Stevens Johnson Syndrome

This paper reports the objective intervention of the Hospital Dentistry team of the Beneficent Association of Campo Grande Santa Casa, contemplating a multi-professional approach to present Low-Level Laser Therapy (LLLT) as a therapeutic alternative for the treatment of individuals with Stevens-Johnson Syndrome (SJS). Male patient, 13 years old, with an initial complaint of pain, edema and burning mouth was treated by in situ applications of LLLT - Aluminium Gallium Indium Phosphide - InGaAlP type diode Laser (Laser duo / DMC Therapy XT, São Carlos, SP, Brazil), to promote photobiomodulation and subsequent repair of the compromised mucosa. Monitoring the patient during four laser therapy sessions with 24-hour intervals between them revealed a favorable evolution of the clinical picture with tissue repair, decreased pain and consequent oropharyngeal homeostasis. The favorable results consolidate LLLT as an alternative to be adopted with considerable effectiveness in combating pain and tissue changes in the oral mucosa resulting from the SJS.

An Institute of Medicine (IOM) panel charged with reviewing the system for overseeing research involving children concluded in 2004 that Institutional Review Boards (IRBs), institutions engaged in research, and study sponsors should "adopt explicit written policies on acceptable and unacceptable types and amounts of payments related to [children's] research participation." 1 We previously reported data on practices and policies in the U.S. regarding payments to children who participate in research and their parents. 2 Here, we report additional results from our study and identify some of the decisions that must be made in developing payment plans and on which payment policies will be expected to offer guidance. We conclude that further conceptual analysis and empirical research are necessary before IRBs, institutions, and sponsors can develop specific rules on numerous aspects of payment. Nevertheless, payment policies that promote the ethical treatment of children in research and their parents can be developed. We propose a structure for such policies.

Stevens-Johnson syndrome is an uncommon inflammatory skin disorder in which immune mechanisms, cytotoxic reactions, and delayed hypersensitivity seem to be involved. herein, an unusual case with strange complaint of "bus allergy" is presented, suffering from severe generalized itching and skin lesions, followed by ulcers in his mouth and genitalia. The diagnosis of Stevens-Johnson syndrome was made and appropriate treatment was advised. however, detailed medical history revealed a completely different cause of his allergic reactions, as he had occasionally used dimenhydrinate because of motion sickness in his history. Therefore, adverse drug reaction to dimenhydrinate was considered as the main underlying cause of the disease. in conclusion, thorough medical history should be taken to make a definitive diagnosis and identify the underlying disease, since accurate diagnosis and appropriate treatment can prevent further complications.

We report our experience of using a hydrogel dressing (Geliperm®, Geistlich) and fluidized-bead bed (Clinitron® bed, SSI Medical Services Ltd, Slough, UK) in the management of three patients with drug-induced toxic epidermal neerolysis (TEN).

The evidence of association between HLA-B ⁄ 1502 and anticonvulsant induced Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) from the Indian population is scant. Patients with a history of SJS/TEN secondary to carbamazepine or phenytoin were enrolled. The control group comprised of patients who had received carbamazepine/phenytoin for P6 months without any adverse cutaneous event. Low-resolution DNA typing for HLA-B and high resolution HLA-B ⁄ 15 typing was performed. Seventeen patients with history of SJS/TEN secondary to carbamazepine (9) or phenytoin (8) and 50 tolerant controls (carbamazepine-37; phenytoin-13) were enrolled. The mean age of patients and controls was 33.9 ± 11.6 and 28.1 ± 9.9 years, respectively. HLA-B ⁄ 1502 was observed in 2/9 (22.2%) carbamazepine-SJS/TEN patients and none of the 37 carbamazepine tolerant controls (p = 0.035). HLA-B ⁄ 1502 was not observed in any of the 8 phenytoin-SJS/TEN patients or the 13 phenytoin tolerant controls. Our data suggests that HLA-B ⁄ 1502 is a risk factor for carbamazepine induced SJS/TEN. Therefore, HLA-B ⁄ 1502 testing should be performed prior to initiating carbamazepine in North Indian population.

The nonsteroidal anti-inflammatory drugs are one of the most commonly prescribed classes of drugs used in medical practice. This review discusses the diverse cutaneous reactions associated with nonsteroidal anti-inflammatory drugs. Adverse cutaneous reactions occur most frequently with benoxaprofen, piroxicam, sulindac, meclofenamate sodium, zomepirac sodium, and phenylbutazone. The most serious adverse cutaneous reactions, Stevens-Johnson syndrome and toxic epidermal necrolysis, appear to be most often associated with sulindac and phenylbutazone. Tolmetin and zomepirac sodium, two structurally similar pyrrole derivatives, have been associated with a disproportionate number of cases of anaphylactoid reactions. Among the currently marketed nonsteroidal anti-inflammatory drugs, piroxicam appears to have the highest rate of phototoxic reactions. This phototoxic eruption is most often vesiculobullous. (J AM ACAD DERMATOL 12: 866-876, 1985.)

Our purpose is to comprehensively review the state of the art with regard to Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to improving the management of associated ocular surface complications. SJS and TEN are two ends of a spectrum of immune-mediated disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. Part I of this review focused on the systemic aspects of SJS/TEN and was published in the January 2016 issue of this journal. The purpose of Part II is to summarize the ocular manifestations and their management through all phases of SJS/TEN, from acute to chronic. We hope this effort will assist ophthalmologists in their management of SJS/TEN, so that patients with this complex and debilitating disease receive the best possible care and experience the most optimal outcomes in their vision and quality of life.

Of the 1124 human immunodeficiency virus (HIV)-infected patients studied, one or more cutaneous lesions were found in 113 (98.3%) of the 115 patients with acquired immunodeficiency syndrome (AIDS) and in 541 (53.6%) of 1009 patients with AIDS-related complex (ARC). Kaposi's sarcoma, multidermatomal, necrotic herpes zoster, and pruritic maculopapular rashes are common cutaneous manifestations of AIDS and its related complex (ARC) in Zambia. The maculopapular rash results from a lymphoplasmacytic angiitis in the dermis, possibly in response to the presence of HIV in the dermis. Candidiasis, severe genital herpes, extensive molluscum contagiosum, and tinea corporis were less frequent and usually refractory to treatment. Drug reactions are also frequent in Zambians with AIDS. In seven patients given streptomycin, thiacetazone, and rifampicin for treatment of pulmonary tuberculosis, Stevens-Johnson syndrome occurred shortly after therapy was begun, and two died despite high-dose prednisone and discontinuance of tuberculosis therapy. Extensive seborrheic dermatitis refractory to topical fluorinated corticosteroids is also an associated condition in AIDS patients who have pulmonary tuberculosis. (J AM ACAO DERM~,TOL 1988;19:451-7.) Human immunodeficiency virus (HIV) infection, like most systemic infections, produces skin lesions that represent cutaneous markers of disease. Recurrent bacterial, viral, and fungal cutaneous infections occur with increased frequency in individuals infected with HIV. ~ We report here the pattern and frequency of skin lesions in Zambian patients presenting with acquired immunodeficiency syndrome (AIDS) and its related complex (ARC).

Une bulle consiste en l'accumulation d'un liquide (sérosité ou exsudat lymphatique) au sein des structures cutanées. On parle de bulle jonctionnelle, ou de bulle sous-épidermique lorsque le mécanisme de formation de la bulle implique un défaut primaire ou secondaire des systèmes de cohésion entre l'épiderme et le derme.

Lesi Vesikobulosa merupakan lesi berisi cairan jernih dan berada pada lapisan epitel, ruptur serta menimbulkan ulserasi. Lesi vesikobulosa dalam rongga mulut memiliki gambaran klinis, sehingga dibutuhkan pemeriksaan penunjang dalam menentukan diferensial diagnosis untuk tatalaksana perawatan yang tepat.

SJS) adalah penyakit langka namun serius karena adanya reaksi hipersensitivitas yang diperantarai kompleks imun, biasanya melibatkan kulit dan membran mukosa. Pada perjalanan penyakit biasanya mengenai mulai dari mulut, hidung, mata, vagina, uretra, pencernaan, dan mukosa pernapasan bawah. Sindrom Stevens-Johnson merupakan gangguan sistemik serius dengan potensi morbiditas parah dan bahkan kematian. Seringkali, Sindrom Stevens-Johnson hanya muncul dengan gejala seperti flu, diikuti dengan ruam merah atau keunguan yang menyebar dan lecet, akhirnya menyebabkan lapisan atas kulit mati dan mengelupas.

Advances in genetic research and molecular biology techniques have made it possible to begin to characterize the underlying genetic factors that predispose patients to serious forms of drug-induced skin injury (DISI). To facilitate research in this area, we have set out standardized phenotypic definitions for (i) Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), (ii) acute generalized exanthematous pustulosis (AGEP), and (iii) hypersensitivity syndrome (HSS; also known as drug reaction with eosinophilia and systemic symptoms (DRESS) and drug-induced hypersensitivity syndrome (DIHS)). A DISI Expert Working Group comprising participants with varied expertise reviewed and debated current terminology and diagnostic criteria for DISI and agreed on the minimum phenotypic criteria for selected forms of DISI (SJS/TEN, AGEP, and HSS). In addition, an algorithm has been developed to aid appropriate clinical categorization of patients with DISI. These standardized criteria will be important in facilitating adequate and accurate patient recruitment in order to advance research in pharmacogenomic, immunological, mechanistic, and epidemiological studies.Clinical Pharmacology & Therapeutics (2011) 89 6, 896–901. doi:10.1038/clpt.2011.79

Epidermal necrolysis (EN)--either Stevens-Johnson syndrome (SJS) or toxic EN (TEN)--is a severe drug reaction. We constructed and evaluated a specific algorithm, algorithm of drug causality for EN (ALDEN), in order to improve the individual assessment of drug causality in EN. ALDEN causality scores were compared with those from the French pharmacovigilance method in 100 cases and the case-control results of the EuroSCAR study. Scores attributed by ALDEN segregated widely. ALDEN pointed to a "probable" or "very probable" causality in 69/100 cases as compared to 23/100 with the French method (P < 0.001). It scored "very unlikely" causality for 64% of medications vs. none with the French method. Results of ALDEN scores were strongly correlated with those of the EuroSCAR case-control analysis for drugs associated with EN (r = 0.90, P < 0.0001), with probable causality being reported in 218/329 exposures. ALDEN excluded causality in 321 drugs that the ...

Objective: To determine predictors and relative incidence of antiepileptic drug (AED)related rash in patients taking all common AEDs. Methods: We reviewed 1,890 outpatients. Eightyone variables were tested as potential predictors of rash. We compared the rate of rash attributed to each AED (AED rash) with the average rate of rash attributed to the other AEDs in all adults (aged Ն16 years; n ϭ 1,649) when taking carbamazepine (CBZ), clobazam (CLB), felbamate (FBM), gabapentin (GBP), lamotrigine (LTG), levetiracetam (LEV), oxcarbazepine (OXC), phenobarbital (PB), phenytoin (PHT), primidone (PRM), tiagabine (TGB), topiramate (TPM), vigabatrin (VGB), valproate (VPA), or zonisamide (ZNS). We repeated this analysis for patients with and without the identified nondrug predictors of AED rash. Results: The average rate of AED rash was 2.8%. The only nondrug predictor significant in multivariate analysis was occurrence of another AED rash (odds ratio 3.1, 95% CI 1.8 to 5.1; p Ͻ 0.0001); the rate of rash in this subgroup was 8.8%, vs 1.7% in those without another AED rash. Higher AED rash rates were seen with PHT (5.9% overall, p ϭ 0.0008; 25.0% in those with another AED rash, p ϭ 0.001), LTG (4.8%, p ϭ 0.00095; 14.4%, p ϭ 0.025), and CBZ (3.7%, not significant; 16.5%, p ϭ 0.01). Lower rates were seen with LEV (0.6% overall; p ϭ 0.00042), GBP (0.3%, p ϭ 0.00035), and VPA (0.7%, p ϭ 0.01). Rash rates were also low (Ͻ1% overall) with FBM, PRM, TPM, and VGB (not significant). These AED differences remained similar in patients with and without other AED rashes. There were four cases of Stevens-Johnson syndrome involving four AEDs.

Background: Erythema multiforme (EM) is a vesiculobullous disorder with variable manifestations which predominantly affects the skin. It is regarded as a hypersensitivity disorder which is triggered by multiple factors such as infection, drugs and food. Varicella zoster virus (VZV) has rarely been reported as an etiological agent, despite its high incidence as a pathogen in childhood. Patients: We describe two children in whom EM preceded VZV infection. In the first, a 5-year-old boy, EM was followed 3 days later by a classical disseminated varicella eruption. The diagnosis was reached by clinical, epidemiological and serological means. The second patient was a 13-year-old boy with EM which was followed 2 weeks later by Ramsay-Hunt syndrome. The diagnosis was confirmed by skin biopsy, positive serology and viral culture. Conclusion: The association of EM and VZV infection is probably more common than reported. In clinical cases of EM, VZV should be included in the list of possible causative agents.

A great many cardiovascular drugs (CVDs) have the potential to induce adverse reactions in the mouth. The prevalence of such reactions is not known, however, since many are asymptomatic and therefore are believed to go unreported. As more drugs are marketed and the population includes an increasing number of elderly, the number of drug prescriptions is also expected to increase. Accordingly, it can be predicted that the occurrence of adverse drug reactions (ADRs), including the oral ones (ODRs), will continue to increase. ODRs affect the oral mucous membrane, saliva production, and taste. The pathogenesis of these reactions, especially the mucosal ones, is largely unknown and appears to involve complex interactions among the drug in question, other medications, the patient's underlying disease, genetics, and life-style factors. Along this line, there is a growing interest in the association between pharmacogenetic polymorphism and ADRs. Research focusing on polymorphism of the cytochrome P450 system (CYPs) has become increasingly important and has highlighted the intra-and inter-individual responses to drug exposure. This system has recently been suggested to be an underlying candidate regarding the pathogenesis of ADRs in the oral mucous membrane. This review focuses on those CVDs reported to induce ODRs. In addition, it will provide data on specific drugs or drug classes, and outline and discuss recent research on possible mechanisms linking ADRs to drug metabolism patterns. Abbreviations used will be as follows:

A prospective study was carried out to elucidate the clinical, epidemiological and laboratory features of human brucellosis. A total of 26 948 blood samples (from adults aged 15 years and above) were screened for serological evidence of brucellosis over a period of 16 years. The slide agglutination/Rose Bengal plate agglutination test gave positive results in 517 patients, of which 509 had detectable titres by the standard tube agglutination test (SAT). The diagnosis of brucellosis was documented in 495 (1?8 %) patients based on diagnostic titres (¢1 : 160, 490 cases) and rising titres from insignificant titres (four cases) by serology and for one case by blood-culture isolation alone. Blood cultures were carried out in 345 cases, of which 191 cases (55?3 %) yielded Brucella melitensis. In 77/79 cases undertaken for follow up, there was a steady fall in 2-mercaptoethanol (2ME) agglutination titres along with clinical improvement (P <0?01). SAT titres remained detectable in most cases for a longer period in spite of an effective antimicrobial therapy and clinical recovery. A substantial number of patients (84?2 %) presented with fever, this being the only complaint in 51?1 % of the cases. Complications were present in 8?8 % of the patients (arthritis excluded): this included the unusual complications of hydrocele (two cases), Stevens-Johnson syndrome (one case) and urinary tract infection (one case). Brucella agglutinins were demonstrated in synovial, testicular, hydrocele and cerebrospinal fluids. There was no clinical suspicion of brucellosis in 439 cases (88?7 %) and the diagnosis was made only by routine serology. A two-drug regimen for 42-84 days with a follow-up 2ME test resulted in lower levels of relapse. These results suggest that, in endemic areas of the world, it should be mandatory to screen routinely for brucellosis due to protean clinical manifestations.

Toxic epidermal necrolysis (Lyell syndrome) is a rare, acute, and potentially life-threatening mucocutaneous disease that is most often triggered by drugs. This is the first case of toxic epidermal necrolysis because of treatment with etofenamate of which we are aware. Fig. 1. Physical examination revealed painful diffusive-painful exfoliative rash on presentation. Clinical Toxicology Downloaded from informahealthcare.com by Dokuz Eylul Univ. on 03/16/15 For personal use only.

1 Hajjeh RA, Conn LA, Stephens DS et al. Cryptococcosis in the United States: population-based multistate active surveillance and risk factors in HIV-infected persons. J Infect Dis 1999; 179 : 449 -454. 2 Gaddoni D, Resta F, Baldassari L et al. Criptococcosi cutanea in corso di AIDS. G Ital Dermatol Venereol 1993; 128 : 129 -132. 3 Vandersmissen G, Meuleman L, Tits G et al. Cutaneous cryptococcosis in corticosteroid-treated patients without AIDS. Acta Clin Belg 1996; 51 (2): 111 -117. 4 Nampoory MR, Khan ZU, Johny KV et al. Invasive fungal infections in renal transplant recipients. J Infect 1996; 33 (2): 95 -101. 5 Krcmery V Jr, Kunova A, Mardiak J. Nosocomial Cryptococcus laurentii fungemia in a bone marrow transplant patient after prophylaxis with ketoconazole successfully treated with oral fluconazole. Infection 1997; 25 (2): 130. 6 Bangert RL, Cho BR, Widders PR et al. A survey of aerobic bacteria and fungi in the feces of healthy psittacine birds. Avian Dis 1988; 32 : 46 -52. 7 Slavikova E, Vadkertiova R. Yeasts and yeast-like organisms isolated from fish-pond waters. Acta Microbiol Pol 1995; 44 (2): 181-189. 8 Bellosta M, Gaviglio MR, Mosconi M et al. Primary cutaneous cryptococcosis in an HIV-negative patient. Eur J Dermatol 1999; 9 (3): 224 -226. 9 Dimino-Emme L, Gurevitch AW. Cutaneous manifestations of disseminated cryptococcosis. J Am Acad Dermatol 1995; 32 (5, Part 2): 844 -850. 10 Kordossis T, Avlami A, Velegraki A et al. First report of Cryptococcus laurentii meningitis and a fatal case of Cryptococcus albidus cryptococcaemia in AIDS patients. Med Mycol 1998; 36 (5): 335 -339. 11 Johnson LB, Bradley SF, Kauffman CA. Fungaemia due to Cryptococcus laurentii and a review of non-neoformans cryptococcaemia. References 1 Carlson JA, Murphy M. Androgen receptors and lichen sclerosus (letter). J Am Acad Dermatol 2000; 43: 559. 2 Clifton M, Smoller B. Androgen receptors and lichen sclerosus (reply). J Am Acad Dermatol 2000; 43: 559. 3 Kohlberger PD, Joura EA, Bancher D, Gitsch G, Breitenecker G, Kieback DG. Evidence of androgen receptor expression in lichen sclerosus: an immunohistochemical study. J Soc Gynecol Invest 1998; 5: 331-333. 4 Powell JJ, Wojnarowska F. Lichen sclerosus. Lancet 1999; 353: 1777-1783. 5 Carlson JA, Ambros R, Malfetano J et al. Vulvar lichen sclerosus and squamous cell carcinoma: a cohort, case control, and investigational study with historical perspective; implications for chronic inflammation and sclerosis in the development of neoplasia. J Am Board Fam Pract 1999; 12: 473 -476. 6 Tidy JA, Soutter WP, Luesley DM, MacLean AB, Buckley CH, Ridley CM. Management of lichen sclerosus and intraepithelial neoplasia of the vulva in the UK.

Erythema multiforme major (EMM) is an acute, self-limited mucocutaneous disease characterized by the abrupt onset of symmetrical fixed red papules evolving to target lesions. It is triggered mainly by infections, such as herpes simplex virus (HSV) and Mycoplasma pneumoniae, or drugs. In instances of extensive skin lesions with "giant" targets, prominent involvement of several mucous sites and fever, it may be difficult to distinguish from Stevens-Johnson syndrome (SJS), a rarer, lifethreatening reaction which is mainly druginduced. We report a 7-year old boy with SJS and Chlamydia pneumoniae infection and 3 patients with erythema multiforme (EM) and co-infection with Chlamydia pneumoniae: a 3year old girl and a 29-year old man developed EMM lesions associated to Mycoplasma pneumoniae and Chlamydia pneumonia and a 20year old woman with EMM associated to herpes simplex type 2 and Chlamydia pneumoniae infection. None of the 4 patients had history of drug intake in the last two months.

Most studies on drug-induced toxic epidermal necrolysis (TEN) report a high mortality rate. This has been attributed partly to the use of corticosteroids for its treatment. However, we consider corticosteroids to be the sheet anchor for saving the patients having TEN. Our approach to the treatment of this disease consists of administering a relatively high dose of corticosteroids to control the reaction at the earliest possible time and then withdrawing corticosteroids at the fastest possible rate. As illustrated by the five case reports, the reaction is controlled within 24 to 48 hours and the corticosteroids are withdrawn within the next 7 to 10 days. During this period, the skin also shows almost complete healing. With the confidence gained with this approach, we undertake the provocation test as a rule in every patient to find the actual drug responsible for the reaction.. Corticosteroids used in an appropriate dosage schedule constitute an important component of the treatment for TEN to ensure early recovery.

Dermatological emergencies include a number of clinical conditions usually accompanied by systemic symptoms that can lead to life-threatening complications. From the broad spectrum of life-threatening dermatoses, three cases are presented: a case of febrile ulceronecrotic Mucha-Habermann disease (FUMHD), a case of pemphigus vulgaris mimicking Stevens-Johnson syndrome (SJS), and a case of toxic epidermal necrolysis (TEN). Those cases were considered extreme, and presented to illustrate the positive outcome of timely intensive dermatological care. An interdisciplinary approach is essential in the diagnosis, treatment, management, and follow up of patients with life-threatening dermatoses.

Background: Drugs can induce different immunologic reactions; T-cell mediated responses produce the most severe reactions. Although in vitro studies show that T cells recognize drugs or their metabolites and induce an effector cytotoxic response, direct in vivo evidence of involvement is lacking. T lymphocytes produce cytotoxic markers that are responsible for 2 major pathways to cell death: granule-mediated exocytosis (perforin and granzyme B) and Fas/FasL interaction. Objective: The purpose of this investigation was to establish the role of proinflammatory TNF-α and cytotoxic markers in subjects with delayed responses to drugs.

Erythema multiforme (EM) and related disorders comprise a group of mucocutaneous disorders characterized by variable degrees of mucosal and cutaneous blistering and ulceration that occasionally can give rise to systemic upset and possibly compromise life. The clinical classification of these disorders has often been variable, thus making definitive diagnosis sometimes difficult. Despite being often caused by, or at least associated with, infection or drug therapy, the pathogenic mechanisms of these disorders remain unclear, and as a consequence, there are no evidencebased, reliably effective therapies. The present article reviews aspects of EM and related disorders of relevance to oral medicine clinical practice and highlights the associated potential etiologic agents, pathogenic mechanisms and therapies.

Osteo-odonto-keratoprostheses (OOKP) is a unique form of keratoprosthesis involving surgical removal of a tooth root and surrounding bone from the patient which are then used to construct an osteo-odonto lamina into which an optical cylinder is cemented. The OOKP procedure is successful and capable of withstanding the very hostile ocular environments found in severe Stevens-Johnson syndrome, pemphigoid, chemical burns, trachoma and multiple corneal graft failure. The existing procedure is complex and time consuming in terms of operative time, and additionally involves sacrifice of the oral structures. This paper discusses the rational search for a ''synthetic" analogue of the dental lamina, capable of mimicking those features of the natural system that are responsible for the success of OOKP. In this study the degradation of selected commercial and natural bioceramics was tested in vitro using a purpose-designed resorption assay. Degradation rate was compared with tooth and bone, which are currently used in OOKP lamina. At normal physiological pH the degradation of bioceramics was equivalent to tooth and bone; however, at pH 6.5-5.0, associated with infectious and inflamed tissues, the bioceramics degrade more rapidly. At lower pH the degradation rate decreased in the following order: calcium carbonate corals > biphasic calcium phosphates > hydroxyapatite. Porosity did not significantly influence these degradation rates. Such degradation is likely to compromise the stability and viability of the synthetic OOKP. Consequently more chemically stable materials are required that are optimized for the surrounding ocular environment. Crown

PURPOSE: To evaluate the use of the Boston keratoprosthesis (KPro) in patients with Stevens-Johnson syndrome (SJS). • DESIGN: Retrospective, noncomparative, interventional case series. • METHODS: Sixteen eyes of 15 patients with SJS underwent KPro surgery at the Massachusetts Eye and Ear Infirmary from January 2000 through December 2005. The preoperative, operative, and postoperative findings were recorded. All patients underwent either the type I or type II Boston KPro surgery by one surgeon (C.H.D.).

We describe two cases of toxic epidermal necrolysis developed during an antiretroviral therapy regimen containing nevirapine. It seems likely that the poor adherence to the dose escalation regimen of nevirapine has caused this life-threatening disease. A complete and written information on the scheduled antiretroviral therapy is mandatory, above all for individuals coming from developing countries where language barriers have not yet been successfully overcome.