Indian Pediatrics 2001; 38: 426  

Toxic Epidermal Necrolysis in a Girl with Leukemia Receiving Methotrexate

A 12-year-old girl was admitted to our hospital with the complaint of fever, rash, vomiting and loss of appetite. She was diagnosed as a case of acute lymphoblastic leukemia and followed up for seven months in our hospital. One week before admission to our clinic she had received intrathecal methotrexate two days following which skin lesions. On physical examination she had cutaneous lesions which were characterized by widespread blister formation and confluent erythema, associated with skin tenderness. Nikolsky sign (denudation of the skin with gentle tangential pressure) was present (Figs. 1 & 2). She also had conjunc-tivitis and oral lesions. The patient was hospitalized, and besides supportive therapy antibiotics were applied. However, she was taken home by the parents on the 3rd day of admission.

Toxic epidermal necrolysis (TEN) is characterized by: (i) widespread blister formation and mor-billiform or conflu-ent erythema, asso-ciated with skin tenderness; (ii) ab-sence of target lesions; (iii) sudden onset and general-ization within 24-49 h; and (iv) histologic findings of full-thickness epidermal necrolysis and a minimal to absent dermal infiltrate. The pathogenesis of TEN is not proved. This condition is triggered by many of the same factors that are responsible for Stevens-Johnson syndrome, principally drugs such as the methotrexate, antibiotics and anti-convulsants; infectious agents, such as the viruses, bacteria and fungi; and neoplasms such as leukemia and lymphoma. Our case had leukemia and methotrexate was given before skin lesions developed.

Fig. 1. Close-up appearance of the cutaneous lesions on the chest and neck region.

Fig. 2. Blister formation demonstrated on the left hand.

Hüseyin Çakesen,
Ahmet Faik Öner,
Department of Pediatrics,
Yüzüncü Yil University,
Faculty of Medicine, Van, Turkey.
E-mail: [email protected]