Improvement of Mortality Prognostication in Patients With Epidermal Necrolysis

Abstract

IMPORTANCEEpidermal necrolysis is a severe cutaneous adverse reaction in which severe systemic inflammation results in extensive epithelial keratinocyte necrosis. The most commonly used prognostic score in epidermal necrolysis, the Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN), was recently found to overestimate mortality in contemporary cohorts. Identification of independent prognostic markers may help to stratify risk more accurately.OBJECTIVE This study evaluates the association between novel inflammatory markers and in-hospital mortality in patients with epidermal necrolysis to study the incremental prognostic value of these markers in combination with SCORTEN. DESIGN, SETTING, AND PARTICIPANTSA retrospective cohort study was conducted over a 17-year period from 2003 to 2019. Patients were enrolled from Singapore General Hospital, the national referral center for epidermal necrolysis. A total of 196 patients with epidermal necrolysis were recruited, 4 (2%) of whom were excluded owing to incomplete data. MAIN OUTCOMES AND MEASURESThe main outcome assessed was the in-hospital mortality rate. Discrimination and calibration of risk scores were assessed using the area under the receiver operating characteristic curve (AUC) and calibration plot, respectively. Evaluation of the incremental prognostic value of these markers was done by comparing the AUC between the old and new risk score, and the use of net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS Among 192 total patients (median [IQR] age 56 years; 114 [59.4%] women), there were 43 (22.4%) who did not survive to discharge. Of the novel inflammatory markers, only red cell distribution width to hemoglobin ratio was significant in predicting in-hospital mortality (odds ratio [OR] 3.55; 95% CI, 1.76-7.16; P < .001) after adjusting for SCORTEN. The RDW/Hb as applied in 4 risk groups showed similar discrimination to SCORTEN (AUC [95% CI]: RDW/Hb in 4 groups, 0.76 [0.69-0.84], vs SCORTEN, 0.78 [0.70-0.85], P = .89). When RDW/Hb was added to SCORTEN, the composite score Re-SCORTEN showed significantly better discrimination than SCORTEN alone (AUC [95% CI]: vs SCORTEN,], P = .02). The overall NRI was 0.94 (95% CI, 0.68-1.20), P < .001. The IDI was 0.06 (95% CI 0.03-0.08), P < .001. Re-SCORTEN showed good calibration based on the calibration plot. CONCLUSIONS AND RELEVANCEIn this cohort of patients, RDW/Hb, an inexpensive and readily available marker, showed similar predictive accuracy with SCORTEN. Furthermore, when used in combination with SCORTEN, it also helped augment prognostic ability.

Novel inflammatory markers and in‐hospital mortality in epidermal necrolysis—A monocentric study of 137 patients

“…In univariate analysis, it was associated with a higher risk of mortality (OR = 6.38 [CI 95%: 2.57-17.61], p = 0.00013), but not in multivariate analysis (OR = 2.16 [CI 95%:0.71-6.86], p = 0.18, Table 1). The results were similar with the threshold of 1.19 calculated by Koh et al 4 Neutrophils and NLR were not associated with mortality (p = 0.70 and 0.17, respectively). Conversely, the lymphocytes count, with a discriminant rate of 900/mm 3 , was associated with a higher mortality in univariate (p < 0.0001) and multivariate analysis (p = 0.0089, Table 1).…”

“…2,3 Several studies suggested their association with the in-hospital mortality in EN. 4,5 We conducted a monocentric retrospective study to investigate the prognostic value of these parameters in our cohort of EN patients.…”

Adalimumab for Sintilimab-Induced Toxic Epidermal Necrolysis in a Patient with Metastatic Gastric Malignancy: A Case Report and Literature Review

“…Despite the high rates of cutaneous irAEs associated with ICI therapy, severe and lifethreatening skin reactions, such as TEN, were reported in approximately 2% to 3% of patients treated with a single-agent ICI. 3,4 In previous studies on TEN cases after the treatment by ICIs, patients were commonly treated by the high-dose corticosteroids or IVIG but with poor outcomes. We summarize these previously reported cases of ICI-induced TEN in Table 1.…”

Clinical value of the prognostic nutritional index and red blood cell distribution width‐to‐albumin ratio for the prediction of severity of and mortality associated with Stevens–Johnson syndrome/toxic epidermal necrolysis

“…For example, iron metabolism and the capability of bone marrow to produce red blood cells may be affected by proinflammatory cytokines (interferon γ and tumor necrosis factor α), leading to an elevated RDW 20 . According to recent investigations, RHR is closely associated with SJS/TEN severity and can predict SJS/TEN mortality 21 …”

“…20 According to recent investigations, RHR is closely associated with SJS/TEN severity and can predict SJS/TEN mortality. 21 Serum albumin levels and total peripheral blood lymphocytes are used to calculate PNI, a commonly used indicator of nutritional status and inflammation. PNI is currently used for evaluating the immunonutritional status of patients with cancer and is a beneficial prognostic marker in adults with a variety of malignancies.…”