Journal of Peking University(Health Sciences) ›› 2019, Vol. 51 ›› Issue (5): 977-980. doi: 10.19723/j.issn.1671-167X.2019.05.032

Previous Articles     Next Articles

Drug-induced toxic epidermal necrolysis with secondary aspergillus fumigatus infection: a case report

Si ZHANG,Xiao-yang LIU,Jian-zhong ZHANG(),Lin CAI,Cheng ZHOU()   

  1. Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
  • Received:2017-08-10 Online:2019-10-18 Published:2019-10-23
  • Contact: Jian-zhong ZHANG,Cheng ZHOU E-mail:rmzjz@126.com;rmpkzc@163.com

RICH HTML

  

Abstract:

Among the various drug induced dermatological entities toxic epidermalnecrolysis (TEN) and Stevens-Johnson syndrome (SJS) occupy a primary place in terms of mortality. Toxic epidermal necrolysis also known as Lyell’s syndrome was first described by Lyell in 1956. Drugs are by far the most common cause of toxic epidermal necrolysis, in which large sheets of skin are lost from the body surface making redundant the barrier function of the skin, with its resultant complications. Drug-induced toxic epidermal necrolysis are severe adverse cutaneous drug reactions to various precipitating agents that predominantly involve the skin and mucous membranes. Toxic epidermal necrolysis is rare but considered medical emergencies as they are potentially fatal. Drugs are the most common cause accounting for about 65%-80% of the cases. The most common offending agents are sulfonamides, NSAIDs, butazones and hydrantoins. An immune mechanism is implicated in the pathogenesis, but its nature is still unclear. There is a prodormal phase in which there is burning sensation all over the skin and conjunctivae, along with skin tenderness, fever, malaise and arthralgias. Early sites of cutaneous involvement are the presternal region of the trunk and the face, but also the palms and soles, rapidly spread to their maximum extent, the oral mucosa and conjunctiva being affected. Initial lesions are macular, followed by desquamateion, or may be from atypical targets with purpuriccenters that coalesce, from bullae, then slough. The earlier a causative agent is withdrawn the better is the prognosis. Several treatment modalities given in addition to supportive care are reported in the literature, such as systemicsteroids, high-dose intravenous immunoglobulins, ciclosporin, TNF antagonists. Recovery is slow over a period of 14-28 days and relapses are frequent. Mortality is 25%-50% and half the deaths occur due to secondary infection. Here we report a 50-year-old female of drug-induced toxic epidermal necrolysis. She was admitted to the dermatology ward with extensive peeling of skin over the trunk and limbs. She had taken alamotrigine for epilepsy. A week after taking the tablets, the patient developed a severe burning sensation all over the body and followed by a polymorphic erythematous dermatitis and widespread peeling of skin. We treated this patient with high dose corticosteroids, high-dose intravenous immunoglobulins and etanercept, but eventually she died of secondary aspergillus fumigatus infection.

Key words: Drug-induced toxic epidermal necrolysis, Aspergillus fumigatus, Infection, Respiratory failure

CLC Number: 

  • R758.25

Figure 1

The first day in the hospital (2016-12-09): skin lesion appear on the face, trunk and limbs. Initial lesions are macular, followed by desquamateion, or may from atypical targets with purpuric centers that coalesce, frombullae, then slough A, the lesion on the back; B, the lesion on the abdomen."

Figure 2

The lesion rapidly spread to their maximum extent, the oral mucosa and conjunctiva being affected (2016-12-16) A, the lesion on the back; B,the lesion on the chest and abdomen; C,the lesion on the vulva; D, the lesion on the mouth mucosa; E,the lesion on the feet; F, the lesion on the flexion of lower limbs."

Figure 3

Bronchoscopy (2017-01-03): there are multiple nodules like pebbles on the tracheobronchial mucosa,with Hyperemia and Edema. A large number of secretion attached on the bronchus"

Figure 4

Tracheobronchialmucosa tissue pathology: a large number of fungal hyphae and spores in the necrotic mucosa tissue A, HE×40; B, HE×100; C, HE×100; D, HE×400."

[1] Mazokopakis EE, Tzortzinis AA, Dalieraki-Ott EI , et al. Coexistence of Hashimoto’s thyroiditis with papillary thyroid carcinoma.a retrospective study[J]. Hormones (Athens), 2010,9(5):312-317.
[2] Pazos C, Ponton J, Del Palaeio A . Contribution of (1,3)-beta-D-glucanchromogenie assay to diagnosis and therapeutic monitoring of invasive aspergillosis in neutropenia adult patients:a comparison with serial screening for circulating galactomannan[J]. J Clin Microbiol, 2005,43:299-305.
[3] 黄晓鸥, 刘霆 . 联合检测半乳甘露聚糖和(1,3)-β- D葡聚糖诊断侵袭性曲霉菌感染的研究进展[J]. 中国呼吸与危重监护杂志, 2011,10(6):610-612.
[4] Bohme A, Ruhnke M, Buehheidt D , et al. Treatment of invasive fungal infections in cancer patients-recommendations of the infectious diseases working party (AGlHO) of the German Society of Hematology and Oncology (DGHO)[J]. Ann Hematol, 2009,88(2):97-110.
[5] Herbrecht R, Denning DW, Patterson TF , et al. Voriconazole versus amphotericin B for invasive aspergillosis.[J]. New Engl J Med, 2002,347(25):2080-2081.
[6] Paradisi A, Abeni D, Bergamo F , et al. Etanercept therapy for toxic epidermal necrolysis[J]. J Am Acad Dermatol, 2014,71(2):278-283.
[7] Espinel-Ingroff A, Cuenca-Estreila M, Fothergill A , et al. Wild-type MIC distributions and epidemiological cutoff values for amphotericin B and Aspergillus spp.for the CLSI broth microdilution method (M38-A2 document)[J]. Antimicrob Agents Chemother, 2011,55(11):5150-5154.
[8] Lockhart SR, Frade JP, Etienne KA , et al. Azole resistance in Aspergillus fumigatus isolates from the ARTEMIS global surveillance is primarily due to the TR/L98H mutation in the cyp51A gene[J]. Antimicrob Agents Chemother, 2011,55(9):4465-4468.
[9] Harr T, French LE . Toxic epidermal necrolysis and Stevens-Johnson syndrome[J]. Arch Dermatol, 2000,136(3):323-327.
[1] Li-fang WANG,Lian-jie SHI,Wu NING,Nai-shu GAO,Kuan-ting WANG. Sjögren's syndrome combined with cold agglutinin disease: A case report [J]. Journal of Peking University (Health Sciences), 2023, 55(6): 1130-1134.
[2] Jie QIAO,Li-xia LU,Yu-ting HE,Chun-cui MEN,Xin-xin CHU,Bei WU,Hui-ping ZHAO,Mei WANG. Fungal peritoneal dialysis catheter-related exit-site infection combined with tunnel infection: A case report [J]. Journal of Peking University (Health Sciences), 2023, 55(4): 748-754.
[3] Hao LIN,Jing-hua LI,Xiao YANG,Xiao-ting CHEN,Yu-hui SHI,Chun CHANG,Yuan-tao HAO,Wang-nan CAO. Discrepancy between behavioral-indicated and perceived candidacy for HIV pre-exposure prophylaxis among men who have sex with men in Chengdu, China [J]. Journal of Peking University (Health Sciences), 2023, 55(3): 511-520.
[4] Zhe WANG,Wei SUN,Xue YANG,Ying SONG,Ai-ping JI,Jie BAI. Clinical analysis of patients with oral and maxillofacial infections in oral emergency [J]. Journal of Peking University (Health Sciences), 2023, 55(3): 543-547.
[5] Yi-lin YE,Heng LIU,Li-ping PAN,Wei-bing CHAI. Periprosthetic gout flare after total knee arthroplasty: A misdiagnostic case report [J]. Journal of Peking University (Health Sciences), 2023, 55(2): 362-365.
[6] Fang CAO,Ming ZHONG,Cong-rong LIU. Uterine POLE mutant endometrioid carcinoma combined with human papilloma virus-associated cervical adenocarcinoma: A case report and literature review [J]. Journal of Peking University (Health Sciences), 2023, 55(2): 370-374.
[7] Xiao-yan XING,Jun-xiao ZHANG,Feng-yun-zhi ZHU,Yi-fan WANG,Xin-yao ZHOU,Yu-hui LI. Clinical analysis of 5 cases of dermatomyositis complicated with macrophage activation syndrome [J]. Journal of Peking University (Health Sciences), 2022, 54(6): 1214-1218.
[8] Zhi-yu KANG,Lei-lei WANG,Yong-zheng HAN,Xiang-yang GUO. Anesthesia management of athletes' operation in Beijing Olympic Winter Games [J]. Journal of Peking University (Health Sciences), 2022, 54(4): 770-773.
[9] ZHANG Pu-li,YANG Hong-xia,ZHANG Li-ning,GE Yong-peng,PENG Qing-lin,WANG Guo-chun,LU Xin. Value of serum YKL-40 in the diagnosis of anti-MDA5-positive patients with dermatomyositis complicated with severe pulmonary injury [J]. Journal of Peking University (Health Sciences), 2021, 53(6): 1055-1060.
[10] Hong MENG,Li-na JI,Jing HUANG,Shuang CHAO,Jia-wen ZHOU,Xue-jun LI,Xiao-mei YIN,Li-rong FAN. Analysis of the changes and characteristics of pediatric outpatient visits in a general hospital in Beijing before and after the COVID-19 pandemic [J]. Journal of Peking University (Health Sciences), 2021, 53(5): 952-956.
[11] DU Qiang,HONG Kai,PAN Bo-chen. Comparison of two methods for detection of Chlamydia trachomatis and Ureaplasma urealyticum in male reproductive tract [J]. Journal of Peking University (Health Sciences), 2021, 53(4): 785-788.
[12] ZHOU Bo-lin,LI Wei-shi,SUN Chui-guo,QI Qiang,CHEN Zhong-qiang,ZENG Yan. Risk factors for multiple debridements of the patients with deep incisional surgical site infection after spinal surgery [J]. Journal of Peking University (Health Sciences), 2021, 53(2): 286-292.
[13] YUAN Yuan,LANG Ning,YUAN Hui-shu. CT spectral curve in differentiating spinal tumor metastasis and infections [J]. Journal of Peking University (Health Sciences), 2021, 53(1): 183-187.
[14] Fang BAO,Wei-li SHI,Jing HU,Di ZHANG,Dong-han GAO,Yun-xia XIA,Hong-mei JING,Xiao-yan KE,Qing-gang GE,Ning SHEN. Analysis of the correlation between lymphocyte subsets and severity of corona virus disease 19 [J]. Journal of Peking University (Health Sciences), 2020, 52(6): 1075-1081.
[15] Di XU,Dong-hao WEI,Ya-chi ZHANG,Ping DI,Ye LIN. Effect of disinfectant with benzethon chloramine and isopropanol as main active ingredients on the accuracy of dental impression [J]. Journal of Peking University (Health Sciences), 2020, 52(6): 1112-1116.
Viewed
Full text


Abstract

Cited

  Shared   
  Discussed   
No Suggested Reading articles found!