|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Journal of Clinical Oncology, Vol 22, No 22 (November 15), 2004: pp. 4649-4651 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.05.003
Complications of Therapy in Cancer PatientsCASE 3. Toxic Epidermal Necrolysis Induced by Oral Phenobarbital and Whole-Brain Radiotherapy in a Breast Cancer PatientUniversity Campus Bio-Medico, Rome, Italy A 51-year-old woman with metastatic breast cancer including brain and lung metastases was admitted to our hospital because of recent appearance of bullous urticarioid lesions, severe stomatitis, and radiotherapy-induced burns along the scalp, involving the top of the ears. Forty-five days earlier, brain metastases were diagnosed and barbiturate-based therapy (oral phenobarbital 100 mg daily) for prevention of epileptic attacks was started. In addition, whole-brain radiotherapy (50 Gy) was completed 2 days before hospital admission. On physical examination, there was a generalized erythema over the whole body. Bullous lesions and some morbilliform target lesions appeared on her neck, trunk, and distal extremities. Finally, sheet-like loss of epidermis and raised flaccid blisters that spread with pressure occurred, and Nikolsky's sign (ie, dislodgment of epidermis by lateral pressure) was positive on erythematous areas. With trauma, full-thickness epidermal detachment yields exposed, red, sometimes oozing dermis (Fig 1A). Oral and genital mucosal sites had erosions and ulcerations (Fig 1B). Moreover, the patient developed keratitis and conjunctival lesions associated with intense photophobia. Clinical presentation strongly fit with toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome (SJS), and no biopsy for histologic examination was considered necessary for diagnosis. Laboratory parameters were all in the normal range at the presentation time. After admission, we discontinued all potentially responsible drugs and started intravenous fluid replacement, aseptic handling, nutrition support, and antimicrobial prophylaxis. Corticosteroids (intravenous dexamethasone 24 mg/d) associated with proton pump inhibitor (pantoprazole) were started, even though their effectiveness has never been demonstrated in controlled trials for TEN and SJS treatment. During the hospitalization, fever developed that was related to urinary infection and was later probably caused by infection of venous central catheter (which was removed). The general clinical condition slowly improved, but 30 days after admission, anxiety and confusion appeared. CBC count showed pancytopenia (anemia, 7.1 g/dL; neutropenia, 710/mL; thrombocytopenia, 23,000/mL). Supportive therapies were started, but during the night of the 33rd day, the patient died, probably in relation to gastrointestinal bleeding.
SJS and TEN are closely related severe, acute, mucocutaneous reactions that are mostly elicited by drugs. Drug-induced SJS and TEN typically begin 1 to 3 weeks after the initiation of therapy but occur more rapidly with rechallenge. More than 100 different compounds have been implicated in both syndromes; barbiturates are some of the most common among them.1 A case-control study clearly demonstrated that SJS and TEN are associated with short-term therapy with phenytoin, phenobarbital, and carbamazepine. Moreover, the authors stated that the period of increased risk is largely confined to the first 8 weeks of treatment.2 In addition, increasing anecdotal reports suggest a synergistic effect between barbiturate therapy and cranial radiotherapy that can result in the life-threatening SJS/TEN.3,4 Usually, cases with detachment of less than 10% of the epidermis are classified as SJS and those with more than 30% as TEN,5 and so we can conclude that this case presents the typical features of TEN. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES
1. Hughes-Davies L: Severe adverse cutaneous reactions to drugs. N Engl J Med 331:1272–1285, 1994 2. Rzany B, Correia O, Kelly JP, et al: Risk of Stevens-Johnson syndrome and toxic epidermal necrolysis during first weeks of antiepileptic therapy: A case-control study—Study Group of the International Case Control Study on Severe Cutaneous Adverse Reactions. Lancet 354:1033–1034, 1999 3. Duncan KO, Tigelaar RE, Bolognia JL: Stevens-Johnson syndrome limited to multiple sites of radiation therapy in a patient receiving phenobarbital. J Am Acad Dermatol 40:493–496, 1999[Medline] 4. Khafaga YM, Jamshed A, Allam AA, et al: Stevens-Johnson syndrome in patients on phenytoin and cranial radiotherapy. Acta Oncol 38:111–116, 1999[CrossRef][Medline] 5. Bastuji-Garin S, Rzany B, Stern RS, et al: Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme. Arch Dermatol 129:92–96, 1993[Abstract]
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
