Abstract
Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) is an acute inflammatory vesiculobullous reaction of the mucosa of the ocular surface, oral cavity, and genitals, and of the skin. Severe ocular complications (SOC) are observed in about half of SJS/TEN patients diagnosed by dermatologists and in burn units. Ophthalmologists treat SOC, and they tend to encounter the patients not only in the acute stage, but also in the chronic stage. Our investigation of the pathogenesis of SJS/TEN with SOC led us to suspect that abnormal innate mucosal immunity contributes to the ocular surface inflammation seen in SJS/TEN with SOC. We confirmed that cold medicines such as NSAIDs and multi-ingredient cold medications are the main causative drugs for SJS/TEN with SOC. Single nucleotide polymorphism (SNP) association analysis of cold medicine-related SJS/TEN with SOC showed that the Toll-like receptor 3 (TLR3)-, the prostaglandin-E receptor 3 (PTGER3)-, and the IKZF1 gene were significantly associated with SNPs and that these genes could regulate mucocutaneous inflammation including that of the ocular surface. We also examined the tear cytokines of SJS/TEN with SOC in the chronic stage and found that IL-8, IL-6, IFN-γ, RANTES, eotaxin, and MIP-1β were significantly upregulated in SJS/TEN with SOC in the chronic stage. Only IP-10 was significantly downregulated in SJS/TEN with SOC in the chronic stage. This mini-review summarizes the pathological mechanisms that we identified as underlying the development of SJS/TEN with SOC.
Highlights
Stevens-Johnson syndrome (SJS) is an acute inflammatory vesiculobullous reaction of the skin, the mucosa of the ocular surface, the oral cavity, and of the genitals; its severe phenotype is called toxic epidermal necrolysis (TEN).Ophthalmologists tend to encounter the patients in the chronic stage, they can find it difficult to differentiate between SJS and TEN because the vesiculobullous skin lesions present in the acute stage have healed, so they tend to report SJS and TEN with severe ocular complications (SOC) broadly as “ophthalmic SJS” [1].Pathogenesis of SJS/TEN With SOCApproximately half of all SJS/TEN patients diagnosed by dermatologists and in burn units presented with SOC, e.g., severe conjunctivitis with pseudomembrane and ocular surface epithelial defects in the acute stage [2]
We suggested that the suppression of PGE2 production by cold medicines might contribute to the pathogenesis and onset of CM-SJS/TEN with SOC [1, 4, 6, 8, 11, 22] because PGE2 acts on EP3 and negatively regulates mucocutaneous inflammation [24,25,26]
We found that CM-SJS/TEN with SOC was significantly associated with human leukocyte antigen (HLA)-B∗44:03 in Indianand Brazilian, especially Caucasian Brazilian patients, and HLA-A∗02:06 was associated with CM-SJS/TEN with SOC in Koreans [36]
Summary
Ophthalmologists treat SOC, and they tend to encounter the patients in the acute stage, and in the chronic stage. Our investigation of the pathogenesis of SJS/TEN with SOC led us to suspect that abnormal innate mucosal immunity contributes to the ocular surface inflammation seen in SJS/TEN with SOC. Single nucleotide polymorphism (SNP) association analysis of cold medicine-related SJS/TEN with SOC showed that the Toll-like receptor 3 (TLR3)-, the prostaglandin-E receptor 3 (PTGER3)-, and the IKZF1 gene were significantly associated with SNPs and that these genes could regulate mucocutaneous inflammation including that of the ocular surface. IP-10 was significantly downregulated in SJS/TEN with SOC in the chronic stage. This mini-review summarizes the pathological mechanisms that we identified as underlying the development of SJS/TEN with SOC
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