Toxic Epidermal Necrolysis: Does Immunoglobulin Make a Difference?

K. M. Brown, G. M. Silver, M. Halerz, P. Walaszek, A. Sandroni, Richard L. Gamelli

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142 Scopus citations

Abstract

Experimental evidence implicates Fas ligand-mediated keratinocyte apoptosis as an underlying mechanism of toxic epidermal necrolysis syndrome (TEN). In vitro studies indicate a potential role for immunoglobulin (Ig) therapy in blocking Fas ligand signaling, thus reducing the severity of TEN. Anecdotal reports have described successful treatment of TEN patients with Ig; however, no study to date has analyzed outcome data in a large series of patients treated with Ig using institutional controls. The SCORTEN severity-of-illness score ranks severity and predicts prognosis in TEN patients using age, heart rate, TBSA slough, history of malignancy, and admission blood urea nitrogen, serum bicarbonate, and glucose levels. A retrospective chart review was performed that included all patients treated for TEN at our burn center since 1997. Ig therapy was instituted for all patients with biopsy-proven TEN beginning in January 2000. Twenty-one TEN patients were treated before Ig (no-Ig group), and 24 patients have been treated with Ig. SCORTEN data were collected, as well as length of stay (LOS) and status upon discharge. Each patient was given a SCORTEN of 0 to 6, with 1 point each for age greater than 40, TBSA slough greater than 10%, history of malignancy, admission BUN greater than 28 mg/dl, HCO3 less than 20 mg/dl, and glucose greater then 252 mg/dl. Outcome was compared between patients treated with Ig and without Ig. Overall mortality for patients treated before Ig was 28.6% (6/21), and with Ig, mortality was 41.7%% (10/24). There was no significant difference in age or TBSA slough. The average SCORTEN between the groups was equivalent (2.2 in no-Ig group vs 2.7 in Ig group, P = 0.3), and no group of patients with any SCORTEN score showed a significant benefit from Ig therapy. Overall LOS as well as LOS for survivors was longer in the Ig group. This series represents the largest single-institution analysis of TEN patient outcome after institution of Ig therapy. Our data do not show a significant improvement in mortality for TEN patients treated with Ig at any level of severity and may indicate a potential detriment in using Ig. Ig should not be given to TEN patients outside of a clinical trial. A multicenter, prospective, double-blinded randomized trial is necessary and urgently indicated to determine whether Ig therapy is beneficial or harmful in the care of TEN patients.

Original languageEnglish (US)
Pages (from-to)81-88
Number of pages8
JournalJournal of Burn Care and Rehabilitation
Volume25
Issue number1
DOIs
StatePublished - Jan 1 2004

ASJC Scopus subject areas

  • Surgery
  • Nursing(all)
  • Emergency Medicine
  • Rehabilitation
  • Health Professions(all)

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    Brown, K. M., Silver, G. M., Halerz, M., Walaszek, P., Sandroni, A., & Gamelli, R. L. (2004). Toxic Epidermal Necrolysis: Does Immunoglobulin Make a Difference? Journal of Burn Care and Rehabilitation, 25(1), 81-88. https://doi.org/10.1097/01.BCR.0000105096.93526.27