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Toksik Epidermal Nekroliz Tedavisinde Siklosporin A Kullanımı; Olgu Sunumu ve Literatür Derlemesi

Yıl 2014, Cilt: 12 Sayı: 2, 116 - 122, 01.09.2014
https://doi.org/10.4274/jcp.43265

Öz

Toksik epidermal nekroliz TEN sıklıkla ilaçlar tarafından tetiklenen, deri, göz, mukozalar ve birden çok organı etkileyebilen, ciddi ve hayatı tehdit eden akut mukokütanöz bir hastalıktır. On bir yaşında kız hasta, epilepsi nedeni ile 3 yıldır valproik asit kullanırken tedavisine bir ay önce lamotrigin eklenmişti. Hasta iki gün önce başlayan ateş, halsizlik, ağız içinde yaralar, gözlerde kızarıklık, sulanma, deride döküntü ve çok sayıda büllöz lezyonlar ile başvurdu. Fizik muayenede, genel durumu kötü, tüm vücutta yaygın makülopapüler döküntüler, purpurik maküller, tipik olmayan hedef benzeri deri lezyonları, vücut yüzeyinin %30’dan fazlasını etkileyen değişik evrelerde en büyüğü 6-10 cm çaplarında çok sayıda büller saptandı. Ağız mukozasında ülsere lezyonlar, her iki gözde keratit, blefarit ve konjunktival hiperemi vardı. Hastaya mevcut bulguları ile TEN tanısı konuldu. Lamotrigin tedavisi kesildi, destek tedavisi, metilprednisolon, intravenöz immunglobulin, deri ve göz lezyonlarına yönelik bakım ve gerekli topikal tedaviler uygulandı. İzleminde klinik tablo ve deri lezyonlarında iyileşme olmaması üzerine hastanın tedavisine siklosporin A eklendi. Siklosporin A tedavisine iyi cevap alınan olgunun klinik tablo ve deri lezyonlarında belirgin iyileşme gözlendi.TEN tedavisinin esasını şüpheli ilacın kesilmesi ve destek tedavisi oluşturmaktadır. TEN tedavisinde, sistemik kortikosteroidler, İVİG gibi immünsüpresif ajanlar tedavide kullanılabilmektedir. Tedaviye dirençli veya ciddi TEN olgularında siklosporin kullanımı tedaviye olumlu katkı sağlayabilir. Siklosporinin TEN tedavisindeki yeri ve etkilerini araştırmaya yönelik ayrıntılı çalışmalara ihtiyaç vardır

Kaynakça

  • 1. Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994;331:1272-85.
  • 2. Lyell A. Toxic epidermal necrolysis: an eruption resembling scalding of the skin. Br J Dermatol 1956;68:355-61.
  • 3. Auquier-Dunant A, Mockenhaupt M, Naldi L, Correia O, Schröder W, Roujeau JC, et al. Correlations between clinical patterns and causes of erythema multiforme majus, StevensJohnson syndrome, and toxic epidermal necrolysis: Results of an international prospective study. Arch Dermatol 2002;138:1019- 24.
  • 4. Harr T, French L. Toxic epidermal necrolysis and StevensJohnson syndrome. Orphanet J Rare Dis 2010;5:1-11.
  • 5. Abood GJ, Nickoloff BJ, Gamelli RL. Treatment strategies in toxic epidermal necrolysis syndrome: Where are we at? J Burn Care Res 2008;29:269-76.
  • 6. Mockenhaupt M, Viboud C, Dunant A, Naldi L, Halevy S, Bouwes Bavinck JN, et al. Stevens-Johnson syndrome and toxic epidermal necrolysis: Assessment of medication risks with emphasis on recently marketed drugs. The EuroSCAR-study. J Invest Dermatol 2008;128:35-44.
  • 7. Revuz J, Penso D, Roujeau JC, Guillaume JC, Payne CR, Wechsler J, et al. Toxic epidermal necrolysis. Clinical findings and prognosis factors in 87 patients. Arch Dermatol 1987;123:1160- 5.
  • 8. Schöpf E, Stühmer A, Rzany B, Victor N, Zentgraf R, Kapp JF. Toxic epidermal necrolysis and Stevens-Johnson syndrome. An epidemiologic study from West Germany. Arch Dermatol 1991;127:839-42.
  • 9. Widgerow AD. Toxic epidermal necrolysis management issues and treatment options. Int J Burn Trauma 2011;1:42-50.
  • 10. Murata J, Abe R, Shimizu H. Increased soluble Fas ligand levels in patients with Stevens- Johnson syndrome and toxic epidermal necrolysis preceding skin detachment. J Allergy Clin Immunol 2008;122:992-1000.
  • 11. Tedesco D, Haragsim L. Cyclosporine: a review. J Transplant 2012;2012:230386. doi: 10.1155/2012/230386. Epub 2012 Jan 4.
  • 12. Lehloenya R. Management of Stevens-Johnson syndrome and toxic epidermal necrolysis. Current Allergy Clinical Immunology 2007;20:124-8.
  • 13. Verma R, Vasudevan B, Pragasam V. Severe cutaneous adverse drug reactions. Med J Armed Forces India 2013;69:375-83.
  • 14. Chan HL. Observations on drug-induced toxic epidermal necrolysis in Singapore. J Am Acad Dermatol 1984;10:973-8.
  • 15. Kaniwa N, Saito Y, Aihara M, Matsunaga K, Tohkin M, Kurose K, et al. HLA-B locus in Japanese patients with anti-epileptics and allopurinol-related Stevens Johnson syndrome and toxic epidermal necrolysis. Pharmacogenomics 2008;9:1617-22.
  • 16. Pellock JM. The clinical efficacy of lamotrigine as an antiepileptic drug. Neurology 1994;44:29-35.
  • 17. Mixkonhaupt M, Messenheimer J. Tennis P, Schlingmann J. Risk for Stevens-Johnson syndrome and toxic epidermal necrolysis in new users of antiepileptics. Neurology 2005;64:1134-8.
  • 18. Li LM, Russo M, O’Donoghue MF, Duncan JS, Sander JW. Allergic skin rash with lamotrigine and concomitant valproic acid therapy: evidence for an increased risk. Arq Neuropsiquiatr 1996;54:47-9.
  • 19. Revuz J, Penso D, Roujeau JC, Guillaume JC, Payne CR, Wechsler J, et al. Toxic epidermal necrolysis. Clinical findings and prognosis factors in 87 patients. Arch Dermatol 1987;123:1160- 5.
  • 20. Chang YS, Huang FC, Tseng SH, Hsu CK, Ho CL, Sheu HM. Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis: acute ocular manifestations, causes, and management. Cornea 2007;26:123-9.
  • 21. Alpsoy E, Dicle Ö, Karakaş AA. Steven-Johnson Syndrome (SJS) and Toxic Epidermal necrolysis. Türkderm 2010;44:180-6.
  • 22. Lebargy F, Wolkenstein P, Gisselbrecht M, Lange F, Fleury-Feith J, Delclaux C, et al. Pulmonary complications in toxic epidermal necrolysis: a prospective clinical study. Intensive Care Med 1997;23:1237-44.
  • 23. Akman A, Alpsoy E. Eritema Multiforme, Steven-Johnson Sendromu ve Toksik Epidermal Nekroliz (Lyell Sendromu). Turkiye Klinikleri J Surg Med Sci 2006;2:6-15.
  • 24. Sotozono C, Ueta M, Koizumi N, Inatomi T, Shirakata Y, Ikezawa Z, et al. Diagnosis and treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis with ocular complications. Ophthalmology 2009;116:685-90.
  • 25. Bastuji-Garin S, Fouchard N, Bertocchi M, Roujeau JC, Revuz J, Wolkenstein P. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol 2000;115:149-53.
  • 26. Chave TA, Mortimer NJ, Sladden MJ, Hall AP, Hutchinson PE. Toxic epidermal necrolysis: current evidence, practical management and future directions. Br J Dermatol 2005;153:241- 53.
  • 27. Hynes AY, Kafkala C, Daoud YJ, Foster CS. Controversy in the use of high-dose systemic steroids in the acute care of patients with Stevens-Johnson syndrome. Int Ophthalmol Clin 2005;45:25-48.
  • 28. Kardaun SH, Jonkman MF. Dexamethasone pulse therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis. Acta Derm Venereol 2007;87:144-8.
  • 29. Roongpisuthipong W, Prompongsa S, Klangjareonchai T. Retrospective analysis of corticosteroid treatment in StevensJohnson syndrome and/or toxic epidermal necrolysis over a period of 10 years in Vajira Hospital, Navamindradhiraj University, Bangkok. Dermatol Res Pract 2014;2014:237821. doi: 10.1155/2014/237821. Epub 2014 Jun 15.
  • 30. Schneck J, Fagot JP, Sekula P, Sassolas B, Roujeau JC, Mockenhaupt M. Effects of treatments on the mortality of Stevens-Johnson syndrome and toxic epidermal necrolysis: A retrospective study on patients included in the prospective EuroSCAR Study. J Am Acad Dermatol 2008;58:33-40.
  • 31. French LE. Toxic epidermal necrolysis and Stevens-Johnson syndrome: Our current understanding. Allergol Int 2006;55:9-16.
  • 32. Mittman N, Chan BC, Knowles S, Shear NH. IVIG for the treatment of toxic epidermal necrolysis. Skin Therapy Letter 2007;12:7-9.
  • 33. Mittmann N, Chan B, Knowles S, Cosentino L, Shear N. Intravenous immunoglobulin use in patients with toxic epidermal necrolysis and Stevens-Johnson syndrome. Am J Clin Dermatol 2006;7:359-68.
  • 34. Huang YC, Li YC, Chen TJ. The efficacy of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis: a systematic review and meta-analysis. Br J Dermatol 2012;167:424-32.
  • 35. Chung WH, Hung SI, Yang JY, Su SC, Huang SP, Wei CY, et al. Granulysin is a key mediator for disseminated keratinocyte death in Stevens Johnson syndrome and toxic epidermal necrolysis. Nat Med 2008;14:1343-50.
  • 36. Paquet P, Jacob E, Damas P, Pirson J, Piérard G. Analytical quantification of the inflammatory cell infiltrate and CD95R expression during treatment of drug-induced toxic epidermal necrolysis. Arch Dermatol Res 2005;297:266-73.
  • 37. Reese D, Henning JS, Rockers K, Ladd D, Gilson R. Cyclosporine for SJS/TEN: a case series and review of the literature. Cutis 2011;87:24-9.
  • 38. Kirchhof MG, Miliszewski MA, Sikora S, Papp A, Dutz JP. Retrospective review of Stevens-Johnson syndrome/ toxic epidermal necrolysis treatment comparing intravenous immunoglobulin with cyclosporine. J Am Acad Dermatol 2014;30:0190-9622(14)01679-X. doi:10.1016/j.jaad. 2014.07.016. [Epub ahead of print]
  • 39. Arevalo JM, Lorente JA, Gonzalez-Herrada C, Jimenez-Reyes J. Treatment of toxic epidermal necrolysis with cyclosporin A. J Trauma 2000;48:473-8.
  • 40. Rai R, Srinivas CR. Suprapharmacologic doses of intravenous dexamethasone followed by cyclosporine in the treatment of toxic epidermal necrolysis. Indian J Dermatol Venereol Leprol 2008;74:263-5.
  • 41. Hashim N, Bandara D, Tan E, Ilchyshyn A. Early cyclosporine treatment of incipient toxic epidermal necrolysis induced by concomitant use of lamotrigine and sodium valproate. Acta Derm Venereol 2004;84:90-1.
  • 42. Valeyrie-Allanore L, Wolkenstein P, Brochard L, Ortonne N, Maitre B, Revuz J, et al. Open trial of ciclosporin treatment for Stevens-Johnson syndrome and toxic epidermal necrolysis. Br J Dermatol 2010;163:847-53.

The Use of Cyclosporine A in the Treatment of Toxic Epidermal Necrolysis; Case Report and Review of Literature

Yıl 2014, Cilt: 12 Sayı: 2, 116 - 122, 01.09.2014
https://doi.org/10.4274/jcp.43265

Öz

Toxic epidermal necrolysis TEN is a serious and life-threatening acute mucocutaneous disease that is often triggered by drugs, can affect skin, eyes, mucous membranes and multiple organs. While an eleven-year-old female patient with epilepsy had been using valproic acid for three years, lamotrigine was added to the treatment one month ago. The patient was admitted complaints such as fever, malaise, sores in the mouth, eye redness, watering of eyes, rashes and many bullous lesions in the skin that had started just 2 days earlier. On the physical examination, whose overall situation was bad, that were common maculopapular rash, purpuric macules on the whole body, atypical target-like skin lesions, and many bullae that affected more than 30% of the body in different stages and whose largest one was 6-10 cm in diameter were detected. There were ulcerated lesions in the oral mucosa and keratitis, blepharitis and conjunctival hyperemia in both eyes. The patient was diagnosed with TEN through the existing findings. The lamotrigine treatment was discontinued; the supportive treatment, methylprednisolone, intravenous immunoglobulin, necessary care for skin and eye lesions and the necessary topical treatment were applied. As no improvement was observed in clinical picture and skin lesions in the follow-up period, cyclosporine A was added to the treatment. Significant improvement was observed in the clinical picture and skin lesions of the patient who responded well to the treatment of cyclosporine A. The basis of the treatment of TEN is composed of discontinuation of the suspicious drug and the supportive therapy. The immunosuppressive agents such as systemic corticosteroids and IVIG therapy may be used in the treatment of TEN. Cyclosporine can positively contribute to the treatment in cases who are resistant to treatment and with a severe TEN condition. There is a need for in-depth studies to investigate the place and impact of cyclosporine in the treatment of TEN.

Kaynakça

  • 1. Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994;331:1272-85.
  • 2. Lyell A. Toxic epidermal necrolysis: an eruption resembling scalding of the skin. Br J Dermatol 1956;68:355-61.
  • 3. Auquier-Dunant A, Mockenhaupt M, Naldi L, Correia O, Schröder W, Roujeau JC, et al. Correlations between clinical patterns and causes of erythema multiforme majus, StevensJohnson syndrome, and toxic epidermal necrolysis: Results of an international prospective study. Arch Dermatol 2002;138:1019- 24.
  • 4. Harr T, French L. Toxic epidermal necrolysis and StevensJohnson syndrome. Orphanet J Rare Dis 2010;5:1-11.
  • 5. Abood GJ, Nickoloff BJ, Gamelli RL. Treatment strategies in toxic epidermal necrolysis syndrome: Where are we at? J Burn Care Res 2008;29:269-76.
  • 6. Mockenhaupt M, Viboud C, Dunant A, Naldi L, Halevy S, Bouwes Bavinck JN, et al. Stevens-Johnson syndrome and toxic epidermal necrolysis: Assessment of medication risks with emphasis on recently marketed drugs. The EuroSCAR-study. J Invest Dermatol 2008;128:35-44.
  • 7. Revuz J, Penso D, Roujeau JC, Guillaume JC, Payne CR, Wechsler J, et al. Toxic epidermal necrolysis. Clinical findings and prognosis factors in 87 patients. Arch Dermatol 1987;123:1160- 5.
  • 8. Schöpf E, Stühmer A, Rzany B, Victor N, Zentgraf R, Kapp JF. Toxic epidermal necrolysis and Stevens-Johnson syndrome. An epidemiologic study from West Germany. Arch Dermatol 1991;127:839-42.
  • 9. Widgerow AD. Toxic epidermal necrolysis management issues and treatment options. Int J Burn Trauma 2011;1:42-50.
  • 10. Murata J, Abe R, Shimizu H. Increased soluble Fas ligand levels in patients with Stevens- Johnson syndrome and toxic epidermal necrolysis preceding skin detachment. J Allergy Clin Immunol 2008;122:992-1000.
  • 11. Tedesco D, Haragsim L. Cyclosporine: a review. J Transplant 2012;2012:230386. doi: 10.1155/2012/230386. Epub 2012 Jan 4.
  • 12. Lehloenya R. Management of Stevens-Johnson syndrome and toxic epidermal necrolysis. Current Allergy Clinical Immunology 2007;20:124-8.
  • 13. Verma R, Vasudevan B, Pragasam V. Severe cutaneous adverse drug reactions. Med J Armed Forces India 2013;69:375-83.
  • 14. Chan HL. Observations on drug-induced toxic epidermal necrolysis in Singapore. J Am Acad Dermatol 1984;10:973-8.
  • 15. Kaniwa N, Saito Y, Aihara M, Matsunaga K, Tohkin M, Kurose K, et al. HLA-B locus in Japanese patients with anti-epileptics and allopurinol-related Stevens Johnson syndrome and toxic epidermal necrolysis. Pharmacogenomics 2008;9:1617-22.
  • 16. Pellock JM. The clinical efficacy of lamotrigine as an antiepileptic drug. Neurology 1994;44:29-35.
  • 17. Mixkonhaupt M, Messenheimer J. Tennis P, Schlingmann J. Risk for Stevens-Johnson syndrome and toxic epidermal necrolysis in new users of antiepileptics. Neurology 2005;64:1134-8.
  • 18. Li LM, Russo M, O’Donoghue MF, Duncan JS, Sander JW. Allergic skin rash with lamotrigine and concomitant valproic acid therapy: evidence for an increased risk. Arq Neuropsiquiatr 1996;54:47-9.
  • 19. Revuz J, Penso D, Roujeau JC, Guillaume JC, Payne CR, Wechsler J, et al. Toxic epidermal necrolysis. Clinical findings and prognosis factors in 87 patients. Arch Dermatol 1987;123:1160- 5.
  • 20. Chang YS, Huang FC, Tseng SH, Hsu CK, Ho CL, Sheu HM. Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis: acute ocular manifestations, causes, and management. Cornea 2007;26:123-9.
  • 21. Alpsoy E, Dicle Ö, Karakaş AA. Steven-Johnson Syndrome (SJS) and Toxic Epidermal necrolysis. Türkderm 2010;44:180-6.
  • 22. Lebargy F, Wolkenstein P, Gisselbrecht M, Lange F, Fleury-Feith J, Delclaux C, et al. Pulmonary complications in toxic epidermal necrolysis: a prospective clinical study. Intensive Care Med 1997;23:1237-44.
  • 23. Akman A, Alpsoy E. Eritema Multiforme, Steven-Johnson Sendromu ve Toksik Epidermal Nekroliz (Lyell Sendromu). Turkiye Klinikleri J Surg Med Sci 2006;2:6-15.
  • 24. Sotozono C, Ueta M, Koizumi N, Inatomi T, Shirakata Y, Ikezawa Z, et al. Diagnosis and treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis with ocular complications. Ophthalmology 2009;116:685-90.
  • 25. Bastuji-Garin S, Fouchard N, Bertocchi M, Roujeau JC, Revuz J, Wolkenstein P. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. J Invest Dermatol 2000;115:149-53.
  • 26. Chave TA, Mortimer NJ, Sladden MJ, Hall AP, Hutchinson PE. Toxic epidermal necrolysis: current evidence, practical management and future directions. Br J Dermatol 2005;153:241- 53.
  • 27. Hynes AY, Kafkala C, Daoud YJ, Foster CS. Controversy in the use of high-dose systemic steroids in the acute care of patients with Stevens-Johnson syndrome. Int Ophthalmol Clin 2005;45:25-48.
  • 28. Kardaun SH, Jonkman MF. Dexamethasone pulse therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis. Acta Derm Venereol 2007;87:144-8.
  • 29. Roongpisuthipong W, Prompongsa S, Klangjareonchai T. Retrospective analysis of corticosteroid treatment in StevensJohnson syndrome and/or toxic epidermal necrolysis over a period of 10 years in Vajira Hospital, Navamindradhiraj University, Bangkok. Dermatol Res Pract 2014;2014:237821. doi: 10.1155/2014/237821. Epub 2014 Jun 15.
  • 30. Schneck J, Fagot JP, Sekula P, Sassolas B, Roujeau JC, Mockenhaupt M. Effects of treatments on the mortality of Stevens-Johnson syndrome and toxic epidermal necrolysis: A retrospective study on patients included in the prospective EuroSCAR Study. J Am Acad Dermatol 2008;58:33-40.
  • 31. French LE. Toxic epidermal necrolysis and Stevens-Johnson syndrome: Our current understanding. Allergol Int 2006;55:9-16.
  • 32. Mittman N, Chan BC, Knowles S, Shear NH. IVIG for the treatment of toxic epidermal necrolysis. Skin Therapy Letter 2007;12:7-9.
  • 33. Mittmann N, Chan B, Knowles S, Cosentino L, Shear N. Intravenous immunoglobulin use in patients with toxic epidermal necrolysis and Stevens-Johnson syndrome. Am J Clin Dermatol 2006;7:359-68.
  • 34. Huang YC, Li YC, Chen TJ. The efficacy of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis: a systematic review and meta-analysis. Br J Dermatol 2012;167:424-32.
  • 35. Chung WH, Hung SI, Yang JY, Su SC, Huang SP, Wei CY, et al. Granulysin is a key mediator for disseminated keratinocyte death in Stevens Johnson syndrome and toxic epidermal necrolysis. Nat Med 2008;14:1343-50.
  • 36. Paquet P, Jacob E, Damas P, Pirson J, Piérard G. Analytical quantification of the inflammatory cell infiltrate and CD95R expression during treatment of drug-induced toxic epidermal necrolysis. Arch Dermatol Res 2005;297:266-73.
  • 37. Reese D, Henning JS, Rockers K, Ladd D, Gilson R. Cyclosporine for SJS/TEN: a case series and review of the literature. Cutis 2011;87:24-9.
  • 38. Kirchhof MG, Miliszewski MA, Sikora S, Papp A, Dutz JP. Retrospective review of Stevens-Johnson syndrome/ toxic epidermal necrolysis treatment comparing intravenous immunoglobulin with cyclosporine. J Am Acad Dermatol 2014;30:0190-9622(14)01679-X. doi:10.1016/j.jaad. 2014.07.016. [Epub ahead of print]
  • 39. Arevalo JM, Lorente JA, Gonzalez-Herrada C, Jimenez-Reyes J. Treatment of toxic epidermal necrolysis with cyclosporin A. J Trauma 2000;48:473-8.
  • 40. Rai R, Srinivas CR. Suprapharmacologic doses of intravenous dexamethasone followed by cyclosporine in the treatment of toxic epidermal necrolysis. Indian J Dermatol Venereol Leprol 2008;74:263-5.
  • 41. Hashim N, Bandara D, Tan E, Ilchyshyn A. Early cyclosporine treatment of incipient toxic epidermal necrolysis induced by concomitant use of lamotrigine and sodium valproate. Acta Derm Venereol 2004;84:90-1.
  • 42. Valeyrie-Allanore L, Wolkenstein P, Brochard L, Ortonne N, Maitre B, Revuz J, et al. Open trial of ciclosporin treatment for Stevens-Johnson syndrome and toxic epidermal necrolysis. Br J Dermatol 2010;163:847-53.
Toplam 42 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Bölüm Case Report
Yazarlar

Yakup Canıtez

Şükrü Çekiç Bu kişi benim

Nihat Sapan Bu kişi benim

Yayımlanma Tarihi 1 Eylül 2014
Yayımlandığı Sayı Yıl 2014 Cilt: 12 Sayı: 2

Kaynak Göster

APA Canıtez, Y., Çekiç, Ş., & Sapan, N. (2014). Toksik Epidermal Nekroliz Tedavisinde Siklosporin A Kullanımı; Olgu Sunumu ve Literatür Derlemesi. Güncel Pediatri, 12(2), 116-122. https://doi.org/10.4274/jcp.43265
AMA Canıtez Y, Çekiç Ş, Sapan N. Toksik Epidermal Nekroliz Tedavisinde Siklosporin A Kullanımı; Olgu Sunumu ve Literatür Derlemesi. Güncel Pediatri. Eylül 2014;12(2):116-122. doi:10.4274/jcp.43265
Chicago Canıtez, Yakup, Şükrü Çekiç, ve Nihat Sapan. “Toksik Epidermal Nekroliz Tedavisinde Siklosporin A Kullanımı; Olgu Sunumu Ve Literatür Derlemesi”. Güncel Pediatri 12, sy. 2 (Eylül 2014): 116-22. https://doi.org/10.4274/jcp.43265.
EndNote Canıtez Y, Çekiç Ş, Sapan N (01 Eylül 2014) Toksik Epidermal Nekroliz Tedavisinde Siklosporin A Kullanımı; Olgu Sunumu ve Literatür Derlemesi. Güncel Pediatri 12 2 116–122.
IEEE Y. Canıtez, Ş. Çekiç, ve N. Sapan, “Toksik Epidermal Nekroliz Tedavisinde Siklosporin A Kullanımı; Olgu Sunumu ve Literatür Derlemesi”, Güncel Pediatri, c. 12, sy. 2, ss. 116–122, 2014, doi: 10.4274/jcp.43265.
ISNAD Canıtez, Yakup vd. “Toksik Epidermal Nekroliz Tedavisinde Siklosporin A Kullanımı; Olgu Sunumu Ve Literatür Derlemesi”. Güncel Pediatri 12/2 (Eylül 2014), 116-122. https://doi.org/10.4274/jcp.43265.
JAMA Canıtez Y, Çekiç Ş, Sapan N. Toksik Epidermal Nekroliz Tedavisinde Siklosporin A Kullanımı; Olgu Sunumu ve Literatür Derlemesi. Güncel Pediatri. 2014;12:116–122.
MLA Canıtez, Yakup vd. “Toksik Epidermal Nekroliz Tedavisinde Siklosporin A Kullanımı; Olgu Sunumu Ve Literatür Derlemesi”. Güncel Pediatri, c. 12, sy. 2, 2014, ss. 116-22, doi:10.4274/jcp.43265.
Vancouver Canıtez Y, Çekiç Ş, Sapan N. Toksik Epidermal Nekroliz Tedavisinde Siklosporin A Kullanımı; Olgu Sunumu ve Literatür Derlemesi. Güncel Pediatri. 2014;12(2):116-22.