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 Table of Contents  
DERMATOLOGY PRACTICE DURING COVID-19 PANDEMIC - CASE REPORTS
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 30-33

Management of toxic epidermal necrolysis in an adult patient: Challenges and their management during COVID-19 pandemic


1 Department of Dermatology, Venereology and Leprosy, PGIMSR, Bengaluru, Karnataka, India
2 Department of ESIC Medical College and PGIMSR, Bengaluru, Karnataka, India

Date of Submission07-Oct-2020
Date of Decision23-Dec-2020
Date of Acceptance23-Dec-2020
Date of Web Publication19-Feb-2021

Correspondence Address:
Ragunatha Shivanna
Professor and Head, Department of Dermatology, Venereology and Leprosy, ESIC Medical College and PGIMSR, Rajajinagar, Bengaluru - 560 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cdr.cdr_125_20

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  Abstract 


An adult male patient who underwent neurosurgery for extradural hematoma following road traffic accident presented with toxic epidermal necrolysis (TEN) secondary to phenytoin. The patient was semiconscious and not responding to verbal commands. The patient was admitted and managed with oral cyclosporine and supportive measures. TEN is a dermatological emergency presenting as acute skin failure. The management requires multidisciplinary approach in an intensive care setup. The treatment includes the administration of immunosuppressant drugs and maintenance of hemodynamic stability. However, the COVID-19 pandemic has resulted in a lot of limitations regarding the use of immunosuppressant drugs and in-patient care because of the possibility of transmission of COVID-19 infection among patients, their caretakers and health-care professionals. Here, we are presenting a case of TEN managed successfully during the pandemic of COVID-19. Strict adherence to all the guidelines recommended by concerned authorities related to the prevention of transmission of COVID-19 and judicious use of immunosuppressant drugs based on risk and benefit ratio is very crucial.

Keywords: Acute skin failure, COVID-19, cyclosporine, toxic epidermal necrolysis


How to cite this article:
Shivanna R, Ramakrishna G, Mannur GK. Management of toxic epidermal necrolysis in an adult patient: Challenges and their management during COVID-19 pandemic. Clin Dermatol Rev 2021;5:30-3

How to cite this URL:
Shivanna R, Ramakrishna G, Mannur GK. Management of toxic epidermal necrolysis in an adult patient: Challenges and their management during COVID-19 pandemic. Clin Dermatol Rev [serial online] 2021 [cited 2021 Feb 28];5:30-3. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/30/309752




  Introduction Top


Toxic epidermal necrolysis (TEN) is a dermatological emergency presenting as acute skin failure. The management requires multidisciplinary approach in an intensive care setup. The treatment includes the administration of immunosuppressant drugs and maintenance of hemodynamic stability. However, the COVID-19 pandemic has resulted in a lot of limitations regarding the use of immunosuppressant drugs and in-patient care because of the possibility of transmission of COVID-19 infection among patients, their caretakers and healthcare professionals.


  Case Report Top


A 37-year-old male patient presented to the casualty of tertiary care teaching hospital with generalized skin lesions of 3 days. The patient was semiconscious and not oriented to verbal commands. On examination, generalized bilaterally symmetrical pleomorphic lesions consisting of petechial and ecchymotic macules and patches were seen distributed over the face, trunk, and both the extremities relatively sparing scalp and lower legs and completely sparing palms and soles. Erosions of varying sizes were present over the face, chest, back, genitalia, arms, and dorsum of hands-on both sides [Figure 1]. A few blisters were present over both the forearms and dorsum of hands. Diffuse congestion of conjunctiva with the purulent discharge was noted on both sides. Labial mucosa was covered with dried hemorrhagic crusts [Figure 2]. Erosions with crusting was observed on the glans penis and preputial skin. The past medical history as told by the patient's brother revealed a history of right temporoparietal occipital decompressive craniotomy with augumentative duroplasty and bone flap in abdomen conducted 6 weeks back for the management of extradural hematoma developed following a road traffic accident. The patient was on phenytoin and levetiracetam for 6 weeks. The drugs and food were administered through nasogastric (NG) tube as the patient was semiconscious, and not able to swallow and follow the instructions. The history also revealed that the patient is a chronic alcoholic, nonsmoker, nondiabetic, and nonhypertensive. At presentation, the patient was afebrile and his blood pressure was 90/60 mm of Hg, pulse rate was 125 beats/min, respiratory rate was 16/min and oxygen saturation was 96%. A diagnosis of TEN secondary to phenytoin was made and the patient was admitted in the general ward with air-condition, oxygen line, and facility for monitoring oxygen saturation. Oral phenytoin and levetiracetam were stopped and intravenous (IV) levetiracetam 500 mg 12th hourly was started.
Figure 1: Extensive erosions and separation of epidermis over the back

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Figure 2: Hemorrhagic crusting of the lips, erosions on the upper chest, and conjunctivitis

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On admission, the laboratory investigations were as follows: hemoglobin 10.6 g%, total count 9120 cells/cmm, platelet count 3.3 lakh/cmm, random blood sugar 68 mg/dl, blood urea nitrogen 14 mg/dl, serum creatinine 0.2 mg/dl, serum bicarbonate 22.9 mmol/L, total bilirubin (TB) 6.3 mg/dl, direct bilirubin (DB) 5.4 mg/dl, total protein 3.9 mg/dl, serum albumin 2.1 mg/dl, aspartate aminotransferase (AST) 756 U/L, alanine aminotransferase (ALT) 739 U/L, alkaline phosphatase (ALP) 488 U/L, gamma-glutamyl transferase (GGT) 788 U/L, Na+ 125 mEq/L, K+ 3.7 mEq/L. Cl+ 93 mEq/L, prothrombin time (PT) 26.9 s, activated partial thromboplastin time (APTT) 72.7 s, and INR was 2.4. The initial SCORTEN was 3 with predicted mortality rate of 35.8%. Vascular access was secured through peripheral veins; NG tube was inserted for oral feeding; and condom catheter was used for drainage of urine. Treatment was started with cyclosporine oral solution 3 mg/kg/day in two divided doses through NG tube, IV dexamethasone 8 mg 24 hourly, and IV amoxicillin and clavulanic acid 1.2 g 12th hourly. A total of 2 L of fluid was administered in the form of 500 ml of IV normal saline and 1500 ml of oral feeds. The oral feed comprised rice porridge, protein powder with milk and water. The vitals and oxygen saturation were monitored every 4 h, and liver function test, renal function tests, serum electrolytes, PT and APTT were investigated every day. The physician opinion was taken for abnormal liver function tests and coagulation profile. Oral ursodeoxycholic acid 150 mg twice daily, Lactulose solution 20 ml at night, Vitamin K 10 mg IV infusion for 3 days, and four units of fresh frozen plasma administered. Tobramycin and homatropine, and carboxymethyl cellulose eye drops were started as advised by the ophthalmologist. During the initial 2 days, the skin over the back denuded leaving behind large erosion covering the entire back with moderate oozing. The coagulation profile returned to normal. However, the TB, DB, ALP, and GGT levels increased and those of AST and ALT decreased. The oozing from the erosions decreased along with drying of lesions. The input and output of fluid were adequately maintained. After 3 days IV dexamethasone was stopped. The complete healing of lesions was achieved after 10 days of admission [Figure 3] and oral cyclosporine was discontinued. The patient was then transferred to medicine for the management of liver disease and neurological abnormality.
Figure 3: Complete healing with reepithelization with post-inflammatory hyperpigmentation following treatment

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At every stage of the management, from the initial evaluation to the management of TEN and comorbidities and even thereafter, there are several unique challenges that the treating doctor needs to address during COVID-19 pandemic.

Challenges and their management

Challenge 1

Whether to admit the patient in the hospital: The institutional guidelines recommended suspension of OPD services and continuing only emergency services. The hospital has been recognized by State Government authorities as first responder hospital for isolating the patients with suspected COVID-19 infection.

Management

TEN being an emergency condition with significant mortality and morbidity, the patient needs to be managed in an intensive care unit (ICU). As our hospital was managing only COVID suspected patients awaiting test results, and the isolation ward was in a separate building with the dedicated healthcare team, we decided to admit the patient in the hospital. The guidelines issued by concerned authorities also suggested in-patient management of emergency cases.[1]

Challenge 2

Availability of resources for the management of the patient: The ICU has been reserved for COVID-19 patients as recommended by the State Government authorities as a part of preparedness. Isolated bed in ICU is required to prevent the acquisition of infection. A significant number of paramedical staff and residents have been diverted to work in COVID-19 isolation ward on rotation basis with 14 days of quarantine following a day of work.

Management

The patient was admitted in general ward which is equipped with the necessary facilities to manage the patient. Despite good number of doctors and residents were posted in COVID-19 isolation ward, adequate number of doctors and paramedical staff were available for the management of non-COVID-19 patients. The personal protective equipment, facial masks, and sanitizers were made available in sufficient quantity by the hospital authorities. As and when the evidence are available, the number of days of quarantine required for healthcare professionals; and infrastructure, equipment, and human resources required for care of patients with COVID can be revised so that adequate resources are ensured for the care of patients.

Challenge 3

Risk associated with managing an emergency during COVID-19 pandemic: The COVID-19 status of the patient is usually not known at the time of clinical evaluation and the situation requires immediate intervention and regular monitoring. There is the risk of transmission of COVID-19 infection among healthcare providers and vice versa. The underlying comorbidities and their treatment may increase the risk of severe COVID-19 disease.

Management

The patient and their attendees were screened for possible exposure to COVID-19 positive patients. The screening doctors were provided with N95 mask, facial shield, gloves, and temperature sensor. The patient was bedridden for 6 weeks and his attendees were residing in the green zone and continuously taking care of him. Hence, throat swab was not sent for the detection of COVID-19 virus as they belonged to low/no risk groups. However, decision on mandatory testing of all patients admitted in the hospital need to be considered depending up on the changing situation and guidelines. The healthcare providers and caretakers were protected with surgical mask and sanitizers as per the ICMR guidelines.[2] The option of hydroxychloroquine prophylaxis has also been advised for healthcare providers involved in the treatment of COVID-19 positive or suspected cases.[3]

Challenge 4

The apprehension and concern among the patients and their caretakers about getting infected with COVID-19 in the hospital: The hospital can act as reservoir of infection as the treatment of asymptomatic patients cannot be ruled out in the current scenario. The healthcare providers are at high risk of exposure to COVID-19 virus. There are many instances where the entire hospital has been locked down and all the staff were put under quarantine when one of the patients, after in-patient treatment, revealed an exposure to COVID-19-positive relative.[1]

Management

The caretakers of the patients were counseled regarding the nature of COVID-19 diseases, risk of infection, and measures taken by the hospital authorities to prevent the transmission of infection inside the hospital. The safety of the patient and their caretakers was assured.

Challenge 5

Whether to treat the patient with immunosuppressant: Immunosuppressant drugs are indicated in the treatment of TEN. These drugs may increase the risk of severe COVID-19 disease.

Management

The patient was suffering from life-threatening dermatological conditions requiring effective therapy to minimize morbidity and mortality. Considering the efficacy and its easy availability, the patient was started with cyclosporine.[4] In the presence of hepatitis, the dose should be reduced as cyclosporine is metabolized in the liver. Cyclosporine can cause cholestatic hepatitis with increase in liver enzymes. Hence, careful monitoring is required. As cyclosporine has been used for short duration (<2 weeks), the risk of immunosuppression in relation to COVID-19 is almost insignificant. Systemic corticosteroids also do not cause significant immunosuppression when used for <1 week. In the present case, systemic corticosteroid was stopped after 3 days. Recent studies have also demonstrated less risk and favorable outcomes in relation to COVID-19 infection in patients who were on immunosuppressants for other comorbidities.[5] Hence, the risk and benefit of any treatment modality in a particular clinical scenario need to be considered. If there is a risk, it is recommended to take adequate precautions to prevent the risk; and thorough monitoring of clinical and laboratory parameters to identify the early signs and symptoms of potential risk.


  Conclusion Top


Learning points

  • Management of dermatological emergencies, especially during COVID-19 pandemic is very challenging
  • Necessary precautions as per the guidelines should be taken to prevent the transmission of COVID-19 infection
  • Patients and their relatives should be counseled regarding the risk of transmission of COVID-19 infection and preventive measures taken by the healthcare facility
  • The risk and benefit ratio of any treatment modality should be evaluated thoroughly
  • The clinical and laboratory parameters of disease progression and response to therapy should be monitored closely.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Advisory for Hospitals and Medical Education Institutions. Available from: https://ksuwssb.karnataka.gov.in/frontend/opt1/images/covid/instructions%20notices/advice_27%20Advisory%20for%20Hospitals%20and%20Medical%20Institutions.pdf. [Last accessed on 2020 Jun 30].  Back to cited text no. 1
    
2.
Revised Guidelines on Clinical Management of COVID – 19. Available from: https://ksuwssb.karnataka.gov.in/frontend/opt1/images/covid/instructions%20notices/advice_35%20Revised%20Guidelines%20on%20Clinical%20Management%20for%20COVID-19(31-03-2020).pdf. [Last accessed on 30 Jun 2020].  Back to cited text no. 2
    
3.
4.
Ng QX, De Deyn ML, Venkatanarayanan N, Ho CY, Yeo WS. A meta-analysis of cyclosporine treatment for Stevens-Johnson syndrome/toxic epidermal necrolysis. J Inflamm Res 2018;11:135-42.  Back to cited text no. 4
    
5.
Thng ZX, De Smet MD, Lee CS, Gupta V, Smith JR, McCluskey PJ, et al. COVID-19 and immunosuppression: a review of current clinical experiences and implications for ophthalmology patients taking immunosuppressive drugs. Br J Ophthalmol 2020;0:1-5. Epub ahead of print: [12th June 2020]. doi:10.1136/ bjophthalmol-2020-316586 [Accessed on 30th June 2020].  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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