Page 261 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 5 of 8 Original Research

TABLE 5: Profile of the 10 patients with infection, organisms isolated and SCORTEN score.
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Drug reaction CD4 (cells/mm ) Infection Organism Comorbidity SCORTEN score Length of hospital stay (days)
TEN 268 Skin infection Pseudomonas aeruginosa (pus swab) TB 2 20
TEN 302 Pneumonia MRSA (ET tube) - 4 35
SJS/TEN 179 Genital ulcers Herpes simplex 28 weeks pregnant 2 15
SJS/TEN 226 UTI E. coli (urine sample) 29 weeks pregnant 2 9
TEN 247 Skin infection Pseudomonas aeruginosa (pus swab) 34 weeks pregnant 3 20
SJS 0 PV discharge Genital warts Candidiasis HPV 30 weeks pregnant 1 4
TEN 437 Skin infection Staphylococcus aureus (pus swab) - 2 24
SJS/TEN 10 Lower respiratory tract infection Pseudomonas aeruginosa (blood cultures) - 3 18
TEN 185 Pneumonia Staphylococcus aureus (blood cultures) 32 weeks pregnant 4 Died on day 4 post admission
SJS-TEN 237 Bartholin abscess E. coli (aspirate of abscess) 29 weeks 2 18
SJS, Stevens–Johnsons Syndrome; TEN, Toxic Epidermal Necrolysis; SJS-TEN overlap; MRSA, methicillin resistant staphylococcus aureus; ET tube, endotracheal tube; UTI, urinary tract infection;
E. coli, Escherichia coli; PV discharge, per vaginal discharge; HPV, Human papilloma virus.
Discussion HIV-associated tuberculous pericarditis demonstrated an
insignificant effect on mortality, cardiac tamponade requiring
This retrospective cohort study has shown that the use of pericardiocentesis and constrictive pericarditis. However, the
systemic corticosteroids together with IVIGs for the treatment incidence of constrictive pericarditis was significantly reduced
of SJS/TENS in HIV-infected patients resulted in a 97.2% by adjunctive corticosteroids (4.4% vs. 7.8%; p = 0.009), but
survival rate compared to the previous report, which has a this also resulted in an increase in HIV-associated malignancy
4
mortality rate of 30.0%. We observed that CD4 cell counts (Kaposi sarcoma). 36
and SCORTEN score did not impact the mortality rate in
HIV-infected patients. The rationale for the use of systemic steroids in SJS/TEN
is mainly due to anti-inflammatory and anti-apoptotic
The use of systemic corticosteroids in SJS/TEN has been an effects. 12,37 There were no adverse effects noted at 3-month
issue of debate for many years, and its use in HIV-infected follow-up of our patients. We thus contend that this dose
patients remains highly controversial as it is thought to and the duration of systemic corticosteroids is unlikely to
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cause further immunosuppression. There have been cause deleterious side effects.
case reports of HIV-infected patients being treated with
systemic steroids and IVIG with a favourable outcome. 22,23,24,25 Studies that have opposed the use of systemic corticosteroids
Systemic corticosteroids in SJS/TEN is beneficial if used are of the view that systemic corticosteroids are associated
in the acute stage, that is, within 3–4 days of the disease with a high rate of sepsis, poor wound healing, prolonged
onset and for short time periods, for less than a week. 12,26 hospital stay and a higher mortality rate. 11,33,34,38 Rasmussen
Hirahara et al. measured pro-inflammatory cytokines IFN ˠ, reported a retrospective analysis of 32 immunocompetent
TNF α, interleukin 6 and 10 before and after high-dose children with SJS, 17 of whom were treated with systemic
methylprednisone therapy. This study showed that there steroids for an unknown duration and of those treated with
27
was a significant decrease in the cytokines post therapy systemic steroids, 9 developed complications ranging from
which could contribute to the survival of these patients. severe infections, seizures, gastrointestinal bleeds, pulmonary
27
There are a number of other studies that support the use of effusion and cushingoid facies. Based on the side effects
33
systemic corticosteroids in SJS/TEN. 18,28,29,30,31 High-dose noted by Rasmussen, a prolonged use of systemic steroids
corticosteroids early in the course of the disease decrease can be inferred. In a study of 30 patients by Helebian et al.
epidermal damage, shorten the recovery period and prevent all of whom were treated in a burns unit, 15 patients
permanent sequelae. Corticosteroids have been noted to received supportive care alone while the other 15 received
32
decrease the intensity of the reaction, control the extension dexamethasone at various doses together with supportive
of necrolysis, decrease fever and discomfort and prevent care. There was a 66% mortality rate in the dexamethasone
damage to internal organs. This is supported by our group as compared to the 33% mortality rate in the supportive
1
34
findings. Kardaun et al. noted that dexamethasone therapy group alone. Helebian et al. did not stipulate the dose of
in SJS/TEN is more efficacious than long term lower dose corticosteroid or the duration of use. This may account for
therapy with a diminished risk of infection and delayed the high mortality noted. Their skin care regimen also
wound healing. 12 changed after the high mortality was noted in the group
treated with systemic steroids. The positive outcome may not
Those opposing the use of systemic steroids argue that be a result of simply omitting systemic steroids but may also
systemic steroids impair the immune system and increase the be due to a more intensive skin care regimen.
risk of infections. 33,34 However, Aberdien et al. noted that
systemic steroids are beneficial in the acute stage of infection in Studies have shown that IVIG arrests disease progression
HIV-infected patients with Pneumocystis jirovecii pneumonia, and reduces the time of skin healing. Two case reports by
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acute bacterial meningitis, tuberculous pericarditis and Tan et al. noted that IVIG administered to HIV-infected
meningitis and in patients with septic shock. A study by patients with TEN lowered morbidity and shortened the
35
22
Mayosi et al. investigating the role of oral prednisone in duration of hospital admission. In contrast, Brown et al.
http://www.sajhivmed.org.za 254 Open Access