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Intensive Care Medicine

, 23:1237 | Cite as

Pulmonary complications in toxic epidermal necrolysis: a prospective clinical study

  • F. Lebargy
  • P. Wolkenstein
  • M. Gisselbrecht
  • F. Lange
  • J. Fleury-Feith
  • C. Delclaux
  • E. Roupie
  • J. Revuz
  • J. C. Roujeau
Originals

Abstract

Objective: To evaluate the incidence, clinical features, and prognosis of pulmonary complications associated with toxic epidermal necrolysis

Design: Prospective study.

Setting: Dermatology intensive care unit in Mondor Hospital, France.

Patients: 41 consecutive patients.

Interventions: On admission, then daily, respiratory evaluation was based on clinical examination, chest X-ray, and arterial blood gas analysis. When clinical symptoms, X-ray abnormalities, or hypoxemia [partial pressure of oxygen (PO2)<80 mm Hg] were present, fiberoptic bronchoscopy was performed.

Results: 10 patients presented early manifestations: dyspnea (n=10), bronchial hypersecretion (n=7), marked hypoxemia (n=10) (PO2=59 ± 8 mmHg). Chest X-ray was normal (n = 8) or showed interstitial infiltrates (n=2). In these 10 patients, fiberoptic bronchoscopy demonstrated sloughing of bronchial epithelium in proximal airways. Delayed pulmonary complications occurred in 6 of these 10 patients from day 7 to day 15: pulmonary edema (n=2), atelectasis (n=1), bacterial pneumonitis (n=4). Mechanical ventilation was required in 9 patients. A fatal outcome occurred in 7 patients. Seven patients did not develop early pulmonary manifestations (PO2 on admission 87 ± 6 mm Hg) but only delayed pulmonary symptoms related to atelectasis (n=1), pulmonary edema (n=4), and bacterial pneumonitis (n=3); bronchial epithelial detachment was not observed. None of them required mechanical ventilation and all recovered with appropriate therapy.

Conclusions: “Specific” involvement of bronchial epithelium was noted in 27 % of cases and must be suspected when dyspnea, bronchial hypersecretion, normal chest X-ray, and marked hypoxemia are present during the early stages of toxic epidermal necrosis. Bronchial injury seems to indicate a poor prognosis, as mechanical ventilation was required for most of these patients and was associated with a high mortality.

Key words

Toxic epidermal necrolysis Stevens-Johnson syndrome Pulmonary complications Fiberoptic bronchoscopy Bronchial epithelial necrosis 

References

  1. 1.
    Lyell A (1956) Toxic epidermal necrolysis: an eruption resembling scalding of the skin. Br J Dermatol 68: 355–361PubMedCrossRefGoogle Scholar
  2. 2.
    Lyell A (1979) Toxic epidermal necrolysis (the scalded skin syndrome): a reappraisal. Br J Dermatol 100: 69–86PubMedCrossRefGoogle Scholar
  3. 3.
    Roujeau JC, Stern RS (1994) Severe adverse cutaneous reactions to drugs. N Engl J Med 10:1272–1284CrossRefGoogle Scholar
  4. 4.
    Guillaume JC, Roujeau JC, Revuz J, Penso D, Touraine R (1987) The culprit drugs in 87 cases of toxic epidermal necrolysis (Lyell’s syndrome) Arch Dermatol 123:1166–1170PubMedCrossRefGoogle Scholar
  5. 5.
    Roujeau JC, Chosidow O, Saiag R Guillaume JC (1990) Toxic epidermal necrolysis (Lyell syndrome). J Am Acad Dermatol 23:1039–1058PubMedCrossRefGoogle Scholar
  6. 6.
    Roujeau JC, Kelly JR Naldi L, Rzani B, Stern RS, Anderson T et al (1995) Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med 333: 1600–1607PubMedCrossRefGoogle Scholar
  7. 7.
    Fournier S, Bastuji-Garin S, Mentec H, Revuz J, Roujeau JC (1995) Toxic epidermal necrolysis associated with Mycoplasma pneumoniae infection. Eur J Clin Microbiol Infect Dis 14: 558–559PubMedCrossRefGoogle Scholar
  8. 8.
    Villada G, Roujeau JC, Cordonnier C, Bagot M, Kuentz M, Weschler J, Vernant J-P (1990) Toxic epidermal necrolysis after bone marrow transplantation: study of nine cases. J Am Acad Dermatol 23: 870–875PubMedCrossRefGoogle Scholar
  9. 9.
    Revuz J, Penso D, Roujeau JC, Guillaume JC, Payne RC, Weschler J, Touraine R (1987) Toxic epidermal necrolysis: clinical findings and prognosis factors in 87 patients. Arch Dermatol 123: 1160–1165PubMedCrossRefGoogle Scholar
  10. 10.
    Chosidow O, Delchier JC, Chaumette MT, Weschler J, Wolkenstein P, Bourgault I, Roujeau JC, Revuz J (1991) Intestinal involvement in drug induced toxic epidermal necrolysis. Lancet 337: 928PubMedCrossRefGoogle Scholar
  11. 11.
    Timsit JF, Mion G, Rouyer N, Le Gulluche Y, Carsin H (1992) Bronchopulmonary distress associated with toxic epidermal necrolysis. Intensive Care Med 18: 42–44PubMedCrossRefGoogle Scholar
  12. 12.
    Virant FS, Redding GJ, Novack AH (1984) Multiple pulmonary complications in a patient with Stevens-Johnson syndrome. Clin Pediatr 24: 412–413CrossRefGoogle Scholar
  13. 13.
    Roupe G, Ahlmen M, Fagerberg B, Suurküla M (1986) Toxic epidermal necrolysis with extensive mucosal erosions of the gastrointestinal and respiratory tracts. Int Arch Allergy Immunol 80: 145–151CrossRefGoogle Scholar
  14. 14.
    Dasgupta A, O’Malley J, Mallya R, Williams JG (1994) Bronchial obstruction due to respiratory mucosal sloughing in toxic epidermal necrolysis. Thorax 49: 935–936PubMedCrossRefGoogle Scholar
  15. 15.
    Wahle D, Beste DJ, Conley SF (1992) Laryngeal involvement in toxic epidermal necrolysis. Otolaryngol Head Neck Surg 107: 796–799PubMedGoogle Scholar
  16. 16.
    Bastuji-Garin S, Rzani B, Stern R, Shear N, Naldi L, Roujeau JC (1993) Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome and erythema multiforme. Arch Dermatol 129: 92–96PubMedCrossRefGoogle Scholar
  17. 17.
    Moore N, Biour M, Paux G et al (1985) Adverse drug reaction monitoring: doing it the French way. Lancet II: 1056–1058CrossRefGoogle Scholar
  18. 18.
    Pham LH, Brun-Buisson C, Legrand P, Rauss A, Verra F, Brochard L, Lemaire F (1991) Diagnosis of nosocomial pneumonia in mechanically ventilated patients. Comparason of a plugged telescoping catheter with the protected specimen brush. Am J Respir Crit Care Med 143: 1055–1061Google Scholar
  19. 19.
    Slutsky AS (1994) Consensus conference on mechanical ventilation. Intensive Care Med 20:150–152PubMedCrossRefGoogle Scholar
  20. 20.
    Roujeau JC, Dubertret LL, Moritz S, Touraine R (1985) Involvement of macrophages in the pathology of toxic epidermal necrosis. Br J Dermatol 113: 425–430PubMedCrossRefGoogle Scholar
  21. 21.
    Villada G, Roujeau JC, Clerici T, Bourgault I, Revuz J (1992) Immunopathology of toxic epidermal necrolysis. Arch Dermatol 128: 50–53PubMedCrossRefGoogle Scholar
  22. 22.
    Paquet P, Nikkeis A, Arrese J, Vanderkelen A, Pierard G (1994) Macrophages and tumor necrosis factor a in toxic epidermal necrolysis. Arch Dermatol 130: 605–608PubMedCrossRefGoogle Scholar
  23. 23.
    Miayauchi H, Hosokawa H, Akaeda T, Iba H, Asada Y (1991) T-cell subsets in drug-induced toxic epidermal necrolysis. Arch Dermatol 127: 851–857CrossRefGoogle Scholar
  24. 24.
    Correia O, Delgado L, Ramos JP, Re-sende C, Fleming Torrinha JA (1993) Cutaneous T-cell recruitment in toxic epidermal necrolysis. Arch Dermatol 129: 466–468PubMedCrossRefGoogle Scholar
  25. 25.
    Friedmann PS, Strickland I, Pirmohamed M, Park K (1994) Investigation of mechanisms in toxic epidermal necrolysis induced by carbamazepine. Arch Dermatol 130: 598–604PubMedCrossRefGoogle Scholar
  26. 26.
    Wolkenstein P, Carrière V, Charue D, Bastuji-Garin, Revuz J, Roujeau JC, Beaune P, Bagot MA (1995) Slow acetylator genotype is a risk factor for sulphonamide-induced toxic epidermal necrolysis and Stevens-Johnson syndrome. Pharmacogenetics 5: 255–258PubMedCrossRefGoogle Scholar
  27. 27.
    Wolkenstein P, Charue D, Laurent P, Revuz J, Roujeau JC, Bagot M (1995) Metabolic predisposition to cutaneous adverse rections. Arch Dermatol 131: 544–551PubMedCrossRefGoogle Scholar
  28. 28.
    Chosidow O, Bourgault I, Roujeau JC (1994) Drug rashes. What are the targets of cell-mediated cytotoxicity? Arch Dermatol 130: 627–629PubMedCrossRefGoogle Scholar
  29. 29.
    Revuz J, Roujeau J-C, Guillaume J-C, Penso D, Touraine R (1987) Treatment of toxic epidermal necrolysis. Arch Dermatol 123: 1156–1158PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 1997

Authors and Affiliations

  • F. Lebargy
    • 1
  • P. Wolkenstein
    • 1
  • M. Gisselbrecht
    • 1
  • F. Lange
    • 1
  • J. Fleury-Feith
    • 1
  • C. Delclaux
    • 1
  • E. Roupie
    • 1
  • J. Revuz
    • 1
  • J. C. Roujeau
    • 1
  1. 1.Höpital Henri-MondorCreteilFrance

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