SHM Converge Scientific Abstract ePoster Gallery-Never in-Ten-Ded for Nivolumab-Induced Toxic Epidermal Necrolysis

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This case report describes a rare but severe adverse reaction to nivolumab, an immune checkpoint inhibitor used to treat metastatic renal cell carcinoma. Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a life-threatening blistering skin disorder typically caused by medications, with TEN defined by more than 30% body surface area involvement. It usually begins with fever or flu-like symptoms followed by erythematous rash, blistering, and skin sloughing. Rapid recognition and immediate discontinuation of the offending drug are critical because TEN carries a high mortality rate of about 30%.<br /><br />A 70-year-old man receiving cabozantinib and nivolumab developed progressive erythema and blisters that began on one elbow and spread to his arms, hands, feet, face, torso, and extremities. On admission, he had widespread painful violaceous macules, bullae, skin sloughing, and a positive Nikolsky sign, affecting about 90% of his body surface area. Dermatology performed a punch biopsy, which showed severe drug eruption with epithelial cytotoxicity consistent with a TEN-like reaction. Nivolumab was considered the most likely cause.<br /><br />He was treated with high-dose corticosteroids, aggressive wound care, and etanercept, a TNF inhibitor, but his skin disease continued to worsen. Given the extent of involvement and poor prognosis, goals of care were discussed, and he transitioned to hospice, dying three days later.<br /><br />The report emphasizes that although SJS/TEN from immune checkpoint inhibitors is extremely rare, clinicians should remain vigilant for this complication, especially because early withdrawal of the causative agent may improve outcomes.

Asset Subtitle

Sahit N. Menon

Meta Tag

Author List Jeremy Chang, Sahit N. Menon, Sherry Zhang

Category Clinical Vignettes

Concept Stevens-Johnson Syndrome

Concept Toxic Epidermal Necrolysis

Concept Total Body Surface Area

Concept Serious Dermatologic Emergency

Concept Skin Sloughing

Distinguished Non-Finalist

Presenter Organization Ucsd

Presenting Author Sahit N. Menon

Track Adult

Keywords

nivolumab

Stevens-Johnson syndrome

toxic epidermal necrolysis

immune checkpoint inhibitor

metastatic renal cell carcinoma

skin sloughing

Nikolsky sign

drug eruption

etanercept

corticosteroids

Stevens-Johnson Syndrome

Toxic Epidermal Necrolysis

Total Body Surface Area

Serious Dermatologic Emergency

Skin Sloughing