Analysis of the clinical features and prognostic influencing factors of toxic epidermal necrolysis

Abstract

Objective: To investigate the clinical features and prognostic influencing factors of toxic epidermal necrolysis (TEN). Methods: A retrospective observational study was conducted. From January 2008 to March 2019, a total of 46 TEN patients who met the inclusion criteria were admitted to Guangdong Provincial People's Hospital. The gender, age, and admission diagnosis of the 46 patients, the category of department of patients complicated with sepsis, death ratio of the sepsis patients with or without treatment history in intensive care unit (ICU)/department of burns and wound repair, and the cause of death of the deceased patients were recorded. Depending on whether complicated with sepsis, the patients were divided into sepsis group (32 cases) and non-sepsis group (14 cases). According to whether died or not, the patients were divided into death group (9 cases) and survival group (37 cases). The specific conditions of suspected pathogenic agents and combined basic diseases, the transaminase/bilirubin abnormality and creatinine and platelet count levels in blood on admission, and the detection of pathogenic microorganisms and drug resistance during the course of disease of patients were recorded in both sepsis group and non-sepsis group. The gender, age, lesion area, severity of illness score for TEN (SCORTEN) system score, combined basic diseases, blood microbial culture positivity, hormone use, and gamma globulin use of patients between sepsis group and non-sepsis group, death group and survival group were compared respectively. Data were statistically analyzed with chi-square test, Fisher's exact probability test, and Mann-Whitney U test. The factors with statistical significant differences between sepsis group and non-sepsis group, death group and survival group were selected for binary multivariate logistic regression analysis, so as to screen the independent risk factors affecting sepsis and death in TEN patients. Results: Of the 46 TEN patients, 30 were male and 16 were female, aged from 8 months to 92 years, with 11 cases (23.91%) of epidermolysis bullosa, 9 cases (19.57%) of exanthemative dermatitis, 9 cases (19.57%) of TEN, 7 cases (15.22%) of epidermolysis bullosa, 6 cases (13.04%) of Stevenss-Johnson syndrome, and 4 cases (8.70%) of severe drug rash for admission diagnosis. The patients complicated with sepsis were admitted to 11 departments, and the death ratio of patients with treatment history in ICU/department of burns and wound repair was similar to that of patients without such department treatment history (P>0.05). All the dead patients were complicated with sepsis, and the main cause of death was sepsis. On admission, the suspected pathogenic agents of patients in sepsis group were mainly allopurinol (11 cases) and non-steroidal anti-inflammatory drugs (4 cases), while those in non-sepsis group were allopurinol (3 cases) and psychotropic drugs (3 cases). Patients in sepsis group combined as many as 10 kinds of basic diseases, while those in non-sepsis group combined only 4 kinds of basic diseases. The proportions of patients with increased creatinine (χ2=13.349, P 0.05). A wide variety of pathogens were detected in the blood, respiratory tract secretions, and skin secretions of 21 patients in sepsis group, and 14 patients were infected with drug-resistant bacteria; among the 9 strains cultured from the blood samples, 8 were drug-resistant bacteria and 6 were Gram-positive bacteria. In non-sepsis group, pathogens were detected in blood, respiratory tract secretions, and skin secretions of 8 patients, with fewer species, and 6 patients were infected with drug-resistant bacteria. The gender, age, lesion area, blood microbial culture positivity, hormone use, and gamma globulin use of patients in sepsis group were similar to those of non-sepsis group (P>0.05). The proportion of patients combined with basic diseases and SCORTEN system score of patients in sepsis group were significantly higher than those in non-sepsis group (χ2=4.493, 7.222, P 0.05). The age and SCORTEN system score of patients in death group were significantly higher than those in survival group (χ2=4.412, 11.627, P<0.05 or P<0.01). The SCORTEN system score was an independent risk factor affecting sepsis and death in TEN patients (odds ratio=3.025, 2.757, 95% confidence interval=1.352-6.769, 1.244-6.110, P<0.05 or P<0.01). Conclusions: The diagnosis of TEN is difficult on admission. Male population is susceptible to TEN, and allopurinol is the common pathogenic agent. The proportion of patients combined with basic diseases is high in TEN patients complicated with sepsis, with mainly drug-resistant bacteria and mostly Gram-positive bacteria in blood-borne infections. The died patients are older than the survival, and the main cause of death is sepsis. The SCORTEN system score is an independent risk factor affecting sepsis and death in TEN patients.