Abstract | November 18, 2023
Treating Hypertension could be Life Threatening: A Case of TEN Associated with Meloxicam and Allopurinol for Treatment of Gout After Starting Hydrochlorothiazide for the Treatment of Hypertension
Learning Objectives
- Identify TEN based on symptoms and body surface area involvement.
- Swift discovery of causative agents should be discontinued.
- Understand the importance of a multidisciplinary team when treating TEN.
Introduction:
Toxic epidermal necrolysis (TEN) is a rare (1.9 per million adults per year in the United States) and life-threatening condition. It has been associated with a 30-50% mortality rate. Medications are the most common cause of this mucocutaneous reaction. Identifying and stopping the causative agent is the mainstay to improve outcomes. Here we present a case of a 41 year old male who was diagnosed with TEN after starting treatment for gout that was a consequence of treating hypertension with hydrochlorothiazide.
Case presentation:
A 41 year old African American man with a medical history of hypertension presented with >50% of desquamative skin rash involving his face, bilateral axillary region, eyes and urogenital region which worsened within a week of starting allopurinol and meloxicam. Three months prior, he was started on hydrochlorothiazide for hypertension and he subsequently developed gout which prompted the initiation of meloxicam and allopurinol. Dermatology performed a punch biopsy with confirmation of TEN. Diluted chlorhexidine and cleansing wipes,petrolatum, bacitracin ointments were used daily. Ophthalmology recommended erythromycin ointments applied around the eyes. Urology recommended Foley placement to prevent any urethral obstruction. He received cefepime, vancomycin x 11 days and 2 g/kg IVIG x 3 days.Allopurinol, meloxicam, and HCTZ were all discontinued and added to the allergy list. Patient experienced significant improvement within two weeks and was discharged on colchicine for gout, amlodipine and losartan for hypertension.
Discussion:
TEN can be caused by medications, infections, vaccines or can be idiopathic. There is no proven effective treatment modality which makes management a challenge. Evaluation with a multidisciplinary team is recommended due to the spectrum and complexity of the symptoms. Though hydrochlorothiazide is one of the first line agents for hypertension, it can be fatal. The patient most likely developed the T-cell mediated, type IV hypersensitivity disorder seen in TEN after the addition of allopurinol and meloxicam.
Conclusion:
Multiple medications have been associated with TEN. A full and detailed medication reconciliation should be performed to identify and stop the causative agent. It is extremely important to educate the patient to prevent further exposures to the causative agent.
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