Toxic epidermal necrolysis complicated by multiple intestinal ulcers
Authors: Sakai Noriyasu , Yoshizawa Yusuke , Amano Akito , Higashi Naoyuki , Aoki Mikako , Seo Tsuguhiko , Suzuki Kenji , Tanaka Syuu , Tsukui Taku , Sakamoto Chouitsu , Arai Masanori , Yamamoto Yasuhiro , Kawana Seiji 
Published: September 2009

On 11 November 2001, a 30‐year‐old woman was treated by an emergency doctor for cold symptoms, including pyrexia and pain in the pharynx. She was prescribed norfloxacin (NFLX), acetaminophen, and tranexamic acid, as well as additional supporting medicines that she chose not to use. On the following day, the patient went to the outpatient unit of the department of internal medicine of a general hospital; she was admitted because of continuing fever. She was prescribed a combination medication for Bifidus bacillus containing mefenamic acid and aluminum hydroxide gel/magnesium hydroxide, as well as NFLX and teprenone, but erosions of her face appeared on 15 November, followed by erosions of the trunk on 17 November. She was suffering from inflammation and blisters over her whole body. She was diagnosed with toxic epidermal necrolysis (TEN) by the department of dermatology of the same hospital. The patient underwent steroid pulse therapy for 3 days from 17 November, which was not effective, and was transferred to our hospital on 22 November.

 In the initial examination, the patient's body was almost entirely covered with blisters, including her face, trunk, and both arms. Erosions were also present in her mouth, on the conjunctivae of both eyelids, and on her vulva (see Fig. 1). In addition, we recognized false membrane formation on the eyelid conjunctivae in both corneas. Abrasions covered 61% of the patient's body.

The patient's body was almost entirely covered with blisters, including her face (a), trunk (b), and both arms (c). Erosions were also present in her mouth, on the conjunctivae of both eyelids, and on her vulva

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 The patient's white blood cells were in the normal range, but impaired liver function and hyperbilirubinemia were recognized, and tests for various virus antibodies showed no meaningful increase.

 A skin biopsy was performed on the dot‐shaped erythema exudativum present on the patient's lower limb. This specimen revealed the formation of cuticle lower part blister eosinophil necrosis, and slight lymphocyte inflammation of blood vessel circumference of upper dermis (Fig. 2).

Skin biopsy specimen from the dot‐shaped erythema exsudativum present on the patient's right lower limb (hematoxylin and eosin stain)

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 The patient was diagnosed with TEN from the clinical features of acute and widespread epidermal sloughing, the clinical history, and pathologic findings of necrosis and dermoepidermal separation.

 She was treated three times with plasma exchange on 22, 23, and 26 November. In addition, the procedures recommended for second‐degree scalding burns were executed, using a burn bed and providing daily external treatment with a povidone iodine and polymyxin B sulfate ointment. Because the patient was not able to eat orally, intravenous hyperalimentation (IVH) management was conducted and antibiotics (fosfomycin, imipenem cilastatin, vancomycin) were administered for secondary infection prevention. The false membrane of the eye was removed. Epidermis formation resumed, and the patient gradually recovered, including recovery of her eyesight on the 14th disease day.

 Despite these recoveries, the patient's diarrhea persisted and there was blood in her stool. Therefore, intestinal and colon endoscopies were performed (Fig. 3). The endoscope was inserted to about 40 cm in the upper part of the jejunum, determined by the disappearance of the kerckring fold. A circular ulcer and general detachment of the villus were identified, as well as an edematous structure on the mucous membrane of the intestine. An examination of the colon revealed no active ulcers, but there was evidence of a healing ulcer. The patient was diagnosed with multiple small intestinal ulcers complicated by TEN. IVH management was performed again to treat the intestinal ulcers. The patient's diarrhea decreased slowly, and it had decreased to a single occurrence per day in early February 2002.

The endoscopic image showed multiple ulcers of the intestine. A circular ulcer, the general detachment of the villus, the disappearance of the kerckring fold, and an edematous structure on the mucous membrane of the intestine were revealed

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 Fluid food was initiated on 4 February. Ileus was recognized shortly thereafter and ingestion was stopped temporarily on 9–13 February, and then reintroduced gradually. Improvement of the ulcer was confirmed by endoscopic findings on 8 March and, by the end of March, the patient was able to take foods orally.

 In addition to the above conditions, pleurisy of the left side was found in December. Thoracentesis and bronchoscopy were performed, but no cause was found. Because the patient's symptoms were slight, it was decided to keep her under observation for pleurisy.

 The patient left the hospital on 18 April. She no longer needed medication at that time. She was investigated by lymphocyte stimulation and by scratch‐patch test; however, all the medicines used were negative by these tests.