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PubMed1993

Patch testing in cutaneous reactions caused by carbamazepine.

The usefulness of patch testing in the diagnosis of carbamazepine-induced allergic skin eruptions was studied in 18 patients with previous histories of skin eruptions caused by carbamazepine. The etiological role of carbamazepine was ascertained by peroral or topical provocation in 15 (out of 18) patients. The clinical reactions caused by the drug were classified as maculopapular exanthema with general symptoms (7 patients), other type of exanthema (3), exfoliative dermatitis (erythroderma) (3), fixed drug eruption (3), erythema multiforme (1) and urticaria (1). Patch testing showed positive reactions to carbamazepine in 7 patients; in addition, 2 patients had doubtful reactions. Positive patch test reactions were seen only in patients with exfoliative dermatitis (all 3 patients) and maculopapular exanthema (4 out of 7). None of the patients with fixed drug eruption, erythema multiforme or urticaria, or the control subjects, had positive patch test reactions to carbamazepine. The present study suggests that patch testing is useful in the diagnosis of carbamazepine allergy in patients with maculopapular eruptions or erythrodermas.

Adolescent↗
PubMed1999

Allergic skin reactions to anticonvulsant medications in patients receiving cranial radiation therapy.

PURPOSE: Erythema multiforme and Stevens-Johnson syndrome have been associated with anticonvulsant medications (AEDs) in patients with brain tumors receiving cranial irradiation. AEDs are also known to cause mild drug rashes. The incidence of these complications has not been well studied among patients with brain tumors. We reviewed the records of patients with brain tumors treated with cranial radiation and AEDs to assess the frequency of both severe and mild skin reactions. METHODS: Retrospective review of 289 radiotherapy records of consecutively treated patients from 1988 to 1993. RESULTS: Only one of 289 patients developed erythema multiforme. Milder rashes, however, occurred in 18% of exposures to AEDs including 22% of exposures to phenytoin, compared with the expected rate of 5-10%. Most of the mild drug rashes occurred before the initiation of radiotherapy, suggesting that radiation was not the cause of these reactions. CONCLUSIONS: Severe skin rashes are rare among patients with brain tumors receiving radiation therapy and AEDs. There is, however, an increased frequency of mild drug rashes among patients with brain tumors that does not appear related to radiation.

Adolescent↗
PubMed1994

The spectrum of Stevens-Johnson syndrome and toxic epidermal necrolysis: a clinical classification.

The nosology of severe bullous erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN) remains controversial. To conduct a prospective case-control study of the etiologic factors of these diseases, we needed to define criteria for classifying the cases. After having reviewed photographs of the skin lesions of more than 200 patients, an international group of dermatologists proposed a classification based on the pattern of "EM-like lesions" (categorized as typical targets, raised or flat atypical targets, and purpuric macules) and on the extent of epidermal detachment. The "consensus" classification in five categories was as follows: bullous erythema multiforme, detachment below 10% of the body surface area (BSA) plus localized typical targets or raised atypical targets; SJS, detachment below 10% of the BSA plus widespread erythematous or purpuric macules or flat atypical targets; overlap SJSTEN, detachment between 10% and 30% of the BSA plus widespread purpuric macules or flat atypical targets; TEN with spots, detachment above 30% of the BSA plus wide-spread purpuric macules or flat atypical targets; TEN without spots, detachment above 10% of the BSA with large epidermal sheets and without any purpuric macules or target. Whether all five categories proposed represent distinct etiopathologic entities will require further epidemiologic and laboratory investigations.

Diagnosis, Differential↗
PubMed1975

[Reactional status of leprosy].

Reactional leprosy is studied according to its clinical forms A) Lepromatous a) Acute lepromatization: encroaching and invasive nature; the patient becomes more and more lepromatous ; bad prognosis. b) Erythema nodosum: "contusiform dermatitis"; variable prognosis not so bad as it is in the preceding case; allergic nature and its evolution is usually detained and therapeutics efficient. c) Erythema multiform. d) Lucio's phenomenon: vascular lesions and consequently necrosis as a complication of the "erythema necrotisans" (beautiful leprosy). B) Tuberculoid Reactional tuberculoid is the only one in this benign type, the Mitsuda's test must always be positive and prognosis consequently good. C) Dimorphous or "Borderline" whose Mitsuda's test is mostly negative, sometimes positive, but not stable. The lesions may stimulate the tuberculoid leprids but they invade mucous membranes, are impregnated by pigmentation, may present the Unna's band, and other characteristics of the Lepromatous type. Are associated (fever, asthenia and emaciation). Prognosis not very good, because of the possibility of lepromatization, according to its tendency. Evolution slower and frequent relapses. Besides there are nodular lesions. Pathogeny 1) Perifocal allergic reaction (Jadassohn). Similar to epituberculosis and Herxheimer reaction. 2) Septicemia. Sensitized tissues inside or outside the lesions, are invaded by the bacilli and so the allergic reaction takes place. Even without culture resources, Mycobacterium leprae has been found in the blood by direct examination. 3) Autoimmunization (Waldenstrom, Matthews and Trantman, 1965). Based upon the similarity between both humoral syndromes, in leprosy reactions and collagenous, diseases, as to: hypergammaglobulins, hypercryoproteins, antigammaglobulins, serological reactions (Wassermann, Kahn, Kline, VDRL) positives, Antistreptolysin O, protein C reactive, antinuclear factors, latex and Wadler-Rose test positives (rheumatoid tests) lowering of complement. If leprosy reaction is like this, it should be the less agressive of the autoimmune diseases. a) Its eruptions are cyclic not of long standing duration, as a general rule. b) Its prognosis has been recognized as good, except lately, because of the use of corticoid therapy which has been fatal, in many cases. After some years the leprosy reaction cures spontaneously. Treatment (see article)

Erythema Multiforme↗
PubMed2004

Stevens-Johnson syndrome after immunization with smallpox, anthrax, and tetanus vaccines.

A 19-year-old male military recruit developed erythema multiforme 20 days after receiving a triad of vaccinations: smallpox (vaccinia virus), anthrax, and tetanus. Over the course of a few days, the erythema multiforme evolved into Stevens-Johnson syndrome, associated with widespread bullae, stomatitis, conjunctivitis, and fever. After 7 days of conservative management, the patient's signs and symptoms improved. This case serves as a timely reminder of a severe and potentially life-threatening complication of smallpox vaccination.

Adult↗
PubMedDate not supplied

Clinical features and management of severe dermatological reactions to drugs.

Cutaneous adverse drug reactions are a frequent occurrence and have been reported in more than 2% of hospitalised patients. Among the most commonly involved drugs are sulphonamides, penicillins, anticonvulsants and non-steroidal anti-inflammatory drugs. Two groups of mechanisms are involved in the pathogenesis of drug reactions: immunological, with all 4 types of hypersensitivity reactions described; and non-immunological, accounting for at least 75% of all drug reactions. Besides minor skin reactions like urticaria, maculopapular rash, fixed eruptions or erythema nodosum, which are generally self-limited, severe life-threatening manifestations also occur. Erythema multiforme is secondary to drugs in half the cases; the minor form is characterised by typical target and iris lesions and is usually benign. However, a much more severe condition, erythema multiforme major or Stevens-Johnson syndrome, is associated with mucosal, ocular and visceral involvement, and carries a mortality of 5 to 15% if untreated. Toxic epidermal necrolysis, which could represent an even more dramatic form of the same disease, is characterised by severe widespread erythema, blisters and loss of skin in sheets, with denudation of more than 10% of the body surface area. This entity is frequently due to drugs. Mortality is 25 to 70%, and 90% of the survivors will have sequelae. Exfoliative dermatitis is an erythematous scaling disease often produced by drugs and carrying significant mortality. Photodermatitis may at times present with severe eczematous features. For clinical and epidemiological reasons it is important to try to identify the culprit drug following an approach based on previous experience with the drug, timing of events, patient reaction to dechallenge, patient reaction to rechallenge (if feasible), alternative aetiological candidates, and drug concentration or evidence of overdose. Management of severe skin reactions to drugs should require admission to a burn unit, where patients should be placed in warmed air-fluidised beds, receive excellent nursing care, analgesics and tranquillisers. Peeling necrotic epidermis should be removed and denuded dermis covered with biological grafts or synthetic dressings. Fluid balance must be adequately maintained; nutritional support and careful monitoring of early signs of skin infections is mandatory to ensure immediate antimicrobial treatment. Ocular care must be excellent to avoid serious sight-threatening sequelae. Steroids are presently not recommended. With these therapeutic modalities, morbidity and mortality can be markedly decreased.

Drug Eruptions↗
PubMed1985

Stevens-Johnson syndrome due to Mycoplasma pneumoniae in an adult.

A case of Stevens-Johnson Syndrome (erythema multiforme major) due to Mycoplasma pneumoniae infection in a 45-year-old man is presented. This association has been previously reported only in children and young adults. A brief review of erythema multiforme, including the Stevens-Johnson syndrome, is described. M. pneumoniae should be added to the list of causes of the Stevens-Johnson syndrome in adults with pneumonia.

Humans↗
PubMed2002

Stevens-Johnson syndrome: case presentation.

Erythema Multiforme (EM) is a rare mucocutaneous disease with a variety of clinical manifestations. EM it was recognized in the early 1800's, and still the etiology is unknown. It has been recently suggested erythema multiforme (EM) major and Stevens-Johnson Syndrome (SJS) could be separated as two distinct clinical disorders with similar mucosal erosions, but different patterns of cutaneous lesions. In particular SJS should be used for a syndrome characterized by mucous membrane erosions and widespread small blisters that appear on erythematous or purpuric maculae, which are different from classic targets. In SJS mouth, eyes, skin, genitalia and occasionally the esophagus and respiratory track may be affected. Oral lesions may cause severe pain and usually lips may become encrusted. Concerning ocular involvement, if there is conjunctivitis or uveitis this may lead to scarring and blindness. Also, the course of disease and the prognosis are in most cases severe.

Anti-Bacterial Agents↗
PubMedDate not supplied

Stevens-Johnson syndrome in an HIV-infected patient.

Stevens-Johnson syndrome (SJS) is a severe and sometimes lethal form of erythema multiforme most often associated with a drug hypersensitivity reaction. HIV-infected patients suffer a higher incidence of SJS than the general population. This article details a case of nevirapine-induced SJS in an HIV-seropositive man and reviews the clinical features of erythema multiforme, SJS, and their association with drugs commonly used in the treatment of HIV infection.

Adult↗
PubMed1977

Acid alpha-naphthyl acetate esterase staining of T lymphocytes in human skin.

T lymphocytes were stained in order to disclose alpha-naphthyl acetate esterase activity (ANAE staining) by adopting the method described by Mueller et al. In ANAE-staining of frozen sections from human lymph nodes, more than 90% of the lymphocytes in paracortical areas (T cell areas) were ANAE-positive, but in cortical follicles (B cell areas) less than 5% of the cells were positive. Lymphocytic infiltrations in various dermatoses (lichen ruber planus, psoriasis, SLE, atropic dermatitis, erythema multiforme, poikiloderma atrophicans vasculare, and Sézary syndrome) were investigated. A high percentage of ANAE-positive lymphoid cells (greater than 80%) was found in most cases. One patient with chron. lymphatic leukaemia, however, had a smaller proportion of ANAE-positive lymphocytic cells in an erythema multiforme skin infiltrate. ANAE staining seems to be an easy method for the identification of T lymphocytes in skin sections. The results of this investigation support the hypothesis that T lymphocytes have an affinity to skin.

Esterases↗
PubMed2006

The role of intradermal skin testing and patch testing in the diagnosis of autoimmune progesterone dermatitis.

Autoimmune progesterone dermatitis is a rare clinical condition in which patients display hypersensitivity to endogenous progesterone. It manifests as a cyclical cutaneous eruption that flares during the luteal phase of the menstrual cycle, when progesterone levels peak, and resolves partially or completely a few days after menses. Its cutaneous manifestations are variable and include urticaria, eczematous eruptions, vesiculopustular eruptions, fixed drug eruptions, stomatitis, erythema multiforme, and anaphylaxis. Autoimmune progesterone dermatitis has been diagnosed previously with intradermal skin testing or intramuscular progesterone challenge. Treatment of progesterone hypersensitivity generally consists of ovulation inhibition with pharmaceutical agents or oophorectomy; other therapies (eg, thalidomide) have also been used with success. We report a case of cyclical erythema multiforme (EM) induced by hypersensitivity to endogenous progesterone in a patient with a history of past oral contraceptive use. After herpes simplex virus was ruled out as an etiologic factor, a diagnosis of progesterone hypersensitivity was confirmed with intradermal skin testing. Results of subsequent patch testing with various progesterone derivatives were negative. The EM outbreaks were suppressed temporarily by continuous administration of Loestrin (ethinyl estradiol plus norethindrone), which also increased the responsiveness of the outbreaks to prednisone tapers.

Adult↗
PubMed1981

Reactive arthritis associated with Yersinia enterocolitica gastroenteritis.

Reactive arthritis associated with Yersinia enterocolitis in adults has not been reported in this country. We are reporting a 26-year old female with a polyarticular arthritis, primarily of the large joints following an episode of diarrhea. She was also observed to have erythema nodosum and erythema multiforme. Yersinia enterocolitica grew in abundance in stool culture. The clinical picture is consistent with the reactive arthritis associated with Yersinia enterocolitis.

Adult↗
PubMed2005

Folliculitis after smallpox vaccination: a report of two cases.

Rashes are frequent and potentially serious adverse consequences of smallpox vaccination. Life-threatening rashes must be differentiated from benign, self-limiting ones. Generalized vaccinia, erythema multiforme, and folliculitis are distinct self-limiting entities but may be difficult to differentiate from one another. Two cases of folliculitis after smallpox vaccination are described. Both patients received anthrax vaccination within 2 weeks before smallpox vaccination. Both presented with a papulopustular rash 9 days after smallpox vaccination. Although the rashes were initially diagnosed as erythema multiforme, the clinical features were more consistent with folliculitis. Self-limiting rashes after smallpox vaccination are common and may be difficult to distinguish from each other. These rashes are clinically distinct, with characteristic features. Improvement in diagnosis may help classify the frequency and risk of rashes after smallpox vaccination. The association of vaccine-associated folliculitis, anthrax vaccine, and other potential antigenic triggers should be further explored.

Adult↗
PubMed1993

Natural history, management and complications of herpes labialis.

Infection with herpes simplex virus (HSV) is a common worldwide problem. Primary infection with HSV-1 rarely causes significant problems although widespread involvement in atopic eczema can be life-threatening as may associated encephalitis. Keratoconjunctivitis, pharyngitis and hepatitis can also complicate primary infection. Twenty to 40% of the population at some stage have recurrent orolabial infections with HSV although in only 1% of these cases is this recurrence severe. Recurrent erythema multiforme appears to be associated with HSV-65% of patients are thought to have preceding herpes labialis. Many primary and recurrent infections with HSV-1 require little more than topical antiseptic therapy to control secondary infection. Systemic acyclovir, however, is indicated in various situations including complicated primary infection, infection in neonates, eczema herpeticum, HSV infections in the immunocompromised, and recurrent erythema multiforme. In the latter, prophylactic treatment with 6 months acyclovir appears to be effective.

Acyclovir↗
PubMed1989

Allergic cutaneous reactions to drugs.

Because the pathophysiology of many drug eruptions is unknown, the presumption that a drug eruption is due to immune mechanisms is often based on clinical features. The drug exanthem, urticaria, and contact dermatitis are the most common adverse cutaneous reactions to medications. Drug exanthems occur in 2 to 3 per cent of medical inpatients and are most commonly caused by antibiotics and blood products. The incidence of drug exanthems is much higher in certain patient populations (for example, patients with AIDS treated with trimethoprim-sulfamethoxazole). Urticaria is the second most common allergic cutaneous reaction to drugs. Individual urticarial lesions last for less than 24 hours and do not leave hyperpigmentation or scarring. Urticaria not accompanied by systemic symptoms should not be treated with systemic corticosteroids or parenteral epinephrine. Allergic contact dermatitis is commonly caused by neomycin, benzocaine, ethylenediamine, diphenhydramine, and transdermal patches. The clinical spectrum of other, less common drug eruptions is wide. Toxic epidermal necrolysis, erythema multiforme, and fixed drug eruptions share similar pathologic features, are caused by many of the same drugs, and may have a similar pathogenesis. Photoallergic drug reactions require the interaction of drugs, UV irradiation, and the immune system. Drugs implicated in causing photoallergy include thiazide diuretics, sulfonamides, and phenothiazines. Eruptions seen in serum sickness include the drug exanthem, urticaria, vasculitis, urticarial vasculitis, and erythema multiforme. Identifying and discontinuing the responsible drug is usually essential for successful therapy of drug eruptions.

Drug Eruptions↗