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On day &#43;84&#44; the patient referred the development of a pruritic generalized acute erythema&#44; associating fever and lichenoid erosions in the oral mucosa&#46; A severe GVHD was suspected and intensification of treatment with sirolimus&#44; ruxolitinib and extracorporeal photopheresis was decided&#46; However&#44; the eruption progressed with blistering and epidermolysis&#46; Given the lack of response&#44; TEN was suspected and all not strictly necessary drugs were withdrawn&#44; while immunosuppressive treatment is reduced&#46; From this moment on&#44; the patient improved and epithelization of all the detached surface was achieved in some weeks&#46; After numerous complications&#44; on the day &#43;229&#44; the patient was released from the hospital with cutaneous&#44; hepatic and ocular chronic GVHD&#44; that was treated with immunosuppressive therapy until day &#43;322&#44; when he died from respiratory infection&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patient two</span>&#58; An allogeneic HSCT was performed in a 61-year-old woman with chronic lymphatic leukemia&#46; The day &#43;16 she developed a gastric GVHD treated with corticosteroid and cyclosporine&#46; On day &#43;38&#44; the patient reported a worsening of her digestive symptoms&#44; associating fever and mild skin rash&#46; Sirolimus was initiated and it coincided with the appearance of a more significant&#44; painful and confluent rash&#44; with serous blisters&#44; epidermal denudation and fibrinoid exulcerations in oral mucosa&#46; Sirolimus was interrupted&#44; along with most of the prophylactic treatments of HSCT&#44; but the rest of the immunosuppressive therapy&#44; with high doses of corticosteroids&#44; cyclosporine&#44; ruxolitinib and photoapheresis&#44; was prolonged&#46; Progressive re-epithelialization and correct clinical-analytical stability are achieved&#46; The patient was discharged from hospital on day &#43;80&#44; and later she showed typical lesions of chronic cutaneous GVHD &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">In the common scenario of an allogenic HSCT&#44; it is very difficult to clearly separate a TEN from a severe acute cutaneous GVHD&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Acute cutaneous GVHD usually debuts in the first 4&#8211;6 weeks after allogeneic hematopoietic stem cell transplantation &#40;HSCT&#41;&#44; with common association with digestive and hepatic symptoms&#46; The severe forms involve more than 50&#37; of the body surface area &#40;stage III&#41; with even blistering and epidermolysis &#40;stage IV&#41;&#46; It corresponds to interface dermatitis with keratinocyte necrosis and dermal lymphocytic infiltrate predominantly T CD8&#44; adding formation of a subepidermal cleavage in grade III and dermo-epidermal separation in grade IV&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Regarding the treatment&#44; the use of glucocorticoids&#44; usually topical and systemic&#44; is accepted as the first line&#46; The second line is not clearly defined&#44; being valid different combinations of immunosuppressants as well as extracorporeal photopheresis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Given that clinically and histologically TEN and severe acute cutaneous GVHD can be identical&#44; dual moderate management is usually chosen&#46; However&#44; it is important to promote studies that define criteria for differential diagnosis&#44; since optimal management of each entity runs in some differences&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The following points may be useful for the differential diagnosis&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Appearance of NET in the 4 weeks following the incorporation of a new medication&#44; with discontinuity of denudation once the suspect drug has been removed&#46; On the contrary&#44; in GVHD it is possible that skin reactions progress or recur&#44; even in a changing manner&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">The coexistence of gastrointestinal or hepatic GVHD&#44; supports the diagnosis of severe acute cutaneous GVHD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Although the histology may be similar&#44; and immunofluorescence lacks of value because it is negative or non-specific&#44; the immunohistochemistry in both reflects a clear predominance of T CD8 lymphocytes in the dermal infiltrate&#46; Recent studies advocate for a CD8 &#47; CD4 ratio higher in the NET&#44; where at least it will be &#62; 4&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">The determination&#44; during the first hours of the suspicious eruption&#44; of certain elevated serum biomarkers like ela&#64257;n&#44; regenerating islet-derived 3-&#945; &#40;REG3&#945;&#41; or soluble interleukin-2 receptor-&#945; &#40;sIL-2R&#945;&#41;&#44; is a non-invasive procedure that can guide both for the diagnosis of the onset of GVHD&#44; as to predict the evolution towards severe GVHD&#46; In particular&#44; the three biomarkers mentioned&#44; measured jointly just when the symptomatology appears&#44; constitute a composite panel that has shown with statistical significance&#44; to be able to differentiate non-GVHD versus any degree GVHD&#46; The analysis in recent literature of the ROC curve of this panel to diagnose GVHD at the time of onset of symptoms&#44; describes a specificity of 100&#37; and a sensitivity of 55&#46;6&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion&#44; we present two clinical cases in which the diagnostic difficulty between these two entities and the importance of looking for clinical&#44; analytical and anatomopathological data that allow to focus therapeutic management&#44; is reflected&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez Tejero A&#44; Badiola Gonz&#225;lez J&#44; Rold&#225;n Mateo L&#44; Molina Leyva A&#46; Necr&#243;lisis epid&#233;rmica t&#243;xica versus enfermedad injerto contra hu&#233;sped cut&#225;nea aguda despu&#233;s de un trasplante de c&#233;lulas madre hematopoy&#233;ticas&#58; un desaf&#237;o diagn&#243;stico y terap&#233;utico&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;81&#8211;82&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">A&#46;</span> Clinical image of patient two&#46; <span class="elsevierStyleBold">B&#46;</span> Hematoxylin-Eosin on a biopsy of patient two &#40;20x&#41;&#46; <span class="elsevierStyleBold">C</span>&#46; CD4&#43; lymphocytes on a skin biopsy of patient two &#40;40x&#41;<span class="elsevierStyleBold">&#46; D&#46;</span> CD8&#43; lymphocytes on a skin biopsy of patient two &#40;40x&#41;&#46; Note that in the dermal lymphocytic infiltrate&#44; a CD8 &#47; CD4 ratio of 2&#46;5&#44; less than 4 and more suggestive in this case of GHVD&#46;</p>"
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Case and Research Letters
Toxic epidermal necrolysis vs. acute cutaneous graft versus host disease after hematopoietic stem cell transplantation: A diagnostic and therapeutic challenge
Necrólisis epidérmica tóxica versus enfermedad injerto contra huésped cutánea aguda después de un trasplante de células madre hematopoyéticas: un desafío diagnóstico y terapéutico
A. Rodríguez Tejeroa,
Autor para correspondencia
andrea_13_3217@hotmail.com

Corresponding author.
, J. Badiola Gonzálezb, L. Roldán Mateoc, A. Molina Leyvaa
a UGC Dermatología Hospital Virgen de las Nieves de Granada. Spain
b UGC Hematologías Hospital Virgen de las Nieves de Granada. Spain
c UGC Anatomía Patológica Hospital Virgen de las Nieves de Granada. Spain
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On day &#43;84&#44; the patient referred the development of a pruritic generalized acute erythema&#44; associating fever and lichenoid erosions in the oral mucosa&#46; A severe GVHD was suspected and intensification of treatment with sirolimus&#44; ruxolitinib and extracorporeal photopheresis was decided&#46; However&#44; the eruption progressed with blistering and epidermolysis&#46; Given the lack of response&#44; TEN was suspected and all not strictly necessary drugs were withdrawn&#44; while immunosuppressive treatment is reduced&#46; From this moment on&#44; the patient improved and epithelization of all the detached surface was achieved in some weeks&#46; After numerous complications&#44; on the day &#43;229&#44; the patient was released from the hospital with cutaneous&#44; hepatic and ocular chronic GVHD&#44; that was treated with immunosuppressive therapy until day &#43;322&#44; when he died from respiratory infection&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patient two</span>&#58; An allogeneic HSCT was performed in a 61-year-old woman with chronic lymphatic leukemia&#46; The day &#43;16 she developed a gastric GVHD treated with corticosteroid and cyclosporine&#46; On day &#43;38&#44; the patient reported a worsening of her digestive symptoms&#44; associating fever and mild skin rash&#46; Sirolimus was initiated and it coincided with the appearance of a more significant&#44; painful and confluent rash&#44; with serous blisters&#44; epidermal denudation and fibrinoid exulcerations in oral mucosa&#46; Sirolimus was interrupted&#44; along with most of the prophylactic treatments of HSCT&#44; but the rest of the immunosuppressive therapy&#44; with high doses of corticosteroids&#44; cyclosporine&#44; ruxolitinib and photoapheresis&#44; was prolonged&#46; Progressive re-epithelialization and correct clinical-analytical stability are achieved&#46; The patient was discharged from hospital on day &#43;80&#44; and later she showed typical lesions of chronic cutaneous GVHD &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">In the common scenario of an allogenic HSCT&#44; it is very difficult to clearly separate a TEN from a severe acute cutaneous GVHD&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Acute cutaneous GVHD usually debuts in the first 4&#8211;6 weeks after allogeneic hematopoietic stem cell transplantation &#40;HSCT&#41;&#44; with common association with digestive and hepatic symptoms&#46; The severe forms involve more than 50&#37; of the body surface area &#40;stage III&#41; with even blistering and epidermolysis &#40;stage IV&#41;&#46; It corresponds to interface dermatitis with keratinocyte necrosis and dermal lymphocytic infiltrate predominantly T CD8&#44; adding formation of a subepidermal cleavage in grade III and dermo-epidermal separation in grade IV&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Regarding the treatment&#44; the use of glucocorticoids&#44; usually topical and systemic&#44; is accepted as the first line&#46; The second line is not clearly defined&#44; being valid different combinations of immunosuppressants as well as extracorporeal photopheresis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Given that clinically and histologically TEN and severe acute cutaneous GVHD can be identical&#44; dual moderate management is usually chosen&#46; However&#44; it is important to promote studies that define criteria for differential diagnosis&#44; since optimal management of each entity runs in some differences&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The following points may be useful for the differential diagnosis&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Appearance of NET in the 4 weeks following the incorporation of a new medication&#44; with discontinuity of denudation once the suspect drug has been removed&#46; On the contrary&#44; in GVHD it is possible that skin reactions progress or recur&#44; even in a changing manner&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">The coexistence of gastrointestinal or hepatic GVHD&#44; supports the diagnosis of severe acute cutaneous GVHD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Although the histology may be similar&#44; and immunofluorescence lacks of value because it is negative or non-specific&#44; the immunohistochemistry in both reflects a clear predominance of T CD8 lymphocytes in the dermal infiltrate&#46; Recent studies advocate for a CD8 &#47; CD4 ratio higher in the NET&#44; where at least it will be &#62; 4&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">The determination&#44; during the first hours of the suspicious eruption&#44; of certain elevated serum biomarkers like ela&#64257;n&#44; regenerating islet-derived 3-&#945; &#40;REG3&#945;&#41; or soluble interleukin-2 receptor-&#945; &#40;sIL-2R&#945;&#41;&#44; is a non-invasive procedure that can guide both for the diagnosis of the onset of GVHD&#44; as to predict the evolution towards severe GVHD&#46; In particular&#44; the three biomarkers mentioned&#44; measured jointly just when the symptomatology appears&#44; constitute a composite panel that has shown with statistical significance&#44; to be able to differentiate non-GVHD versus any degree GVHD&#46; The analysis in recent literature of the ROC curve of this panel to diagnose GVHD at the time of onset of symptoms&#44; describes a specificity of 100&#37; and a sensitivity of 55&#46;6&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion&#44; we present two clinical cases in which the diagnostic difficulty between these two entities and the importance of looking for clinical&#44; analytical and anatomopathological data that allow to focus therapeutic management&#44; is reflected&#46;</p></span></span>"
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ISSN: 15782190
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