INTRODUCTION
Toxic epidermal necrolysis (TEN) can be described as the separation of the dermal-epidermal junction and its pathology is similar to the second-degree superficial burns.It may be accepted as the most severe form of erythema multiforme spectrum.This disease usually results from an unwanted effect of a drug and may cause life threatening functional impairment of the skin.
The incidence of TEN is increased in bone marrow transplant recipients,collagen vascular diseases,cerebral tumors and human immunodeficiency virus (HIV) infections.
TEN causes some complications including sepsis,shock,and multiorgan failure syndrome which may accompany major burns,resulting a mortality rate ranging between 10% and 70 % in severe cases［1］.
Our case had a drug usage history after a coronary artery bypass graft operation,he had poor prognostic factors and despite aggressive resuscitation in the intensive care unit he died due to septic shock.
We would like to present this case,to review the principals of treating TEN patients and remind the importance of intensive care unit follow-up.
CASE REPORT
A 67 years old male had undergone coronary artery bypass grafting operation a month ago,any complication was not observed in preoperative and postoperative intensive care follow-up.At the postoperative period,150 mg acetylsalicylic acid (Ecoprin, Abdi brahim, stanbul, Turkey), 200 mg amiodarone HCl (Cordarone, Sanofi-Aventis, Ambares, France), 1.25 mg perindopril-indapamide (Coversyl, Servier, Berkshire, England), 40 mg furosemide (Lasix, Sanofi-Aventis, Ambares, France)，25 mg indomethacin (Endol, Deva, Istanbul, Turkey) were administered daily. Approximately, 15 days after the operation, high fever and bullous necrosis of the epidermis were developed. On the 12th day of the postoperative period he was referred to the infectious diseases clinic due to neutropenia, high fever leading an initial diagnosis of TEN with respect to signs and symptoms.
On the third day of his transportation to infectious diseases clinic,acidosis and respiratory distress became evident and endotracheal intubation was perfomed and ventilatory support was started.In his initial physical examination,the patient's signs were as:body temperature 36.2 ℃,heart rate 114 beats/min,arterial blood pressure 80/40 mm Hg,Glasgow Coma Scale E1M1e,pupils 2/2 and light reflex +/+.His whole body surface and the oral mucosa were covered with ulcerous epidermal bullouses.His blood count and biochemical tests were as follows:Hb:9.1 g/dl,Htc:31.5 %,leucocyte 900/mm3,platelets 65.000/mm3 and blood urine nitrogene (BUN):133 mg/dl.When measured central venous pressure (CVP) reached up to 14 cm H2O,he was supported by 15 μg/kg/min dopamine,15 μg/kg/min dobutamine and 1 mg/h adrenaline.Approximately 12 h after this intervention,bradycardia and hypotension persisted with no response to aggressive therapy and the patient died despite of effective cardiopulmonary resuscitation.
DISCUSSION
Skin is the outer surface of the body and functions as a mechanical barrier protecting the organism from environmental risks,also avoids loss of biological fluids.Acute failure of the skin results in many important problems including loss of fluids,infection and impairment of thermoregulation.TEN is a severe dermatological disorder which can be diagnosed by the presence of fever,bullous lesions and erosions covering more than 20% of the body,presence of the bullous lesions over the erythematous background and incorporating of the mucous membranes to this clinic［2］.
TEN may develop in every age;it is 1.5 times more frequent in males.In the etiology of TEN 70%~80 % drug usage is determined.A study of Guillaume,et al. ［3］ in 87 TEN patients found that most of the patients were using more than one drug and TEN related signs were observed 14~22 days after the administration of the first drug. Drugs increasing the risk are especially cotrimaxazole, aminopenicillins, cephalosporines, quinolones, phenobarbitale, phenitoin, carbamazepine, valproic acid, piroxicam, tenoxicam and chlormezanone, allo-purinol［4］, indomethacin［5］, indapamide［6］ and systemic steroids［3］.
Infection agents which may have a role in the etiology of TEN include hepatitis,yersinia,mycoplasma pneumonia, rubeola, voricella, herpes simplex,herpes zoster and echerichia coli.Factors affecting the prognosis of the disease are advanced age, larger lesions, increased BUN, granulosytopenia which is progressive or lasts more than 5 days［7］.
In our case;important risk factors like gender,advanced age,a major surgical intervention which may impair immune system,multiple drug usage at the postoperative period (especially acetylsalicylic acid,indapamide and indomethacin type drugs with high risk),leucopenia,widespread skin lesions and acinetobacter baumannii infection contributed to the development of TEN all together.
TEN's pathogenesis is not completely explained and its clinical,histological,and immunological symptoms are similar to graft versus host disease so;it is possible to say that,TEN is a disorder of the cell-mediated immunity［8,9］.If TEN is thought to be an immunological reaction,systemic steroids and immunosuppressive drugs should be considered to be effective.However,steroid usage in TEN is controversial.Plasmapheresis,pentoxyphylline,cyclophosphamide,thalidomid and intravenous immunoglobulin were reported as effective in some case reports for TEN therapies［10~13］.On the other hand,granulocyte colony stimulating factor,amniotic membrane transplantations for skin lesions are some other treatment modalities for TEN［12］.In our case,systemic steroid administration and wound site-injury lesions' treatment with antiseptic solutions were performed in the clinic where TEN diagnosis was made.
Prior to,the treatment modalities mentioned above whose affectivity are controversial;symptomatic support in intensive care is the main concept of the therapy.Intensive fluid replacement,enteral nutrition,regulation of the environmental temperature and following the rules of asepsis-antisepsis are the most important issues of the patients' care.Prophylactic antibiotic therapy is not recommended but the most common causes of exitus in TEN are staphylococcus aureus and pseudomonas aeruginosa infections;therefore appropriate antibiotic management has to be started immediately when there is a doubt about infection or a diagnosis of infection was made［12］.
The patient was consultated by our intensive care team,while he was being followed-up by another clinic and he was transported to our reanimation unit.Continuous blood pressure,CVP and arterial blood gases were monitorized and rapid fluid resuscitation,inotropic support were started.Blood and wound cultures taken after intensive care transport revealed resistant acinetobacter baumannii growth.Unfortunately,due to the development of septic shock the patient died just 12 h after his arrival in our intensive care unit,avoiding us from applying further interventions.
We believe that patients with poor prognostic factors for TEN should be consultated with intensive care specialists as soon as possible and their care and follow-up should be done in the intensive care unit.