Stevens-Johnson syndrome / toxic epidermal necrolysis: an Asia-Pacific perspective

Stevens-Johnson syndrome associated with pancytopenia: a case report

Introduction and importance

Stevens-Johnson syndrome (SJS) is a rare and unusual hypersensitivity reaction to certain drugs like allopurinol, commonly used for treating gout. SJS is recognized by extensive necrosis and detachment of skin and mucus membranes. Pancytopenia, characterized by decreased levels of red blood cells, white blood cells and platelets, is an exceedingly rare occurrence in the rare disorder SJS.

Case presentation

The authors present a 61-year-old male who exhibited symptoms of fever and rash for 5 days accompanied by pancytopenia and liver injury.

Clinical discussion

The abdomen and bilateral lower extremities exhibited several well-defined dusky-colored hyperpigmented macular lesions. Initially, these lesions were small, tender, erythematous, and raised, later transitioning to a dark red. Multiple distinct ulcerations were present on the lips and buccal cavity. Additionally, there was denudation of the skin with bleeding observed between the toes of both legs. The causality was assessed as a definite adverse drug reaction according to the Naranjo and ALDEN algorithm. The patient received treatment consisting of intravenous steroid along with prophylactics antibiotics. The individual's pancytopenia was resolved without requiring any blood cells or plasma or platelet concentrate transfusion.

Conclusion

The exact pathophysiology of SJS associated with pancytopenia has not yet been fully elucidated. The authors' study hypothesized that the cause of pancytopenia in SJS could be either the direct cytotoxicity of drugs or immune-mediated damage to the bone marrow cells. Additional studies are necessary to establish the precise pathophysiology of the condition. Moreover, our study also indicates that pancytopenia can resolve in SJS without the need for blood cells or plasma or platelet concentrate transfusion. Once more, further studies are required to establish precise management strategies for managing SJS associated with pancytopenia.

Hydroxychloroquine-Induced Stevens-Johnson Syndrome in the Patient with Systemic Lupus Erythematosus: A Case Report in Kurdish Region - Iraq

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that mainly affects women. Hydroxychloroquine (HCQ) and chloroquine are widely used in the treatment of many diseases, such as malaria, rheumatic arthritis, systemic lupus erythematosus, and other Rheumatic diseases. The Stevens-Johnson Syndrome (SJS) is a rare immune complex-mediated hypersensitivity disorder that is characterised as a vesiculobullous erythema multiform of the skin, mouth, eyes, and genitals. We decided to report a thirty-year-old female patient with HCQ-developed side effects of induced SJS and its appropriate management. In conclusion, the HCQ tablet does have known side effects. One of the side effects of HCQ is SJS caused by the drug; given the worldwide use of this drug in Rheumatic diseases and its increasing need, we need to be careful about its use to control and manage its side effects.

Carbamazepine-Induced Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Overlap Treated Successfully with Oral Cyclosporin: Case report and literature review

Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute life-threatening mucocutaneous drug reactions. Several therapies have been used in the treatment of SJS/TEN but none of them have yet been established as the gold standard treatment. Studies have shown that cyclosporine (CsA) can be used off-label in TEN/SJS, which has shown promising therapeutic effectiveness in such diseases. Here we report a 38-year-old woman who presented to Ar Rustaq Hospital, Rustaq, Oman in 2019 with SJS/TEN overlap and was treated successfully with CsA along with supportive management. This case report also includes a literature review on the use of CsA in the treatment of SJS/TEN.

Genotyping HLA alleles to predict the development of Severe cutaneous adverse drug reactions (SCARs): state-of-the-art

Introduction: Pharmacogenomics has great potential in reducing drug-induced severe cutaneous adverse drug reactions (SCARs). Pharmacogenomic studies have revealed an association between HLA genes and SCARs including acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN).Areas covered: Pharmacogenomics-guided therapy could prevent severe drug hypersensitivity reactions. The US Food and Drug Administration (FDA), Clinical Pharmacogenetics Implementation Consortium (CPIC), and Dutch Pharmacogenetics Working Group (DPWG) provided guidelines in the translation of clinically relevant and evidence-based SCARs pharmacogenomics research into clinical practice. In this review, we intended to summarize the significant HLA alleles associated with SCARs induced by different drugs in different populations. We also summarize the SCARs associated with genetic and non-genetic factors and the cost-effectiveness of screening tests.Expert opinion: The effectiveness of HLA screening on a wider scale in clinical practice requires significant resources, including state-of-the-art laboratory; multidisciplinary team approach and health care provider education and engagement; clinical decision support alert system via electronic medical record (EMR); laboratory standards and quality assurance; evidence of cost-effectiveness; and cost of pharmacogenomics tests and reimbursement.

Quality of Life of Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) and Stevens-Johnson Syndrome (SJS) and/or Toxic Epidermal Necrolysis (TEN) Patients

PURPOSE

Drug Reaction With Eosinophilia and Systemic Symptom (DRESS), Stevens-Johnson Syndrome (SJS), and Toxic Epidermal Necrolysis (TEN) are acute hypersensitivity reactions with the potential to reduce the quality of life of exposed individuals. This study aims to determine the quality of life of patients suffering from DRESS, SJS, SJS/TEN.

PATIENTS AND METHODS

A cross-sectional approach was used to get the quality of life data from DRESS, SJS, and/or TEN patients at Dr. Sardjito general hospital, Yogyakarta. The utility index and VAS score differences of EQ-5D-5L were analyzed based on the diagnosis.

RESULTS

We recruited 58 patients. Most of the patients were female (63%). The mean value of utility index was 0.61, 0.08 and 0.03 for DRESS, SJS and SJS/TEN patients, respectively (p value <0.01). Furthermore, the mean of VAS score was 73.36, 57.93 and 50.00 for DRESS, SJS and SJS/TEN patients, respectively (p value <0.01).

CONCLUSION

In general, the quality of life of DRESS patients is better than the quality of life of SJS and/or TEN patients.

Drug-related Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review

Introduction

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening, allergic reactions affecting the skin and mucous membranes. SJS is considered to be a milder form with less than 10% of body surface area (BSA) involvement. We report successful management of two cases of SJS and TEN. Firstly, a case of a 24-year-old female who presented with rashes over face, chest, and upper limbs after the oral intake of ciprofloxacin and local application of moxifloxacin eye drops. She developed high-grade fever and difficulty in breathing requiring intubation and lung-protective mechanical ventilation and was treated with high-dose methylprednisolone, azithromycin, soframycin skin dressings, and topical ocular antibiotics. Secondly, another case of a 16-year-old female who developed bullous eruptions over the trunk, arms, hands, face, and sole involving 60% of BSA, after oral intake of albendazole. She was diagnosed as TEN and successfully managed with sterile silver nitrate, soframycin dressings, and antibiotics.

Key message

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening, allergic reactions affecting the skin and mucous membranes. Early identification, withdrawal of the suspected drug, and early transfer to a specialized center decrease mortality.

How to cite this article

Arora R, Pande RK, Panwar S, Gupta V. Drug-related Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review. Indian J Crit Care Med 2021;25(5):575-579.

Challenges and Opportunities in Implementing Pharmacogenetic Testing in Clinical Settings

The clinical implementation of pharmacogenetic biomarkers continues to grow as new genetic variants associated with drug outcomes are discovered and validated. The number of drug labels that contain pharmacogenetic information also continues to expand. Published, peer-reviewed clinical practice guidelines have also been developed to support the implementation of pharmacogenetic tests. Incorporating pharmacogenetic information into health care benefits patients as well as clinicians by improving drug safety and reducing empiricism in drug selection. Barriers to the implementation of pharmacogenetic testing remain. This review explores current pharmacogenetic implementation initiatives with a focus on the challenges of pharmacogenetic implementation and potential opportunities to overcome these challenges.

Recent developments in drug hypersensitivity in children

Introduction: Drug allergy is an important public health problem that causes 0.4-10.3% of hospital admissions in children. The epidemiology, clinical spectrum, diagnosis, and management of drug hypersensitivity reactions (DHRs) differ in pediatric and adult patients. However, the same algorithms used in adults have often been applied in the pediatric population due to a lack of evidence in the literature. Areas covered: In this review, we aimed to discuss recent developments in the area of pediatric DHRs based on the growing body of literature advancing our understanding of the epidemiology, clinical aspects, and diagnostic approaches to DHRs in children. Expert opinion: Misdiagnosis, under-diagnosis, and self-diagnosis are common problems related to drug allergies in children. Viral infections are particularly frequent in children and make diagnosis difficult. Identifying true DHR is a key step in the management of drug allergy in children. Therefore, a complete allergy work-up with standardized drug allergy tests is necessary. In order to eliminate non-standardized tests, future studies including larger numbers of children should be conducted to determine more accurate standardized tests for diagnosing DHRs in the pediatric population.

Structure-activity relationships of fraxamoside as an unusual xanthine oxidase inhibitor

Fraxamoside, a macrocyclic secoiridoid glucoside featuring a hydroxytyrosol group, was recently identified as a xanthine oxidase inhibitor (XOI) comparable in potency in vitro to the standard antigout drug allopurinol. However, this activity and its considerably higher value than its derivatives oleuropein, oleoside 11-methyl ester, and hydroxytyrosol are not explained by structure-activity relationships (SARs) of known XOIs. To exclude allosteric mechanisms, we first determined the inhibition kinetic of fraxamoside. The resulting competitive mechanism prompted a computational SAR characterization, combining molecular docking and dynamics, which fully explained the behavior of fraxamoside and its derivatives, attributed the higher activity of the former to conformational properties of its macrocycle, and showed a substantial contribution of the glycosidic moiety to binding, in striking contrast with glycoside derivatives of most other XOIs. Overall, fraxamoside emerged as a lead compound for a new class of XOIs potentially characterized by reduced interference with purine metabolism.

Is universal HLA-B*15:02 screening a cost-effective option in an ethnically diverse population? A case study of Malaysia

BACKGROUND

A strong association has been documented between HLA-B*15:02 and carbamazepine-induced severe cutaneous adverse reactions (SCARs) in Asians. Human leucocyte antigen testing is potentially valuable in many countries to facilitate early recognition of patient susceptibility to SCARs.

OBJECTIVES

To determine the cost-effectiveness of universal HLA-B*15:02 screening in preventing carbamazepine-induced Stevens-Johnson syndrome/toxic epidermal necrolysis in an ethnically diverse Malaysian population.

METHODS

A hybrid model of a decision tree and Markov model was developed to evaluate three strategies for treating newly diagnosed epilepsy among adults: (i) carbamazepine initiation without HLA-B*15:02 screening (current practice); (ii) universal HLA-B*15:02 screening prior to carbamazepine initiation; and (iii) alternative treatment [sodium valproate (VPA)] prescribing without HLA-B*15:02 screening. Base-case analysis and sensitivity analyses were performed over a lifetime time horizon. Incremental cost-effectiveness ratios were calculated.

RESULTS

Both universal HLA-B*15:02 screening and VPA prescribing were dominated by current practice. Compared with current practice, universal HLA-B*15:02 screening resulted in a loss of 0·0255 quality-adjusted life years (QALYs) at an additional cost of 707 U.S. dollars (USD); VPA prescribing resulted in a loss of 0·2622 QALYs at an additional cost of USD 4127, owing to estimated differences in antiepileptic treatment efficacy.

CONCLUSIONS

Universal HLA-B*15:02 screening is unlikely to be a cost-effective intervention in Malaysia. However, with the emergence of an ethnically diverse population in many other countries, this may render HLA-B*15:02 screening a viable intervention when an increasing proportion of the population is at risk and an equally effective yet safer antiepileptic drug is available.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a review

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are uncommon, acute and potentially life-threatening adverse cutaneous drug reactions. These pathologies are considered a hypersensitivity reaction and can be triggered by drugs, infections and malignancies. The drugs most often involved are allopurinol, some antibiotics, including sulfonamides, anticonvulsants such as carbamazepine, and some non-steroid anti-inflammatory drugs (NSAIDs). Necrosis of keratinocytes is manifested clinically by epidermal detachment, leading to scalded skin appearance. The rash begins on the trunk with subsequent generalization, usually sparing the palmoplantar areas. Macular lesions become purplish, and epidermal detachment occurs, resulting in flaccid blisters that converge and break, resulting in extensive sloughing of necrotic skin. Nikolsky's sign is positive in perilesional skin. SJS and TEN are considered to be two ends of the spectrum of one disease, differing only by their extent of skin detachment. Management of patients with SJS or TEN requires three measures: removal of the offending drug, particularly drugs known to be high-risk; supportive measures and active interventions. Early diagnosis of the disease, recognition of the causal agent and the immediate withdrawal of the drug are the most important actions, as the course of the disease is often rapid and fatal.

Chronic Ocular Complications of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: The Role of Systemic Immunomodulatory Therapy

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, but potentially blinding diseases that affect the skin and mucous membranes. Although the cutaneous manifestations tend to be self-limited and resolve without sequelae, the chronic ocular complications associated with SJS/TEN can persist despite local therapy. Poor understanding of the underlying pathophysiology and lack of a standardized clinical approach have resulted in a paucity of data in regards to suitable treatment options. Inflammatory cellular infiltration and elevated levels of ocular surface cytokines in the conjunctival specimens of affected patients give credence to an underlying immunogenic etiology. Furthermore, the presence of ongoing ocular surface inflammation and progressive conjunctival fibrosis in the absence of exogenous aggravating factors suggest a possible role for systemic immunomodulatory therapy (IMT). We review in detail the proposed immunogenesis underlying chronic ocular SJS/TEN and the possible utility of systemic IMT.

The rapid suicide protection of mood stabilizers on patients with bipolar disorder: A nationwide observational cohort study in Taiwan

BACKGROUND

The suicide rate is high among bipolar disorder (BD) patients. Previous studies have focused on the anti-suicidal effect of long-term treatment with mood stabilizers but less on the immediate preventive effects of interventions. The aim of the study was to evaluate the short-term and immediate anti-suicidal effects of mood stabilizers on recent-onset BD patients.

METHODS

The National Health Insurance Database (NHID) of Taiwan was used to perform a nationwide cohort observation study of suicide behaviors in bipolar disorder. All the recent-onset BD patients (ICD-9-CM code 296 except 296.2 and 296.3) diagnosed between 2000-2005 were collected (n=5091) and followed through 2009. The primary endpoint was the presence of a suicide code or the end of observation; exposure to mood stabilizers in the final month of observation was the independent variable.

RESULTS

The hazard ratios (HRs) of suicide-related events, completed suicide, and all-cause mortality were significantly lower for those treated with lithium, divalproex, or carbamazepine compared with no use in the last month (HRs of suicide-related events were 0.10, 0.14 and 0.10, respectively, and all-cause mortality HRs were 0.03; P<0.0001); there was no significant difference in HR between the mood stabilizers.

LIMITATIONS

The NIHD does not provide information on the severity, mood status, or treatment adherence of BD patients. Neither substance-related disorder nor personality disorder were included in the analysis. We focused on the effect of the final prescription time period, not the long-term protective effect.

CONCLUSIONS

The immediate recent use of any mood stabilizer significantly lowers the rate of death, suicide, or suicidal behavior in BD.

Ibuprofen induced Stevens-Johnson syndrome - toxic epidermal necrolysis in Nepal

Despite the fact that any drug can be an impending cause of hypersensitivity reactions, Ibuprofen, an over-the-counter drug used extensively as an analgesic and antipyretic in Asia, is considered to be relatively safe. But herein we report a rare extremely 'rapid onset' occurrence of a severe case of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in a 22-year-old male, induced by 3 doses of 400 mg of Ibuprofen taken at 8-hour interval for eye pain, probably the first case report of rapid onset of TEN by nonsteroidal antiinflammatory drugs in Nepal. SJS and TEN are idiosyncratic, delayed hypersensitivity inflammatory adverse drug reactions that are severe adverse cutaneous drug reactions which predominantly involve the skin and mucous membranes and are linked with high morbidity and mortality. Nevertheless, removal of ibuprofen and its metabolites with plasma exchange and treatment with antibiotics and intravenous corticosteroids along with supportive therapy improved the course of the disorder. This rare case report addresses the fact that severe hypersensitivity reactions can occur with Ibuprofen, which can be potentially dangerous and life threatening. It is thus important for the clinicians to be alert to such severe hypersensitivity reactions even with drugs which are deemed to be probably safe.

Cost-effectiveness analysis of genotyping for HLA-B*5801 and an enhanced safety program in gout patients starting allopurinol in Singapore

AIMS

Allopurinol is an efficacious urate-lowering therapy (ULT), but is associated with rare serious adverse drug reactions of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with higher risk among HLA-B*5801 carriers. We assessed the cost-effectiveness of HLA-B*5801 testing, an enhanced safety program or strategies with both components.

METHODS

The analysis adopted a health systems perspective and considered Singaporean patients with chronic gout, over a lifetime horizon, using allopurinol or probenecid. The model incorporated SJS/TEN and gout treatment outcomes, allele frequencies, drug prices and other medical costs.

RESULTS

Based on cost-effectiveness threshold of US$50,000 per quality-adjusted life year, HLA-B*5801-guided ULT selection or enhanced safety program was not cost effective. Avoidance of ULTs was the least preferred strategy as uncontrolled gout leads to lower quality-adjusted life years and higher costs.

CONCLUSION

The analysis underscores the need for biomarkers with higher positive predictive value for SJS/TEN, less expensive genetic tests or safety programs, or more effective gout drugs. .

Patterns of inpatient dermatology referral and predictors of diagnostic accuracy in non-dermatologists in a Northern District hospital in Singapore

BACKGROUND

A wide range of dermatological conditions is often encountered in the inpatient setting. Many non-dermatologists experience difficulty in their diagnosis, and referral to a dermatologist is often warranted. In our local setting, this is made through a formal written referral letter, which is usually drafted by the junior doctor on the team.

OBJECTIVES

This study was conducted to characterize patterns of inpatient dermatology referral and to investigate whether predictors of diagnostic concordance between the referring non-dermatologist and the reviewing dermatologist can be identified.

METHODS

A total of 168 inpatient dermatology referrals made between June and September 2013 at a Northern District hospital in Singapore were identified and reviewed. Collated variables were broadly divided into: (i) patient demographic details; (ii) the referring details of non-dermatologists; and (iii) the response details of reviewing dermatologists.

RESULTS

No predictors of diagnostic concordance could be identified statistically. A total of 90.5% (n = 152) of referrals were made for both diagnostic and management purposes, whereas 9.5% (n = 16) of referrals were made purely for management purposes. Of the 152 diagnostic and management referrals, a preliminary diagnosis was reflected in 69.1% (n = 105). In 47.6% of all referrals (n = 80), more than one dermatological condition was identified. The fungal smear was the most commonly requested ancillary investigation (22.6%, n = 38/168). Cutaneous skin infections (32.0%, n = 85/266) and endogenous eczema (32.0%, n = 85/266) were by far the two most commonly identified dermatological conditions in our local cohort of patients.

CONCLUSIONS

The need for a dedicated inpatient dermatology service is reinforced. However, targeted education may be employed to facilitate the referral process.

Clinical characteristics and treatment outcome of Stevens-Johnson syndrome and toxic epidermal necrolysis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are erythematous skin lesions with blister formation accompanied by mucosal involvement. These conditions are considered to be life-threatening illnesses. Understanding the clinical presentation, risk factors, treatment options and results will be advantageous for physicians in the management of patients in the future. The aim of the present study was to review and analyze the clinical manifestations, drug implications, treatment and outcome of patients with SJS and/or TEN who had been hospitalized in a tertiary care center. All hospitalized patients with SJS and/or TEN during a 5-year period were retrospectively reviewed. The clinical severity was graded according to the score of toxic epidermal necrolysis (SCORTEN) scale. Clinical symptoms, diagnosis, possible precipitating factors, management and outcome data were collected for analysis. A total of 43 patients (mean age, 49.5 years) were hospitalized and classified into the SJS group (55.8%), SJS/TEN overlap group (20.9%) and TEN group (23.3%). The majority of the patients (90.7%) had mucocutaneous eruptions associated with oral drug administration. Allopurinol, anticonvulsants and antibiotics were the most common causative agents for the mucocutaneous eruption. Twenty-eight patients (65.1%) were treated with corticosteroids. The mortality rate was 6.9%. Comparison between the survival group and the non-survival group revealed that patient age >70 years (P=0.014) and body surface area involvement >20% (P<0.01) were the significant factors associated with mortality. The use of systemic steroids was higher in the survival group in comparison with the non-survival group (65.1 vs. 0%, respectively; P=0.014). The mucocutaneous eruptions in SJS and TEN are mostly caused by medication. With early recognition and treatment, the mortality rate in this study was lower than that in previous reports. Patient age and the area of mucocutaneous involvement were significant factors associated with mortality.

A 13-year retrospective study evaluating the efficacy of using air-fluidised beds for toxic epidermal necrolysis patients

OBJECTIVES

Toxic epidermal necrolysis (TEN) is a potentially life-threatening dermatological disease involving large areas of skin loss with systemic symptoms. This study evaluated the efficacy of air-fluidised bed therapy for TEN patients.

METHODS

Of 27 people with TEN, 11 used air-fluidised beds (the air-fluidised group) and 16 used standard beds (the control group). Days to complete re-epithelialisation, re-epithelialisation rate, incidence of complications, mortality, pain measured by visual analogue score and the incidence of cutaneous infection were compared in these groups.

RESULTS

The mean body surface area of involvement was 77.0 ± 11.8% and baseline mean severity-of-illness score for TEN (SCORTEN) was 2.81 ± 1.08. The re-epithelialisation rate in the air-fluidised group was 100% but was only 56.3% in the control group (P < 0.05). There was a significant difference in the time taken to complete re-epithelialisation between the air-fluidised group (13 days [95% CI: 9.0-17.0]) and the control group (21 days [16.5-25.5], P < 0.05). Furthermore, the incidence of complications was 18% in the air-fluidised group versus 75% in the control group, including fewer cutaneous infections (P < 0.05). There was a significant reduction in pain among the air-fluidised group compared with the control group (P < 0.05). There were no deaths in the air-fluidised group while 19% of the control group died.

CONCLUSION

Air-fluidised beds can reduce the time to complete re-epithelialisation, relieve pain and increase the re-epithelialisation rate of TEN patients, but there was no significant difference between them in mortality rate in our study.

Lamotrigine-induced toxic epidermal necrolysis confirmed by in vitro granulysin and cytokine assays

Lamotrigine is a recent medication which is prescribed for various neuropsychiatric conditions. It is generally well-tolerated, but recent pharmacoepidemiological evidence suggests that lamotrigine is associated with risks of developing severe cutaneous drug reactions like toxic epidermal necrolysis (TEN). However, there still remains the diagnostic challenge regarding how to confirm the drug causality in suspected cases. In most cases so far, lamotrigine causality has not been objectively demonstrated, which was possibly due to high risk of oral challenge tests or the lack of useful in vitro drug assays. Here we report a case of lamotrigine-induced TEN, of which the drug causality was confirmed by in vitro granulysin and cytokine assays.

Diclofenac-serratiopeptidase combination induced stevens - johnson syndrome - a rare case report with review of literature

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions (SCAR) which are frequently caused by exposure to drugs and cause significant morbidity and mortality. A careful literature search revealed that only a few reports of diclofenac induced and one case of serratiopeptidase associated case report of SJS or TEN have been published till date. However, to our knowledge, no case report of diclofenac-serratiopeptidase combination induced SJS have been published till date. In this backdrop, we describe the first case of a 62-year-old woman who developed diffuse, erythematous rash on face, trunk and both extremities which later turned into blisters following five day treatment with diclofenac and serratiopeptidase combination. There was extensive ulceration of buccal, genital and ocular mucosa. The body surface area involvement of the patient at the time of presentation was 9%. A provisional diagnosis of SJS was made by the treating physician. After administration of intravenous antibiotic, topical antiseptic, anti-histamine, topical lubricants, fluid therapy and parenteral nutrition patient recovered and were discharged.

Hypersensitivity to antiepileptic drugs

Adverse reactions to antiepileptic drugs (AEDs) may lead to treatment failure, morbidity, and mortality. Drug hypersensitivity reactions (DHRs) are potentially fatal. AED DHRs present with a variety of clinical manifestations. The pathogenesis of AED DHRs has not been fully elucidated. Bioactivation, detoxification, covalent adduct formation, presentation to the immune system, and consequent formation of antibody and T-cell immune effectors have been suggested. This article summarizes the epidemiology, pathogenic mechanisms, risk factors, clinical features, and management of allergic reactions to the aromatic AEDs carbamazepine, phenytoin, and lamotrigine.