Page 262 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 6 of 8 Original Research

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showed that there was no therapeutic benefit in using IVIG. our patients with TEN had tuberculosis and Pseudomonas co-
This study showed a higher mortality rate of patients infection with a positive outcome. De Prost et al. noted that BSA
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receiving IVIG than in controls and concluded that there is no involvement was the main predictor of infection. This group
role of IVIG in the setting of TEN and this should not be used identified Staphylococcus aureus, Pseudomonas and
outside of trials. 39 Enterobacteriaceae as the most commonly implicated pathogens
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leading to mortality. These were similar pathogens noted in
Recent studies have shown that a combination of our patients. Complications noted in our patients who died are
corticosteroids and IVIG arrested disease progression, unlikely to have been due to the administration of systemic
and decreased hospitalisation and mortality in patients corticosteroids and IVIG. We receive patients that may have
with SJS/TEN more than the use of corticosteroids as been at more than one health care facility prior to being
monotherapy. Jagadeesan et al. noted that combining transferred to our unit. Nosocomial infections may have been
2
systemic steroids and IVIG may have a synergistic action acquired at the referral centres prior to systemic corticosteroid
targeting the different pathways of apoptosis active in use. Infections noted in the pregnant women included herpes
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SJS/TEN. Thus, combination therapy was noted to arrest simplex, vaginal discharge and vaginal warts. Urinary tract
disease progression and there was a faster onset of re- infections are common in pregnancy and may be independent
epithelialisation with no adverse side effects. A systematic to the use of systemic corticosteroids. Cutaneous Pseudomonas
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review showed that patients who received systemic steroids and Staphylococcus aureus infection may have been owing to the
and IVIG had a favourable clinical outcome compared to immunocompromised pregnancy state and HIV infection and
patients who received supportive care alone. 40 may or may not be dependent on the use of systemic
corticosteroids. Anaemia in one patient may be due to HIV
disease, blood loss from the wounds, pregnancy and renal
Local studies oppose the use of systemic steroids and
immunoglobulins in patients with SJS/TEN. Kannenberg impairment. Drug-induced hepatitis was most likely due to
et al. conducted a study in which 78.9% of the patients were nevirapine and trimethoprim/sulfamethoxazole use as the
HIV-infected. All patients in the study received extensive liver dysfunction returned to normal once the drugs were
supportive care. There was a mortality rate of 29.8% in the stopped. Infectious hepatitis was excluded in the study
HIV-infected patients and 6.0% in the non-infected patients. population.
The prognostic indicators noted were HIV -tuberculosis co- Ocular lesions are the most common and devastating
9
infection, sepsis and BSA > 40.0%. Knight et al. implemented complications in SJS/TEN (20% – 79% of patients). Araki
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similar treatment strategies of extensive supportive care in et al. noted that steroid pulse therapy with methylprednisone
their study. Seventy-eight per cent of their cohort was at the onset of SJS/TEN is of great therapeutic importance
HIV-infected. The study concluded that the extent of BSA in preventing ocular complications. Kim et al. noted that
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involvement increases the risk of bacterial skin infections early treatment with systemic steroids and IVIG improved
and that tuberculosis co-infection and bacterial skin ocular outcomes. The aetiology of deep vein thrombosis is
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infections increase the mortality rate. This study had a multifactorial, and in one patient it may have been due to
mortality rate of 9%. 41 prolonged hospital stay, HIV infection, low CD4 cell count,
pregnancy or IVIG used. 48,49,50
Many view TEN and major burns as similar entities based
on BSA involvement, and hence the general principles of In our study, the high female-to-male ratio may be due to the
management should be the same. However, burns differ in use of nevirapine which is implicated as the cause of SJS/
13
pathophysiology, presentation, long term sequelae; hence, TEN. It was prescribed in pregnant women (who accounted
target therapy to counteract the process of apoptosis such for 44.4% of the study sample) as part of the HIV treatment
as the use of systemic corticosteroids and IVIG is indicated guidelines at the time of the study.
for SJS/TEN. The admission of patients to specialised
dermatology centres has shown good clinical outcomes, and The three drugs most implicated included nevirapine,
this is illustrated in our cohort. 18 trimethoprim/sulfamethoxazole and anti-tuberculosis
medication – mainly isoniazid and rifampicin. Risk factors for
None of the patients in this cohort had wound debridement, nevirapine-induced SJS/TEN include female gender, baseline
and this is supported by a number of studies. 1,19 Blisters CD4 counts > 250 cells/mm in women and > 400 cells/mm in
3
3
act as a natural biological dressing which favours re- men, history of drug allergy, low body weight, high nevirapine
epithelialisation. Fluid management also differs between serum levels and certain human lymphocyte antigen types. 5,51,52
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SJS/TEN and burns patients in that SJS/TEN patients require Pregnant woman in the study had a mean CD4 count of 267.2
only two-thirds to three-quarters of the fluid requirements (s.d. 60.6) cells/mm , a risk factor in keeping with nevirapine-
3
of burns patients. 43 induced SJS/TEN as noted in the literature.
Infection is the leading cause of death in patients with SJS/TEN Pregnancy was not a risk factor for developing a drug reaction
and maybe as high as 40% in tertiary centres. Knight et al. in our patient profile. This is contrary to what has been
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noted that epidermal detachment > 30% in SJS/TEN has an suggested in the literature. 5,24 Pregnancy is associated with
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increased risk of bacterial infections and mortalities. One of immune dysregulation, which may predispose a woman to
http://www.sajhivmed.org.za 255 Open Access