Search

SUMMARY.— A typical phage group 2 staphylococcal isolate from a case of toxic epidermal necrolysis of Ritter's type produces a diffusible macromolecular thermolabile product which rapidly induces epidermal necrolysis in new-born mice. The susceptibility to this necrolytic factor decreases markedly with age. The factor responsible has been partly purified.

Objective: To report a case of fatal toxic epidermal necrolysis associated with carvedilol treatment. Case summary: Two days after the initiation of carvedilol treatment, a 70-year old woman presented with skin eruptions in the form of maculous rash with blisters that rapidly progressed to epidermal necrolysis. Although the suspected drug was withdrawn, the reaction was extremely rapid in its development with fatal outcome. Discussion: Carvedilol is not a drug commonly associated with TEN. To our knowledge there are no cases of carvedilol related TEN reported in the literature. Conclusion: Because of the close temporal relationship between the initiation of carvedilol treatment and the appearance of skin eruptions, and because carvedilol was the only new medication the patient had taken, the etiology of TEN was most likely a reaction to this drug. Physicians should be aware of this extremely rare but serious ADR.

The reporting frequency of eight adverse reaction terms was assessed from 1970 to 1986: agranulocytosis, anaphylactoid reaction, aplastic anemia, epidermal necrolysis. exfoliative dermatitis, hemolytic anemia, pancytopenia, and Stevens-Johnson syndrome. These terms historically have a high probability of drug/biologic involvement and also represent conditions that are likely to result in serious outcomes. The average yearly percentage of spontaneous, domestic reports with age and sex present that had at least one of these adverse reaction terms during 1970 to 1986 was 4.1 % (SD= 1.3 %). This shows a remarkably steady proportion of such reports in the total received for each of the 17 years, even though various changes in the adverse reaction system were occurring throughout this time period.

Ten new consecutive cases of toxic epidermal necrolysis (TEN) have been studied clinically, bacteriologically, histopathologically, and histochemically and compared with dermatitis exfoliativa neonatorum (DEN) Ritter von Rittershain's disease) both from reports in the literature and personal study of histologic material from patients with that disease. The clinical picture and the histopathology in the two conditions are identical and also diagnostic. In the hematoxylin and eosin-stained sections there is a reversal of the tinctorial properties of the stratum corneum and stratum Malpighi, with transepidermal, or subepidermal separation, and minimal dermal inflammatory change. The pathodynamics of the process and the significance of certain phage types of staphylococcus hemolyticus and drug reactions in what is obviously a reaction pattern of multifactoral etiology are discussed. Appropriate therapy is outlined, and a new name is proposed for the single united syndrome.