Sudden Conjunctivitis, Lymphopenia, and Rash Combined With Hemodynamic Changes (SCoRCH) After Trimethoprim-Sulfamethoxazole Use

Abstract

ImportanceTrimethoprim-sulfamethoxazole (TMP-SMX) hypersensitivity reaction, ranging from circulatory shock to aseptic meningitis and respiratory failure, is a potentially life-threatening condition with dermatologic relevance.ObjectiveTo describe the mucocutaneous findings and clinical features of TMP-SMX hypersensitivity reaction.Design, Setting, and ParticipantsThis was a retrospective case series study of 7 patients who developed a characteristic rash, hemodynamic changes, and end-organ dysfunction after treatment with TMP-SMX at a large university hospital system during January 2013 to March 2022.ExposuresTreatment with TMP-SMX within 2 weeks of the reaction.Main Outcome and MeasuresDescriptions of the condition, including the demographic information of the affected population, the reaction timeline, and mucocutaneous and clinical features.ResultsThe cohort comprised 7 patients (median [range] age, 20 [15-66] years; 4 female and 3 male). The most common mucocutaneous findings were generalized sunburn-like erythema without scale, conjunctivitis, and mild facial and acral edema. Three patients had previous exposure to TMP-SMX and developed symptoms in 1 day or less, while those without prior exposure presented from 4 to 11 days after drug initiation. Among the 7 patients, 6 had fever, 7 had hypotension, and 7 had tachycardia. All patients had lymphopenia and evidence of end-organ dysfunction with either kidney or liver involvement. Median (range) time to resolution was 72 (48-96) hours.Conclusions and RelevanceThis retrospective case series indicates that SCoRCH (sudden conjunctivitis, lymphopenia, and rash combined with hemodynamic changes) should be considered in the differential diagnosis of patients presenting with acute generalized sunburn-like erythema, conjunctivitis, systemic symptoms, and hemodynamic changes in the setting of recent TMP-SMX use.

Expanding the Histologic Spectrum of Sudden Conjunctivitis, Lymphopenia, and Rash Combined With Hemodynamic Changes

“…Although various types of rashes have been described in the literature in patients with severe hypersensitivity reactions to TMP-SMX, mucocutaneous findings have not been well-characterized until the recent case series describing SCoRCH by O'Brian et al 2 Our patient's clinical findings, including bilateral conjunctivitis, facial edema, sunburn-like erythema, hemodynamic changes, lymphopenia, and resolution of symptoms within days after TMP-SMX cessation are consistent with the reported cases of SCoRCH. Although the exact mechanism of SCoRCH is unknown, it may be due to T-cell–mediated immune responses to new antigens.…”

“…4 Unlike SJS/TEN, mucosal sloughing has not been described. 2 Moreover, compared with SJS/TEN or DIHS, SCoRCH reportedly manifests earlier in TMP-SMX course with rapid improvement after cessation of the medication. 4…”

“…1 More recently, the entity of sudden conjunctivitis, lymphopenia, and rash combined with hemodynamic changes (SCoRCH) has been described as a hypersensitivity reaction toTMP-SMX. 2…”

“…1 More recently, the entity of sudden conjunctivitis, lymphopenia, and rash combined with hemodynamic changes (SCoRCH) has been described as a hypersensitivity reaction toTMP-SMX. 2 SCoRCH has been described as a delayed-type hypersensitivity reaction to TMP-SMX that differs from other severe drug reactions based on mucocutaneous clinical features and duration. 2 The hallmark of this reaction is the circulatory shock and anaphylactic-like reaction to TMP-SMX that is not observed in other hypersensitivity reactions; in addition, it resolves spontaneously within a few days after exposure.…”

“…2 SCoRCH has been described as a delayed-type hypersensitivity reaction to TMP-SMX that differs from other severe drug reactions based on mucocutaneous clinical features and duration. 2 The hallmark of this reaction is the circulatory shock and anaphylactic-like reaction to TMP-SMX that is not observed in other hypersensitivity reactions; in addition, it resolves spontaneously within a few days after exposure. 2,3 Recently proposed by O'Brian et al, this entity histopathologically presented in 1 case as a nonspecific superficial perivascular dermatitis.…”