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Life-Threatening Drug-Induced Rashes

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181. Mycosis Fungoides (Treatment)

therapy, inducing complete remission in four of five patients in one study. [ ] Previous Next: Treatment of Sézary Syndrome The treatment of Sézary syndrome should be predicated on disease burden and rapidity of progression. [ ] Because infection is the major cause of death in patients with mycosis Sézary syndrome, one should attempt to preserve immune response, use immunomodulatory therapy before chemotherapy unless the disease burden or therapeutic failure requires otherwise, and consider (...) combination therapy, particularly systemic immunomodulatory therapy plus skin-directed treatments, as a better option than monotherapy. Because Staphylococcus infection may be associated with a disease flare, systemic antibiotics should be administered when in doubt to prevent life-threatening sepsis. Pruritus treatment is an important quality-of-life consideration and should not be neglected. [ ] It can be so severe that special itch-targeted therapies may need to be devised. Mogamulizumab, a CCR4

2014 eMedicine.com

182. Strongyloidiasis (Overview)

ability to persist and replicate within a host for decades while producing minimal or no symptoms (individuals with an intact immune system) and its potential to cause life-threatening infection (hyperinfection syndrome, disseminated strongyloidiasis) in an immunocompromised host (60-85% mortality rate). [ , , ] Rhabditiform larva of Strongyloides stercoralis in stool specimen (wet mount stained with iodine). The symptoms related to strongyloidiasis may reflect the nematode's systemic passage, its (...) procyonis . These species have animal hosts and are thus responsible for zoonotic infections. [ ] Infections are initiated when exposed skin contacts contaminated soil. Autoinfection commonly occurs allowing infection to persist decades. The longest documented asymptomatic infection was more than 65 years. Hyperinfection is typically triggered by drug-induced or disease-associated defects in cellular immunity, which allows a massive increase in parasite burden and dissemination to nearly all organ

2014 eMedicine.com

183. Strongyloidiasis (Overview)

ability to persist and replicate within a host for decades while producing minimal or no symptoms (individuals with an intact immune system) and its potential to cause life-threatening infection (hyperinfection syndrome, disseminated strongyloidiasis) in an immunocompromised host (60-85% mortality rate). [ , , ] Rhabditiform larva of Strongyloides stercoralis in stool specimen (wet mount stained with iodine). The symptoms related to strongyloidiasis may reflect the nematode's systemic passage, its (...) procyonis . These species have animal hosts and are thus responsible for zoonotic infections. [ ] Infections are initiated when exposed skin contacts contaminated soil. Autoinfection commonly occurs allowing infection to persist decades. The longest documented asymptomatic infection was more than 65 years. Hyperinfection is typically triggered by drug-induced or disease-associated defects in cellular immunity, which allows a massive increase in parasite burden and dissemination to nearly all organ

2014 eMedicine.com

184. Factor XIII (Overview)

02, 2018 Author: Robert A Schwartz, MD, MPH; Chief Editor: Perumal Thiagarajan, MD Share Email Print Feedback Close Sections Sections Factor XIII Deficiency Overview Practice Essentials Factor XIII (FXIII), which was initially termed fibrin stabilizing factor, is involved in clot preservation. FXIII also participates in other physiologic processes, including wound repair and healing. FXIII deficiency, an autosomal recessive disorder, is a rare but potentially life-threatening cause (...) as part of the innate immune system. [ ] Use of relatively new specific FXIII assays are pivotal to avoid missing the diagnosis of FXIII deficiency, a rare but potentially life-threatening disorder. [ ] Previous Next: Pathophysiology Structure, production, and half-life of FXIII Plasma FXIII is a heterotetramer consisting of 2 identical proenzyme subunits (A 2 ) and 2 identical carrier protein subunits (B 2 ). Subunit A contains the catalytic site, the activation peptide, a calcium-binding site

2014 eMedicine.com

185. Erythema Multiforme (Stevens-Johnson Syndrome) (Overview)

this condition may be related to recurrent HSV, recurrences of erythema multiforme may follow, with many affected individuals experiencing several recurrences per year. Target lesion of erythema multiforme. Raised atypical targets and arcuate lesions. Erythema multiforme major is a more severe, potentially life-threatening disorder. One or more mucous membranes are involved and up to 10% of body area may have epidermal detachment. More than 50% of all cases are attributed to medications. Erythema multiforme (...) , Kawada I, et al. Unexpected recalcitrant course of drug-induced erythema multiforme-like eruption and interstitial pneumonia sequentially occurring after nivolumab therapy. J Dermatol . 2017 Jul. 44 (7):818-821. . Vivar KL, Deschaine M, Messina J, Divine JM, Rabionet A, Patel N, et al. Epidermal programmed cell death-ligand 1 expression in TEN associated with nivolumab therapy. J Cutan Pathol . 2017 Apr. 44 (4):381-384. . Caro-Gutiérrez D, Floristán Muruzábal MU, Gómez de la Fuente E, Franco AP

2014 eMedicine.com

186. Erythema Multiforme (Overview)

be related to recurrent HSV, recurrences of erythema multiforme may follow, with many affected individuals experiencing several recurrences per year. Target lesion of erythema multiforme. Raised atypical targets and arcuate lesions. Erythema multiforme major is a more severe, potentially life-threatening disorder. One or more mucous membranes are involved and up to 10% of body area may have epidermal detachment. More than 50% of all cases are attributed to medications. Erythema multiforme versus Steven (...) of drug-induced erythema multiforme-like eruption and interstitial pneumonia sequentially occurring after nivolumab therapy. J Dermatol . 2017 Jul. 44 (7):818-821. . Vivar KL, Deschaine M, Messina J, Divine JM, Rabionet A, Patel N, et al. Epidermal programmed cell death-ligand 1 expression in TEN associated with nivolumab therapy. J Cutan Pathol . 2017 Apr. 44 (4):381-384. . Caro-Gutiérrez D, Floristán Muruzábal MU, Gómez de la Fuente E, Franco AP, López Estebaranz JL. Photo-induced erythema

2014 eMedicine.com

187. Drug Eruptions (Treatment)

life threatening. Timely recognition of the syndrome and immediate discontinuation of the anticonvulsant or other offending drug are crucial. Patients may require liver transplantation if the drug is not stopped in time. Treatment with systemic corticosteroids has been advocated. References Monteagudo B, Cabanillas M, Iriarte P, Ramírez-Santos A, León-Muinos E, González-Vilas D, et al. Clindamycin-induced Maculopapular Exanthema with Preferential Involvement of Striae Distensae: A Koebner (...) , Quatresooz P. Novel treatments for drug-induced toxic epidermal necrolysis (Lyell's syndrome). Int Arch Allergy Immunol . 2005 Mar. 136(3):205-16. . Iannini P, Mandell L, Felmingham J, Patou G, Tillotson GS. Adverse cutaneous reactions and drugs: a focus on antimicrobials. J Chemother . 2006 Apr. 18(2):127-39. . Coopman SA, Johnson RA, Platt R, Stern RS. Cutaneous disease and drug reactions in HIV infection. N Engl J Med . 1993 Jun 10. 328(23):1670-4. . Taddio A, Lee CM, Parvez B, Koren G, Shah V

2014 eMedicine.com

188. Antiepileptic Drugs: An overview

with caution in susceptible populations, and routine screening must be performed to detect the condition early. CNS effects occur particularly in the cerebellum and the vestibular system, causing ataxia and nystagmus. PHT is not a generalized CNS depressant; however, some degree of drowsiness and lethargy is present, without progressing to hypnosis. Nausea and vomiting, rash, blood dyscrasias, headaches, vitamin K and folate deficiencies, loss of libido, hormonal dysfunction, and bone marrow hypoplasia (...) of tolerability between slow-release CBZ and OXC are not available. Available formulations are tablets (150 mg, 300 mg, 600 mg), and the recommended frequency of administration is twice a day. The initial dose in children is 10 mg/kg/d, with titration up to a maximum of 30 mg/kg. In adults, the dose is 600 mg/d up to a maximum of 2400 mg/d. Some patients require low starting doses (300 mg/d) and slower titration for better tolerability. Somnolence, headache, dizziness, rash, hyponatremia, weight gain

2014 eMedicine.com

189. Benign Vulvar Lesions (Treatment)

nigricans Acanthosis nigricans is a diffuse pigmentary change typically observed in intertriginous areas and skin folds. It may be hereditary, drug induced, or associated with obesity or endocrine diseases. [ ] It sometimes represents a paraneoplastic syndrome, revealing associated malignant epithelial tumors or lymphoproliferative disorders. Lentigo, lentiginosis, and benign vulvar melanosis Lentigo, lentiginosis, and benign vulvar melanosis are characterized by benign epidermal melanocytic hyperplasia (...) dermatitis consists of a subacute or chronic, symmetric, and ill-defined eczematous rash, usually involving the labia majora and, less frequently, the labia minora and inner thighs. The eruption is characterized by mild erythema, dryness, and fine scaling. Itching and burning are common symptoms. Excoriation secondary to repeated scratching may cause bacterial superinfection with honey-colored crusting and, in chronic forms, lichenification. In some patients, the itch-scratch-itch cycle may gradually

2014 eMedicine.com

190. Autoimmune Hepatitis (Treatment)

guidelines as to how mycophenolate mofetil should be tapered if a therapeutic response has been achieved. The authors have used doses as low as 500 mg twice per day to maintain patients in a drug-induced remission. Budesonide has been has been used with variable success in patients who had treatment failures. [ , ] Limited data are available regarding the use of tacrolimus, methotrexate, and other agents. Incomplete response Incomplete response is defined as an improvement that is insufficient to satisfy (...) of disease activity. Such flares may be severe and potentially life-threatening. Previous Next: Liver Transplantation Liver transplantation is an effective form of therapy for patients in whom medical therapy has failed, or those with decompensated cirrhosis caused by autoimmune hepatitis. [ ] Liver transplantation also may be used to rescue patients who present with fulminant hepatic failure secondary to autoimmune hepatitis. A low threshold should exist for transferring patients with acute liver

2014 eMedicine.com

191. Oral Manifestations of Systemic Diseases (Treatment)

, purpura, paraneoplastic pemphigus, Sweet syndrome) or therapy-induced lesions (eg, drug reactions, graft vs host disease). [ , ] Oral manifestations are more common in acute leukemias than in chronic leukemias. [ ] Gingival hypertrophy and hyperplasia are most commonly associated with acute myelogenous leukemia and acute promyelocytic leukemia. [ ] The gingiva are friable, edematous, and erythematous. [ , ] Thrombocytopenia commonly manifests as petechiae and ecchymoses on the mucosal surfaces (...) counts. [ , , ] These failures lead to transient recurrent fevers, malaise, and recurrent infections that may be life threatening. [ ] Onset of symptoms occurs in childhood and may improve as the patient approaches adulthood. [ ] Cutaneous manifestations are generally due to poor immune function and include skin infections and abscesses. [ ] Oral manifestations are present in over 90% of patients with cyclic neutropenia. [ ] In one series, investigators found that 94% have recurrent ulcers similar

2014 eMedicine.com

192. Lymphoma, Cutaneous T-Cell (Treatment)

therapy, inducing complete remission in four of five patients in one study. [ ] Previous Next: Treatment of Sézary Syndrome The treatment of Sézary syndrome should be predicated on disease burden and rapidity of progression. [ ] Because infection is the major cause of death in patients with mycosis Sézary syndrome, one should attempt to preserve immune response, use immunomodulatory therapy before chemotherapy unless the disease burden or therapeutic failure requires otherwise, and consider (...) combination therapy, particularly systemic immunomodulatory therapy plus skin-directed treatments, as a better option than monotherapy. Because Staphylococcus infection may be associated with a disease flare, systemic antibiotics should be administered when in doubt to prevent life-threatening sepsis. Pruritus treatment is an important quality-of-life consideration and should not be neglected. [ ] It can be so severe that special itch-targeted therapies may need to be devised. Mogamulizumab, a CCR4

2014 eMedicine.com

193. Migraine Headache: Pediatric Perspective (Treatment)

and vegetables. Medications Over-the-counter (OTC) and prescription medications can trigger or exacerbate migraines. Excessive use of OTC pain medications and analgesics can cause occasional migraine attacks to convert to analgesic-abuse headaches or drug-induced refractory headaches. Drugs that can increase migraine frequency include the following: Cimetidine Estrogen Histamine Hydralazine Nifedipine Nitroglycerin Ranitidine Reserpine Advise patients to avoid frequent or long-term use of nonsteroidal anti (...) examination findings should be completely normal. Appropriate follow-up evaluations are necessary for patients with any of the following: Abnormal vital signs Nuchal rigidity Cranial nerve abnormalities Macrocephaly Bruits Papilledema Cutaneous lesions Cognitive changes Asymmetrical signs Previous Next: Associated Diseases and Differentials Headache may be a presenting symptom of a benign condition or a life-threatening disorder. The patient's medical history and physical examination findings often

2014 eMedicine.com

194. Uveitis, Evaluation and Treatment (Treatment)

spondyloarthropathies HLA-B27, sacroiliac films Aphthous ulcers Behçet disease HLA-B5, HLA-B51 Postsurgical, posttraumatic Infectious endophthalmitis Vitreous tap, vitrectomy Medication induced Rifabutin None None Idiopathic Possibly HLA-B27 Moderate severity of pain and redness Shortness of breath, African descent, subcutaneous nodules Sarcoidosis Serum ACE, lysozyme, chest radiograph or chest CT scan, gallium scan, biopsy Posttraumatic Traumatic iritis ... Increased IOP, sectorial iris atrophy, corneal dendrite (...) Herpetic iritis ... Poor response to steroid, manifestations of 2° or 3° syphilis, HIV Syphilis Rapid plasma reagent (RPR) or VDRL, FTA-ABS Postcataract extraction, white plaque on posterior capsule Endophthalmitis, intraocular lens (IOL)- related iritis Vitrectomy and/or culture, consider anaerobic and fungal cultures Medication induced Etidronate (Didronel), metipranolol (OptiPranolol), latanoprost (Xalatan) History of HIV, alcohol abuse, exposure to infected individuals, residence in endemic regions

2014 eMedicine.com

195. Hypertriglyceridemia (Treatment)

hepatotoxic than immediate-release niacin but is better tolerated. [ ] Flushing, itching, and rash are expected adverse effects that are less common with long-acting formulations. These symptoms are an annoyance but are not life threatening and may be minimized by starting at low doses and increasing slowly. Switching from immediate-release niacin to an equal dose of time-release preparation has been reported to cause severe hepatotoxicity. Niacinamide, also called vitamin B-3, has no lipid-lowering (...) risk equivalent in whom optimal statin therapy has been achieved. However, the FDA withdrew approval for this indication when the agency found that, in light of several large trials, "scientific evidence no longer supports the conclusion that a drug-induced reduction in triglyceride levels and/or increase in HDL-cholesterol levels in statin-treated patients results in a reduction in the risk of cardiovascular events." [ , ] A review of gemfibrozil, fenofibrate, and bezafibrate described

2014 eMedicine.com

196. Liver Disease and Pregnancy (Treatment)

-threatening condition often develops in the second half of pregnancy (range: 27-40 weeks' gestation), usually close to term, with a reported mean gestational age of 36 weeks (see the calculator), but AFLP may not be diagnosed until the postpartum period. The differential diagnosis includes fulminant , drug-induced hepatic toxicity, i , adult-onset Reye syndrome, and . Risk factors No clear geographic or racial predisposition for AFLP exists. Risk factors include older maternal age, primiparity, multiple (...) insulin sensitivity and increased baseline cortisol levels in the children of mothers with severe hyperemesis compared to those in the control group. [ ] The lifelong effect of this difference in still unknown, but it may place these children at higher risk for type 2 diabetes and cardiovascular disease. Previous Next: Acute Fatty Liver of Pregnancy The prevalence of , in which microvesicular fatty infiltration of the liver can lead to liver failure, [ ] is 1 per 10,000-15,000 pregnancies. This life

2014 eMedicine.com

197. Nonlaser Hair Removal Techniques (Treatment)

, abdomen) caused by excess androgens in women [ , , , ] Hypertrichosis: Congenital or drug-induced increase in hair growth in areas that are not androgen dependent; occurs in both men and women Pseudofolliculitis (second image below): Hair growth from grafted donor sites, preoperative hair removal, and sex-change operations performed in men The third image below depicts the anatomy of a hair follicle. Woman with hirsutism. Man with pseudofolliculitis barbae on his neck. Anatomy of a hair follicle. Many (...) not be performed on moles, warts, or irritated, sunburned, or broken skin. Pay special attention to the temperature of wax to avoid burning skin. Adverse effects from waxing include pain, hyperpigmentation, scarring, folliculitis, and ingrown hair pseudofolliculitis. A life-threatening Streptococcus pyogenes and herpes simplexvirus infection of the external genitalia occurred in a 20-year-old diabetic woman following a routine perineal "Brazilian" bikini wax. [ ] Additionally, while the pathogenesis

2014 eMedicine.com

198. Nonneoplastic Epithelial Disorders of the Vulva (Treatment)

nigricans Acanthosis nigricans is a diffuse pigmentary change typically observed in intertriginous areas and skin folds. It may be hereditary, drug induced, or associated with obesity or endocrine diseases. [ ] It sometimes represents a paraneoplastic syndrome, revealing associated malignant epithelial tumors or lymphoproliferative disorders. Lentigo, lentiginosis, and benign vulvar melanosis Lentigo, lentiginosis, and benign vulvar melanosis are characterized by benign epidermal melanocytic hyperplasia (...) dermatitis consists of a subacute or chronic, symmetric, and ill-defined eczematous rash, usually involving the labia majora and, less frequently, the labia minora and inner thighs. The eruption is characterized by mild erythema, dryness, and fine scaling. Itching and burning are common symptoms. Excoriation secondary to repeated scratching may cause bacterial superinfection with honey-colored crusting and, in chronic forms, lichenification. In some patients, the itch-scratch-itch cycle may gradually

2014 eMedicine.com

199. Neutropenia (Overview)

, namely neutrophils, eosinophils, and basophils. However, the term granulocytopenia is often used synonymously with neutropenia and, in that sense, is again confined to the neutrophil lineage alone. The risk of serious infection increases as the absolute neutrophil count (ANC) falls to the severely neutropenic range (< 500/µL). The duration and severity of neutropenia directly correlate with the total incidence of all infections and of those infections that are life threatening. Tuberculosis (see (...) if infection has been present Painful aphthous ulcers in the oral cavity Swollen and tender gums See for more detail. Diagnosis Previous to a major workup, rule out infectious and drug-induced causes of neutropenia; then, obtain the following laboratory studies: Complete blood count: Including a manual differential in evaluating cases of agranulocytosis Differential white blood cell count Peripheral smear review by a pathologist The following studies are applicable in some patients with neutropenia

2014 eMedicine.com

200. Oral Manifestations of Systemic Diseases (Overview)

, purpura, paraneoplastic pemphigus, Sweet syndrome) or therapy-induced lesions (eg, drug reactions, graft vs host disease). [ , ] Oral manifestations are more common in acute leukemias than in chronic leukemias. [ ] Gingival hypertrophy and hyperplasia are most commonly associated with acute myelogenous leukemia and acute promyelocytic leukemia. [ ] The gingiva are friable, edematous, and erythematous. [ , ] Thrombocytopenia commonly manifests as petechiae and ecchymoses on the mucosal surfaces (...) counts. [ , , ] These failures lead to transient recurrent fevers, malaise, and recurrent infections that may be life threatening. [ ] Onset of symptoms occurs in childhood and may improve as the patient approaches adulthood. [ ] Cutaneous manifestations are generally due to poor immune function and include skin infections and abscesses. [ ] Oral manifestations are present in over 90% of patients with cyclic neutropenia. [ ] In one series, investigators found that 94% have recurrent ulcers similar

2014 eMedicine.com

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