STEVENS J. SYNDROME AND TOXIC EPIDERMAL NECROLYSIS

1. Drug-Induced Medical
Emergencies

2. • Drug-induced medical diseases can be due
to medical errors but are frequently
inevitable.
• They can affect virtually all body systems
• This talk concentrates on emergency
conditions with special highlight on skin

4. ANAPHYLAXIS
Triggers of anaphylaxis:
beta-lactam antibiotics, some NSAIDs and
opioids

5. Cardiac Complications
Bradycardia/AV blockade :
–Beta blockers, Calcium channel blockers and Digoxin
Supraventricular and ventricular tachycardia:
–Sympathomimetics and Theophylline
Cardiotoxicity :
–cancer chemotherapy

6. Respiratory
Non-cardiogenic pulmonary edema
–Opiates, Sedative-hypnotics, salicylates, Beta
blockers and Calcium-channel blockers
Bradypnea/hypoventilation
–Antidepressants, Antipsychotics and
Antiepileptics
Pulmonary Toxicity
–Nitrofurantoin

7. Hepatobiliary
Drug-induced liver injury (DILI)
• Over 1000 medications and herbal products have been
implicated
• DILI can be classified in several ways by clinical
presentation, mechanism of hepatotoxicity (predictable
or idiosyncratic) and histological finding (hepatitis,
cholestasis or steatosis)
• Withdrawal of the offending drug remains the primary
treatment for DILI.

8. Gastrointestinal
• GIT Hemorrhage
• Anti-thrombotics, NSAIDS and Steroids
• C. difficile colitis
• Antibiotics

9. RENAL
• Acute Interstitial Nephritis
• Acute Tubular Necrosis
• Drug induced thrombotic microangiopathy
(DITMA)
• Crystal nephropathy
• Acute nephrocalcinosis

10. NEUROLOGICAL
Seizures
–Sympathomimetics, Antidepressants, Salicylates,
Imipenem, Penicillins and Ciprofloxacin
Coma
–Anticholinergics, Antihistamines, Antidepressants,
SSRI, Beta blockers, Calcium channel blockers and
Benzodiazepines

11. Neuroleptic Malignant Syndrome(NMS)
– Anti-psychotics
Intracranial Hemorrhage
–Anti-thrombotics

12. METABOLIC
Hypoglycemia
– Insulin, OHG, Beta blockers and Salicylates
Hyperkalemia
– Beta blockers and Cardiac glycosides
Hypokalemia
– Diuretics, Beta-agonists and Theophylline
Rhabdomyolysis
– Corticosteroids, Sympathomimetics, Anticholinergics
and Isoniazid

13. Hematological
Myelosuppression
• Anti-thyroid, NSAIDS, antipsychotics, antibiotics
Hemolysis
– Immune: Dapson, methyldopa, NSAIDS, ribavirin
and penicillins
– Non-immune: interferon, IVIG, lead and copper

14. Drug Induced Skin
Emergencies

15. –Steven Johnson syndrome and toxic epidermal necrolysis
–Urticaria, angioedema
–Acute generalized erythematous pustulosis
–Drug reaction with eosinophilia and systemic symptoms
(DRESS)
–Leucocytoclastic vasculitis
–Warfarin-induced skin necrosis and heparin induced skin
reaction
–Staphylococcal scalded skin syndrome

16. URTICARIA AND ANGIOEDEMA

18. ACUTE GENERALIZED
ERYTHEMATOUS PUSTULOSIS
(AGEP)
Commonly occur with penicillins,
quinolones and macrolides

20. DRUG REACTION WITH EOSINOPHILIA
AND SYSTEMIC SYMPTOMS (DRESS)

22. HYPERSENSITIVITY VASCULITIS
(LEUCOCYTOCLASTIC
VASCULITIS)

24. WARFARIN INDUCED SKIN
NECROSIS

26. HEPARIN INDUCED SKIN
REACTION

27. FIXED DRUG ERUPTION
(FDE)

29. STEVENS-JOHNSON SYNDROME
& TOXIC EPIDERMAL
NECROLYSIS

30. • TEN & SJS are life-threatening syndromes with an incidence
ranging from 0.5 to 7.1 cases per million person per year.
• Percentage of skin detachment determines the
classification (10% – 30%)
• A prodromal phase of fever and sore throat precede skin
sloughing.
• Mucous membranes involvement occur in about 85% of
cases
• Additionally, epithelium of gastrointestinal and respiratory
tract may be involved.

31. IMPLICATED DRUGSHLAB1502&cyp2c19

32. Prognosis (Score TEN)
• Age > 40
• History of malignancy
• Body surface area detached > 10%
• Pulse > 120 b/min
• Urea > 10 mmol/L
• Glucose > 250 mg/dl
• Bicarb < 20 mmol/l

34. Prompt withdrawal of the
culprit drug is the cornerstone of
management

35. • Wound care: the extent of epidermal detachment should
be evaluated. Some centers may surgically debride
wounds, others may use anti-shear wound care.
• Fluid and electrolyte replacement with nutritional
assessment.
• Ocular care
• Prevention of infection: sterile handling, antiseptic
solutions
• Antibiotics are given according to cultures results.

36. Systemic steroids
Results from EuroSCAR and RegiSCAR studies done on
more than 500 patients from France and Germany DON’T
support the use of systemic steroids for the treatment of
SJS/TEN.
In addition, since steroids are associated with increased
risk of sepsis, catabolism and poor wound healing, their
use in such cases is contraindicated.

37. Intravenous immunoglobulins
Data surrounding the use of IVIG in
SJS/TEN patients are conflicting.

38. Cyclosporine
A survival benefit for patients treated with
cyclosporine (dosed at 3 – 5 mg/kg/day) was
noted in RegiSCAR cohort study, however
further studies are required to confirm its rule
in SJS/TEN.

39. Tumor necrosis factor inhibitor (Anti-TNF)
• A single infusion of 5 mg/kg of anti-TNF halted
the progression of skin detachment and
induced rapid re-epithelialization.
• Etanercept 50 mg single subcutaneous
injection has been successful in some cases.

40. Thank you