Pulmonary complications in toxic epidermal necrolysis: a prospective clinical study

Objective: To evaluate the incidence, clinical features, and prognosis of pulmonary complications associated with toxic epidermal necrolysis. Design: Prospective study. Setting: Dermatology intensive care unit in Mondor Hospital, France. Patients: 41 consecutive patients. Interventions: On admission, then daily, respiratory evaluation was based on clinical examination, chest X-ray, and arterial blood gas analysis. When clinical symptoms, X-ray abnormalities, or hypoxemia [partial pressure of oxygen (PO2) < 80 mm Hg] were present, fiberoptic bronchoscopy was performed. Results: 10 patients presented early manifestations: dyspnea (n = 10), bronchial hypersecretion (n = 7), marked hypoxemia (n = 10) (PO2 = 59 +/- 8 mm Hg). Chest X-ray was normal (n = 8) or showed interstitial infiltrates (n = 2). In these 10 patients, fiberoptic bronchoscopy demonstrated sloughing of bronchial epithelium in proximal airways. Delayed pulmonary complications occurred in 6 of these 10 patients from day 7 to day 15: pulmonary edema (n = 2), atelectasis (n = 1), bacterial pneumonitis (n = 4). Mechanical ventilation was required in 9 patients. A fatal outcome occurred in 7 patients. Seven patients did not develop early pulmonary manifestations (PO2 on admission 87 +/- 6 mm Hg) but only delayed pulmonary symptoms related to atelectasis (n = 1), pulmonary edema (n = 4), and bacterial pneumonitis (n = 3); bronchial epithelial detachment was not observed. None of them required mechanical ventilation and all recovered with appropriate therapy. Conclusions: "Specific" involvement of bronchial epithelium was noted in 27% of cases and must be suspected when dyspnea, bronchial hypersecretion, normal chest X-ray, and marked hypoxemia are present during the early stages of toxic epidermal necrosis. Bronchial injury seems to indicate a poor prognosis, as mechanical ventilation was required for most of these patients and was associated with a high mortality.