Oseltamivir
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Oseltamivir Toxic epidermal necrolysis: case report
A 43-year-old man developed toxic epidermal necrolysis (TEN) during treatment with oseltamivir for nosocomial respiratory infection due to influenza A virus. The man was referred to a hospital due to lumbar pain without previous trauma. He was previously diagnosed of refractory arterial hypertension. The initial exam did not reveal neurological deficit. He showed abdominal perimeter increase, abdominal violaceous striae, thin skin, weight loss more significant in the last month, intense proximal weakness in the lower limbs, ecchymosis, toenails and armpits fungal lesions, erythema and moon facies; all these symptoms developed over the course of 1 year. He had never taken any corticoids. After that, he was diagnosed of a nosocomial respiratory infection due to influenza A virus and was initiated on treatment with oseltamivir [route and dosage not stated]. An X-ray and a CT scan revealed multiple vertebral compression fractures in thoracic T6 level, thoracolumbar T11, T12, L1, L2 and L4, L5 lumbar levels. An MRI confirmed multiple vertebral fractures without malignant signs, which suggested osteoporotic fractures. Dual energy X-ray absorptiometry showed osteoporosis in spine and hip. In a suspicion of Cushing’s syndrome, he was referred to the endocrinologist for a confirmation study and ACTH-dependent Cushing’s disease due to a pituitary microadenoma was diagnosed. Pituitary function was preserved, except for hypogonadotropic hypogonadism secondary to hypercortisolism. He was initially treated with an unspecified anti-hypertensive therapy, ketoconazole and testosterone. Additionally, teriparatide was given to treat osteoporosis. However, he started to have spine and neck erythema and non-puriginic painful thorax. He was treated by the dermatologist because of the lesions’ deterioration which had expanded to the trunk, limbs, head and neck, with some blisters appearing in areas of friction with associated epidermolysis and Nikolsky sign. A skin biopsy confirmed TEN, probably related to oseltamivir [duration of treatment to reaction onset and outcome not stated]. He underwent an endoscopic-assisted endonasal trans-sphenoidal excision of the pituitary adenoma, with hypercortisolism resolution and development of secondary adrenal insufficiency, which required hydrocortisone for 15 months. After three months, he showed forward inclination of the trunk and had difficulties for standing or walking. CT and MRI showed multiple vertebral compression fractures in thoracic T6, thoracolumbar T11, T12, L1, L2 and lumbar L4, L5 levels without cleft or vacuum signs and diffuse hypointense in T1-weighted and T2-weighted sequences, which excluded osteonecrosis. However, X-ray of the spine showed thoracolumbar kyphosis and disabling sagittal deformity. Secondary kyphosis thoracolumbar deformity and sagittal imbalance was treated by two-level Smith-Petersen osteotomies and instrumented posterolateral arthrodesis T10-L3 using fenestrated pedicles screws with polymethyl methacryla
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