Recurrent toxic epidermal necrolysis with two different drugs in a patient with chronic kidney disease-A case report with an atypical presentation.

Toxic epidermal necrolysis (TEN) is a dermatologic emergency usually attributed to drugs. Recurrent episodes of TEN are more common in the pediatric population than in adults. Patients carrying susceptible specific haplotypes, cross-reactivity between the drugs, and drug metabolites generated by the Cytochrome P450 are the key factors for the recurrent episodes. Chronic kidney disease (CKD) increases the risk of toxic epidermal necrolysis by altering the pharmacokinetics and pharmacodynamics of the drug with comparatively higher mortality in this group of patients. We hereby present an elderly female with 2 episodes of TEN following intake of furosemide at present and Nimesulide 3 years back. Cross-reactivity between these drugs because of the similar stereochemical structure might have triggered the second episode. The second episode of TEN was milder in presentation with a short latency period without any constitutional symptoms as compared to the first episode. Thus, treating physicians should always consider cross-reactivity between the chosen drugs in order to prevent subsequent life-threatening episodes, especially in patients with CKD.