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)

Stevens-Johnson syndrome secondary to massive inflammatory hyperplasia of bilateral lingual margins: a case report and literature review / 华西口腔医学杂志

Stevens-Johnson syndrome (SJS), also known as the multifactorial erythematous drug eruption, is a class of adverse reactions of the skin and mucous membranes primarily caused by drug allergy often involving the oral cavity, eyes, and external genital mucosa, generally accompanied by fever, and can be life-threatening in severe cases. In February 2022, the Department of Stomatology, the First Affiliated Hospital of Zhengzhou University admitted a patient with huge inflammatory hyperplasia of bilateral lingual margins secondary to SJS. Upon admission, no other obvious symptoms were observed except for tongue hyperplasia. The patient suffered from a severe adverse drug reaction caused by acetaminophen 2 months ago and was complicated by liver dysfunction and pulmonary infection. After 1 month of treatment and rehabilitation, he developed a secondary tongue mass and was subsequently admitted to Dept. of Oral and Maxillofacial Surgery Ward 2, the First Affiliated Hospital of Zhengzhou University. After completing the examination, the tongue mass was surgically removed. After a follow-up of 11 months, the patient's condition was satisfactory and no temporary discomfort was observed. The case of tongue mass secondary to SJS is extremely rare. If a stomatologist encounters a similar case, we should carefully inquire about the drug allergy history and recent medication history, and be alert to whether or not they had adverse drug reactions recently.

Síndrome de Stevens-Johnson asociado al tratamiento con metotrexato de la leucemia linfoblástica aguda: a propósito de un caso / Stevens-Johnson Syndrome associated with methotrexate treatment for acute lymphoblastic leukemia: a case report

La necrólisis epidérmica tóxica y el síndrome de StevensJohnson son enfermedades mucocutáneas raras que están asociadas a una evolución prolongada y a un desenlace potencialmente mortal. Principalmente están inducidas por fármacos y las tasas de mortalidad son muy elevadas. Aunque la piel es la más comprometida, también pueden estar afectados múltiples aparatos o sistemas como el cardiovascular, pulmonar, gastrointestinal y urinario. En este artículo, describimos el caso de un paciente con síndrome de Stevens-Johnson asociado al tratamiento con metotrexato, quien desarrolló insuficiencia cardíaca aguda y hemorragia gastrointestinal además de las manifestaciones en la piel. El paciente recibió un tratamiento satisfactorio con metilprednisolona e inmunoglobulina por vía intravenosa y continuó la quimioterapia con metotrexato.

Toxic epidermal necrolysis and Stevens-Johnson syndrome are rare mucocutaneous diseases which are associated with a prolonged course and potentially lethal outcome. They are mostly drug induced and mortality rates are very high. Although mostly skin is involved, multiple organ systems such as cardiovascular, pulmonary, gastrointestinal, and urinary systems may be affected. Here, we report a case of StevensJohnson Syndrome associated with methotrexate treatment who developed acute cardiac failure and gastrointestinal hemorrhage beside skin findings. He had been treated with intravenous immunglobulin and methylprednisolone succesfully and continued chemotherapy with methotrexate treatment again.

Necrolisis epidérmica tóxica en el curso de un síndrome hemofagocítico secundario a linfoma de Hodgkin: caso clínico / Toxic epidermal necrolysis during a hemophagocytic syndrome secondary to Hodgkin lymphoma: report of one case

Toxic epidermal necrolysis (TEN) is a lethal entity, characterized by extensive epidermal necrosis and multiorgan failure. Hemophagocytic syndrome (HFS) is also a rare and lethal syndrome characterized by hyperinflammation that leads to the appearance of fever, pancytopenia, organomegaly and hemophagocytosis. The concomitance of these diseases is extremely uncommon. We report a 38 years old female, who during the course of a HFS secondary to Hodgkin Lymphoma (HL), presented a TEN secondary to antibiotics. She was admitted due to a consumptive syndrome, lymphadenopathy, visceromegaly and severe pancytopenia. Laboratory and bone marrow tests confirmed HFS. Due to constant fever, imipenem was indicated. On the third day she started with pain and skin rash. She evolved with positive Nikolsky sign. Cutaneous biopsy was concordant with extensive TEN, which was managed with intravenous immunoglobulin and dexamethasone. A complete response and normalization of the blood count were achieved. Finally, the lymph node biopsy showed HL of mixed cellularity type, which was managed with 8 cycles of ABVD chemotherapy, achieving complete remission.

Stevens-Johnson syndrome and toxic epidermal necrolysis: epidemiological and clinical outcomes analysis in public hospitals

Abstract: Background: Adverse drug reactions are harmful and involuntary responses to drugs that occur at doses normally used for a given condition. Among them are Stevens-Johnson syndrome and toxic epidermal necrolysis, both rare and potentially fatal conditions. Objectives: To analyze the epidemiological and clinical characteristics related to patients diagnosed with Stevens-Johnson syndrome and toxic epidermal necrolysis in public hospitals in the Federal District - Brazil. Methods: Retrospective, cross-sectional and descriptive study, in which data were collected referring to patients hospitalized in the public healthcare system of the Federal District from 1999 to 2014. Results: Between 1999 and 2014, 86 cases of hospitalized patients with diagnosis of Stevens-Johnson syndrome and toxic epidermal necrolysis in the Federal District were reported. The majority of patients were women; the most affected age group was 0 to 10 years. Patients older than 60 years (elderly) represent 6.98% of the cases. Most patients admitted to the referral hospital were discharged. However, occurrence of deaths exceeded that of discharge in elderly patients. Limitations of the study: There is fragility in the registry of hospitalization of patients, both in the hospital information system and in the medical records of the reference hospital. Conclusion: There is a need for greater production and better dissemination of information on the incidence of adverse drug reactions.

Trimetroprim-sulfametoxazol: Un caso de Necrólisis Epidérmica Tóxica / Trimethoprim-sulfamethoxazole: A Case of Toxic Epidermal Necrolysis

Necrólisis Epidérmica Tóxica (NET) es una rara pero grave emergencia caracterizada por difusa exfoliación de la piel y las membranas mucosas debido a pérdida de la epidermis, mediada por respuesta inmune que puede llevar a sepsis y fallo ventilatorio. El Trimetropin-Sulfametoxazol es un antibiótico ampliamente utilizado que es causa de dicha entidad. El diagnóstico prematuro y el tratamiento agresivo es esencial para la reducción de los elevados niveles de morbilidad y mortalidad asociadas con esta enfermedad. Presentamos un caso que fue precipitado debido al uso de Trimetropin-Sulfametoxazol en un hombre de 22 años de edad...(AU)

Toxic Epidermal Necrolysis (TEN) is a rare but serious emergency characterized by diffuse exfoliation of the skin and mucous membranes due to loss of the epidermis, mediated by immune response that can lead to sepsis and ventilatory failure. Trimetropin-Sulfamethoxazole is a widely used antibiotic that causes this entity. Premature diagnosis and aggressive treatment is essential for reducing the high levels of morbidity and mortality associated with this disease. We present a case that was precipitated due to the use of Trimetropin-Sulfamethoxazole in a man of 22 years of age ... (AU)

Abordagem cutânea na necrólise epidérmica tóxica / Cutaneous approach in toxic epidermal necrolysis

Introdução: Necrólise epidérmica tóxica é uma erupção mucocutânea aguda grave, geralmente induzida por medicamentos, associada a alta taxa de morbidade e mortalidade. Os cuidados com as lesões mucosas e cutâneas e a abordagem multidisciplinar são muito importantes para o prognóstico e sequelas futuras. Objetivos: Discutir os principais aspectos dessa síndrome por meio da revisão de literatura, ilustrada por um caso clínico. Métodos: Revisão de literatura utilizando bases de dados on-line PubMed e Scielo. Incluímos artigos em língua inglesa, portuguesa, francesa e espanhola, e ilustração com caso clínico pediátrico. Termos procurados foram "toxic epidermal necrolysis", "Stevens-Johnson overlap", ''necrólise epidérmica tóxica'', ''síndrome Stevens-Johnson''. Resultados: Apresentamos dados para guiar o manejo de pacientes com necrólise epidérmica tóxica para cirurgiões plásticos, pediatras, intensivistas, dermatologistas e emergencistas. O caso tratado teve evolução favorável, sem sequelas cutâneas. Conclusão: O alto nível de suspeição é imprescindível para um diagnóstico e estratificação de risco adequados e instituição precoce de medidas de suporte, e o tratamento deve ser realizado por uma equipe multidisciplinar treinada para reduzir sequelas e mortalidade.

Introduction: Toxic epidermal necrolysis is a severe acute mucocutaneous condition usually induced by drugs associated with a high rate of morbidity and mortality. The care of the mucous lesions and skin and a multidisciplinary approach are very important for the prognosis and future sequelae. Objectives: To discuss the main aspects of this syndrome through a literature review illustrated by a clinical case. Methods: Review of the literature using the PubMed and SciELO online databases was performed. Articles in English, Portuguese, French, and Spanish were included and illustrated with a pediatric clinical case. The keywords used were as follows: "toxic epidermal necrolysis," "Stevens-Johnson overlap," "necrólise epidérmica tóxica," and "síndrome Stevens-Johnson." Results: We presented data to guide the management of patients with toxic epidermal necrolysis for plastic surgeons, pediatricians, intensivists, dermatologists, and emergency physicians. The case treated had a favorable disease course without sequelae. Conclusion: A high level of suspicion is necessary for an adequate diagnosis and risk stratification, and early support measures and treatment should be performed by a multidisciplinary team trained to minimize damage and mortality.

Caso 13 / Case 13

Homem de 34 anos de idade foi atendido na Unidade Básica de Saúde comodinofagia, eritema conjuntival, mal-estar geral, mialgia e temperatura corpórea de 39°C, tendo sido tratado empiricamente com dipirona e amoxicilina. Relatou picadas de carrapatos nesse mesmo dia. Poucas horas após o uso da medicação prescrita, evoluiu com erupção eritematoviolácea, placas confluentes e vesículas sero-hemorrágicas em face, tronco e membros, com acometimento de mucosa oral e peniana. Iniciou há dois meses o uso de alopurinol e atenolol para tratamento de, respectivamente, hiperuricemia e hipertensão arterial sistêmica.

Cyclosporine in Stevens Johnson syndrome and toxic epidermal necrolysis and retrospective comparison with systemic corticosteroid.

Background: Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening dermatological emergencies. Many immunosuppressive modalities have been tried with variable results. Aims: To determine the efficacy of cyclosporine in cases of SJS and TEN and compare the efficacy with systemic corticosteroid in the same condition. Methods: Study was conducted at a tertiary hospital during 01 July 2011 to 30 June 2012. SCORTEN was assessed at the time of admission. Total body surface area (TBSA) assessment was like any burn patients. Cyclosporine was administered in the dose of 3 mg/kg body weight in three divided dosage for 07 days and then tapered over another 07 days. Data were compared to a historical series of SJS/TEN patients, managed by systemic steroids a year ago. Results: A total of 11 consecutive patients with a mean age of 32.09 and standard deviation (SD 16.17) were enrolled in to cyclosporine group, which were retrospectively compared to 6 patients with a mean age of 27.87 (SD 13.97) years in the corticosteroid group. The mean duration of re-epithelialization was 14.54 (SD 4.08) and 23 days (SD 6.68) in cyclosporine and corticosteroid group respectively (P = 0.009956). Mean hospital stay was 18.09 (SD 5.02) and 26 (SD 6.48) days in cyclosporine and corticosteroid group respectively (P = 0.02597). A total of 1.11 and 0.51 patients were expected to die against no death and two deaths in cyclosporine and corticosteroid group respectively (Standardized mortality ratio = 3.92) (P = 0.04321). Conclusion: This study definitely suggests that cyclosporine has encouraging role in the management of uncomplicated cases of SJS, SJS-TEN overlap or TEN.

Necrolisis epidérmica tóxica como manifestación de lupus eritematoso sistémico: reporte de un caso y revisión de la literatura / Toxic epidermal necrolysis as a manifestation of systemic lupus erythematosus: report on a case and literature review

Presents a case of a young woman with a recent diagnose of systemic lupus erythematosus (SLE), with a sligth initial skin condition that envolves into toxic epidermal necrolysis (TENS): On account of this case, areview is presented of the physiopathology, clinical presentation and treatment of this infrequent form of dermatological manifestation of (SLE).

Se presenta el caso de una joven con diagnóstico reciente de lupus eritematoso sistémico (LES), con compromiso cutáneo inicial leve que evoluciona hacia necrolisis epidérmico tóxica (NET). A propósito de ello, se revisa la fisioptología, presentación clínica y tratamiento de esta infrecuente forma de manifestación dermatológica de LES.

Grandes dosis de corticoides sistémicos en pacientes con síndrome de Stevens-Johnson y necrólisis epidérmica tóxica: descripción de siete casos y revisión de la literatura / Treating Stevens-Johnson syndrome and toxic epidermal necrolysis with high dose of glucocorticosteroids: report of seven cases and review of the literature

Antecedentes: El síndrome de Stevens-Johnson y la necrólisis epidérmica tóxica hacen parte del espectro de reacciones medicamentosas graves caracterizadas por una destrucción progresiva de la piel y las mucosas, y que son mediadas por una respuesta inmunitaria exagerada. A pesar de los múltiples avances en el entendimiento de su fisiopatología, no existe un tratamiento farmacológico que tenga suficiente evidencia clínica como para respaldar su uso de manera rutinaria. No obstante, a través de los años, varios investigadores han utilizado esteroides, con diferentes resultados. El objetivo del presente trabajo fue describir nuestra experiencia con el uso de esteroides en dosis grandes, para el manejo del síndrome de Stevens-Johnson y la necrólisis epidérmica tóxica. Materiales y métodos: Se revisaron las historias clínicas de todos los pacientes mayores de 18 años que ingresaron a la Fundación Valle Lili (Cali, Colombia) con diagnóstico de síndrome de Stevens-Johnson o necrólisis epidérmica tóxica, entre el 1 de enero de 2006 y el 31 de mayo de 2010. Se registraron datos clínicos, epidemiológicos y resultados de pruebas de laboratorio solicitados a su ingreso al servicio de urgencias; se excluyeron los pacientes con un tiempo mayor de 10 días, desde el inicio de los síntomas hasta su ingreso a la institución. Resultados: Se incluyeron siete pacientes, con una edad promedio de 44 años (rango, 27 a 56 años), de los cuales, cinco eran mujeres; se registraron seis casos del síndrome de Stevens-Johnson y uno de necrólisis epidérmica tóxica. La mayoría de los pacientes presentaron una reacción cutánea generalizada, uno presentó un importante compromiso de las mucosas exclusivamente. En promedio, los esteroides se iniciaron 4,4 días después del inicio de los síntomas, con una duración del tratamiento de 3,7 días (rango, 3 a 5 días) y una estancia hospitalaria total promedio de 10,2 días (rango,4 a 19 días). El efecto secundario más común fue hipopotasiemia leve (6 de los 7 pacientes); una paciente presentó hiperglucemia, que requirió manejo con insulina, y bradicardia asociada al uso de metilprednisolona al tercer día de iniciado el tratamiento. Dos pacientes presentaron sepsis sin aislamiento del germen, lo que conllevó a una mayor estancia hospitalaria en uno de ellos. Conclusión: En nuestra serie de pacientes, el uso de grandes dosis de esteroides se asoció a una rápida resolución de las manifestaciones cutáneas, teniendo como efecto secundario más frecuente la hipopotasiemia leve que mejoró de forma adecuada con la reposición.

Síndrome de Dress y Síndrome de Steven Johnson / Dress Syndrome and Steven Johnson Syndrome

Las enfermedades de la piel muchas veces se asocian a medicamentos que pueden resultar en consecuencias fatales si no se detecta su causa a tiempo. El síndrome de Dress (Drug reaction with eosinophilia and systemic symptoms) es una enfermedad caracterizada por la triada rash, compromiso sistémico y visceral y en la mayor¡a de los casos se ha reportado la presencia de eosinofilia; que se asocia en la mayoría de las veces al uso de antiepilépticos aunque no de manera exclusiva. El síndrome de Steven Johnson, es una reacción mucocutánea que se caracteriza por un rash macular en cara y tronco, con fiebre los primeros tres días y culmina con la presencia de bulas que son el resultado de un desacoplamiento de la epidermis y la dermis. Ambas enfermedades están asociadas a infecciones o al uso de medicamentos y mejoran con el diagnóstico oportuno y la suspención inmediata del medicamento...

Coin-shaped epithelial lesions following an acute attack of erythema multiforme minor with confocal microscopy findings.

We report an interesting ocular finding of bilateral multiple coin-shaped epithelial lesions along with the confocal microscopy findings in a patient following an acute attack of erythema multiforme (EM) minor. A 30-year-old male presented with a history of watering and irritation in both eyes of three days duration. He was diagnosed to have EM minor and was on oral acyclovir. Slit-lamp examination revealed multiple coin-shaped epithelial lesions. Confocal microscopy showed a corresponding conglomerate of hyper-reflective epithelial lesions. The corneal lesions resolved over six weeks with oral steroids and acyclovir. An immunological mechanism is suspected.

Role of systemic steroids in the outcome of Stevens-Johnson syndrome and toxic epidermal necrolysis

Stevens-Johnson syndrome [SJS] and toxic epidermal necrolysis [TEN] are cutaneous adverse reactions which usually develop as a result of drug therapy. The role of systemic steroids in the treatment of SJS and TEN is debatable. To see the clinical outcome of patients suffering from SJS or TEN, treated with or without steroids. Forty patients of SJS and TEN were enrolled from the inpatient department of Jinnah Hospital Lahore. Clinical data were recorded on a pro forma. Clinical outcome of patients treated with or without steroids was recorded and analyzed. A total of forty patients were enrolled in the study. Twenty nine patients were suffering from SJS and 11 were suffering from TEN. Twenty three patients of SJS [79.31%] were treated without steroids. Two patients died [8.7%] and twenty one [91.30%] recovered. Six patients were given steroids [20.68%], out of these 2 [33.3%] died and 4 [66.76%] recovered. There were eleven patients of TEN, four [36.37%] were managed without steroids, one expired [25%] and rest of the three [75%] patients recovered. Seven [63.63%] patients were given steroids, three [43.86%] patients expired while four [57.14%] recovered

Toxic epidermal necrolysis and agranulocytosis: Rare adverse effects of ciprofloxacin.

Ciprofloxacin is one of the most commonly used antibacterial agents with relatively few side effects. Serious adverse reactions reported with ciprofloxacin are rare with an incidence of 0.6%. Recently we came across two rare adverse effects of ciprofloxacin, viz. toxic epidermal necrolysis and agranulocytosis. To our knowledge, a total of seven cases have been reported in the literature documenting an association between oral ciprofloxacin administration and toxic epidermal necrolysis. One case of granulocytopenia, four of pancytopenia and fifteen of leucopenia worldwide have been reported. With the use of ciprofloxacin becoming more and more widespread, these two rare but fatal complications of ciprofloxacin should be borne in mind.

Uso de inmunoglobulina humana endovenosa en pacientes con necrolisis epidérmica tóxica y síndrome de sobreposición Stevens Johnson necrolisis tóxica epidérmica / Use of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis and Stevens-Johnson/toxic epidermal necrolysis overlap syndrome. Review of 15 cases

Background: Toxic epidemial necrolysis (TEN) is an acute adverse drug reaction, that has an unpredictable progression and a 30 percent mortality. The incidence of TEN in the general population is approximately 0.4 to 1.2 cases/million/year. It is characterized pathologically by keratinocyte apoptosis which leads to epidemial detachment. Keratinocyte apoptosis is triggered by activation of the Fas-FasL, pathway and could be prevented by the use of intravenous immunoglobulin (IVIG). Aim: To report the experience with the use of IVIG in TEN. Material and methods: Retrospective study of 15 patients with a diagnosis of Stevens-Johnson/TEN overlap (SJS/TEN) or TEN, that received a total dose of 23 ± 0.6 mg/kg of IVIG over aperiod of 3 to 4 days. The infusion was initiated during the first 24 hours after diagnosis and was associated with standard care for burn victims. Steroids were avoided if the patient was not in chronic steroidal therapy. Results: All patients responded to IVIG in a lapse of 46.4 ± 14.2 hours from the beginning of infusion. Eighty percent of patients survived, but one developed acute renal failure due to IVIG, and another became blind due to corneal opacities, a complication of TEN. Those who survived were discharged after a lapse of 19-8 ± 6.6 days from the beginning of the disease. Conclusions: Despite the lack of blind, multicentric and randomized trials, we agree with some international studies that IVIG is beneficial as a treatment for SSJ/NET and TEN.

Progresión a necrólisis epidérmica tóxica por uso de lamotrigina: A propósito de un caso / Progression to toxic epidermal necrolysis by using lamotrigina: In connection of a case

El Síndrome de Stevens Johnson (SSJ), el Síndrome de Superposición (SSJ/ NET) y la Necrólisis Epidérmica Tóxica (NET) son formas clínicas cutáneo-mucosas graves, desencadenadas por fármacos y muy frecuentemente por anticonvulsivantes. Comunicamos el caso de una paciente medicada por su epilepsia, quién presentó un cuadro incipiente de SSJ empeorando rápidamente hasta derivar en la NET. A pesar de la gravedad, la paciente respondió satisfactoriamente a altas dosis de corticoides sistémicos desde el comienzo y por las medidas de soporte del equipo médico multidisciplinario del hospital.

The Stevens Johnson Syndrome, the Overlape Syndrome (SSJ / NET), and the Toxic Epidermal Necrolysis are clinical cutaneous mucouse forms due to drugs administration and most frequently due caused by antiepileptic. We communicate the case of a patient treated with lamotrigina for epilepsy, who presented an incipient case of Stevens Johnson Syndrome, worsened rapidly causing a Toxic Epidermal Necrolysis. Nevertheless, the patient gained a satisfactory answer due to high doses of corticoids, which were given from the beginning as well as the measures and the support of the whole medical team of the hospital.