Heng-Leong Chan

Observations on drug-induced toxic epidermal necrolysis in Singapore

Fifteen patients with toxic epidermal necrolysis (TEN) were studied. In all of them the TEN was related to drug ingestion and believed to be drug-induced. The drugs implicated include pyrazolone derivatives, allopurinol, barbiturates, tetracycline, phenytoin, and penicillamine. Possible etiologic co-factors are infections, cancer, and the systemic lupus erythematosus diathesis. The extent of skin loss varied from 25% to almost 100% involvement of the total body surface. Seven of the fifteen patients had more than 75% epidermal loss. Three deaths were recorded (20%). From observations on these fifteen patients it was found that a single drug can cause two reaction patterns, namely, Stevens-Johnson syndrome (or erythema multiforme) and TEN, at the same time or at different times in one and the same patient. It is stressed that from the prognostic and therapeutic viewpoints patients with TEN may be equated to patients with extensive partial-thickness burns and should be treated in a burn unit.

Usefulness of case report literature in determining drugs responsible for toxic epidermal necrolysis

To evaluate the usefulness of the case report literature concerning toxic epidermal necrolysis, we surveyed English-language reports published from January 1966 to April 1987, using epidermal necrolysis as a key word in the MEDLINE database. Of the 345 articles identified, 80 definitely or possibly contained individual case reports of at least 100 words; 59 of these 82 (72%) were available and reviewed. These 59 reports included a total of 73 separate cases of toxic epidermal necrolysis possibly related to drugs, which represents less than 5% of the case of toxic epidermal necrolysis that occurred in this period. In 62% of these 73 cases the apparent purpose of the report was to show an association between a given drug and the development of toxic epidermal necrolysis. The drugs most frequently associated with toxic epidermal necrolysis are allopurinol, the nonsteroidal anti-inflammatory agents, phenytoin, and the sulfonamide antibiotics. Given that only a small proportion of cases of toxic epidermal necrolysis appear in the case report literature, except to present association with drugs not previously reported, the contribution of case reports in providing an estimate of the relative risk of drug-associated toxic epidermal necrolysis is limited. Furthermore, our analysis suggests that the adoption of specific diagnostic criteria for and more uniform reporting of signs, symptoms, and therapy could greatly increase the usefulness of the case report literature. We propose a minimum set of informational and specific diagnostic criteria.

Glomeruloid hemangioma –- a specific cutaneous marker of POEMS syndrome

In December 1998, a 49‐year‐old woman was referred by the Department of Neurology to the Dermatology Clinic for evaluation of multiple, bright red papules on her face and trunk of 6u2003months duration. Two years prior to the appearance of the cutaneous eruption, she was seen for intermittent numbness and burning sensation of both hands of several months duration and was found to have decreased sensory and motor nerve conduction velocities. Electromyography suggested axongenic demyelinating polyneuropathy. On admission for further studies in April 1996, she was noted to have generalized skin hyperpigmentation and mild splenomegaly. Laboratory studies at that time revealed anemia [hemoglobin, 9.6u2003g/dL (normal male, 13.5–17.5u2003g/dL; normal female, 12.0–16.0u2003g/dL)], hypothyroidism [thyroxine, 3.86u2003ng/dL (normal, 5.0–12.4u2003ng/dL); triiodothyronine, 35.4u2003ng/dL (normal, 62–168u2003ng/dL); thyroid‐stimulating hormone, 12.3 mIU/L (normal, 0.4–4.5 mIU/L)], and lambda‐type immunoglobulin A (IgA) paraprotein in the serum. A bone marrow biopsy showed marked plasma cell infiltration. POEMS (polyneuropathy, organomegaly, endocrinopathy, M‐protein, skin changes) syndrome was diagnosed at that time and she was treated with prednisolone (15–30u2003mg/day) and melphalan (75u2003mg/day). In 1997, she developed pulsatile headache and blurred vision. Increased intracranial pressure and hydrocephalus were found. Increased intracranial pressure was relieved by placement of a lumbar peritoneal shunt. In January 1998, she suffered from recurrent pleural effusion and ascites, which were treated by intermittent pleurocentesis and ascites tapping, respectively.

Dermatomyositis and Cancer in Singapore

Abstract: Of 12 patients with adult dermatomyositis studied. 5 (41 %) had associated malignancies, of which 3 were nasopharyngeal carcinomas. The youngest was a 23‐year‐old woman. In view of the high incidence of cancer and the predominance of nasopharyngeal carcinoma, malignancy evaluation in Chinese patients from the Far East, 20 years of age or older with dermatomyositis should have extended workups for postnasal cancer. Two patients who had positive antinuclear not have associated cancers. Three patients died of acute myocardial infarction.

Intraepidermal neutrophilic IgA dermatosis.

We report a patient with a vesiculopustular eruption with features distinct from typical subcorneal pustular dermatosis. Clinically, well-formed pustular lesions, which were flowerlike in appearance, were present. Histopathologically, early vesicular lesions showed intraepidermal bullae containing numerous neutrophils, a few eosinophils, and acantholytic cells. Direct immunofluorescence study revealed IgA deposits in the intercellular space of the epidermis. The patients serum, however, did not contain circulating antibodies reactive with the epidermis. We consider this eruption an immunologically mediated, intraepidermal blistering disease, similar to intraepidermal neutrophilic IgA dermatosis.

Lupus-scleroderma syndrome induced by ethosuximide.

Features of both systemic lupus erythematosus and scleroderma developed in a young Chinese girl while on multiple anticonvulsant therapy. These were reversed after withdrawal of the drugs. Readministration of ethosuximide for control of epilepsy caused a relapse with predominant sclerodermatous features. These clinical signs again resolved after ethosuximide withdrawal.

Generalized Granuloma annulare Associated with Granulomatous Mycosis fungoides

We describe a 68-year-old man with plaque stage mycosis fungoides (MF) for 8 years. He developed tumorous lesions of granulomatous MF (GrMF) and generalized granuloma annulare (GA) after a previously indolent clinical course. Since then, the clinical course was aggressive with involvement of the bone marrow and lymph nodes, and leukemic change occurred. Systemic chemotherapy was given, but the patient died 9 months later due to neutropenic fever and septic shock. GA in malignant lymphoma has been reported most frequently in association with Hodgkin’s disease. To the best of our knowledge, GA associated with GrMF has never been reported in the English language literature. The prognostic significance of the association of granulomatous inflammation and malignancy is reviewed.

Cutaneous manifestations of non-01 Vibrio cholerae septicemia with gastroenteritis and meningitis

A 58-year-old man with diabetes had fever and chills 5 days after ingestion of raw seafood. Nausea, vomiting, watery diarrhea, bilateral calf pain, and neck stiffness subsequently developed. Generalized edema and ecchymotic patches with a vesiculobullous eruption appeared on the extremities. Four blood cultures were positive for Vibrio cholerae non-01. The patient was successfully treated with antibiotics. This is the first documented case of V. cholerae non-01 septicemia with cutaneous lesions and meningitis in Taiwan.

Long-term follow-up study of clear cell papulosis

BACKGROUNDnClear cell papulosis (CCP) was described as a new entity in 1987. Since then, only case reports or small case series have appeared in the literature and the long-term outcome of CCP remains unknown.nnnOBJECTIVESnThe aim of this study was to review cases of CCP diagnosed at our institution and to investigate their outcome.nnnMETHODSnNineteen patients given a diagnosis of CCP more than 6 years previously were identified. Their medical records and histopathologic findings were reviewed.nnnRESULTSnWith a median follow-up duration of 11.5 years, regression of skin lesions was observed in 85.7% of patients. Persistence of skin lesions 11.5 years after diagnosis was confirmed histopathologically in one case, with a reduction in clear cell density.nnnLIMITATIONSnRetrospective nature of the study is a limitation.nnnCONCLUSIONnNo treatment is necessary for CCP because the skin lesions are asymptomatic and most patients experience at least partial regression.

Fixed Drug Eruptions: A Study of 20 Occurrences in Singapore

ABSTRACT: Twenty occurrences of fixed drug eruptions (FDE) were studied. Of these, 12 were due to tetracyclines and 4 were due to analgesics (3 from pyrazolone derivatives and 1 from acetylsalicylic acid). Sixteen of the patients had less than 10 lesions each. The lips were affected in eight instances, and therefore seem preferentially involved. At presentation, seven patients were unaware of a drug relationship to their condition. A comparison of six reported series (including this one) revealed that the causative drugs varied over the years 1956‐1983 as well as by region.