Cephradine-Induced Toxic Epidermal Necrolysis: A Case Report of Treatment With Etanercept

Abstract

Toxic epidermal necrolysis (TEN) is a rare yet life-threatening severe cutaneous adverse reaction (SCAR) to various causative agents, including medications, vaccinations, infections, and malignancies, in addition to some other uncommon external stimuli. TEN is characterized by the sudden appearance of generalizeddusky erythematous targetoid macules with a purpuric center, which coalesces to form bullae and flaccid blisters, leading to an eventual sheet-like epidermal detachment of all necrotic areas. Extensive epidermal denudation in TEN is usually accompanied by thermoregulatory impairment, insensible fluid loss, and hemodynamic instability. The severity of presentation for TEN is calculated through the use of a "Severity-of-Illness Score for Toxic Epidermal Necrolysis" (SCORTEN) score. Certain medications, including antibiotics, anticonvulsants, corticosteroids, and nonsteroidal anti-inflammatory drugs, are considered the primary cause of this dermatosis. In this report, we describe a case of TEN caused by Cephradine, a first-generation cephalosporin antibiotic drug, in a 43-year-old South Asian male who presented to the emergency department one day after receiving Cephradine for the treatment of cellulitis. At presentation, this patient had a calculated SCORTEN score of 4 according to the SCORTEN criteria found in the literature, placing his mortality rate at 58%. His treatment plan consisted of a single 50mg dose of Etanercept (ENBREL), a soluble anti-tumor necrosis factor alpha inhibitor (TNF-α) monoclonal antibody, as an emergent intervention at presentation, along with cyclosporine and hydrocortisone in tapered doses. This is the first reported case of severe TEN in the Kingdom of Bahrain successfully treated with a TNF-α inhibitor, Etanercept in this case, achieving complete healing and remission within 20 days of presentation, after initially showing a poor prognosis and a high risk of fatality.

Keywords: cephradine; enbrel; etanercept; scorten; ten; toxic epidermal necrolysis.

Figure 1. Upon presentation to the ED: Eruptions of painful apoptotic macular exanthema all over the body with evident mucosal involvement.

Figure 2. Seventh day of hospitalization: Complete sheet-like epidermal detachment of all the cutaneous necrotic areas.

Figure 3. 14th day of hospitalization: re-epithelialization and healing of the cutaneous layers.

Figure 4. 20th day of hospitalization upon time of discharge: substantial healing and resurfacing of the cutaneous layers.

Figure 5. During the outpatient follow-up visit after three weeks of discharge from the hospital: Complete remission of disease with some hypo- and hyper-pigmented areas post-healing.