Possible involvement of CD14+ CD16+ monocyte lineage cells in the epidermal damage of Stevens-Johnson syndrome and toxic epidermal necrolysis

Background Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are characterized by keratinocyte apoptosis and necrosis, resulting in epidermal detachment. Although monocytes abundantly infiltrate the epidermis in SJS/TEN skin lesions, the properties and functions of these cells have not been fully examined. Objectives To determine the properties of monocytes infiltrating into the epidermis in SJS/TEN. Methods Immunostaining of skin sections was performed to examine the membrane markers of monocytes infiltrating into skin lesions. Results Immunostaining of cryosections from 11 SJS/TEN skin lesions revealed numerous CD14+ monocytes located along the dermoepidermal junction and throughout the epidermis. The cells coexpressed CD16, CD11c and HLA‐DR. CD14+ CD16+ cells were identified in very early lesions without epidermal damage, suggesting that their infiltration is a cause, rather than a result, of epidermal damage. Moreover, these cells expressed CD80, CD86 and CD137 ligand, indicative of their ability to facilitate the proliferation and cytotoxicity of CD8+ T cells. CD16+ cells infiltrating the epidermis and detected at the dermoepidermal junction were immunostained and counted in paraffin‐embedded skin sections obtained from 47 patients with drug rash manifested as TEN, SJS, maculopapular‐type rash or erythema multiform‐type rash. The number of CD16+ monocytes infiltrating the epidermis increased significantly, depending on the grade of epidermal damage. Conclusions These findings suggest that the appearance of CD14+ CD16+ cells of monocyte lineage plays an important role in the epidermal damage associated with SJS/TEN, most probably by enhancing the cytotoxicity of CD8+ T cells.     

CD8+ lymphocytes in the blister fluid of severe acute cutaneous graft-versus-host disease: further similarities with toxic epidermal necrolysis.

BACKGROUND: Graft-versus-host disease (GvHD) remains the major toxicity of allogeneic bone marrow transplantation (BMT). In the acute form of the disease, the differential diagnosis includes viral rash and drug eruptions. METHODS: We report two patients with chronic myeloid leukemia submitted to allogeneic BMT who developed a severe form of acute cutaneous GvHD, with clinical and histological pictures mimicking toxic epidermal necrolysis (TEN). RESULTS: We found a predominance of peripheral CD8+ T lymphocytes and, at the same time, studying the cellular profile of the blister fluid, just in the beginning of blister eruption, we also found a high proportion of CD8+ T lymphocytes, mainly CD8+CD57-. CONCLUSION: These data are in agreement with previous reports of the presence of CD8+ T cells in the blister fluid of patients with TEN, further emphasizing similar immunoinflammatory pathways in both diseases.     

Granzyme-B-containing lymphocyte involvement in epidermal injury in graft-versus-host disease

BACKGROUND: Skin lesions from graft-versus-host disease (GVHD) show histological features of epidermal cell death with lymphocyte infiltration. Perforin and granzyme B are involved in the process of apoptosis induced by cytotoxic T lymphocytes (CTL). OBJECTIVE: To elucidate the role of CTL in the mechanism of epidermal injury in GVHD. METHODS: We studied immunohistochemical staining for granzyme B and perforin in the skin lesions of 8 patients who developed GVHD after bone marrow transplantation. RESULTS: Granzyme-B-positive lymphocytes were CD8 positive and were observed in the epidermis of 3 out of 6 specimens in acute GVHD, and of 5 specimens of chronic GVHD except for 1 sclerotic type in which it was negative. Perforin-positive lymphocytes were observed in the epidermis of the specimens from 1 acute and 1 chronic GVHD. CONCLUSIONS: Granzyme B derived from CTL may be involved in the mechanisms of epidermal injury in GVHD.     

Carbamazepine ('Tegretol') and toxic epidermal necrolysis: report of three cases with histopathological observations

Three patients who developed toxic epidermal necrolysis whilst receiving carbamazepine are described. Two patients experienced severe oropharyngeal ulceration and extensive cutaneous necrolysis with subsequent transient alopecia, nail shedding and persistent ulceration of the tongue. Histology of the skin revealed changes resembling those found in not only erythema multiforme and toxic epidermal necrolysis but also homograft rejection and the acute graft-versus-host reaction, suggesting that cutaneous damage was mediated by ‘aggressor lymphocytes’ sensitized to epidermal cells.     

Clinical, histological, and immunohistological studies of postoperative erythroderma

We report 7 cases of acute fatal illness characterized by fever, diffuse erythematous rash, and progressive leukopenia occurring 10 days after surgical operation. The outcome was uniformly fatal. The biopsy findings consisted of eosinophilic individual necrosis of epidermal cells, satellite cell necrosis, basal liquefaction degeneration, and scanty cell infiltration into the dermis. T lymphocytes were found in the epidermis but Langerhans cells disappeared. These findings are compatible with acute graft-vs-host disease following blood transfusion. Explanations based upon drug allergy, infection, toxic shock syndrome, or toxic epidermal necrolysis seem less reasonable.     

Immunohistochemistry of cutaneous graft-versus-host disease after allogeneic bone marrow transplantation

Graft-versus-host disease (GVHD) is an immunologically mediated disease occurring most frequently after allogeneic bone marrow transplantation. The aim of this study was to evaluate the contribution of immunohistochemistry in the diagnosis of cutaneous GVHD. Patients transplanted for either leukemia or beta-thalassemia were included in the study. Skin lesions of acute and chronic GVHD were examined both by direct immunofluorescence to detect immunoglobulin deposits and by an avidin-biotin-peroxidase complex technique to evaluate the inflammatory cell infiltrate. Epidermal and dermal fluorescent bodies (IgG and IgM) were frequently found in both acute and chronic GVHD. Most of the infiltrating cells were CD3+ T lymphocytes, with CD8+ cells representing the major cell population invading the epidermis both in acute GVHD and in chronic lichenoid GVHD. A small proportion of the dermal cells were CD14+ macrophages; no B cells were detected. HLA-DR, but not HLA-DQ antigens, were variably expressed by keratinocytes in all cases of acute GVHD and in chronic lichenoid GVHD. KL-1, a monoclonal antikeratin antibody specific for the 56.5 KD acidic polypeptide usually present in suprabasal keratinocytes, stained all epidermal layers, including the basal layer. Langerhans cells were dramatically reduced in number in the epidermis of both acute and chronic lichenoid GVHD. It is concluded that immunohistologic analysis may be supportive in the diagnosis of acute and early chronic lichenoid cutaneous GVHD.     

A Case of Chronic GVHD Following Bone Marrow Transplantation from a Phenotypically HLA-Matched Unrelated Donor

A 45-year-old male with chronic myelocytic leukemia who received a bone marrow transplantation from a phenotypically HLA-matched unrelated donor developed chronic GVHD on day 100 post transplantation. He developed a slight fever, malaise, hepatic dysfunction and extensive itchy erythema with scaling over his entire body. The inflammatory skin lesion developed into erythroderma in about two weeks. H&E staining of a skin biopsy revealed eosinophilic bodies and a lymphocytic infiltration in the dermis and epidermis, which were compatible with the early phases of chronic GVHD. Immunohistochemistry revealed that keratinocytes expressed dense HLA-DR and ICAM-1 epitopes. Langerhans cells (CD1a⁺ cells) had disappeared from the epidermis. Many T cells (CD3⁺ cells) had migrated into the epidermis as well as into the reticular dermis. The majority of the T cells in the epidermis were CD8⁺ cells, while almost all the T cells in the dermis were CD4⁺ cells. These immunohistochemical features were similar to those previously reported for acute cutaneous GVHD. Despite the corticosteroid therapy, the eruptions did not disappear. The patient was then treated with whole body bath-methoxsalen (Oxsoralen®) plus ultraviolet A (UVA). The bath-psoralen plus UVA therapy was effective in this patient.     

Graft-versus-host disease-like syndrome following blood transfusion in a patient with duodenal ulcer

Graft-versus-host disease (GVDH)-like syndrome occurred in a 45 year-old man with duodenal ulcer who had received a transfusion of 8 units of packed red blood cells. Clinical features included high fever, macropapular rash, hepatic dysfunction, pancytopenia and, finally, fatal septicemia. A skin biopsy obtained from the chest revealed satellite cell necrosis of epidermal cells, mononuclear cell infiltrate of the upper dermis and epidermis, and vacuolar degeneration of basal cells. Autopsy bone marrow was aplastic. The occurrence of GVHD in immunologically normal individuals following blood transfusion is extremely rare.     

Common histopathological processes of phenytoin drug eruption.

Fifteen patients (6 males and 9 females) with phenytoin drug eruptions which ultimately resulted in various skin manifestations were analyzed histopathologically. The following types of skin manifestations were noted; 2 cases of toxic epidermal necrolysis, 2 cases of mucocutaneous ocular syndrome, 6 cases of erythema exudative multiform, 3 cases of lichenoid, and 2 cases of the maculopapular type. All of the biopsied specimens from these different skin manifestations exhibited some of the more common histopathological findings: 1) adhesion of the infiltrated cells to the basal layer of the epidermis, 2) cell infiltration into the epidermis, 3) vacuolation of the basal cells, 4) dyskeratotic cells in the epidermis, and epidermal necrosis. Immunohistopathological examinations in 5 typical cases with different skin manifestations revealed that epidermal cells and infiltrating cells were HLA-DR antigen positive. The infiltrating cells in the dermis consisted of almost equal numbers of CD4+ and CD8+ cells; CD8+ cells were predominant in the cells infiltrating into the epidermis. These findings suggest a possibility that the various clinical features in phenytoin drug eruptions may share some common mechanisms.     

Isomorphic cutaneous graft-versus-host disease reaction after ultraviolet exposure: clinical, histological and direct immunofluorescence studies of four allo-transplanted patients

Background  Acute and chronic graft-versus-host disease (GVHD) continues to be a major limitation to successful haematopoietic stem cell transplantation. If experimental studies and clinical observations could partially elucidate the pathophysiology of acute GVHD, the biology of chronic GVHD is still much less well understood.
Objectives  The aim of this study is to describe a peculiar photoinduced rash which triggered acute and then chronic lesions of GVHD in four allogenic haematopoietic-transplated patients and discuss the possible aetiology and treatment.
Patients/methods  Four patients, two children and two adults affected by either mild or severe chronic GVHD, developed an erythematous rash on sun- or narrow-band ultraviolet B-exposed area, which triggered the onset of acute lesions of GVHD. Any of the patients presented neither a history of photosensitivity nor circulating autoantibodies nor urinary/fecal porphyrine.
Results  The histopathologic findings were characterized by an interface dermatitis with sparse perivascular infiltrate of lymphocytes and scattered necrotic keratinocytes, especially in the upper part of epidermis. Direct immunofluorescence studies excluded lupus-like pattern, revealing nests of fluorescent bodies at the dermal–epidermal junction and in papillary dermis.
Conclusions  This peculiar isomorphic reaction of cutaneous GVHD after sun or narrow-band ultraviolet B exposures is described, and the possible mechanism involved is discussed. It may represent an interesting model of progression of chronic GVHD, starting with an acute stage and ending up with chronic clinical and histological findings, especially considering that there is no animal model that fully replicates all of the features of chronic GVHD in humans.

Conflicts of interest

None declared.     

Toxic Epidermal Necrolysis Possibly Linked to Hyperacute Graft-versus-Host Disease after Allogeneic Bone Marrow Transplantation

Toxic epidermal necrolysis (TEN) is a severe blistering skin disease of high mortality. TEN may occur after bone marrow transplantation (BMT). In such cases, TEN have been attributed to graft-versus-host disease (GVHD) or an adverse drug reaction. It is very difficult to distinguish the causes of TEN after BMT. We report a 21-year-old Japanese man who developed TEN eight days after BMT, evaluate the differential diagnosis of hyperacute GVHD and an adverse drug reaction, and deduce that hyperacute GVHD was the more likely pathogenesis of TEN in this patient.     

Involvement of macrophages in the pathology of toxic epidermal necrolysis

In toxic epidermal necrolysis (TEN), as in the 'epidermal type' of erythema multiforme, the necrotic epidermis is infiltrated with mononuclear cells. We studied the epidermal infiltrate in seven cases of TEN. About half the cells obtained from pieces of cleaved epidermis dissociated by trypsin were non-epithelial. On cytologic analysis, 80% of these foreign cells exhibited markers of macrophages, 15% were granulocytes and only 5% were lymphocytes (almost exclusively OKT8 T lymphocytes). Semi-thin sections of early prenecrotic lesions showed exocytosis of mononuclear cells within the epidermis with features of satellite cell necrosis and formation of colloid bodies. Almost all these mononuclear cells were macrophages as evidenced by endogenous peroxidase-positive granules. These findings suggest that some kind of macrophage-mediated cytotoxicity may play a role in the necrosis of epidermal cells during TEN.     

Numerical, morphological and phenotypic changes in Langerhans cells in the course of murine graft-versus-host disease

BACKGROUND: In the course of graft-versus-host disease (GVHD) or diseases that histologically mimic GVHD (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome), it is known that epidermal Langerhans cells (LCs) are depleted from the epidermis. However, the mechanism and significance of LC depletion is not well known. OBJECTIVES: To investigate the numerical, morphological and phenotypic changes in LCs and apoptosis of LCs in the course of GVHD using a non-irradiated mouse GVHD model. METHODS: BALB/c nu/nu mice and C57BL/6 mice were used as recipients and donors, respectively. Recipient mice were injected with T-cell-enriched donor spleen cells. Skin samples were harvested at various times after the inoculation. The numerical and morphological changes were examined by an immunofluorescence study of epidermal sheets. Apoptosis was studied by the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labelling method and flow cytometric analysis using annexin V. Phenotypic change was studied by flow cytometric analysis of epidermal cell suspensions. The mixed epidermal cell lymphocyte reaction (MELR) was performed to examine functional changes in the epidermal cells. RESULTS: Five days after inoculation, a graft-versus-host reaction occurred. Epidermal LCs began to decrease from the sixth day. On the fifth day, the LCs became larger and had prominent dendrites. Immediately before the LCs began to decrease, many LCs became round in shape, with scanty dendrites. LC apoptosis was not observed in the epidermis either on the fifth or seventh day. Phenotypically, the expression of CD40, CD80, CD86 and major histocompatibility complex class II antigen on the LCs was upregulated on the fifth and seventh day. Epidermal cells from GVHD mice showed an increased allostimulatory capacity in the secondary MELR. CONCLUSIONS: These results suggest that at early GVHD onset, most LCs may not undergo apoptosis in the epidermis but are phenotypically activated, resulting in further activation of alloreactive T cells and aggravation of the disease.     

Correlations between clinical patterns and causes of erythema multiforme majus,Stevens-Johnson syndrome,and toxic epidermal necrolysis: results of an international prospective study

BACKGROUND: It was proposed that Stevens-Johnson syndrome and toxic epidermal necrolysis differed from erythema multiforme majus by the pattern and localization of skin lesions. OBJECTIVE: To evaluate the validity of this clinical separation. DESIGN: Case-control study. SETTINGS: Active survey from 1989 to 1995 of 1800 hospital departments in Europe. PATIENTS: A total of 552 patients and 1720 control subjects. METHODS: Cases were sorted into 5 groups (erythema multiforme majus, Stevens-Johnson syndrome, Stevens-Johnson syndrome-toxic epidermal necrolysis overlap, toxic epidermal necrolysis, and unclassified erythema multiforme majus or Stevens-Johnson syndrome) by experts blinded as to exposure to drugs and other factors. Etiologic fractions for herpes and drugs obtained from case-control analyses were compared between these groups. RESULTS: Erythema multiforme majus significantly differed from Stevens-Johnson syndrome, overlap, and toxic epidermal necrolysis by occurrence in younger males, frequent recurrences, less fever, milder mucosal lesions, and lack of association with collagen vascular diseases, human immunodeficiency virus infection, or cancer. Recent or recurrent herpes was the principal risk factor for erythema multiforme majus (etiologic fractions of 29% and 17%, respectively) and had a role in Stevens-Johnson syndrome (etiologic fractions of 6% and 10%) but not in overlap cases or toxic epidermal necrolysis. Drugs had higher etiologic fractions for Stevens-Johnson syndrome, overlap, or toxic epidermal necrolysis (64%-66%) than for erythema multiforme majus (18%). Unclassified cases mostly behaved clinically like erythema multiforme. CONCLUSIONS: This large prospective study confirmed that erythema multiforme majus differs from Stevens-Johnson syndrome and toxic epidermal necrolysis not only in severity but also in several demographic characteristics and causes.     

Lyell syndrome in Senegal: responsibility of thiacetazone

INTRODUCTION: Toxic epidermal necrolysis is a severe disease often leading to death or to mucosal, particularly ocular, after effects. The principle drugs responsible are antibacterial sulfonamides, anti-epileptics, non-steroid anti-inflammatories, allopurinol and chlormezanone. We report a series of 38 cases of toxic epidermal necrolysis, observed in Dakar, imputable to thiacetazone and lethal in 60 percent of cases. PATIENTS AND METHODS: Our study was retrospective. Diagnosis of toxic epidermal necrolysis was made in patients presenting more than 30 p. 100 of the epidermis of their total body surface stripped off, multi-orificial mucosal damage and epidermal necrosis revealed on histological examination. Drug imputability was established on classical criteria. Treatment was composed of reanimation and antibiotics. RESULTS: Among the 38 cases of toxic epidermal necrolysis counted, 24 were imputable to thiacetazone. All the patients presented typical clinical features, confirmed histologically. Evolution was lethal in 60 p. 100 of cases. The causes of death were frequently hypovolemic shock during the first week and septic shock during the second. The deceased were generally aged over 50, had more than 50 p. 100 of total epidermis stripped off, presented evolving tuberculosis at the time of the accident and HIV infection at the AIDS stage. After effects were vaginal synechia and 2 cases of blindness. COMMENTS: Our series is exceptional in that a) the drug responsible: thiacetazone, an economic tuberculostatic of minor efficacy, was systematically introduced after 2 months of intensive treatment with 4 major anti-tuberculosis agents; b) the 60 percent mortality rate, two-fold greater that that usually observed. Other than the known elements of poor prognosis in our patients, the treatment conditions of this dermatological emergency explain this high rate of mortality.     

T-cell subsets in drug-induced toxic epidermal necrolysis. Possible pathogenic mechanism induced by CD8-positive T cells

A patient with bromisovalum-induced toxic epidermal necrolysis showed pronounced delayed hypersensitivity to bromisovalum by patch testing. Biopsy specimens from the cutaneous lesion and the site of the positive patch test reaction were analyzed and compared immunohistologically. The findings were similar: most of the mononuclear cells disposed along the dermoepidermal junction and migrating into the epidermis were CD8-positive lymphocytes, whereas the dermal inflammatory infiltrates were composed predominantly of CD4-positive lymphocytes. This case showed the potential usefulness of patch testing in evaluating cases of toxic epidermal necrolysis. We believe that delayed hypersensitivity plays a crucial role in the development of drug-induced toxic epidermal necrolysis. Furthermore, potential effector cells with phenotypic characteristics of CD8-positive lymphocytes (suppressor/cytotoxic T cells) seem to represent important mediators of the epidermal damage of the cutaneous lesion in our case.     

Increased interleukin 10, tumor necrosis factor alpha,and interleukin 6 levels in blister fluid of toxic epidermal necrolysis

BACKGROUND: Toxic epidermal necrolysis is a severe, usually drug-induced disease that shares clinical, histologic, and immunologic similarities with the severe forms of cutaneous acute graft-versus-host disease. OBJECTIVE: Our purpose was to further characterize common immune-inflammatory pathways in these skin disorders by measurement of different cytokines. METHODS: Evaluation of serum levels of interleukin 10 (IL-10), tumor necrosis factor alpha, IL-6, and soluble IL-6 receptor in the early phase of both diseases and in blister fluid of toxic epidermal necrolysis. RESULTS: Serum levels of IL-10 and IL-6 were significantly higher in patients with toxic epidermal necrolysis (P =.0001) and acute graft-versus-host disease (P =.001) compared with those of blood donors. We found an increase in IL-6 levels in blister fluid and significantly higher levels of IL-10 (P =.018) and tumor necrosis factor alpha (P =.028) in blister fluid compared with serum in patients with toxic epidermal necrolysis. CONCLUSION: A similar serum cytokine profile of toxic epidermal necrolysis and acute graft-versus-host disease further emphasizes common immunologic mechanisms. The presence of inflammatory cytokines, IL-6 and tumor necrosis factor alpha, in the blister fluid of patients with toxic epidermal necrolysis is associated with significantly higher levels of IL-10, which through its down-regulatory role, may be involved in limitation of the disease extension.     

Late appearance of acute graft-vs-host disease after suspending or tapering immunosuppressive drugs

BACKGROUND: Graft-vs-host disease (GVHD) is divided into acute and chronic phases based on time and clinical and histological features. The criterion of 100 days after transplantation for separating acute GVHD from chronic GVHD has been challenged on the following points: (1) the lichenoid rash of chronic GVHD may be observed as early as day 31 and acute GVHD may persist after day 100 in some cases, and (2) specific histological features do not consistently separate acute from chronic GVHD defined as the number of days after transplantation. However, the appearance of acute cutaneous GVHD after day 100 is not well established. OBSERVATIONS: Three patients developed a rash with clinical and histological features of acute GVHD between days 153 and 192 after allogeneic bone marrow transplantation or peripheral blood stem cell transplantation. In all patients, the late flare of acute GVHD occurred after tapering or suspending the immunosuppressive regimen with cyclosporine or corticosteroids, and was accompanied by stigmata of chronic GVHD in other target organs. CONCLUSIONS: The rash of acute GVHD may be observed as late as 192 days after transplantation, especially after tapering or suspending the immunosuppressive drugs, and should be considered in the differential diagnosis of late erythematous eruptions after transplantation.     

Toxic epidermal necrolysis: a study of 22 cases

Toxic epidermal necrolysis leads to extensive exfoliative epidermal slough, fever, systemic toxic reactions, conjunctivitis and severe mucous membrane involvement. As it evolves many other organs can be affected. Whether or not toxic epidermal necrolysis is the most severe form of erythema multiform is still a subject of discussion. The pathophysiological events involved are not well understood. Indirect evidence suggests a hypersensitivity reaction, but the search for potential immunological mechanisms has resulted in little data to support this hypothesis. Drug reactions remain the most common associated factor. Twenty-two patients, 3-84 years old, have been included in this retrospective study. In 15 patients, clinical evidence points to drugs as the most important cause of toxic epidermal necrolysis. Recent infections were implicated in three patients and ulcerative colitis and lymphoma in one case each. Symptomatic therapy included fluid replacement, nutritional support and local treatment. Steroids were administered in 13 patients, followed by plasmapheresis in three. The mortality rate was approximately 27%. Elderly patients and patients with extensive lesions were at greater risk. Results of immunofluorescence and immunoblot analysis were of no significant interest.     

Cutaneous adverse reactions to valdecoxib distinct from Stevens-Johnson syndrome and toxic epidermal necrolysis

OBJECTIVE: To assess the type of severe skin reactions caused by valdecoxib treatment. DESIGN: Case registry of severe skin reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. SETTING: All hospitals in Germany that treat patients with severe skin reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. PATIENTS: Five case notifications of Stevens-Johnson syndrome after the use of valdecoxib were reevaluated following the withdrawal of valdecoxib on April 7, 2005. RESULTS: A thorough review of all reported cases of severe skin reactions caused by valdecoxib revealed extensive erythematous, targetlike skin eruptions in addition to facial edema and dyspnea. Histologic changes, clinical pattern, and outcome demonstrated a distinct disease entity. CONCLUSION: Valdecoxib induces severe skin reactions different from those of Stevens-Johnson syndrome and toxic epidermal necrolysis in clinical and histopathologic findings, course, and outcome.