Brief report
Nevirapine-induced toxic epidermal necrolysis and toxic hepatitis treated successfully with a combination of intravenous immunoglobulins and N-acetylcysteine

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Abstract

We describe a case of an HIV-seropositive patient presenting with a severe stomatitis that initially improved with anti-infective agents. Only 13 days after the onset of the stomatitis, the patient developed rapidly progressive constitutional symptoms and a cutaneous eruption. He was diagnosed with a Stevens–Johnson syndrome (SJS) caused by the antiretroviral drug nevirapine (NVP). Despite meticulous supportive care and withdrawal of all drugs, his situation worsened and developed into a toxic epidermal necrolysis (TEN), or Lyell's syndrome, complicated by a toxic hepatitis. Treatment with a novel combination of intravenous immunoglobulins (IVIG) and N-acetylcysteine (NAC) resulted in an exceptionally fast recovery. A literature research revealed no other cases of patients treated with both NAC and IVIG for the combination of TEN and toxic hepatitis. Because of the rapid clinical recovery, this approach merits further investigation. This case report also illustrates the importance of early suspicion of SJS when an HIV-infected patient treated with nevirapine presents with stomatitis.

Introduction

For HIV-infected patients, it is common practice to continue treatment despite mild side effects, such as mild rashes, which generally regress and disappear spontaneously after a few weeks [1]. We report on an HIV-positive patient with a rapidly progressive toxic epidermal necrolysis (TEN), combined with toxic hepatitis which was caused by nevirapine (NVP). Treatment with a novel combination of intravenous immunoglobulins (IVIG) and N-acetylcysteine (NAC) resulted in an exceptionally fast recovery.

Section snippets

Case report

A 39-year-old African male with known HIV infection presented at our emergency ward with a painful mouth and sore throat. The complaints had begun 1 week earlier. He had been using chlorhexidine mouthwash for 4 days without benefit. There were no other symptoms. On physical examination, a severe stomatitis was seen with hemorrhagic crusts and white nonadherent plaques but no visible necrotic lesions. There were no other mucocutaneous lesions and vital parameters were consistent with a mild

Discussion

SJS and TEN (or Lyell's syndrome) form part of a spectrum of drug-induced, life-threatening, blistering skin conditions. The spectrum is determined by the extent of skin detachment: less than 10% is defined as SJS, more than 30% as TEN with a gray zone in-between [2], [4]. Patients generally develop flu-like prodromal symptoms, like fever, sore throat, and malaise, usually within the first 2 months of causative therapy. After a few days, fever becomes persistent and mucocutaneous lesions

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