Page 258 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 8 Original Research

7,8
of trimethoprim/sulfamethoxazole. In addition, the high Participants who presented with organ failure and fulfilled
rates of tuberculosis co-infection in individuals with intensive care admission criteria were referred to the intensive
HIV leads to the use of a vast array of drugs to treat these care unit where they were co-managed with critical care
infections. This results in greater susceptibility to SJS/TEN specialists and the dermatology team.
and an associated increase in mortality. 9
Data collection and classification
Other factors that contribute to mortality included The review of patient’s clinical records during admission,
lymphopenia, neutropenia and hypernatremia, as well as weekly after discharge for the first month and then monthly
low-serum haemoglobin and hypoalbuminemia. 9,10
for the following 3 months were recorded. Demographics,
SCORTEN score, drug history, CD4 count, comorbidities and
The use of systemic corticosteroids in the treatment of complications were documented from the records.
11
SJS/TEN is controversial. Systemic steroids in the setting of
SJS/TEN has immune-modulating anti-apoptotic effects SCORTEN (SCORe of toxic epidermal necrosis) is a score
which downregulate Fas-Fas L binding. This results in used to assess severity and predict mortality in patients
12
anti-inflammatory properties which inhibit interleukin 2, with SJS/TEN. It uses seven criteria (Table 1). One point is
tumour necrosis factor (TNF) α and interferon (IFN)γ, and given to each criterion, and this correlates with a predicted
immunosuppressant properties which inhibit T cells. 12,13 mortality rate. 10
Intravenous immunoglobulins (IVIGs) contain anti-Fas
antibodies that block the Fas-Fas L interactions on the Criteria used to determine drug causality were timing of the
keratinocyte and thus prevent apoptosis that results in skin lesions after the administration of the drugs (temporality),
14
epidermal detachment. Studies have shown that IVIG increase of drug dose, previous history of drug reactions and
arrests disease progression and reduces time to skin if the drug reaction occurred when the drug was restarted,
21
healing. 14,15,16 By combining systemic corticosteroids and criteria noted in the Naranjo scale. Score of > 9 = definite
IVIG, the inflammatory cascade and the undesirable ADR (adverse drug reaction), 5–8 = probable ADR, 1–4 =
adverse effects are prevented. Systemic corticosteroids and possible ADR, 0 = doubtful ADR.
IVIG abort the inflammatory cascade in SJS/TEN and,
hence, the deleterious effects that ensue. Therefore, this Treatment plan
retrospective cohort study assessed the outcomes of intensive The standard-of-care protocols included identifying and
supportive care combined with systemic corticosteroids and eliminating the possible causative drug, initiating oral
IVIG for 3 consecutive days in HIV-infected patients with prednisone (1 mg/kg/day) on admission for 3 consecutive
TEN. In addition, we assessed the outcome of managing days, and adding IVIG (1 g/kg) for 3 consecutive days to
these patients in a general dermatology ward without participants with TEN (n = 12).
implementing wound debridement. Some centres treat SJS/
TEN as a partial thickness burn as the clinical presentation Biochemical assessments on admission included a full blood
17
is similar to a burn wound, although it is an immune- count, glucose level, and renal and liver function tests.
mediated hypersensitivity reaction. However, SJS/TEN Vital signs were registered every 4 h, and plasma glucose
should not be managed strictly as a burn but rather in a was monitored every 12 h. A screen for sepsis was done
specialised dermatology ward without debridement. 1,18,19 We when clinically indicated. Fluid depletion and electrolyte
believe the treatment of SJS/TEN should differ from that of abnormalities were corrected, nutritional support was guided
burn treatment because of the different aetiology and by the dietician and pain management was optimised. Oral
pathophysiological mechanism. 1,20 mucosal care included glycothymol irrigation every 6 h,
removal of haemorrhagic crusting and the application of a
Methods mixture of prednisolone, remicaine, nystatin and sucralfate
(8:8:8:1 formulation) to the lips and oral mucosa. Genital
The study was undertaken at the Greys Hospital Department mucosa was treated with daily potassium permanganate sitz
of Dermatology, a tertiary referral centre in Pietermaritzburg, baths and lubricated with petroleum jelly (Vaseline ®) to
KwaZulu-Natal, South Africa. It is a 530-bed tertiary
hospital, serving 3.5 million people in the western part of TABLE 1: SCORTEN score.
KwaZulu-Natal. SCORTEN score Mortality rate (%) Criteria
1 3.2 Age > 40 years
Study population 2 3 12.1 Heart rate > 120 bpm
BSA > 10%
35.8
The clinical records of all 39 participants with SJS/TEN 4 58.3 Serum urea > 10 mmol/L
admitted to a general dermatology ward from 01 January ≥ 5 90.0 Serum bicarbonate < 20 mmol/L
2010 until July 2011 were retrospectively reviewed. Three - - - - Serum glucose > 14 mmol/L
Cancer or haematological malignancies
patients were HIV-negative and were thus excluded from the Source: Bastuji-Garin et al. 10
study. All participants were of black African descent. BSA, body surface area; bpm, beats per minute.

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