COLONIC PERFORATION SECONDARY TO TOXIC EPIDERMAL NECROLYSIS

Case Presentation A 59-year-old male patient presented with a diffuse rash, blistering lesions across the body and buccal mucosa, fever, tremors, and tachypnea, progressively worsening for five days prior to admission. Thirty days earlier, he had started lamotrigine for drug-resistant epilepsy. Toxic epidermal necrolysis (TEN) secondary to lamotrigine was diagnosed. Three days after admission, the patient developed abdominal pain and distension. An abdominal X-ray revealed a hyperlucent area above the liver, and a computed tomography (CT) scan confirmed a large pneumoperitoneum. Exploratory laparotomy identified a pinpoint perforation in the transverse colon and localized peritonitis, leading to the decision to perform a transverse colostomy. The patient showed good clinical recovery and was discharged on the 12th postoperative day with significant improvement in skin and mucosal lesions. During outpatient follow-up, intestinal continuity was restored 21 months after the colostomy.

Discussion TEN is a severe, rare delayed hypersensitivity reaction to medication, characterized by purpuric exanthema with mucosal involvement, blisters, and detachment of more than 30% of the body surface area. The disease's pathogenesis involves a delayed type IV hypersensitivity immune reaction, resulting in keratinocyte apoptosis mediated by CD8+ cytotoxic T cells. Aromatic anticonvulsants, such as lamotrigine, are the leading cause of TEN in Latin American patients. TEN is part of the Stevens-Johnson syndrome spectrum but involves a larger body surface area and has a more lethal progression. The epidermal detachment in TEN typically affects the skin or mucosa, most commonly ocular and respiratory epithelium. Mortality rates can reach 40%, primarily due to sepsis caused by skin barrier loss and respiratory involvement. Intestinal mucosal involvement is rare, with only six cases of colonic necrosis secondary to TEN reported in the literature. This case, involving focal necrosis and a pinpoint perforation, represents a highly atypical presentation.

Conclusion TEN is a severe drug reaction, and colonic perforation secondary to it is extremely rare.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025