In October 2017, a 51-year-old man, suffering from loose blisters, large-area skin peelings (nearly involving the entire body), mucosal erosion and fever, visited The First Affiliated Hospital with Nanjing Medical University. He had been diagnosed with stage IV EGFR-mutation-positive advanced NSCLC with pleural metastasis in 2016 and received treatments at a thoracic hospital regularly. After chemotherapy (pemetrexed plus cisplatin for six cycles) was completed, icotinib continued to be used till August 2017 when the drug resistance was revealed. Once EGFR T790M mutation was diagnosed, he started taking AZD-9291 with a dose of 80 mg/day to delay the disease progression. Twenty-one days later, he presented with several oral blisters and scattered erythematous maculopapular rashes, which rapidly developed into mucosal erosion and general epidermal detachment involving his entire body with exfoliation on his back skin (). When admitted into our department, he was unable to get up owing to severe pain, extreme feebleness, fever, and lower limb edema.
A 70-year-old female patient without other relevant medical history was started on pemetrexed and carboplatin for mesothelioma after vitamin B12 and folic acid supplementation. The patient developed a rash on the anterior chest wall 7 days after the first cycle which persisted despite treatment with loratadine. Four days after the second cycle (14 days after the onset of the rash), the patient was admitted with widespread maculopapular eruptions treated with betamethasone valerate 0.1% cream along with cetirizine 10 mg twice daily. The patient’s additional symptoms were fever, pancytopenia, including neutropenia, seizures and confusion, pulmonary embolism, and nausea. Over the next few days, the rash continued to coalesce and spread. Forty days after the initial onset, 80% of the total body’s surface area (TBSA) was affected with beginning denudation (). Histology showed widespread epidermal necrosis with multiple dyskeratotic keratinocytes. A TEN-like reaction was diagnosed. Treatment with prednisone 50 mg daily to be weaned off by 10 mg every 7 days was initiated along with supportive measures. The patient could be discharged to the community in a stable condition 50 days after the initial rash. Chemotherapy was discontinued and palliative care was initiated due to the sADRs including the diagnosis of a TEN-like reaction.