Annals of Oncology Advance Access originally published online on May 9, 2006
Annals of Oncology 2006 17(10):1601; doi:10.1093/annonc/mdl089
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© 2006 European Society for Medical Oncology
letters to the editor |
Toxic epidermal necrolysis in patients with malignancies
1 University of Rome Tor Vergata, Rome, Italy
2 Burn Centre – S. Eugenio Hospital, Rome, Italy
3 University "La Sapienza" of Rome, Rome, Italy
4 Institute CNR for Organ Transplantation and Immunocytology, S.Eugenio Hospital, Rome, Italy
*(E-mail: ggravante{at}hotmail.com)
Curigliano and colleagues recently published an interesting letter focusing on the appearance of toxic epidermal necrolysis (TEN) in a breast cancer patient [1]. TEN manifestations started 5 days following the administration of voriconazole given for an invasive pulmonary aspergillosis which followed chemotherapy administration, suggesting the possibility for a role of voriconazole in TEN pathogenesis. This patient was successfully treated with human intravenous immunoglobulin in an intensive care unit.
This is an interesting observation which attracted our attention on a rare life threatening complication of drugs administration such as TEN, possibly affecting oncologic patients undergoing anti-infective treatments. In this contest, we would like to give our contribution to this subject as follows: first by introducing a further discussion on the relationship between TEN and voriconazole; and second, by providing information about our experiences on TEN developed in patients with malignancies. Although it is likely to believe that voriconazole contributed to trigger TEN in the patient described by Curigliano et al., it is not clear whether voriconazole had a direct role in the generation of such disease since (i) the patient was also on phenitoin medication (phenitoin has been clearly linked to TEN in a variety of patients) [2] and (ii) voriconazole and phenitoin were simultaneously discontinued at the onset of TEN manifestation. However, in support of a direct link between voriconazole and TEN comes a recent publication describing a similar case developed in a patient who was solely treated with voriconazole, confirming a direct role of the drug in the pathogenesis of the syndrome [2].
We recently reviewed 16 cases of histological-proved TEN patients diagnosed in our burns centre since 1999. Our standard protocol of treatment consisted of steroids (methylprednisolone 2 mg/kg for 5 days) and immunoglobulins (400 mg/kg/day) given in an intensive care setting. We found that four of them (25%) were affected by malignancies. Patient 1 was a 62-year-old male affected by brain cancer upon sertraline medication only. After an 8-day treatment, he developed TEN involving 22% of his total surface area (TSA). He was treated according to our standard protocol. Nineteen days later the patient successfully recovered. Patient 2 was a 44-year-old female affected by idiopathic myelofibrosis who developed a pulmonary infection. This patient was treated with metronidazole and piperacillin. Fifteen days later, the patient developed TEN involving 50% of TSA. Unfortunately, this patient died 13 days later due to sepsis caused by Acinetobacter baumanii. Patients 3 and 4 were respectively 66 and 74 year old males affected by chronic myelogenous leukaemia (CML). Patient 3 developed TEN involving 35% of TSA after a 6-day ceftazidime-based treatment of a respiratory infection. Patient 4, had TEN involving 100% of TSA developed after a 30-day piperacillin based treatment also for a respiratory infection. Both patients survived and recovered after 16 and 18 days treatment respectively.
Although rare, due to the increasing use of anti infective drugs in chemotherapy immunosuppressed patients we believe that onco-hematologists should take in account the possibility that these patients may develop a life-threatening TEN.
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1. Curigliano G, Formica V, De Pas T, et al. (2006) Life-threatening toxic epidermal necrolysis during voriconazole therapy for invasive aspergillosis after chemotherapy. Ann Oncol [Epub ahead of print].[CrossRef][Web of Science][Medline]
2. Huang DB, Wu JJ, Lahart CJ. (2004) Toxic epidermal necrolysis as a complication of treatment with voriconazole. South Med J 97:111116–1117.[Web of Science][Medline]
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