A 23-year old female presented with fever, respiratory symptoms and subsequently developed conjunctival congestion and mucocutaneous lesions after being treated with multiple medications including gentamicin, piroxicam, roxithromycin and cefoperazone sulbactam at other hospitals. She was admitted to KMCH hospital and was started on high dose steroids. Laboratory tests including autoimmune panel and cultures were negative. A diagnosis of toxic epidermal necrolysis was considered. The patient was managed supportively with IV steroids, antihistamines and eye care. Skin biopsy results were awaited to confirm the diagnosis.

1. CASE PRESENTATION
PHARMACOTHERAPEUTICS -II
1
Presented by :
A. sri sharika
pharm.D 3rd year.

2. TOXIC EPIDERMAL
NECROLYSIS
DRUG INDUCED
2

3. CASE SUMMARY
A 23 year old female had fever with upper respiratory symptoms from13/1/2020 for which she
was hospitalized elsewhere and medications were given (Gentamicin , piroxicam , roxithromycin ,
cefoperazone sulbactam). Subsequently she developed conjunctival congestion with mucocutaneous
lesions .0n 23/1/2020 she was admitted in our KMCH hospital . TEN vs Autoimmune cause (SLE/Behcets)
was considered . She was started on high dose parenteral steroids . Her autoimmune panel (ANA + ANCA)
were negative. her blood urine & throat swab culture were negative . She was managed with parenteral
dexamethasone with other supportive care. Dermatology skin biopsy results were awaited .
Then further will see into it…….
3

4. PATIENT PROFILE :
• IP NO: F40099.
• AGE /SEX : 23YR OLD / FEMALE.
• MARRITAL STATUS : UNMARRIED.
• NATIVE PLACE: SALEM.
• PURSUING STUDY: M.SC. BIOTECH.
• DATE OF ADMISSION: 23/1/2020.
• DATE OF DISCHARGE: 30/1/2020.
• PRIMARY CONSULTANTS: DR.VARUN SUNDARAMOORTHY .
DR. JEEVAN KUMAR (MD) DERMATOLOGIST.
4

5. SUBJECTIVE EVIDENCE
• PAST MEDICAL HISTORY: FEVER FROM 13/1/2020.
• TREATED IN MULTIPLE HOSPITALS FROM 18/1/2020.
• PRIMARILY ADMITTED IN MAGIL HOSPITAL ON 18/1/2020.
• DR. J. SHAAMLI M.B.B.S
RX
 INJ. GENTALAB - 1
 INJ. DOLOFORCE - 1
 TAB.ROXID 150 - 6 (1-0-1)
 TAB.PARAMET - 6 (1-0-1)
 CAP.BENADRYL - 3 (0-0-1)
FEVER PERSISTS NOT CURED.
5
Composition of each brand
1) Gentamicin .
2) Piroxicam .
3) Roxithromycin.
4) Paracetamol & metoclopramide.
5) Diphenhydramine.

6. ON 20/1/2020 SHIFTED TO SARAVANA HOSPITAL
6
Dr . Ssr
Rx
 Inj. Pan - 40mg
 Inj. Emeset
 NS 500ml
 NS 100ml
 RL 500ml
Dr. R.k.
Rx
 Inj. Fytobact -1.5 g ( cefoperazone sodium 1g + sulbactam 500mg)
 NS -100ml,500ml
 RL - 500ml.
 Inj. Pan - 40ml
 Neb.Duolin respule - 3ml 3 ( levosalbutamol + ipratropium bromide)
 Neb.Budecort - 0.5mg respules 3 (budesonide)
 Tab. Dolo -650 mg 2
 Syp. Viscodyne -1 (Ambroxol Hcl, Guaiphenesin , Terbutaline
sulfate, Menthol , Phenylephedrine Hcl)
still FEVER persists.

7. PHARMACIST INTERVENTION
7
Sulphur containing drugs and sulpha drugs which contains an SO2 & NH2 group with may cause cytotoxic reaction and toxic
necrolysis such as TEN. Gentamycin sulphate and piroxicam also contains the same sulphur group.

8. 0N 21/1/2020 @12:33PM
8
Dr. S.R.K
Betadine gargle 2% solution
Tab. Azee 500mg
Inj. Para
Inj. Emeset
sumo –L 100ml IVF (paracetamol 1000mg/100ml).
 Severe reaction of those drugs developed : started from 19/1/2020.
 conjunctival congestion.
 Pustular skin lesions (erythema).
 Oral ulcers/ aphthous ulcers (coated tongue).
 Shortness of breath.
 Burning micturition.
 Supra pubi tenderness.
 Purulent genital discharge.
 Membranous tonsillitis (exudate on tonsils).

9. OBJECTIVE EVIDENCE
0N 23/1/2020 ADMITTED IN OUR KMCH HOSPITAL
• @ 3:30PM
PRIMARY INVESTIGATION’S WERE DONE .
ON PHYSICAL EXAMINATION:
 Conscious , oriented , afebrile.
 Purulent conjunctivitis++,coated tongue , skin lesions in face pealing, throat pain
(rt tonsil enlarged), oral ulcers (difficulty in swallowing informed by patient), shortness of
breath, burning micturition.
9

10. 10

11. 11

12. Suggestions Dr’s advice for physical examination
@5:40pm
Not suggestive of diphtheria tonsillitis?
Viral conjunctivitis?
@3:30pm
IVF NS @ 700cc/hr stat (473.176ml)
Inj. Pan 40mg IV/ stat.
Inj. Emeset 8mg IV/ stat.
Inj. para 1g IV(SOS).
Inj. Augmentin 1.2 g IV/stat.
CBC , RFT , LFT , Blood C/S , urine , CRP ,
ESR , ECG , Throat swab , Na, K Hco3, urine
C/S .
@10:20 pm
IVF NS @ 125cc/hr .
Inj. Pan 40mg IV/ OD.
Inj. Emeset 8mg IV/ TID.
Inj. Fevastin 800mg IV(SOS).
Tab. Azithromycin 1g OD.
Ofloxacin eye drops 2°-2°-2°.
@ 23/1/2020
12

13. Laboratory parameters On 23/1/2020 24/1/2020
Total WBC count ↑13300cells/cumm. Normal in number.
PCV ↓30.6% -
MCV ↓76.5µm3 -
MCH ↓26.8pg/cell -
Hb 10.7g/dL -
ESR 26mm/hr -
CRP 85mg/L -
SGOT 17U/L -
SGPT 18U/L -
Eosinophils 00% 02%
Cortisol (random) - 15.15µg/dL
ABNORMAL LAB VALUES:
13

14. URINE ANALYSIS:MACROSCOPIC
EXAMINATION
Colour Pale yellow
Appearance Slightly turbid.
Specific gravity 1.020
Reaction Acidic
Albumin Trace
Sugar Not detected
Acetone +ve
Bile salts -ve
Bile pigments -ve
urobilinogen Increased.
MICROSCOPIC EXAMINATION
Pus cells 15-20cells/HPF
RBC 3-4cells/HPF
Epithelial 2-3cells/HPF
Bacteria Nil
crystals Nil
Casts Nil
Flagellates Nil
Others Nil
14

15. 15
Date Time Heart rate
(beats/min)
Respiratory rate
(breaths/min)
Blood pressure (mmHg) SpO2 % Temp
23/1 4:15p
m
5:15p
m
6:15p
m
7:15p
m
8:15p
m
102
102
100
100
100
22
22
22
22
-
130/80
120/80
120/80
120/90
-
98%
98%
98%
98%
-
98.8°C
98.2°C
98°C
98.1°C
24/1 2am
6am
10am
2pm
6pm
10pm
78
76
74
78
76
80
18
20
20
18
20
20
120/80
110/70
110/60
120/80
110/70
110/70
97%
97%
97%
98%
96%
96%
97.9°C
97.9°C
98°C
97.5°C
97.7°C
98°C
25/1 2am
6am
10am
2pm
6pm
82
78
76
76
74
18
20
20
18
20
120/80
110/70
110/60
120/80
110/70
97%
97%
97%
98%
96%
97.9°C
98°C
97.9°C
97.3°C
98°C

16. 16
Date Time HR(beats/min) RR(Breaths/min) BP (mmHg) SpO2% Temp
27/1 2am
6am
10am
6pm
10pm
74
108
76
78
70
18
18
18
20
18
100/70
110/70
100/60
110/70
110/70
97%
96%
98%
98%
96%
98°C
98°C
97.8°C
98°C
98°C
28/1 2am
6am
10am
2pm
6pm
10pm
78
74
72
70
74
76
18
18
18
18
20
18
110/70
100/70
110/60
110/80
110/70
110/70
98%
98%
97%
98%
98%
96%
98°C
97.8°C
97.9°C
98.2°C
98°C
98°C
29/1 2am
6am
10am
2pm
6pm
10pm
76
72
70
78
70
80
16
16
20
18
20
18
110/70
100/60
100/70
100/60
100/70
100/70
96%
96%
97%
96%
96%
96%
98°C
98°C
98°C
98°C
98°C
98°C
Due to dexamethasone and other topical steroids ,the resting heart rate is slightly lower than usual. BP also tend to in
normal condition,
On 30/1/2020 , the vitals were normal HR-76bts/min,RR-18breaths/min,BP-110/70mmHg, SpO2-98%.

17. 17
Blood sugar panel:
Blood sugar F/R Date Values
RBS 26/1 119
FBS 27/1 102
FBS 28/1 102
FBS 29/1 106
FBS 30/1 95
On 30th jan inj. Dexa is been stopped –so insulin resistance is neglected on the day.

18. 0n 24/1/2020 @10:00am
ADVICE TO DO:
 ANA IF serology , ENA profile ANCA.
 Random cortisol .
 Stop Tab. Azithromycin
 IVF RL 2pint & NS 1pint /@ 125cc/hr.
 Syp. mucaine gel 2tsp Q4H.
 Derm aid .
 IV Steroids after dermaid .
Signs of current condition Physician’s impression of condition
Afebrile
Conjunctivitis
Oral ulcer/aphthous ulcer
Genital discharge
Skin lesions (erythema) & skin pealing.
Dr.Varun sundaramoorthy
TEN?
Pempighus vulgaris?
CTD?
Autoimmune (behcets disease)?
18

19. 19

20. 20

21. 24/1/2020 @ 12:50pm
Dr. Jeevan kumar (dermatologist)
Physical examination:
 erythema multiforme
 skin multiple lesions
 conjunctival congestion
PLAN:
 skin biopsy – HPE & DIF
 HSV type I & II
 IGg & IGm Serum (serology)
EMPIRICAL THERAPY :
TESS OD Oral Ointment.
quadragel OD .
clonate F cream .
On 25/1/2020 @10:00am
TEN?
Behcet’s disease?
SLE?
Infection (least possible)?
Dr. Jeevan kumar
Rx
 Tab. Colchicine (0.5mg) 1-0-1
 Inj. Dexa (4mg) /IV/ BD
 Chlorocol H eye ointment (BD)
(over the lids) external application .
 Genteal eye drops 6times/day .
 FML E/D 3times/day.
 Genteal eye gel (BD). 21

22. 22

23. 23
DATE TIME NS/RL QUANTITY
24/1 2am
5am
10am
8pm
NS
RL
RL
RL
500ml
500ml
500ml
500ml
25/1 12am
7am
DNS
NS
500ml
500ml
26/1 4am
2pm
RL
RL
500ml
500ml
28/1 9am
12:30pm
5pm
11pm
RL
NS
NS
NS
500ml
500ml
500ml
500ml
29/1 11am
4pm
NS
NS
500ml
500ml
RL- provides more stable pH of 6.5 than the normal saline. But it wont stay in body as long as saline solution.

24. Date Intake Output
23/1/2020 IVF -875ml
Oral -100ml
= 975ml Total intake
Urine -350ml
=350ml Total output
24//1/2020 IVF -1750ml
Oral - 750ml
= 2500ml Total intake
Urine -1000ml
=1000ml Total output
25/1/2020 IVF -1125ml
Oral - 950ml
= 2075ml Total intake
Urine – 1750ml
=1750ml Total output
26/1/2020 Total intake =1150 oral Urine – 1800ml
= 1800ml Total output
27/1/2020 IVF - 1000ml
Oral – 1350ml
=2350ml Total intake
Urine - 1850ml
= 1850ml Total output
28/1/2020 IVF – 2000ml
Oral – 1150
= 3150ml Total intake
Urine - 1600ml total output
29/1/2020 IVF – 1000ml
Oral – 1300ml
= 2300ml Total intake
Urine – 1950 ml
Total output =1950 ml.
Positive fluid
balance.
24

25. SPECIAL TEST REPORTS:
• PATHOLOGY REPORT:24/1/2020
RBCS: Crowding of rbcs + normocytic
normochromic rbcs to microcytic
hypochromic rbcs elliptocytes+
WBCS: Adequate in no with few reactive
lymphocytes.
HEMOPARASITES: ABSENT.
• SEROLOGY REPORT: 27/1/2020
IgG & IgM– NEGATIVE .
ON 25/1/2020 REPORTS :
• AUTOIMMUNE PANEL: (Serum sample)
• ANA+ANCA WERE NEGATIVE.
• ANTI MPO : -VE(0.0874)
• ANTI PR3 : -VE(3.6368)
• CULTURE TESTS:
Blood, urine, throat swab culture
were NEGATIVE.
25

26. ASSESSMENT
• TOXIC EPIDERMAL NECROLYSIS
The patients current condition
26

27. 27
A cytotoxic reaction of antibiotics is treated with IV
corticosteroids and antihistamines .
IgE mediated reaction may be?
Hypersentivity to gentamycin and cefaperozone salbactam.

28. PHYSICIAN’S PLAN
28

29. GOALS OF TREATMENT
• To improve the quality of life.
• To reduce the serious adverse effects of drugs.
• To prevent further complications.
• To reduce the irritation of eyes and mucocutaneous lesions.
• To prevent further ulceration of lips.
• To reduce the genital irritation.
29

30. 30
Drugs / dose / route / freq Time 23/1 24/1 25/1 26/1 27/1 28/1 29/1 30/1
Inj. Pantocid
40mg/IV/OD
6am Emr       
Inj. Esemet
8mg/ IV/ TID
6am
2pm
10pm
-
-
Emr





















Inj. Fevastin
600mg/ IV/ SOS
Tab . Azithromycin
1g/ oral/OD
9am -
Emr
Stop
Ofloxacin eye drops
2̊-2̊-2̊/ instill/ TID
6am
2pm
10pm
-
-
Emr


















Syp.mucaine gel
2tsp / oral/ Q4H
2am
6am
10am
2pm
6pm
10pm
-
-
-
-
-
-
-
-
-






























Freq
Change
d.

31. 31
Drugs / dose / route / freq Time 23/
1
24/1 25/1 26/1 27/1 28/1 29/1 30/1
Tess ointment
Oral cavity / OD
6am - -
9.30
     
Quadrajel ointment
Oral cavity/ OD
9am - -
9.30pm
     -
Clonate F cream
Bodily/ BD
6am
6pm
-
-
-
9.30










-
-
Tab. Colchicine
0.5/ oral / BD
9am
9pm
-
-
-
-
-









-
-
Genteal eye drops
2drops/instill/ 6times a day
12am
4am
8am
12pm
4pm
8pm
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-



























-
-
-
discharg
e
Eye drops FML
2drops/ instill/TID
10am
3pm
10pm
-
-
-
-
-
-
-














-
discharg
e

32. 32
Drugs / dose / route / freq Time 25/1 26/1 27/1 28/1 29/1 30/1
Genteal eye gel
Inner the eye /BD
9am
9pm
-
4.30pm










-
discharg
e
Chlorocol H eye ointment
Over lids/BD
9am
9pm
-

-








Inj. Dexa
4mg/IV/ BD
6am
6pm
-








-
Stopped
On 29/1
Tab. Ivermectin
12mg/ oral / OD
10.45am - - - - 
Tab. Omnacortil
30mg/ oral / OD
9am - - - - 6.30pm 
Syp . Mucaine gel
2tsp / oral / TID
2am
12pm
8pm
- - - - - -


33. 33
But efficacy is higher
than side effects.

34. 34
PHARMACIST INTERVENTION:
There were no serious drug – drug interaction .
By the different route of administration – the interaction of drugs is
been neglected.
The proper absorption of drugs were found .
The systemic administration of dexamethasone is very important
dosage move and its been increased the efficacy of drug than the
adverse effects.
Higher efficacy than side effects is proved.

35. THERAPEUTIC OUTCOME’S OF THERAPY
• The eye compliance is reduced and response to treatment is excellent.
• Skin lesions is been reduced by the ointments .
• IV corticosteroids such as dexamethasone played a great role in therapy , symptoms subsided
very nice.
Discharge plan:
• Oral corticosteroids been prescribed on discharge.
• Further to eradicate the lesions ,patient is been discharged with bodily oinment cream and oral
cavity applications .
• To reduce allergy response antihistamine drugs is prescribed.
• To reduce hypersensitive reaction of lungs: cough syrup is given.
35

36. DISCHARGE SUMMARY
Medicine Dosage Morning Afternoon Evening Night A/B Food Duration
Tab. Omnacortil 30mg 1 0 0 0 AF 1week
Tab. Nexpro RD 20mg 1 0 0 0 AF 1week
Tab. Tayo - 1 0 0 0 AF 1week
Tab. Bilagra 20mg 0 0 0 1 AF 1week
Syp. Chericof LS 2tsp 2tsp 0 2tsp - 1bottle
Quadrajel &
TESS
FOR LOCAL APPLICATIO
N
Clonate F cream FOR LOCAL APPLICATIO
N
36
Patient discharged with hemodynamically stable in condition , tolerating oral feeds well and normal diet is encourag
After 1 week review with CBC ,cr,

37. PHARMACIST INTERVENTION
• In discharge – Tab.Nexpro RD – after food .
• It should be prescribed before food . its efficacy rate is higher and long lasting
when taken atleast 1 hr before food.
PATIENT COUNSELLING:
• Further to any illness- need to inform about her sulphur drug reaction and allergic
conditions to physician’s.
• Normal diet with proper intake of foods ,such as green leafy veggie etcc…,
37

38. REFERENCE
 www.ncbi.nlm.nih.gov
 www.merckmanuals.com
 emedicine.medscape.com (TEN).
 www.ciplamed.com (drugs).
 www.uspharmacist.com .
 Wikipidia .
38