A case report of Stevens-Johnson syndrome and toxic epidermal necrolysis due to diclofenac sodium

Stevens-Johnson syndrome (SJS) is a severe skin reaction most often triggered by particular drugs in most of the cases. A more severe form of the condition is called toxic epidermal necrolysis (TEN) which involves more than 30% of the skin surface and extensive damage to the mucous membranes. SJS and TEN previously were thought to be separate conditions, but they are now considered part of a disease spectrum. The main drugs which induce SJS were anti-gout drugs, anti-epileptics, analgesics, NSAIDs and antibiotics. Diclofenac which is a NSAID and phenyl acetic acid derivative that rarely causes SJS. Although diclofenac induced Stevens-Johnson syndrome is reported very rare among adults, it shouldn’t be neglected. In this report we mentioned about the Stevens-Johnson syndrome (SJS) which was later developed into TEN due to usage diclofenac sodium, in a 65 years old female patient.

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Stevens - Johnson Syndrome and Toxic Epidermal Necrolysis; Extensive Review of Reports of Drug-Induced Etiologies, and Possible Therapeutic Modalities

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2018.148 ◽

2018 ◽

Vol 6 (4) ◽

pp. 730-738 ◽

Cited By ~ 8

Author(s):

Adegbenro Omotuyi John Fakoya ◽

Princess Omenyi ◽

Precious Anthony ◽

Favour Anthony ◽

Precious Etti ◽

...

Keyword(s):

Adverse Drug Reaction ◽

Toxic Epidermal Necrolysis ◽

Stevens Johnson Syndrome ◽

Hypersensitivity Reactions ◽

Extensive Review ◽

Drug Induced ◽

Therapeutic Modalities ◽

Johnson Syndrome ◽

Mucous Membranes ◽

Degrees Of Severity

Stevens - Johnson Syndrome and Toxic Epidermal Necrolysis are adverse hypersensitivity reactions that affect the skin and mucous membranes. They are characterised by erythematous macules and hemorrhagic erosions of the mucous membranes. Epidermal detachments of varying degrees of severity also occur in these conditions. Various aetiologies are associated with these conditions, with adverse drug reaction being the most common. Though the worldwide incidence of these conditions is recorded as low, diverse types of medication are being observed to lead to these conditions. This review compiles information on the details of Stevens-Johnson syndrome and Toxic Epidermal Necrolysis, the pathophysiology, therapeutic management, and largely considers the drug-induced etiologies associated with these conditions.

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Head and Neck Manifestations of Erythema Multiforme in Children

Otolaryngology ◽

10.1177/01945998941113p112 ◽

1994 ◽

Vol 111 (3P1) ◽

pp. 236-242 ◽

Cited By ~ 7

Author(s):

Michael G. Stewart ◽

Newton O. Duncan ◽

Daniel J. Franklin ◽

Ellen M. Friedman ◽

Marcelle Sulek

Keyword(s):

Oral Cavity ◽

Toxic Epidermal Necrolysis ◽

Head And Neck ◽

Erythema Multiforme ◽

Medication Use ◽

Stevens Johnson Syndrome ◽

Striking Increase ◽

Johnson Syndrome ◽

Mucosal Involvement ◽

Mucous Membranes

Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis are related disorders of skin and mucous membranes, which are typically associated with antecedent medication use or infection. We review 108 cases of erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis from Texas Children's Hospital, Houston, Texas, from 1981 to 1991, and illustrate the characteristic skin and mucosal lesions. In addition, we describe in detail two unusual cases requiring intensive airway management. Head and neck manifestations were present in 4 of 79 patients (5%) with erythema multiforme and 26 of 28 patients (93%) with Stevens-Johnson syndrome. In Stevens-Johnson syndrome, mucosal involvement of the lip (93%), conjunctiva (82%), oral cavity (79%), and nose (36%) were most common. Antecedent medication use was identified in 59% of erythema multiforme patients and 68% of Stevens-Johnson syndrome patients. We note a striking increase in the number of cases in our series caused by cephalosporins. Fifty percent of Stevens-Johnson syndrome patients required supplemental hydration or alimentation because of the severity of the oral cavity involvement. The head and neck mucosal manifestations largely respond to local care, and the routine use of prophylactic antibiotics or systemic steroids is not recommended.

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Warfarin-induced toxic epidermal necrolysis after mitral valve replacement

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492320951024 ◽

2020 ◽

Vol 28 (9) ◽

pp. 601-603

Author(s):

Taiyo Kuroda ◽

Yukifusa Yokoyama ◽

Masao Yamada ◽

Satoshi Yuhara ◽

Hiroki Hasegawa ◽

...

Keyword(s):

Mitral Valve ◽

Toxic Epidermal Necrolysis ◽

Drug Hypersensitivity ◽

Lymphocyte Transformation ◽

Lymphocyte Transformation Test ◽

Stevens Johnson Syndrome ◽

Valve Prosthesis ◽

Mitral Valve Prosthesis ◽

Johnson Syndrome ◽

Mucous Membranes

Stevens-Johnson syndrome and toxic epidermal necrolysis are rare diseases that cause acute destruction of the epithelium of the skin and mucous membranes, almost always attributable to drugs. However, warfarin-induced Stevens-Johnson syndrome and toxic epidermal necrolysis is extremely rare. We report the case of 71-year-old woman who died due to destructive erosion all over her skin and mucous membranes. She had received a mitral valve prosthesis, and warfarin was prescribed for antithrombotic therapy. A lymphocyte transformation test for drug hypersensitivity and the clinical history confirmed this phenomenon as warfarin-induced toxic epidermal necrolysis.

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Toxic Epidermal Necrolysis. A case report

Journal of Clinical Pediatric Dentistry ◽

10.17796/jcpd.35.2.w824062838u53t22 ◽

2010 ◽

Vol 35 (2) ◽

pp. 197-198 ◽

Cited By ~ 2

Author(s):

Patricia Villalta ◽

Ines Velez ◽

Lina Mejia ◽

Ana Maria Ospina

Keyword(s):

Hearing Loss ◽

Case Report ◽

Toxic Epidermal Necrolysis ◽

Immune Reaction ◽

Extreme Case ◽

Severe Form ◽

Stevens Johnson Syndrome ◽

Johnson Syndrome

We present an extreme case of Toxic Epidermal Necrolysis, which corresponds to a severe form of Stevens Johnson Syndrome. This is a potentially fatal immune reaction that affects skin and mucosa, producing blisters and sloughing of the epithelium. Severe sequelae, including blindness, hearing loss, tooth malformation and esophageal destruction are seen in this case.

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Rifampicin- and allopurinol-induced Stevens-Johnson syndrome: A case series

Indian Journal of Physiology and Pharmacology ◽

10.25259/ijpp_386_2020 ◽

2021 ◽

Vol 65 ◽

pp. 51-54

Author(s):

Bhavana Srivastava ◽

Reena Bhardwaj ◽

Renu Khanchandani ◽

Zafar Masood Ansari ◽

Gunjita Belwal

Keyword(s):

Adverse Effects ◽

Pulmonary Tuberculosis ◽

Causality Assessment ◽

Case Series ◽

Young Male ◽

Stevens Johnson Syndrome ◽

Johnson Syndrome ◽

Mucous Membranes ◽

Life Threatening ◽

Severe Skin Reaction

Stevens-Johnson syndrome (SJS) is a rare, serious disorder and may be life threatening affecting mainly mucocutaneous tissues. It is a type of generalised, multisystemic hypersensitivity reaction directly linked to the drug intake. It is one of the few serious adverse effects of drugs involving skin and mucous membranes which are characterised by rash, bullae and blisters spread on skin, mucous membranes, swelling with erosive lesions on lips and face and hyperpigmentation. Normally, SJS is a self-resolving condition but it has potential to be converted into life-threatening disease. Here, we describe and present a case series of SJS inflicted by rifampicin and allopurinol. First one is a 28-year-old-female and second case is a 50-year-old male, both received rifampicin for pulmonary tuberculosis. Third patient is a 22-year-old young male taken allopurinol for hyperuricemia. All these patients noticed a severe skin reaction which is a part of erythema multiforme spectrum. Causality assessment was done in these patients with the help of Naranjo’s algorithm and diagnosed as cases of SJS.

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A rare case of toxic epidermal necrolysis in pregnancy

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20200391 ◽

2020 ◽

Vol 9 (2) ◽

pp. 846

Author(s):

Reena Yadav ◽

Astha Srivastava ◽

Preeti Pawar ◽

Vibhu Mendiratta ◽

Prerna Tayal

Keyword(s):

Toxic Epidermal Necrolysis ◽

Perinatal Outcome ◽

Rare Case ◽

Rare Condition ◽

Stevens Johnson Syndrome ◽

Successful Pregnancy ◽

Johnson Syndrome ◽

Mucous Membranes ◽

Epidermal Necrosis ◽

In Pregnancy

Stevens-Johnson syndrome (SJS) is a group of toxic necrolytic group of disorder of skin and mucous membrane with significant morbidity and mortality. It is a highly serious allergic reaction to medications affecting the skin and mucous membranes. Pregnant women with SJS or toxic epidermal necrolysis (TEN) are a unique subset, and both conditions can simultaneously affect the mother and fetus. It is a rare condition with a reported incidence of one case per million people per year. Till date, few cases of pregnancy with SJS/TEN have been reported. We are reporting a case of 20-year-old primigravida with 31+3 weeks of gestation presenting with extensive toxic epidermal necrosis. Attack of SJS developing in pregnancy can be fatal because immunity is compromised. This patient was managed in our institute with involvement of multidisciplinary team and had a successful pregnancy outcome. Perinatal outcome was also good in this case.

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Analysis of the Acute Ophthalmic Manifestations of the Erythema Multiforme/Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Disease Spectrum

Ophthalmology ◽

10.1016/s0161-6420(95)30811-1 ◽

1995 ◽

Vol 102 (11) ◽

pp. 1669-1676 ◽

Cited By ~ 171

Author(s):

William J. Power ◽

Mohammed Ghoraishi ◽

Jesus Merayo-Lloves ◽

Renato A. Neves ◽

C. Stephen Foster

Keyword(s):

Toxic Epidermal Necrolysis ◽

Erythema Multiforme ◽

Stevens Johnson Syndrome ◽

Ophthalmic Manifestations ◽

Disease Spectrum ◽

Johnson Syndrome

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A case report of toxic epidermal necrolysis (TEN) in a patient with COVID-19 treated with hydroxychloroquine: are these two partners in crime?

Clinical and Molecular Allergy ◽

10.1186/s12948-020-00133-6 ◽

2020 ◽

Vol 18 (1) ◽

Cited By ~ 1

Author(s):

Carlo Maria Rossi ◽

Flavio Niccolò Beretta ◽

Grazia Traverso ◽

Sandro Mancarella ◽

Davide Zenoni

Keyword(s):

Toxic Epidermal Necrolysis ◽

Fatal Outcome ◽

Total Body Surface Area ◽

Stevens Johnson Syndrome ◽

First Case ◽

Cutaneous Adverse Reaction ◽

Johnson Syndrome ◽

Mucous Membranes ◽

Total Body ◽

The Moment

Abstract Background Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is the most Serious Cutaneous Adverse Reaction (SCAR) often with a fatal outcome. Coronavirus Disease (COVID-19) is caused by Severe Acute Respiratory Syndrome–Coronavirus—2 (SARS-COV2) and is an emergent pandemic for which no cure exist at the moment. Several drugs have been tried often with scant clinical evidence and safety. Case presentation Here we report the case of 78-years-old woman with cardiometabolic syndrome and COVID-19. A multidrug regimen including others hydroxychloroquine, antibiotics, dexamethasone and paracetamol, low-molecular-weight-heparin and potassium canrenoate was started. After almost 3 weeks, the patient started to display a violaceous rash initially involving the flexural folds atypical targetoid lesions and showing a very fast extension, blister formation and skin detachments of approximately 70% of the total body surface area and mucous membranes involvement consistent with toxic epidermal necrolysis (TEN). The ALDEN algorithm was calculated inserting all drugs given to the patient in the 28 days preceding the onset of the skin manifestations. The highest score retrieved was for hydroxychloroquine. Other less suspicious drugs were piperacillin/tazobactam, ceftriaxone and levofloxacin. Conclusions To our knowledge, this is the first case of TEN in a patient suffering from COVID-19 probably associated with hydroxychloroquine. Given the activation of the immune system syndrome induced by the virus and the widespread off-label use of this drug, we suggest a careful monitoring of skin and mucous membranes in all COVID-19 positive patients treated with hydroxychloroquine in order to early detect early signs of toxicities.

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IVIG and under Burn Unit Care Yield Favorable Outcomes in Pediatric Patients with Toxic Epidermal Necrolysis: A Case Report and Literature Review

Case Reports in Dermatological Medicine ◽

10.1155/2020/6274053 ◽

2020 ◽

Vol 2020 ◽

pp. 1-5

Author(s):

Tareq Z. Alzughayyar ◽

Wasim Noureddin Ibrahim Hamad ◽

Eman A. S. Abuqweider ◽

Bilal Nabeel Mohammad Alqam ◽

Sadi A. Abukhalaf ◽

...

Keyword(s):

Toxic Epidermal Necrolysis ◽

Severe Form ◽

Stevens Johnson Syndrome ◽

Care Level ◽

Johnson Syndrome ◽

Management Protocol ◽

Burn Unit ◽

Threatening Condition ◽

Life Threatening ◽

Cutaneous Reactions

Body reactions to drugs can manifest as Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). TEN is the most severe form of cutaneous reactions with an incidence rate of 1-2 per million cases per year. Despite TEN being a critical and life-threatening condition, there is little to no evidence of clear management protocol. We reported a 5-year-old male child who presented with lamotrigine-induced TEN and was successfully treated with intravenous immune globulin (IVIG) with a burn unit care level, while TEN treatment with IVIG is an appropriate approach with predictable good outcomes, burn unit care is also effective in creating highly favorable effects. Upon reviewing the literature, several studies indicate that TEN patients treated with the combination of IVIG and burn unit care lead to decreased levels of morbidity and mortality than when treated with IVIG or burn unit care alone. Therefore, treatment involving both IVIG and burn unit care should be considered for TEN patients.

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