TOKSİK EPİDERMAL NEKROLİZİS BENZERİ BÜLLÖZ CİLT REAKSİYONU: BİR OTOPSİ OLGUSU

Yıl 2015, Cilt: 29 Sayı: 2, 118 - 123, 31.08.2015

Hüseyin Eş Murat Nihat Arslan Gülhan Yağmur Ferah Anık Karayel

https://izlik.org/JA52RN99NP

Öz

Toksik epidermal nekrolizis epidermisin dermisten ayrılması ile karakterize bir durumdur. Deride maküler lezyonların üzerinde vezikül ile bül oluşumu izlenir ve bunlar kolayca yırtılarak yerlerinde erode alanlar kalır. Patogenezi tam olarak bilinmemekle birlikte toksik epidermal nekrolizis genellikle ilaçlara daha az sıklıkla da hepatit, mikoplazma, varisella, herpes, Escherichia coli septisemine bağlı gelişir. Antibiyotikler, antikonvülzan ve nonsteroidal antiinflamatuar ilaçlar etiyolojide en sık karşılaşılan ilaçlardır. Mortalitesi yüksek bir tablo olup çeşitli yayınlarda %20-60 arasında olduğu bildirilmiştir. En sık ölüm nedeni sepsis ve buna bağlı olarak gelişen akciğer tutulumudur. Ölüme neden olan sepsisten sorumlu mikrobiyal ajanlar genellikle Enterococcus spp, Acinetobacter spp, Staphylococcus aureus, Pseudomanas aurigonasa’dır. 40 yaşında erkek olgu, bilinci kapalı bir şekilde 112 ambulansı ile hastaneye getirilmiş ve gelişen kardiyak arrest nedeniyle yoğun bakım servisinde takip edilmeye başlanmıştır. 1 haftalık takip sonrasında ölümü nedeniyle kesin ölüm sebebinin tespiti için otopsiye gönderilmiştir. Olgunun dış muayenesinde sakral ve gluteal bölgede bası yaraları, göğüs ve sırt bölgeleri hariç tüm vücutta yer yer epidermal büller ve büllerin patlamasına bağlı tabanı hiperemik yer yer mor kırmızı renk değişikliği olan epidermal soyulmalar izlenmiştir. İç muayenede göğüs boşluklarında ve karında kirli sarı renkte mayi boşaltıldı. Trakea, özefagus alt kısmı ve omentum enfekte görünümde izlenmiştir. Histopatolojik incelemede akciğerde taze lobuler pnömoni, bronşit, ince ve kalın bağırsaklarda şiddetli aktif enterit, kolit görülmüştür. Yapılan toksikolojik incelemede kanda 78,4ng/ml Pentobarbital, 169ng/ml Thiopental, Pheniramine, Ranitidine, Metoclopromid tespit edilmiştir. Mikrobiyolojik örneklerde kanda ve beyin omurilik sıvısında E. coli, Enterococcus faecium, akciğerde E. coli, Candida albicans, dalak ve karaciğerde E. coli, batın sıvısında E. coli, Proteus spp, bül sıvısında E. coli, Enterococcus faecium ürediği görülmüş olup prokalsitonin düzeyi 2,26ng/ml bulunmuştur. Olgunun ölüm sebebi yaygın sistemik enfeksiyon olarak düşünülmüştür.

Anahtar Kelimeler

Toksik Epidermal Nekrolizis , Escherichia coli , sepsis , otopsi

TOXIC EPIDERMAL NECROLYSIS LIKE BULLOUS SKIN REACTION: AN AUTOPSY CASE

https://izlik.org/JA52RN99NP

Öz

Toxic epidermal necrolysis TEN is characterized by detachment of epidermis from underlying dermis. Vesicular and bullous lesions arise on macules. These lesions rupture easily and eroding lesions remain. Pathogenesis of TEN is not fully clear yet but in general some medications, hepatitis, septicemias of Mycoplasma, Varicella, Herpes, Escherichia coli infections are suspected. Antibiotics, anticonvulsant drugs or nonsteroidal anti-inflammatory drugs are most commonly involved drugs. In some publications mortality rate reported as between 20 and 60 per cent. Most common cause of death is sepsis and subsequent pulmonary involvement in TEN. Enterococcus spp, Acinetobacter spp, Staphylococcus aureus, Pseudomanas aurigonasa are most common causes of sepsis in those cases. A forty year-old man, transported to the hospital in unconscious state without any medical or judicial antecedent and followed in intensive care unit because of cardiac arrest. After one week follow-up patient died and referred to the Council of Forensic Medicine There were widespread except chest and back epidermal bullous lesions and concomitant ruptured bullae with hyperemic and purplecolored underlying tissue. During autopsy there were yellow effusions in chest and abdominal cavity. Lower segments of trachea and esophagus and greater omentum had infective appearance. On the histopathological examination of lungs lobular pneumonia and bronchitis were detected. Severe active enteritis and colitis were detected on small intestine and bowel specimens. On the toxicological screening of blood, 78.4ng/ml Pentobarbital, 169ng/ml Thiopental; Pheniramine, Ranitidine and Metoclopromide were detected. On postmortem microbiological study of blood and cerebrospinal fluid E. coli, Enterococcus faecium; at the lung tissue E. coli, Candida albicans; on the splenic tissue E. coli were colonized. On the microbiological study of abdominal effusion E. coli and Proteus spp were colonized and on bullae fluid E. coli and Enterococcus faecium were colonized. Serum Procalcitonin level was 2.26ng/ml. Cause of death determined as widespread systemic infection.

Anahtar Kelimeler

Toxic Epidermal Necrolysis , Escherichia coli , sepsis , autopsy

Kaynakça

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