Steven Johnson syndrome - patient case presentation. One in 10,000 case mainly an allergic reaction to drugs.

1. By :- Teena
1412818
Pharm.D 4th yr
Case Presentation
On
STEVEN JOHONSON
SYNDROME

2. SJS
Rare but serious disorder of skin & mucous membrane.
Most often, it's a severe reaction to a medicine. SJS
is thought to arise from a disorder of the immune
system.
SYMPTOMS
 begins with fever, sore
throat, and fatigue,
 Painful red or purple skin
 Blisters on your
skin, mouth, nose, and
genitals
 Red, painful, watery eyes

3. CAUSES
 Medicines for gout, especially allopurinol
 Pain relievers such as acetaminophen, ibuprofen, and
naproxen sodium .
 Sulfa antibiotics
 Medicines that treat seizures carbamazepine.
Infections that can cause Stevens-Johnson syndrome
include:
 Herpes (herpes simplex or herpes zoster)
 Pneumonia
 HIV
 Hepatitis

4. Case Description
 A 23yr old Female admitted to MMIMSR hospital on 06.08.2015 with the
C/O
 Rashes over whole body except legs *2 days
 Vomiting *1 day
 Fever *1 day
 Painful swallowing
O/E
 Multiple ulcers present over lips & oral cavity
 Macular rashes present over face, neck, abdomen & upper
limbs
 Odynophagia
 Difficulty in speech

5.  Past medical history : Epilepsy (7YRS back )
pt. has earlier developed SJS in 2010 due to
carbamazipine
 Past medication history:
 Mirtazapine {50mg}
 Clonazepam {0.5mg}
 Propanolol
 Lorazepam
 also took ayurvedic medicines
 Family and Social History: non smoker, no
addiction , vegetarian, sleep & appetite decrease

6. Physical Investigations

7. Vitals 6/8 7/8 8/8 9/8 10/8 11/8 12/8 13/8
BP(mm/
Hg)
112/76 122/78 90/60 130/90 88/54 120/80 100/60 110/90
Pulse
Rate
(/min)
88 86 96 100 88 96 84 120
Resp
Rate
(/min)
18 20 16 18 16 18 18 18
Temp (F) Afeb. Afeb. 102⁰ Afeb. Afeb. Afeb. Afeb. Afeb

8. Vitals 14/8 15/8 16/8 17/8 18/8 19/8 20/8
BP(mm
/Hg)
110/60 110/90 102/60 108/70 90/70 90/70 110/70
Pulse
Rate
(/min)
84 80 88 84 88 86 86
Resp
Rate
(/min)
16 16 16 16 18 16 16
Temp
(F)
Afeb. Afeb. Afeb. Afeb. Afeb. Afeb. Afeb.

9. Laboratory Investigations

10. Constituents Normal Range 7/8 11/8 18/8
DLC
Polymorphs
40 – 75% *80 71 *78
Lymphocytes 20 – 40% *17 25 *19
Eosinophils 02 – 6% 03 03 03
Monocytes 02 – 10% *00 01 *00
Basophils 00 – 1% 00 00 00
ESR 0-20mm/1st hr *22 *70 *35
HB 12 – 15gm % 10.4 10.6 11
Platelet count 1.5 – 4.5 lac/ cumm *1.4 2.0
TLC 4000 – 10000/cumm 9800 1300

11. Constituents Normal Range 7/8 18/8
LFT
BilirubinTotal
0.20 – 1.00 mg/dl 0.77
Bilirubin Direct 0.10 – 0.30 mg/dl 0.34
SGOT 5 – 40 IU/L *74
SGPT 5 – 35 IU/L *123
Alkaline
Phosphatase
5 – 112 IU/L *217
RFT
Urea
15 – 40 mg/dl 20 18
Creatinine 0.40 – 1.40 mg/dl 1.1 0.89
Sodium 135 – 145 mEq/L 132 132
Chloride 96 – 106 mmol/L 98 107
Potassium 3.50 – 5.00 mEq/L 3.7 3.9

12. URINE CULTURE
7/8 11/8 18/8
VOLUME 20ml 20ml 40ml
COLOR Pale yellow Pale yellow Pale yellow
U. ALBUMIN ++ Traces NIL
U. SUGAR
FASTING
NIL NIL NIL
PUS CELL 10-12 HPF 4-5 2-3 HPF
EPITHELIAL CELL 6-8 HPF 2-3 HPF 2-3 HPF
CAST & CRYSTALS NIL NIL NIL

13. Specific Test
 USG Abdomen
 Impression : normal
 HbsAg : Negative
 HCVTridot : Negative
 Malarial parasite : Negative

14. SOAP Note

15. SUBJECTIVE
 Patient came with complaints of
 Rashes over whole body except legs
*2 days
 Vomiting *1 day
 Fever *1 day
 Painful swallowing

16. OBJECTIVE
 To correct the abnormal values of :-
 Monocytes
 Polymorphs
 Lymphocytes
 ESR
 SGPT
 Alk. phosphatase
 Urine albumin

17. ASSESSMENT/ FINAL DIAGNOSIS
 The patient on basis of subjective and objective
information was diagnosed with
STEVEN JOHNSON SYNDROME
(SJS)

18. PLAN
 SHORTTERM GOALS
 Relieve symptoms.
 Make pt. take orally
food
 LONGTERM GOALS
 Delaying or halting the
progression of SJS
 Controlling the
disease from getting
more complicated.
 Also controlling the
epilepsy disease

20. DRUGS + API Dose +
Route
Date
of
Start
Date
of
Stop
Category Frequ
ency
Tab. Dexanil
(escitalopram)
10mg
oral
7/8 10/8 selective sertonin
reuptake inhibitors
OD
Tab.Mirtazapine 7.5mg
Oral
7/8 -- noradrenergic and
specific serotonergic
antidepressant
( NaSSA) & tetracyclic
antidepressants
HS
Cap.Cyclosporin 50mg
Oral
7/8 20/8 immunosuppressants OD
Betadine gargles
( povidone-
iodine)
Oral 7/8 20/8 Oral Antiseptic
Solution
QID

21. DRUGS + API Dose +
Route
Date
of
Start
Date
of
Stop
Category Frequen
cy
Candid mouth
wash
(clotrimazole)
Oral 7/8 20/8 anti-fungal oral
medication
QID
Inj .Ceftriaxone 1 g
IV
8/8 20/8 Antibiotic OD
Tab. Dolo
( PCM)
650mg
Oral
8/8 8/8 Anti pyretic +
Anlagesic
BD
Eye dropTear Plus 9/8 20/8 Lubricant BD
Tab. Linezolid 600 mg
oral
10/8 20/8 oxazolidinone
antibiotic
BD
Inj Decca
(NANDROLONE
DECANOATE )
1st day 2cc
followed by
1 cc
10/8 14/8 anabolic steroids OD

22. DRUGS +
API
Dose +
Route
Date
of
Start
Date
of
Stop
Category Frequ
ency
Tab.
Cyclosporin
100 mg
Oral
11/8 20/8 Immuno
suppressants
OD
Tab Instazine
(cetirizine)
11/8 - Anti histaminic &
Anti allergic
SOS
KMnO₄ topical
solution
10/8 20/8 disinfectant,
deodorising and
astringent
BD

23. Patient Counselling
 Adhere to the medication
 Periodic checkup.
 Take adequate rest .
 Take adequate fluids and nutrients as your body
needs to stay hydrated, and your skin needs
protein to rebuild.
 Maintain hygiene . Clean your wounds regularly.
 Take care of your eyes.