Skip to main content
NCBI home page
Springer Nature - PMC COVID-19 Collection logoLink to Springer Nature - PMC COVID-19 Collection
. 1997;23(12):1237. doi: 10.1007/s001340050492

Pulmonary complications in toxic epidermal necrolysis: a prospective clinical study

F Lebargy 1, P Wolkenstein 1,✉, M Gisselbrecht 1, F Lange 1, J Fleury-Feith 1, C Delclaux 1, E Roupie 1, J Revuz 1, J C Roujeau 1
PMCID: PMC7095164  PMID: 9470079

Abstract

Objective: To evaluate the incidence, clinical features, and prognosis of pulmonary complications associated with toxic epidermal necrolysis

Design: Prospective study.

Setting: Dermatology intensive care unit in Mondor Hospital, France.

Patients: 41 consecutive patients.

Interventions: On admission, then daily, respiratory evaluation was based on clinical examination, chest X-ray, and arterial blood gas analysis. When clinical symptoms, X-ray abnormalities, or hypoxemia [partial pressure of oxygen (PO2)<80 mm Hg] were present, fiberoptic bronchoscopy was performed.

Results: 10 patients presented early manifestations: dyspnea (n=10), bronchial hypersecretion (n=7), marked hypoxemia (n=10) (PO2=59 ± 8 mmHg). Chest X-ray was normal (n = 8) or showed interstitial infiltrates (n=2). In these 10 patients, fiberoptic bronchoscopy demonstrated sloughing of bronchial epithelium in proximal airways. Delayed pulmonary complications occurred in 6 of these 10 patients from day 7 to day 15: pulmonary edema (n=2), atelectasis (n=1), bacterial pneumonitis (n=4). Mechanical ventilation was required in 9 patients. A fatal outcome occurred in 7 patients. Seven patients did not develop early pulmonary manifestations (PO2 on admission 87 ± 6 mm Hg) but only delayed pulmonary symptoms related to atelectasis (n=1), pulmonary edema (n=4), and bacterial pneumonitis (n=3); bronchial epithelial detachment was not observed. None of them required mechanical ventilation and all recovered with appropriate therapy.

Conclusions: “Specific” involvement of bronchial epithelium was noted in 27 % of cases and must be suspected when dyspnea, bronchial hypersecretion, normal chest X-ray, and marked hypoxemia are present during the early stages of toxic epidermal necrosis. Bronchial injury seems to indicate a poor prognosis, as mechanical ventilation was required for most of these patients and was associated with a high mortality.

Key words: Toxic epidermal necrolysis, Stevens-Johnson syndrome, Pulmonary complications, Fiberoptic bronchoscopy, Bronchial epithelial necrosis

References

  • 1.Lyell A. Toxic epidermal necrolysis: an eruption resembling scalding of the skin. Br J Dermatol. 1956;68:355–361. doi: 10.1111/j.1365-2133.1956.tb12766.x. [DOI] [PubMed] [Google Scholar]
  • 2.Lyell A. Toxic epidermal necrolysis (the scalded skin syndrome): a reappraisal. Br J Dermatol. 1979;100:69–86. doi: 10.1111/j.1365-2133.1979.tb03571.x. [DOI] [PubMed] [Google Scholar]
  • 3.Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med. 1994;10:1272–1284. doi: 10.1056/NEJM199411103311906. [DOI] [PubMed] [Google Scholar]
  • 4.Guillaume JC, Roujeau JC, Revuz J, Penso D, Touraine R. The culprit drugs in 87 cases of toxic epidermal necrolysis (Lyell’s syndrome) Arch Dermatol. 1987;123:1166–1170. doi: 10.1001/archderm.123.9.1166. [DOI] [PubMed] [Google Scholar]
  • 5.Roujeau JC, Chosidow O, Saiag R, Guillaume JC. Toxic epidermal necrolysis (Lyell syndrome) J Am Acad Dermatol. 1990;23:1039–1058. doi: 10.1016/0190-9622(90)70333-D. [DOI] [PubMed] [Google Scholar]
  • 6.Roujeau JC, Kelly JR, Naldi L, Rzani B, Stern RS, Anderson T, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;333:1600–1607. doi: 10.1056/NEJM199512143332404. [DOI] [PubMed] [Google Scholar]
  • 7.Fournier S, Bastuji-Garin S, Mentec H, Revuz J, Roujeau JC. Toxic epidermal necrolysis associated with Mycoplasma pneumoniae infection. Eur J Clin Microbiol Infect Dis. 1995;14:558–559. doi: 10.1007/BF02113442. [DOI] [PubMed] [Google Scholar]
  • 8.Villada G, Roujeau JC, Cordonnier C, Bagot M, Kuentz M, Weschler J, Vernant J-P. Toxic epidermal necrolysis after bone marrow transplantation: study of nine cases. J Am Acad Dermatol. 1990;23:870–875. doi: 10.1016/0190-9622(90)70307-4. [DOI] [PubMed] [Google Scholar]
  • 9.Revuz J, Penso D, Roujeau JC, Guillaume JC, Payne RC, Weschler J, Touraine R. Toxic epidermal necrolysis: clinical findings and prognosis factors in 87 patients. Arch Dermatol. 1987;123:1160–1165. doi: 10.1001/archderm.123.9.1160. [DOI] [PubMed] [Google Scholar]
  • 10.Chosidow O, Delchier JC, Chaumette MT, Weschler J, Wolkenstein P, Bourgault I, Roujeau JC, Revuz J. Intestinal involvement in drug induced toxic epidermal necrolysis. Lancet. 1991;337:928–928. doi: 10.1016/0140-6736(91)90273-R. [DOI] [PubMed] [Google Scholar]
  • 11.Timsit JF, Mion G, Rouyer N, Le Gulluche Y, Carsin H. Bronchopulmonary distress associated with toxic epidermal necrolysis. Intensive Care Med. 1992;18:42–44. doi: 10.1007/BF01706425. [DOI] [PubMed] [Google Scholar]
  • 12.Virant FS, Redding GJ, Novack AH. Multiple pulmonary complications in a patient with Stevens-Johnson syndrome. Clin Pediatr. 1984;24:412–413. doi: 10.1177/000992288402300711. [DOI] [PubMed] [Google Scholar]
  • 13.Roupe G, Ahlmen M, Fagerberg B, Suurküla M. Toxic epidermal necrolysis with extensive mucosal erosions of the gastrointestinal and respiratory tracts. Int Arch Allergy Immunol. 1986;80:145–151. doi: 10.1159/000234043. [DOI] [PubMed] [Google Scholar]
  • 14.Dasgupta A, O’Malley J, Mallya R, Williams JG. Bronchial obstruction due to respiratory mucosal sloughing in toxic epidermal necrolysis. Thorax. 1994;49:935–936. doi: 10.1136/thx.49.9.935. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Wahle D, Beste DJ, Conley SF. Laryngeal involvement in toxic epidermal necrolysis. Otolaryngol Head Neck Surg. 1992;107:796–799. doi: 10.1177/019459988910700616.1. [DOI] [PubMed] [Google Scholar]
  • 16.Bastuji-Garin S, Rzani B, Stern R, Shear N, Naldi L, Roujeau JC. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome and erythema multiforme. Arch Dermatol. 1993;129:92–96. doi: 10.1001/archderm.129.1.92. [DOI] [PubMed] [Google Scholar]
  • 17.Moore N, Biour M, Paux G, et al. Adverse drug reaction monitoring: doing it the French way. Lancet. 1985;II:1056–1058. doi: 10.1016/S0140-6736(85)90918-3. [DOI] [PubMed] [Google Scholar]
  • 18.Pham LH, Brun-Buisson C, Legrand P, Rauss A, Verra F, Brochard L, Lemaire F. Diagnosis of nosocomial pneumonia in mechanically ventilated patients. Comparason of a plugged telescoping catheter with the protected specimen brush. Am J Respir Crit Care Med. 1991;143:1055–1061. doi: 10.1164/ajrccm/143.5_Pt_1.1055. [DOI] [PubMed] [Google Scholar]
  • 19.Slutsky AS. Consensus conference on mechanical ventilation. Intensive Care Med. 1994;20:150–152. doi: 10.1007/BF01707673. [DOI] [PubMed] [Google Scholar]
  • 20.Roujeau JC, Dubertret LL, Moritz S, Touraine R. Involvement of macrophages in the pathology of toxic epidermal necrosis. Br J Dermatol. 1985;113:425–430. doi: 10.1111/j.1365-2133.1985.tb02356.x. [DOI] [PubMed] [Google Scholar]
  • 21.Villada G, Roujeau JC, Clerici T, Bourgault I, Revuz J. Immunopathology of toxic epidermal necrolysis. Arch Dermatol. 1992;128:50–53. doi: 10.1001/archderm.128.1.50. [DOI] [PubMed] [Google Scholar]
  • 22.Paquet P, Nikkeis A, Arrese J, Vanderkelen A, Pierard G. Macrophages and tumor necrosis factor a in toxic epidermal necrolysis. Arch Dermatol. 1994;130:605–608. doi: 10.1001/archderm.130.5.605. [DOI] [PubMed] [Google Scholar]
  • 23.Miayauchi H, Hosokawa H, Akaeda T, Iba H, Asada Y. T-cell subsets in drug-induced toxic epidermal necrolysis. Arch Dermatol. 1991;127:851–857. doi: 10.1001/archderm.127.6.851. [DOI] [PubMed] [Google Scholar]
  • 24.Correia O, Delgado L, Ramos JP, Re-sende C, Fleming Torrinha JA. Cutaneous T-cell recruitment in toxic epidermal necrolysis. Arch Dermatol. 1993;129:466–468. doi: 10.1001/archderm.129.4.466. [DOI] [PubMed] [Google Scholar]
  • 25.Friedmann PS, Strickland I, Pirmohamed M, Park K. Investigation of mechanisms in toxic epidermal necrolysis induced by carbamazepine. Arch Dermatol. 1994;130:598–604. doi: 10.1001/archderm.130.5.598. [DOI] [PubMed] [Google Scholar]
  • 26.Wolkenstein P, Carrière V, Charue D, Bastuji-Garin, Revuz J, Roujeau JC, Beaune P, Bagot MA. Slow acetylator genotype is a risk factor for sulphonamide-induced toxic epidermal necrolysis and Stevens-Johnson syndrome. Pharmacogenetics. 1995;5:255–258. doi: 10.1097/00008571-199508000-00011. [DOI] [PubMed] [Google Scholar]
  • 27.Wolkenstein P, Charue D, Laurent P, Revuz J, Roujeau JC, Bagot M. Metabolic predisposition to cutaneous adverse rections. Arch Dermatol. 1995;131:544–551. doi: 10.1001/archderm.131.5.544. [DOI] [PubMed] [Google Scholar]
  • 28.Chosidow O, Bourgault I, Roujeau JC. Drug rashes. What are the targets of cell-mediated cytotoxicity? Arch Dermatol. 1994;130:627–629. doi: 10.1001/archderm.130.5.627. [DOI] [PubMed] [Google Scholar]
  • 29.Revuz J, Roujeau J-C, Guillaume J-C, Penso D, Touraine R. Treatment of toxic epidermal necrolysis. Arch Dermatol. 1987;123:1156–1158. doi: 10.1001/archderm.123.9.1156. [DOI] [PubMed] [Google Scholar]

Articles from Intensive Care Medicine are provided here courtesy of Nature Publishing Group

RESOURCES