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Toxic epidermal necrolysis as a manifestation of drug hypersensitivity syndrome: 3 case reports Three patients developed toxic epidermal necrolysis [TEN] as a manifestation of drug hypersensitivity syndrome during treatment with lamotrigine (patient 1), sulfasalazine and omeprazole (patient 2) or carbamazepine (patient 3). Patient 1 was a 32-year-old man with epilepsy. Lamotrigine 25 mg/day was added to his usual valproic acid regimen due to persistent seizures. After 1 week, he developed facial oedema, formication of his toes and throat pain. He received corticosteroids and antihistamines, but his symptoms persisted. He had widespread oedema and shivers 5 days later. He had burning pain in his feet and could not walk. He had a temperature of 39°C, a BP of 105/60 mmHg, a HR of 130 beats/min, and lymphadenopathy and hepatosplenomegaly. He developed massive skin peeling, with >30% body surface area [BSA] detachment. He had haemorrhagic blisters on his hands and feet, haemorrhagic crusts on his lips, and erosions of his oral and genital mucosa. He had impaired vision due to purulent exudation and a conjunctival reaction. Nikolsky’s sign was positive. He had peripheral blood eosinophilia and increased liver enzyme levels and erythrocyte sedimentation rate. He had low pO2 and high pCO2 levels, consistent with slight respiratory failure. Skin swabs isolated Candida spp. and E. coli from his oral cavity. A skin biopsy suggested TEN. Lamotrigine was stopped and treatment included methylprednisolone, antibacterials, antimycotics and ophthalmic drugs. His condition improved in 6 weeks and he was discharged. On follow-up 1 month after treatment, he had nail manifestations. He experienced total loss of his lower eyelashes and corneal damage. Patient 2, a 32-year-old man with inflammatory bowel disease started receiving sulfasalazine [Salazopyrine] 1500 mg/day and omeprazole 20 mg/day. He developed an erythematous maculo-papulous rash on photo-exposed skin areas 13 days later. His rash worsened after 2 days and he developed flaccid blisters and diffuse erosions on erythematous macules with poorly defined borders; about 30% of his BSA was affected. Nikolsky’s sign was positive. He had erosions of his genital, oral and nasal mucosa. He had conjunctival involvement with exudation. His temperature was 39°C on admission and laboratory tests were suggestive of liver dysfunction and strong inflammatory reactions. Skin swabs showed Staphylococcus haemolyticus and Streptococcus epidermidis, and Acinetobacter baumanii was isolated from his oral cavity. Histopathology showed complete absence of his epidermis and a mainly perivascular infiltrate. Sulfasalazine was stopped and he received methylprednisolone, antibacterials, antimycotics and ophthalmic drugs. His symptoms resolved and he was discharged. On follow-up 1 month after treatment, he had nail manifestations, total loss of his lower eyelashes and corneal damage. At 3 months follow-up, he had signs of hypothyroidism. Patient 3 was a 28-year-old man with a long history of alcohol a