Reactions 1916, p218 - 23 Jul 2022 1

Glipizide/lisinopril/hydrochlorothiazide S

Toxic epidermal necrolysis: case report

A 48-year-old man developed toxic epidermal necrolysis during antihypertensive treatment with lisinopril/hydrochlorothiazide
and glipizide treatment for steroid induced hyperglycaemia [routes and dosages not stated].
The man presented to hospital with four day history of worsening desquamating rash on the lips, face, trunk, arms, legs and back.
Toxic epidermal necrolysis was suspected. A punch biopsy was performed. Subsequently, he was admitted. His medical history
included autoimmune hepatitis for which, he had been receiving prednisone daily. During the course of the treatment he developed
steroid induced hyperglycaemia. He then started receiving glipizide for hyperglycaemia. He had been also receiving
antihypertensive treatment with lisinopril/hydrochlorothiazide, started around one month prior to symptoms onset. Upon
admission, physical examination revealed dusky papules, plaques over the trunk, lips, face, bilateral lower and upper extremities
and genitals. Desquamation of 60–70% of total body surface area (TBSA) was noted. On day 2, her rash progressed with increased
sloughing of extremities and face. Pathological findings revealed full thickness epidermal necrosis and prominent dyskeratosis at all
epidermal levels. These findings were deemed consistent with toxic epidermal necrolysis [duration of treatment to reaction onset
not stated].
The man was operated for debridement on day 4. He received autologous skin cell suspension (ASCS) on the anterior surface,
circumferential right upper extremity and chitosan based chytoform gelling fiber dressing [Opticell] on posterior surface and left
upper extremity. Postoperatively, he developed iatrogenic pneumothorax on day 5. Later, he became febrile. He started receiving
empirical treatment with vancomycin, Flagyl and cefepime. Blood cultures revealed Staphylococcus aureus growth. Wound culture
revealed Staphylococcus aureus, Enterobacter cloacae, Pseudomonas aeruginosa and Klebsiella aerogenes growth. He received
unspecified antibiotic treatment. His toxic epidermal necrolysis specific severity of illness (SCORTEN) score was 5, indicating >90%
mortality. He received immune globulin [IVIG] on day 7. Epithelialization of large portion of the anterior wounds was observed on
day 10. Two days later, his condition progressed. On the following day, he received ASCS on the posterior surface and left upper
extremity. On day 18, his TBSA on back, thighs and buttocks was 12% open. On day 19, his TBSA was only 3% open. On the
following day, he was discharged with 2% TBSA open. Eventually, all the wounds were completely healed. At 14–day follow-up, he
was observed in ambulatory setting.
Pang A, et al. Autologous Skin Cell Suspension Application for Toxic Epidermal Necrolysis: A Case Report. Journal of Burn Care and Research 43: 508-513, No. 2, Mar
2022. Available from: URL: http://journals.lww.com/burncareresearch 803685030

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