Treatment of toxic epidermal necrolysis by a multidisciplinary team. A review of literature and treatment results

Papp, Anthony; Sikora, Sheena; Evans, Morgan; Song, Diana; Kirchhof, Mark G.; Miliszewski, Monica A.; Dutz, Jan P.

doi:10.1016/j.burns.2017.10.022

Cited by 41 publications

(30 citation statements)

References 29 publications

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“…[6][7][8]15,41 It has been discussed whether sex should have an influence on prognosis. Some studies suggested a higher mortality risk for either males 42,43 or females, 15 considered as an independent prognostic factor. In the corresponding univariate analysis (described in the Appendix S1, Supporting information, section 7), the percentage of male patients showed a significant correlation with a decrease in the O/E ratio, although this result must be interpreted carefully since we can incur an ecological fallacy, 44 which refers to the possibility of making erroneous inferences when individual characteristics (such as sex and age) are summarized for a group of patients.…”

Section: Discussionmentioning

confidence: 99%

“…Regarding the possibility of adding other parameters, impaired renal function could be largely discussed. 43,51,54 Theoretically, this parameter is reflected indirectly in blood urea nitrogen and bicarbonate serum, but many studies have disagreed on this point. 6,7,9,10,12,14 In addition, it has been demonstrated that the cytokines involved in SJS/TEN have intrinsic nephrotoxic properties.…”

Section: Discussionmentioning

confidence: 99%

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Accuracy of SCORTEN to predict the prognosis of Stevens‐Johnson syndrome/toxic epidermal necrolysis: a systematic review and meta‐analysis

Torres‐Navarro

Briz‐Redón

Botella‐Estrada

2020

Acad Dermatol Venereol

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Background The SCORTEN score is a specific predictor of the probability of death for patients diagnosed with Stevens‐Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). Objectives To evaluate the overall accuracy of SCORTEN and the influence of several moderators such as age, sex, geographical region and age of the study. Methods A systematic search was performed on MEDLINE, The Cochrane Library, EMBASE, SCOPUS and Web of Knowledge, with no restriction on language (last update 5 February 2019 for all databases). Original studies on the use of SCORTEN were eligible. The standardized mortality ratio (SMR), defined as the quotient between the number of deaths observed and the number expected following SCORTEN, was taken as the measurement of analysis. Results Sixty‐four papers were part of the main meta‐analysis carried out in the study. A pooled log(SMR) of −0.0889 (95% CI: −0.2023 to 0.0245) was obtained, suggesting a reasonable behaviour of SCORTEN as a predictor of mortality. The possible influence of several factors in the accuracy of SCORTEN was studied by means of meta‐regression models. Multivariate meta‐regression allowed finding that the mean age of the patients and the ending year of the study are the only factors that significantly influence SCORTEN predictions. The mean age of the group of patients was associated with a significant increase in the observed/expected ratio, whereas a progressive reduction in the observed/expected ratio can be appreciated over the years. Finally, an underestimation of mortality was found for SCORTEN values of 3 or less and the opposite for those above 3 (SCORTEN range: 0–7). Conclusions The rarity of the disease and the heterogeneity of the studies included are major limitations. Despite the overall remarkable accuracy displayed by SCORTEN, the influence of several factors, as comorbidities (e.g. renal impairment), involved body surface area and patient's age, seem of enough relevance to consider a redefinition of the scale.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Accuracy of SCORTEN to predict the prognosis of Stevens‐Johnson syndrome/toxic epidermal necrolysis: a systematic review and meta‐analysis

Torres‐Navarro

Briz‐Redón

Botella‐Estrada

2020

Acad Dermatol Venereol

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“…Another salient aspect of the case is the favorable evolution of the patient given that this type of SCAR is typically associated with a bad prognosis [35][36][37], even more so because the patient displayed all the negative typical prognostic factors also for COVID-19 [38][39][40][41], indeed the calculation of the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) in our patient led to an estimated mortality rate of 58.3% (CI 36,6 -77,59) ( Table 2) [42,43].…”

Section: Discussionmentioning

confidence: 99%

A case report of toxic epidermal necrolysis (TEN) in a patient with COVID-19 treated with hydroxychloroquine: are these two partners in crime?

et al. 2020

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Background Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is the most Serious Cutaneous Adverse Reaction (SCAR) often with a fatal outcome. Coronavirus Disease (COVID-19) is caused by Severe Acute Respiratory Syndrome–Coronavirus—2 (SARS-COV2) and is an emergent pandemic for which no cure exist at the moment. Several drugs have been tried often with scant clinical evidence and safety. Case presentation Here we report the case of 78-years-old woman with cardiometabolic syndrome and COVID-19. A multidrug regimen including others hydroxychloroquine, antibiotics, dexamethasone and paracetamol, low-molecular-weight-heparin and potassium canrenoate was started. After almost 3 weeks, the patient started to display a violaceous rash initially involving the flexural folds atypical targetoid lesions and showing a very fast extension, blister formation and skin detachments of approximately 70% of the total body surface area and mucous membranes involvement consistent with toxic epidermal necrolysis (TEN). The ALDEN algorithm was calculated inserting all drugs given to the patient in the 28 days preceding the onset of the skin manifestations. The highest score retrieved was for hydroxychloroquine. Other less suspicious drugs were piperacillin/tazobactam, ceftriaxone and levofloxacin. Conclusions To our knowledge, this is the first case of TEN in a patient suffering from COVID-19 probably associated with hydroxychloroquine. Given the activation of the immune system syndrome induced by the virus and the widespread off-label use of this drug, we suggest a careful monitoring of skin and mucous membranes in all COVID-19 positive patients treated with hydroxychloroquine in order to early detect early signs of toxicities.

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“…Assessing the involvement of four limbs and greater than 20% of the skin could play an important role for diagnostic criteria. Burn center management provides multidisciplinary staff trained to utilize resources for burn and non-burn skin wounds to improve patient outcomes [88]. The most common surgeries performed were amputations, with BKAs being the most common procedure.…”

Section: Discussionmentioning

confidence: 99%

Surgical outcomes in adults with purpura fulminans: a systematic review and patient-level meta-synthesis

et al. 2019

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Background Cutaneous manifestations of purpura fulminans (PF) present many challenges for clinicians and surgeons. In a state of septic shock complicated by limb ischemia, surgical interventions are necessary to control the pathological cascade and improve patient outcomes. The objective of this article was to report etiologies and surgical outcomes associated with cutaneous manifestations in adults. Methods This systematic review and meta-analysis compared 190 adult patients with etiologies, signs and symptoms, and surgical outcomes associated with cutaneous manifestations of PF. The PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched. Patient and clinical characteristics, surgical interventions, outcomes, and complications were recorded. Results Seventy-nine studies were eligible for the systematic review, and 77 were eligible for meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and Cochrane guidelines. A total of 71/190 (38%) cases reported surgical debridement. Fasciotomies were reported in 12/190 (6%) cases and 20 procedures. Amputations were reported in 154/190 (81%) cases. Reconstruction was reported in 45 cases. Skin grafts were applied in 31 cases. Flaps were used for reconstruction in 28 cases. Median (IQR) surgical procedures per patient were 4 (4, 5) procedures. Infectious organisms causing PF were 32% Neisseria meningitidis (n = 55) and 32% Streptococcus pneumonia (n = 55). Coagulase-negative Staphylococcus (95% confidence interval (CI)(8.2–177.9), p = 0.032), Haemophilus influenza (95%CI (7.2–133), p = 0.029), Streptococcus pneumonia (95% CI (13.3–75.9), p = 0.006), and West Nile Virus (95%CI (8.2–177.9), p = 0.032) were associated with significantly more extensive amputations compared to other organisms. Conclusion This systematic review and patient-level meta-analysis found the most common presentation of PF was septic shock from an infectious organism. Neisseria meningitidis and Streptococcus pneumonia were equally the most common organisms associated with PF. The majority of cases were not treated in a burn center. The most common surgeries were amputations, with below-the-knee-amputations being the most common procedure. Skin grafting was the most commonly performed reconstructive procedure. The most common complications were secondary infections. Organisms with significantly more extensive amputations were coagulase-negative Staphylococcus, Haemophilus influenza, Streptococcus pneumonia, and West Nile Virus. Interpretation of findings should be cautioned due to limited sample data.

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Treatment of toxic epidermal necrolysis by a multidisciplinary team. A review of literature and treatment results

Cited by 41 publications

References 29 publications

Accuracy of SCORTEN to predict the prognosis of Stevens‐Johnson syndrome/toxic epidermal necrolysis: a systematic review and meta‐analysis

Accuracy of SCORTEN to predict the prognosis of Stevens‐Johnson syndrome/toxic epidermal necrolysis: a systematic review and meta‐analysis

A case report of toxic epidermal necrolysis (TEN) in a patient with COVID-19 treated with hydroxychloroquine: are these two partners in crime?

Surgical outcomes in adults with purpura fulminans: a systematic review and patient-level meta-synthesis

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