BI01 Toxic epidermal necrolysis in advanced HIV: a case report and therapeutic considerations

Abstract

Toxic epidermal necrolysis (TEN) is a rare but potentially fatal drug-induced mucocutaneous reaction. People living with HIV are at increased risk due to immune dysregulation and exposure to high-risk medications. A 31-year-old man initially presented with generalized tonic-clonic seizures. Brain imaging demonstrated a ring-enhancing lesion. Biopsy confirmed cerebral toxoplasmosis. Subsequent testing revealed advanced HIV infection (CD4 nadir 0.06 × 109 cells L−1; HIV RNA 3.9 million copies mL−1). Treatment was initiated with pyrimethamine, sulfadiazine, folinic acid, ­bictegravir–emtricitabine–tenofovir alafenamide and levetiracetam. Six weeks later, he re-presented with fever and a rapidly progressive papular eruption of 2 days’ duration. Dermatology assessment was obtained, and skin biopsies were performed. On day 5, he developed extensive epidermal detachment associated with severe skin pain. Nikolsky sign was positive. Histopathology demonstrated features supporting the evolving clinical impression of TEN, including keratinocyte necrosis at varying levels. As no single culprit medication could be identified, several therapies, including antiretroviral therapy, were discontinued or modified. His SCORTEN on admission was 2 (heart rate, body surface area), with approximately 80% total body surface area involvement. He was managed in the intensive care unit and received a single 50-mg dose of etanercept on the second day of blistering. Surgical management included hydrosurgical debridement using a high-pressure saline system, followed by placement of a biosynthetic skin substitute. Clinical improvement was rapid, with reduced pain and fluid losses. He walked out of hospital after 5 weeks. People living with HIV are at increased risk of TEN, particularly in the setting of sulfonamide exposure and certain antiretroviral or antiepileptic therapies. Etanercept, a tumour necrosis factor-α antagonist, has emerging evidence supporting its use in TEN through modulation of the inflammatory cascade and promotion of re-epithelialization. Etanercept was well tolerated and effective in the management of TEN in this severely immunocompromised patient.