Toxic Epidermal Necrolysis Induced: CASE REPORT
Case 1
A 45-year-old Korean man, who had alcoholic liver cirrhosis, suddenly developed blurred vision accompanied by a headache. After emergency ophthalmic surgery, topical brinzolamide was applied to his eyes to control post-operative intraocular pressure resulting from pre-existing glaucoma. Two weeks later, after applying brinzolamide 3 times a day, the patient reported pruritic erythematous to violaceous targetoid papules with erosions on the oral and genital mucosa. The patient complained of intermittent high fever (> 38oC). Erythematous patches developed on the face, palms and soles in the early stage, and then extended to other skin surface areas. Three days later, skin detachment developed over approximately 50% of his body surface area (Fig. 1A, B). Laboratory studies revealed an elevated LDH level (743 U/L; normal value 218~472 U/L) without any other significant changes. The blood cell count, rapid phase reactants, liver function tests, renal function tests and electrolytes were within normal limits in the early stage of the illness. He was initially treated with oral prednisolone at 45 mg per day, but epidermal detachment progressed to over 80% of his body. Intravenous immunoglobulin (IVIG) of 10 g was introduced, but a persistent high fever > 38.5oC and neutropenia prohibited continuation of IVIG therapy. The skin lesions improved with re-epithe- lialization, although his general condition deteriorated. The patient developed acute renal failure due to excessive water and albumin loss from the body surface. The patient died from sepsis on the 20th day after the initial skin lesion developed.
Fig. 1. (A) Variable sized scattered vesicles on erythematous patches seen over the entire body of patient 1. (B) Vesicles and erythematous patches became dusky, red-colored confluent patches with Nikolsky sign. Widespread necrolytic skin detachment finally developed after 7 days of disease progression. (C) Dusky, red-colored confluent patches on the face and neck. Note the flaccid bullae caused by necrolytic epidermis on the auricle of patient 2.
Case 2
A 45-year old Korean man, who had chronic hepatitis B, developed oral ulcers and generalized purpuric targetoid papules. For the previous 2 weeks, he had been applying dorzolamide for the treatment of early open-angle glaucoma. Physical examination revealed intermittent fever, tense palmar and plantar bullae with erythematous targetoid papules (Fig. 1C). Mucosal erosions were observed in his oral cavity, conjunctiva, urethral orifice and perianal area. During the early course of the disease, laboratory studies revealed elevated levels of LDH (818 U/L, normal level; 218-472 U/L) and CRP (17.3 mg/dl, normal level; 0.1-1 mg/dl) and abnormal liver function tests (AST 42 U/L, ALT 56 U/L). Three days later, the scattered targetoid papules became very large, confluent patches and epidermal detachment developed over nearly 90% of the body surface area. The patient was treated with IVIG 80 mg/day for 4 days from the early stage of the disease, but he became hypovolemic and hyponatremic due to the denuded skin. The patient was admitted to the intensive care unit (ICU) and received ventilator therapy due to renal failure and pulmonary edema. His condition gradually improved after starting ICU care and the skin was in the process of re-epithelialization. He was discharged after 46 days of the hospital course.
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