frecuentes, pero con una alta mortalidad hasta del 40%. Caso clínico: El siguiente caso clínico es un masculino de 34 años de edad que inició un cuadro de eritema generalizado inmediatamente tras la administración del medicamento trimetoprima/sulfametoxazol. Se le solicitó un hemograma mostrando leucocitosis, neutrofilia, VSG elevada, PCR elevada, IgE elevada, y tras el interrogatorio clínico se realiza el algoritmo ALDEN dando positivo con 10 puntos asociado al medicamento previamente dicho. Por lo tanto se le inicia tratamiento con metilprednisolona, difenhidramina, inmunoglobulina humana intravenosa y un plan terapéutico cutáneo, dando como resultado una mejoría clínica, evitando complicaciones y secuelas, hasta el día de su egreso. A manera de conclusión, se requiere un manejo multidisciplinario para atender las manifestaciones clínicas del inmunoglobulina humana intravenosa.

Abstract Introduction: Stevens Johnson Syndrome (SJS) is a potentially fatal dermatosis characterized by extensive epidermal and mucosal necrosis accompanied by an attack on the general condition, which together with Toxic Epidermal Necrolysis (TEN) are considered type IV hypersensitivity reactions, related to certain drugs in 60% of cases, being one of the rare diagnoses, but with a high mortality of up to 40%. Case report: The following clinical case is a 34 year old male who started a generalized erythema picture immediately after administration of the medication trimethoprim/sulfamethoxazole, for which a complete blood count was requested showing leukocytosis, neutrophilia, elevated ESR, elevated PCR, elevated IgE, and after the clinical questioning, the ALDEN algorithm was performed, giving positive with 10 points associated with the previously mentioned medication, for which treatment was started with methylprednisolone, diphenhydramine, intravenous human immunoglobulin and a skin therapeutic plan, resulting in clinical improvement, avoiding complications and sequelae, until the day of discharge. In conclusion, a multidisciplinary management is required to attend to the clinical manifestations of the patient, helping him to a quick and effective recovery.

Síndrome de Stevens-Johnson y Necrólisis epidérmica tóxica: presentación en un paciente pediátrico / Stevens-Johnson syndrome and toxic epidermal necrolysis: presentation in a pediatric patient

El síndrome de Stevens-Johnson (SSJ) y la necrólisis epidérmica tóxica (NET), constituyen el espectro de una enfermedad aguda, originada por una reacción de hipersensibilidad, secundaria a ingesta de medicamentos o infecciones, que afecta la piel y las membranas mucosas, causadas por apoptosis y posterior necrosis de los queratinocitos. Se presenta un escolar masculino de 8 años de edad, con antecedente de epilepsia estructural, a quien en su último control por Neuropediatría, se le indicó tratamiento con Lamotrigina, presentando posteriormente lesiones tipo pápulas faciales, que progresaron rápidamente en sentido céfalo caudal; a las 48 horas, las lesiones evolucionaron a pústulas en mentón, y posteriormente a flictenas. Se utilizaron medidas de soporte vital, limpieza quirúrgica, obteniéndose mejoría clínica progresiva, incluyendo recuperación de las lesiones en piel. El aislamiento temprano por contacto, los cuidados de la piel y la mínima invasión, fueron factores fundamentales en la evolución satisfactoria de este paciente(AU)

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) constitute the spectrum of an acute disease, caused by a hypersensitivity reaction, secondary to medication intake or infections, which affects the skin and mucous membranes. Caused by apoptosis and subsequent necrosis of keratinocytes. An 8-year-old male schoolboy is presented, with a history of structural epilepsy, who was prescribed treatment with Lamotrigine during his last Neuropediatric check-up, subsequently presenting facial papule-type lesions, which progressed rapidly in the cephalocaudal direction; 48 hours later, the lesions evolved into pustules on the chin, and later to blisters. Life support measures and surgical cleaning wereused, obtaining progressive clinical improvement, including recovery of skin lesions. Early contact isolation, skin care and minimal invasion were fundamental factors in the satisfactory evolution of this patient(AU)

TEN mimics: Classification and practical approach to toxic epidermal necrolysis-like dermatoses

Toxic epidermal necrolysis (TEN) is an acute life-threatening dermatologic emergency. However, many dermatoses can present with a TEN-like eruption. Those “TEN-mimics” are a true diagnostic challenge and an alarming differential diagnosis to such a serious condition. Herein, we will expose and classify the landscape of TEN-mimics. Also, the key differentiating clinical and/or laboratory points will be highlighted to help an accurate diagnosis of either a TEN or a TEN-like presentation.

Múltiples reacciones adversas graves a fármacos en un paciente luego de la infección por COVID-19: informe de un caso / Drug-induced severe cutaneous adverse reactions in a patient after COVID-19 infection: case report

Durante la pandemia por COVID-19 se observaron diversas reacciones adversas a fármacos. Esto pudo haber estado relacionado con una mayor susceptibilidad inmunológica de los pacientes con SARS-CoV-2 a presentar este tipo de cuadros, así como también con la exposición a múltiples medicamentos utilizados en su tratamiento. Comunicamos el caso de un paciente con una infección respiratoria grave por COVID-19, que presentó 2 reacciones adversas graves a fármacos en un período corto de tiempo. (AU)

During the COVID-19 pandemic, various adverse drug reactions were observed. This could have been related to a greater immunological susceptibility of patients with SARS-CoV-2 to present this type of symptoms, as well as exposure to multiple drugs used in their treatment. We report the case of a patient with a severe respiratory infection due to COVID-19, who presented 2 serious adverse drug reactions associated with paracetamol in a short period of time. (AU)

A case report on ofloxacin-induced Stevens–Johnson syndrome: Scorten-based approach

Stevens–Johnson syndrome (SJS) is a rare immune-mediated severe cutaneous adverse reaction with an incidence rate of 0.05–2 persons/million population/month. Drugs are the most commonly implicated in 95% of cases. In our report, a 52-year-old male patient presented with chief complaints of skin rashes over the body and was having a history of using a tab. ofloxacin for gastroenteritis. The severity of SJS was assessed using SCORTEN (=1). The drug can be considered as a probable/likely cause of adverse drug reaction as per causality assessment of the suspected adverse drug reactions. Early diagnosis helps the clinician to elude secondary infection and subsequent complications. It highlights the mandatory reporting of the offending drug and the necessity of pharmacovigilance in different countries.

Síndrome de stevens johnson, a propósito de un caso

El síndrome de Stevens Jonson y la Necrolisis Epidérmica Toxica forman parte de un mismo espectro clínico caracterizado por lesiones cutáneas y mucosas con necrosis y desprendimiento de la piel, se diferencian por la extensión y la gravedad de las lesiones, aunque existen casos traslapados como en este caso, donde la paciente presentaba lesiones en más del 30% del cuerpo pero, solo fueron lesiones cutáneas y no así mucosas, lo que favoreció a su recuperación exitosa sin necesidad de ingresar a un servicio de terapia intensiva.

The Stevens Johnson syndrome and Toxic Epidermal Necrolysis are part of the same clinical spectrum characterized by cutaneous lesions and mucous membranes with necrosis and detachment of the skin. They differ by the extent and severity of the lesions. Although, there are overlapping cases as in this case, where the patient had lesions in more than 30% of the body. But they were only skin lesions and not mucous membranes, which favored her successful recovery without the need to enter and ITS (intensive therapy service).

A Report of Staphylococcus Scalded Skin Syndrome in Adult

Summary@#Staphylococcal scalded skin syndrome (SSSS) is typically a clinical diagnosis,1 affecting primarily neonates and children. It is characterised by a diffuse skin disorder with tenderness, erythema, large wrinkled superficial blistering, and desquamation caused by the hematogenous dissemination of exotoxin-producing strains of staphylococcus aureus to the skin.4,10 Hospital admission is required for intravenous anti-staphylococcal antibiotic therapy and supportive care. The rarity of SSSS in adults is best explained by the presence of exotoxins neutralizing antibodies and renal elimination of the toxins.2 Two major risk factors are kidney failure and immunosuppression. Therefore, SSSS in adults warrants thorough evaluation.3 Mortality is also greater than 60% in adults, attributed to predisposing comorbid conditions.1,4 One of the mimickers of SSSS is toxic epidermal necrolysis (TEN). Here, we report a successful treatment of SSSS in an adult with recreational drug abuse and incidental liver cirrhosis possibly secondary to hepatitis C viral infection, after careful exclusion of TEN.

Comparison of the performance of SCORTEN and ABCD-10 in evaluating the prognosis of Stevens-Johnson syndrome/toxic epidermal necrolysis / 中华皮肤科杂志

Objective:To compare the performance of the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) and ABCD-10 (age, bicarbonate, cancer, dialysis, 10% body surface area) scoring systems in predicting death in patients with Stevens-Johnson syndrome (SJS) /toxic epidermal necrolysis (TEN) .Methods:Clinical data were collected from 85 patients with SJS/TEN who were hospitalized in Sichuan Provincial People′s Hospital from January 2010 to April 2021, and retrospectively analyzed. The predicted mortality and actual mortality were compared at each score level of SCORTEN and ABCD-10. The receiver operating characteristic (ROC) curve and Hosmer-Lemeshow goodness-of-fit test were used to evaluate the predictive power and calibration of SCORTEN and ABCD-10 on mortality.Results:Among the 85 patients, 37 were males and 48 were females, and their ages were 52.36 ± 19.31 years (range, 14 - 88 years) . There were 61 cases of SJS, 6 of SJS/TEN overlap, and 18 of TEN. Ten patients died in hospital and the fatality rate was 11.76%. Among the SCORTEN and ABCD-10 components, age > 40 years or ≥ 50 years, epidermal exfoliation > 10% body surface area on the 1st day after admission, heart rate > 120 beats per minute, serum urea nitrogen level > 10 mmol/L and serum bicarbonate level < 20 mmol/L were significantly correlated with death ( χ2 = 4.46, 6.18, 25.50, 15.13, 7.59, 8.38, respectively, all P < 0.05) , while malignancies, serum glucose level > 14 mmol/L, and pre-hospital dialysis were not significantly correlated with death ( χ2 = 0.35, 0.10, 1.38, respectively, all P > 0.05) . There were no significant differences between the predicted mortality and actual mortality at every score level of SCORTEN and ABCD-10 (all P > 0.05) . The ROC curve showed that both SCORTEN and ABCD-10 had good predictive power for death (areas under the curve: 0.874 and 0.867, 95% CI: 0.758 - 0.990, 0.773 - 0.962, respectively) , but the model goodness-of-fit of SCORTEN was superior to that of ABCD-10 ( P = 0.944, 0.048, respectively) . Conclusion:Both SCORTEN and ABCD-10 scoring systems could accurately predict mortality of SJS/TEN patients at early stage, but SCORTEN showed more favourable predictive power and calibration.

Reacciones cutáneas adversas graves en la infancia / Severe adverse skin reactions in the childhood

RESUMEN Las reacciones cutáneas a drogas son cada vez más frecuentes en edades pediátricas, con un alto impacto en la salud de los niños. Pueden manifestarse en formas muy disímiles, desde un exantema transitorio hasta cuadros graves con afectación multisistémica potencialmente fatales. En la presente revisión se hace énfasis en las farmacodermias graves en la infancia, con el objetivo de promover el conocimiento por parte del personal médico para facilitar su diagnóstico y tratamiento oportuno. Se desarrolló una búsqueda en la Biblioteca Virtual de Salud de Infomed y en Google: se revisaron 28 trabajos científicos sin limitación de año y país, 24 de ellos pertenecen a los últimos cinco años y de estos 17 a los últimos tres. El dominio de los elementos para el diagnóstico precoz y las opciones terapéuticas son indispensables para elegir la conducta adecuada frente a estas reacciones cutáneas graves y disminuir la morbimortalidad por estas afecciones (AU).

ABSTRACT Skin reactions to drugs are increasingly common at pediatric ages, with a high impact on children's health. They can appear in very dissimilar forms, from a transient rash to serious pictures with potentially fatal multisystem involvement. This review focuses on severe pharmacodermies in the childhood, with the aim of promoting medical staff knowledge to facilitate their timely diagnosis and treatment. A search was led in the Infomed Virtual Health Library and in Google: 28 scientific papers were reviewed without limitation of year and country, 24 of them belong to the last five years and from these 17 to the last three. Mastery of the elements for early diagnosis and therapeutic options are indispensable to choose the appropriate behavior against these serious skin reactions and to decrease morbidity and mortality due to these conditions (AU).

Toxic epidermal necrolysis associated with anticonvulsants / Necrólisis epidérmica tóxica asociada a anticonvulsivantes

ABSTRACT Background and Objectives: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered as a continuum of the same process. TEN or Lyell Syndrome is the most severe form. Both entities involve an acute mucocutaneous blistering reaction associated with systemic inflammation. Materials and Methods: We present a case of a young woman who developed TEN following concomitant treatment with valproate, lamotrigine, and phenobarbital. Despite the extensive mucocutaneous detachment (over 90%), prognostic evaluation was favorable (SCORTEN score 2; probability of survival 88%), and this patient evolved satisfactorily. Five days after admission, valproate was reinitiated without any subsequent adverse reaction. Results: Causality evaluation identified both lamotrigine and phenobarbital as "very probable" (ALDEN score = 6) causes and valproate as "very unlikely" (ALDEN score = 0) cause of TEN. Conclusions: SJS and TEN are true life-threatening medical emergencies. This case emphasizes the importance of early diagnosis and treatment, including the discontinuation of the causative agent, which can be lifesaving.

RESUMEN Antecedentes y objetivos: El síndrome de Stevens-Johnson (SSJ) y la necrólisis epidérmica tóxica (NET) se consideran un continuum del mismo proceso. La NET o síndrome de Lyell es la forma más grave. Ambas entidades implican una reacción ampollosa mucocutánea aguda asociada con inflamación sistémica. Materiales y métodos: Presentamos el caso de una mujer joven que desarrolló NET posterior al tratamiento concomitante con valproato, lamotrigina y fenobarbital. A pesar del extenso desprendimiento mucocutáneo (más del 90%), la evaluación pronóstica fue favorable (puntuación SCORTEN 2; probabilidad de supervivencia 88%), y esta paciente evolucionó satisfactoriamente. Cinco días después de su ingreso, se reinició el valproato sin ninguna reacción adversa posterior. Resultados: La evaluación de causalidad identificó tanto la lamotrigina como el fenobarbital como causas "muy probables" (puntuación ALDEN = 6) y el valproato como causas "muy improbables" (puntuación ALDEN = 0) de NET. Conclusiones: El SJS y la NET son verdaderas emergencias médicas potencialmente letales. Este caso enfatiza la importancia del diagnóstico y tratamiento tempranos, incluida la interrupción del agente causal, lo cual puede salvar la vida del paciente.

Enfermedad de injerto contra huésped cutánea frente a necrólisis epidérmica tóxica en un receptor de trasplante de células madre hematopoyéticas / Cutaneous graft-versus-host disease versus toxic epidermal necrolysis in a hematopoietic stem cell transplant recipient

El diagnóstico diferencial entre la enfermedad de injerto contra huésped aguda grave (estadio IV) y la necrólisis epidérmica tóxica pude resultar difícil en el contexto de un paciente trasplantado, ya que ambas tienen presentaciones clínicas similares. Sin embargo, la distinción entre ellas es fundamental porque ocasionan una gran morbimortalidad, y su manejo y pronóstico difieren. Algunas pequeñas diferencias clínicas e histopatológicas son de gran ayuda para el diagnóstico diferencial y el dermatólogo deberá reconocerlas para tomar una conducta correcta y oportuna. Se comunica el caso de un paciente que presentó ampollas y epidermólisis después del trasplante de células hematopoyéticas y en el que se planteó la dificultad diagnóstica para diferenciar entre ambas afecciones.

The differental diagnosis between severe graft-versus-host disease (stage IV) and toxic epidermal necrolysis can be difficult in the context of a transplant patient, since both conditions have similar clinical presentations. However, the distinction between these two entities is critical because they produce great morbidity and mortality and their management and prognosis differ. Some small clinical and histopathological differences are of great help for the differential diagnosis, and the dermatologist must recognize them in order to take a correct and timely conduct. We present the case of a patient who developed blisters and epidermolysis after hematopoietic cell transplantation, and in whom the diagnostic difficulty to differentiate between the two entities was raised.

Cuidados de Enfermagem a um Adolescente com Necrólise Epidérmica Tóxica: Relato de Caso / Nursing Care of an Adolescent with Toxic Epidermal Necrolysis: A Case / Report Cuidados de enfermería prestados a un adolescente con necrólisis epidérmica tóxica: reporte de caso

Objetivo: Relatar a assistência de enfermagem diante do caso de um adolescente com diagnóstico de Necrólise Epidérmica Tóxica (NET) internado em uma Unidade de Terapia Intensiva de Queimados. Método: Trata-se de um relato de caso sobre as intervenções de enfermagem realizadas em um adolescente com diagnóstico de NET, internado por um mês em 2020 na Unidade de Terapia Intensiva de Queimados de Goiás. As informações foram coletadas do prontuário do paciente. Resultados: Apresentamos práticas clínicas para auxiliar no manejo de pacientes com NET. O caso apresentado teve um desfecho positivo. Conclusão: Os cuidados de enfermagem são essenciais para o prognóstico positivo do paciente. Nesse caso, a enfermagem atuava principalmente no cuidado de feridas, administração de medicamentos, laserterapia e vigilância para prevenção de infecções

Objective: To report nursing care facing a case of an adolescent diagnosed with Toxic Epidermal Necrolysis (TEN) hospitalized in a Burns Intensive Care Unit. Method: This is a case report on the nursing interventions performed on a teenager diagnosed with TEN, who was hospitalized for a month in 2020 at the Burn Intensive Care Unit in the state of Goiás. The information was collected from the patient's medical record. Results: We present clinical practices to assist the management of patients with TEN. The case presented had a positive outcome. Conclusion: Nursing care is essential for the positive prognosis of the patient. In this case, nursing acted mainly in wound care, medication administration, laser therapy and surveillance to prevent infections

Objetivo: Informar los cuidados de enfermería en el caso de un adolescente diagnosticado de Necrólisis Epidérmica Tóxica (TNE) ingresado en una Unidad de Cuidados Intensivos por Quemados. Método: Se trata de un relato de caso sobre las intervenciones de enfermería prestadas a un adolescente diagnosticado de TNE, hospitalizado durante un mes en 2020 en la Unidad de Cuidados Intensivos Quemados de Goiás, información obtenida de la história clínica del paciente. Resultados: Presentamos prácticas clínicas para ayudar en el manejo de pacientes con TNE. El caso presentado tuvo un resultado positivo. Conclusión: El cuidado de enfermería es fundamental para el pronóstico positivo del paciente. En este caso, la enfermería trabajó principalmente en el cuidado de heridas, administración de medicamentos, terapia con láser y vigilancia para prevenir infecciones.

Necrólisis epidérmica tóxica, a propósito de un caso / Toxic epidermal necrolysis, a case report

Introducción: La necrólisis epidérmica toxica (NET) son reacciones cutáneas más severas que ocurren en los niños. Los medicamentos son los principales inductores del problema. Se ha empleado inmunoglobulina humana intravenosa (IGIV) en problemas autoinmunes de la piel, incluyendo reacciones cutáneas severas por medicamentos. Informe del caso: Paciente de seis años de edad con antecedentes de a haber recibido 3 semanas previas cefalosporina de tercera generación, es internada por cuadro clínico de tres días con alzas térmicas, rinorrea, estornudos, náuseas, odinofagia, disfagia, hiporexia, hiperemia conjuntival, tos, episodios de desaturación y erupción cutánea que se inició en la cara y se extendió al tronco y extremidades. Examen físico. Paciente decaída, febril, en mal estado general, aparición de lesiones cutáneas eritematosas maculopapulares con rápida evolución a formación de flictenas con desprendimiento de la epidermis (Nikolski positivo), con afectación mayor al 30% de superficie corporal. Se observó conjuntivitis no purulenta; eritema y hemorragia de encías y labios, informe de anatomía patológica de lesiones cutáneas concluyó en NET. Se le administró IGIV a 1 g/kg/dosis/día. Al segundo día y segunda dosis, las lesiones cutáneas mejoraron. Discusión. La IGIV se ha utilizado en niños con reacciones cutáneas severas inducidas por drogas, con respuesta favorable, a partir de la 2 dosis de su administración.

Introduction: Toxic epidermal necrolysis (NET) are more severe skin reactions that occur in children. Medications are the main inducers of the problem. Human intravenous immunoglobulin (IGIV) has been used in autoimmune skin problems, including severe skin reactions from medications. Case report: Six-year-old patient with a history of having received third generation cephalosporin 3 weeks previously, hospitalized for a clinical picture of three days with thermal rises, rhinorrhea, sneezing, nausea, odynophagia, dysphagia, hyporexia, conjunctival hyperemia, cough, episodes of desaturation and skin rash that started on the face and spread to the trunk and extremities. Physical exam. Decayed, feverish patient, in poor general condition, appearance of maculopapular erythematous skin lesions with rapid evolution to formation of blisters with detachment of the epidermis (Nikolski positive), with involvement greater than 30% of body surface. Non-purulent conjunctivitis was observed, erythema and bleeding gums and lips, report of pathological anatomy of cutaneous lesions concluded in NET. IGIV was administered at 1 g/kg/dose/day. On the second day and second dose, the skin lesions improved. Discussion. IVIG has been used in children with severe drug-induced skin reactions, with a favorable response, from the 2nd dose of administration.

Analysis of Drug Use in a Patient with Rare Camrelizumab-induced Toxic Epidermal Necrolysis by Clinical Pharmacists / 中国药房

OBJECTIVE：To introduce the role of clinical pharmacists in the treatment of camrelizumab-induced toxic epidermal necrolysis （TEN），and to provide reference for the therapy of similar ADR. METHODS：The clinical pharmacist participated in therapy duration of a patient with TEN caused by camrelizumab. The patient was treated with Camrelizumab for injection combined with Apatinib mesylate tablet as anti-tumor therapy，and was admitted to hospital due to extensive skin lesions. After consulting relevant literatures and analyzing the patient’s admission diagnosis [severe epidermolysis bullosa，severe drug eruption（erythema multiforme），abnormal liver function，etc.] and examination results（hypokalemia，etc.），clinical pharmacists suggested to stop above anti-tumor drugs and given Methylprednisolone sodium succinate for injection（160 mg→80 mg→60 mg， qd，ivgtt） for anti-inflammatory treatment，Imiperan cilastatin for injection （1 g，q8 h，ivgtt） for an ti-infection treatment， Potassium chloride injection（1 g，qd，ivgtt）for electrolyte regulation，Compound amino acid injection（3AA）（10.65 g，qd，ivgtt） for nutritional support treatment，Pantoprazole sodium for injection（40 mg，qd，ivgtt）for acid inhibition and stomach protection， Reduced glutathione for injection（2.4 g，qd，ivgtt）for liver protection. Before medication，the patient was given cognitive and behavioral education and medication publicity. The changes of relevant indicators were closely monitored during medication，and the patient was given medication guidance when he was discharged. RESULTS：The doctors adopted the suggestions of clinical pharmacists，and 16 days after treatment，the skin lesions of the trunk and limbs were improved，and the double eyelids were still erosive and exuded a lot of secretions. The patient requested transfer for treatment. CONCLUSIONS：Clinical pharmacists assisted physicians to improve the treatment plan of patients with TEN caused by camrelizumab，and carried out cognitive and behavioral education and medication publicity for patients to ensure the effectiveness and safety of their medication.

Drug-induced erythroderma in patients with acquired immunodeficiency syndrome / 世界急诊医学杂志（英文）

@#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.

Cohort study of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis in China: evaluation of risk models and new predictor of pulmonary consolidation on computed tomography / 医学前沿

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.

Stevens-Johnson syndrome/toxic epidermal necrolysis successfully treated with Chinese herbal medicine Pi-Yan-Ning: A case report / 中西医结合学报

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare adverse cutaneous reaction with a low incidence and high mortality. Despite posing a serious threat to patients' health and lives, there is no high-quality evidence for a standard treatment regimen. Here we report the case of a 62-year-old man with stage IV pancreatic cancer who experienced immunotherapy-induced SJS/TEN. After consensus-based regular treatments at a local hospital, his symptoms became worse. Thus, he consented to receive Chinese herbal medicine (CHM) therapy. The affected parts of the patient were treated with the CHM Pi-Yan-Ning which was applied externally for 20 min twice a day. After 7 days of treatment, the dead skin began peeling away from the former lesions that had covered his hands, feet, and lips, indicating that skin had regenerated. After 12 days of treatment, the patient's skin was completely recovered. In this case, SJS/TEN was successfully treated with Pi-Yan-Ning, suggesting that there might be tremendous potential for the use of Pi-Yan-Ning in the treatment of severe skin reactions to drug treatments. Further basic investigations and clinical trials to explore the mechanism and efficacy are needed.

A pattern of serious adverse drug reactions reported in a tertiary care hospital, Rangaraya Medical College, Kakinada, Andhra Pradesh

Background: Serious adverse drug reactions (ADRs) constitute a major limitation in clinical development of a drug thus necessitating close monitoring. Studies regarding the pattern of serious ADRs are limited in southern India. The present study was conducted in tertiary care hospital in Andhra Pradesh with an objective to evaluate the pattern of severe cutaneous and non-cutaneous ADRs in our hospital and to assess the causality, severity, and preventability of these reactions.Methods: A retrospective observational study was conducted over two years, from January 2016 till January 2018 in our ADR monitoring center. The pattern of serious adverse drug reactions, the nature of ADR, suspected drug, the outcome and preventability were analyzed using Modified Hartwig and Siegel scale, and modified Schumock and Thorton scale.Results: Out of 734 ADRs reported, 42 were serious, while 692 were non-serious. Out of 42, 22 were dermatological in origin while the others were acute kidney injury, acute psychosis, febrile neutropenia, gynecomastia, and lipodystrophy. According to WHO causality assessment scale, 27 were probable while 15 were possible. The majority were reported in the age group of 16 to 65 years with female (34) preponderance. The most common drug category responsible was antimicrobials, followed by antiretrovirals, anti-epileptics, and analgesics.Conclusions: Antimicrobial, anti-epileptics, and analgesics contributed to serious ADRs. Although non-cutaneous ADRs did not result in hospitalization, they caused social inhibition and mental stress in the patient.

Bilateral panophthalmitis following toxic epidermal necrolysis: A case report

A 70 year old man presented with systemic signs of toxic epidermal necrolysis (TEN) following consumption of diclofenac tablets for a prodromal illness a week back. Ophthalmic evaluation showed no perception of light in both eyes along with lid edema, total corneal sloughing, and pus-filled anterior chamber. An amniotic membrane transplant was planned but within a few hours, both eyes developed panophthalmitis with restricted extraocular movements and mild proptosis and had to be eviscerated. This is perhaps the first case showing such devastating sequelae of TEN.