AJPH -- eLetters for Chen et al., 93 (3) 489-492

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RESEARCH AND PRACTICE:
Kow-Tong Chen, Shiing-Jer Twu, Hong-Jen Chang, and Ruey-Shiung Lin
Outbreak of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Associated With Mebendazole and Metronidazole Use Among Filipino Laborers in Taiwan
Am J Public Health 2003; 93: 489-492 [Abstract] [Full text] [PDF]

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Mycoplasma Pneumoniae Infection and Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis: Ta-Chen Su (17 February 2004)

Mycoplasma Pneumoniae Infection and Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis 17 February 2004

Ta-Chen Su,
M.D.
Attending Physician, Department of Internal Medicine, National Taiwan University Hospital
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Re: Mycoplasma Pneumoniae Infection and Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis

tachensu{at}ha.mc.ntu.edu.tw Ta-Chen Su

To the Editor:
We read with great interest the study reported by Chen et al on the etiologic inference of outbreak of Stevens-Johnson Syndrome (SJS)/toxic epidermal necrolysis (TEN) associated with mebendazole and metronidazole use among Filipino laborers in Taiwan.(1)
From epidemiological study, the result showed that ever use of anthelmintic drugs with both metronidazole and mebendazole in the preceding 6 weeks increase the odds ratio for development of SJS/TEN by 9.5.(1) However, the plausible etiologic causes from literature search for SJS/TEN, metronidazole and mebendazole are very rare.(2,3) Among other possible etiologies that related with SJS/TEN, mycoplasma pneumoniae should be considered.(4-6) We had taken care two cases of TEN among Dr. Chenˇ survey and mycoplasma pneumonia infection was associated. They worked in a crowded dormitory of video display terminals assembly factory in north Taiwan. Prior to Taiwan, they took anthelmintic drugs (case 1: metronidazole 1500 mg and mebendazole 1000 mg and case 2: metronidazole 2000 mg and mebendazole 1000 mg) once per week for two times. These two young (25 and 23 years-old) female Filipino workers came to Taiwan on July 1996. They presented with intermittent fever, skin rash and elevated liver transaminase about four weeks after arrival. The initial presentation of skin lesions was erythematous rashes, and then it became many erythematous patches with papules and confluent plaques about 10 days later. After all, generalized nonblanchable erythematous macules and patches developed all over the body and accompanied with significant blisters and bullaes over the abdomen, and then progressed to back, face and four limbs. The pathologic reports for the skin lesions revealed subepidermal bullae with full layer necrosis of the overlying epidermis, which were compatible with TEN. After serial serologic studies, these two cases fulfilled the diagnostic criteria of Kenny et al by complement fixation test (fourfold Ig G antibody increase or high antibody titer >=1:32) for current mycoplasma pneumoniae infection as table.(7) Atypical pneumonia also was noted in case 1, which resolved after treatment with Zithromycin for one week. There are studies reports that cross-reactivity would happen while using two imidazoles,(8) which also could be an explanation of this unusual outbreak of SJS/TEN. Antibiotics use before the occurrence of exanthem intensified the dermatosensitive potential of mycoplasma pneumonia infection in a picture similar to ampicillin associated exanthem in infectious mononucleosis.(6) In summary, this outbreak of SJS/TEN may be highly suspected as a dermatosensitive effect associated with M. pneumoniae infection in subjects with preceding use of metronidazole and mebendazole.
Reference: 1. Chen KT, Twu SJ, Chang HJ, Lin RS. Outbreak of Stevens-Johnson Syndrome/Toxic Epidermal necrolysis associated with mebendazole and metronidazole use among Filipino laborers in Taiwan. Am J Public Health. 2003;93:489-492. 2. Robinson HR, Samorodin CS. Thiabendazole-induced toxic epidermal necrolysis. Arch Dermatol. 1976;112:1757-1760. 3. Egan CA, Grand WJ, Morris SE, Saffle JR, Zone JJ. Plasmaphoresis as an adjunct treatment in toxic epidermal necrolysis. J Am Acad Dermatol. 1999;40:458-561. 4. McCormack JG. Mycoplasma pneumoniae and the erythema multiforme -- Stevens-Johnson syndrome. J Infect. 1981;3:32-36. 5. Mycoplasma pneumoniae infections and Stevens-Johnson syndrome. Report of eight cases and review of the literature. Clin Pediatr. 1991;30:42-49. 6. Cherry JD. Anemia and mucocutaneous lesions due to mycoplasma pneumoniae infections. CID. 1993;17(Suppl 1):S47-51. 7. Kenny GE, Kaiser GG, Conney MK, Foy HM. Diagnosis of mycoplasma pneumoniae pneumonia: sensitivities and specificities of serology with lipid antigen and isolation of the organism on soy peptone medium for identification of infections. J Clin Microbiol. 1990;28:2087-2093. 8. Knowles S, Choudhury T, Shear NH. Metronidazole hypersensitivity. Ann Pharmacother. 1994;28:325-326.