We describe a case of toxic epidermal necrolysis after intranasal application of mupirocin in a 76-year-old woman. The drug was given for eradication of methicillin-resistant Staphylococcus aureus (Infect Control Hosp Epidemiol 2003;24:459-460).Toxic epidermal necrolysis (TEN) is characterized by an erythemato-bullous skin eruption followed by epidermal necrolysis with skin scaling and mucosal involvement. The general consequences are extended burns. Mortality is approximately 20% to 30%, increasing with age and the extent of the lesions. 12 The most severe complications are sepsis and ocular involvement. The mechanisms responsible for the accelerated apoptosis of the keratinocytes remain unclear, but, besides multiple factors, drugs are clearly implicated. Many agents are deemed responsible for TEN. Among the most frequently cited are nonsteroidal anti-inflammatory drugs, sulfonamides, and anticonvulsants.3 Until now, TEN occurring after topical intranasal applications of mupirocin has never been described. CASE REPORTA 76-year-old woman with a tracheostomy after operation for an oropharyngeal carcinoma was admitted to our hospital for ventilatory weaning. Her usual medications were prednisone, ipratropium bromide, salbutamol, citalopram, hydrochlorothiazide, lisinopril, aspirin, and acetaminophen. She had been treated with the same medication regimen for several weeks before entering our hospital. She was allergic to penicillin and had asthma.Eighteen days later, sputum cultures yielded methicillin-resistant Staphylococcus aureus. The patient was isolated, bathed with chlorhexidine once a day, and treated with mupirocin intranasally twice a day. Two days later, a skin eruption of a maculo-erythematous type appeared around the nares, evolving rapidly into bullae and extending to the cheeks and neck, accompanied by a fever (temperature, 38°C and higher). The patient had been given two baths with chlorhexidine and four intranasal applications of mupirocin before the onset of the rash. Despite the discontinuation of intranasal mupirocin and the chlorhexidine baths, the skin lesions progressed in the form of large bullae involving the face and upper trunk, covering approximately 20% of the body surface area. A positive Nikolsky sign confirmed the clinical diagnosis of TEN. With the consent of the patient, considering her dismal oncologic prognosis and bedridden state, no life support was started. Five days after the eruption of the dermal lesions, the patient died of sepsis. DISCUSSIONIn this patient, TEN appeared after the application of mupirocin for eradication of methicillin-resistant S. aureus. It is highly probable that mupirocin, introduced 2 days before the appearance of the skin disease, was the cause because, except for chlorhexidine skin antisepsis given at the same time, no other medication had been introduced during the 4 preceding weeks. In particular, acetaminophen, often cited as a cause of TEN, 4 had been given for many weeks for the patient's chronic pain due to the oropharyngeal carcino...
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