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and involvement of the oral&#44; ocular&#44; vaginal and perineal mucous membranes &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Additionally&#44; given the upper airway edema&#44; she was orotracheal intubated&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Under immunoglobulin therapy&#44; there was a clinical worsening&#44; with an increase in the body surface involvement&#44; from 85&#37; to 100&#37;&#46; In addition&#44; she developed multiorgan failure with hematological&#44; cardiovascular&#44; hepatic&#44; gastrointestinal and renal dysfunction&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On the eighth day of hospitalization&#44; the patient received a single infliximab dose &#40;5&#8201;mg&#47;kg&#44; EV&#41; and was started on a pulse of dexamethasone &#40;100&#8201;mg&#44; EV&#8201;&#215;&#8201;1&#47;day&#41; for three days&#46; After administration of infliximab and dexamethasone pulse&#44; the patient evolved favorably with the progressive resolution of multiorgan dysfunction&#44; and on the nineteenth day&#44; the patient presented epithelialization of the entire body surface&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">According to literature&#44; TEN is a severe idiosyncratic reaction&#44; mostly drug-induced&#46; It is characterized by a detachment of the skin and mucous membranes at the level of the dermis-epidermis junction as a result of the necrosis of keratinocytes&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of TEN is clinical&#46; It is characterized by a prodromal phase with flu-like symptoms that precede the appearance of mucocutaneous lesions&#46; The confirmation of the diagnosis involves a skin biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In patients with probable drug-induced TEN&#44; early diagnosis and immediate removal of the drug are essential to improve the prognosis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Apart from supportive care&#44; there is no established treatment&#46; However&#44; several immunosuppressants and immunomodulators have been used&#44; and although there are no adequate randomized studies&#44; some drugs have shown promise&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Corticosteroids were among the first drugs used&#59; however&#44; their use is currently controversial&#46; Although some studies demonstrate a worse prognosis&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> there are others that show benefits with the administration of high doses over a short period of time&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">IVIg used to be the most consensual therapy for the treatment of this syndrome&#46; However&#44; a meta-analysis published in 2012 concluded that this drug is not associated with a better prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">TNF-alpha inhibitors seem promising drugs in the treatment of TEN&#46; There are some case reports where a single dose of infliximab or etanercept interrupted the progression of the disease and induced regression of the skin lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In fact&#44; the case we reported is in line with these findings since the patient did not show any improvement after IVIg administration but had a great response to infliximab and high-dose dexamethasone&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0075" class="elsevierStylePara elsevierViewall">J&#226;nia Dara J&#225;come Pacheco&#58; Collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; management of case studies&#59; critical review of the manuscript&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Maria Rodrigues Viegas Ribeiro&#58; Critical review of the literature&#59; collection&#44; analysis&#44; and interpretation of data&#59; drafting and editing of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Catarina Sousa Duque Soares Queir&#243;s&#58; Critical review of the manuscript&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Maria F&#225;tima Cameira Martins Xambre&#58; Approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Letter
Therapeutic approach of Lyell syndrome with infliximab and dexamethasone pulse: report of a clinical case
Jânia Dara Jácome Pachecoa,
Autor para correspondência
jania_pacheco@hotmail.com

Corresponding author.
, Maria Rodrigues Viegas Ribeiroa, Catarina Sousa Duque Soares Queirósb, Maria Fátima Cameira Martins Xambrea
a Department of Anaesthesiology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
b Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Toxic Epidermal Necrolysis &#40;TEN&#41; is a rare&#44; life-threatening mucocutaneous disease&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 23-year-old female presented with TEN after treatment with diclofenac&#44; metamizole and etoricoxib&#46; She was febrile&#44; with oral&#44; ocular&#44; and perineal mucositis and a maculopapular rash involving an estimated body surface area of 20&#37;&#46; She was admitted to the dermatology department&#44; skin biopsies were collected&#44; and Intravenous Immunoglobulin &#40;IVIg&#41; was started&#46; However&#44; her clinical condition worsened&#44; so she was transferred to the burn unit&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Upon admission&#44; the patient had an extensive maculopapular rash&#46; There were also positive Nikolsky signs in her face&#44; back&#44; palms and feet soles&#44; and involvement of the oral&#44; ocular&#44; vaginal and perineal mucous membranes &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Additionally&#44; given the upper airway edema&#44; she was orotracheal intubated&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Under immunoglobulin therapy&#44; there was a clinical worsening&#44; with an increase in the body surface involvement&#44; from 85&#37; to 100&#37;&#46; In addition&#44; she developed multiorgan failure with hematological&#44; cardiovascular&#44; hepatic&#44; gastrointestinal and renal dysfunction&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On the eighth day of hospitalization&#44; the patient received a single infliximab dose &#40;5&#8201;mg&#47;kg&#44; EV&#41; and was started on a pulse of dexamethasone &#40;100&#8201;mg&#44; EV&#8201;&#215;&#8201;1&#47;day&#41; for three days&#46; After administration of infliximab and dexamethasone pulse&#44; the patient evolved favorably with the progressive resolution of multiorgan dysfunction&#44; and on the nineteenth day&#44; the patient presented epithelialization of the entire body surface&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">According to literature&#44; TEN is a severe idiosyncratic reaction&#44; mostly drug-induced&#46; It is characterized by a detachment of the skin and mucous membranes at the level of the dermis-epidermis junction as a result of the necrosis of keratinocytes&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of TEN is clinical&#46; It is characterized by a prodromal phase with flu-like symptoms that precede the appearance of mucocutaneous lesions&#46; The confirmation of the diagnosis involves a skin biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In patients with probable drug-induced TEN&#44; early diagnosis and immediate removal of the drug are essential to improve the prognosis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Apart from supportive care&#44; there is no established treatment&#46; However&#44; several immunosuppressants and immunomodulators have been used&#44; and although there are no adequate randomized studies&#44; some drugs have shown promise&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Corticosteroids were among the first drugs used&#59; however&#44; their use is currently controversial&#46; Although some studies demonstrate a worse prognosis&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> there are others that show benefits with the administration of high doses over a short period of time&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">IVIg used to be the most consensual therapy for the treatment of this syndrome&#46; However&#44; a meta-analysis published in 2012 concluded that this drug is not associated with a better prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">TNF-alpha inhibitors seem promising drugs in the treatment of TEN&#46; There are some case reports where a single dose of infliximab or etanercept interrupted the progression of the disease and induced regression of the skin lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In fact&#44; the case we reported is in line with these findings since the patient did not show any improvement after IVIg administration but had a great response to infliximab and high-dose dexamethasone&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0075" class="elsevierStylePara elsevierViewall">J&#226;nia Dara J&#225;come Pacheco&#58; Collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; management of case studies&#59; critical review of the manuscript&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Maria Rodrigues Viegas Ribeiro&#58; Critical review of the literature&#59; collection&#44; analysis&#44; and interpretation of data&#59; drafting and editing of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Catarina Sousa Duque Soares Queir&#243;s&#58; Critical review of the manuscript&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Maria F&#225;tima Cameira Martins Xambre&#58; Approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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