Abstract: PUB020
A Case of Allopurinol-Induced Toxic Epidermal Necrolysis Complicated by Kidney Failure
Session Information
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Pham, Steven, Unity Health, Searcy, Arkansas, United States
- Graham, Gabriel Charles, Unity Health, Searcy, Arkansas, United States
- Nguyen, Kayla, Kaiser Permanente, Bakersfield, California, United States
Introduction
Toxic epidermal necrolysis (TEN) is a life-threatening condition marked by extensive blistering, rapidly developing exanthema, and mucosal involvement, with mortality exceeding 30%. Acute kidney injury (AKI) is defined by a sudden decline in kidney function, characterized by elevated creatinine level or reduced urine output. AKI is associated with a high incidence in TEN cases, but the full manifestation remains unclear. We report a case of allopurinol-induced TEN leading to severe oliguria and AKI.
Case Description
An 89-year-old female presented with a full-body rash. Two weeks prior, she was hospitalized, during which she received rocephin, and was discharged with a prednisone taper and diphenhydramine as needed. Skin biopsy at that time showed lichenoid dermatitis secondary to allopurinol that was started two weeks earlier. Upon rehospitalization, she had a diffuse, painful macular rash covering 65-75% of her body. Her dermatological symptoms worsened daily and there was positive Nikolsky’s sign along with numerous bullae. Skin sloughing affected her torso and mucous membranes. Repeat skin biopsy confirmed TEN. Her creatinine rose from 2.3 mg/dL to 5.3 mg/dL, with inadequate urine output despite adequate fluid resuscitation and oral intake given through a nasogastric tube. Transfer to any nearby tertiary burn centers was not feasible due to the unavailability of a skin biopsy result at that time. After discussing with her family, a decision was made to move towards comfort-directed care due to a significantly poor prognosis. She expired shortly after care withdrawal.
Discussion
Managing TEN is challenging due to invasive skin exfoliation, with current protocols primarily providing supportive care. Extensive fluid loss from wounds can decrease renal blood flow if not promptly resuscitated. The loss of extracellular fluid and albumin, compounded by oliguria, disrupts protective barriers and facilitates bacterial translocation. Infections, due to the compromised skin barrier, can precipitate renal dysfunction. Additionally, stress-induced vasoconstriction from skin exfoliation exacerbates renal impairment. Consequently, AKI in TEN is associated with a high risk of sepsis and multi-organ failures, indicating a poor prognosis.