Stevens-Johnson syndrome

Stevens-Johnson syndrome - Acute
Rahul Soman, M. Pharm

 

Definition  

Acute, eruptive skin disorder that occurs in response to a variety of antigenic stimuli

 

Medical History  

* Anticonvulsant use

* Beta-Lactam use

* NSAID use

* Sulfonamide use

* Mycoplasma pneumonia

* Pediatric (0-18 years) , Herpesvirus infection

* Pediatric (0-18 years) , Complication due to vaccination

* Systemic lupus erythematosus

* HIV infection

* Genetic predisposition

 

Findings  

* Conjunctivitis

* Cough

* Disorder of mucous membrane

* Fever

* Genital ulcer

* Headache

* Oral lesion

* Skin lesion

* Upper respiratory infection

* Anorectal lesion

* Esophageal erosions

* Finding of lacrimation

* Lesion of eye structure

* Malaise

* Myalgia

* Pain in throat

* Vomiting

 

Tests  

 

Initial evaluation of Stevens-Johnson syndrome  

* Electrolytes measurement, serum

* Urinalysis

* Creatinine measurement, serum

 

Suspected pneumonia  

* Plain chest X-ray: The presence of alveolar infiltrates on chest x-ray, in combination with suggestive clinical features, establishes the diagnosis of pneumonia .

 

Suspected Stevens-Johnson syndrome  

* White blood cell count: A WBC count less than 9,000/mm3 is a common finding in Stevens-Johnson syndrome, noted within 72 hours of the appearance of skin lesions .

 

Initial evaluation of Stevens-Johnson syndrome if infection is suspected  

* Bacterial culture, Skin lesion sample

 

Initial evaluation of Stevens-Johnson syndrome if sepsis is suspected  

* Blood culture

 

Initial evaluation of Stevens-Johnson syndrome .  

* Blood urea nitrogen measurement

 

Suspected Stevens-Johnson syndrome  

* Biopsy of skin: Biopsy in Stevens-Johnson syndrome reveals superficial dermal perivasculitis , minimal dermal infiltrate, and full-thickness epidermal necrosis .

 

Differential Diagnosis  

* Toxic epidermal necrolysis - Acute

* Kawasaki disease - Acute

* Fixed drug eruption

* Varicella-zoster virus infection

* Epidermolysis bullosa

* Impetigo - Acute

* Bullous pemphigoid

* Pemphigus vulgaris

 

Treatment  

 

Drug Therapy  

 

 

Stevens-Johnson syndrome  

 

METHYLPREDNISOLONE SODIUM SUCCINATE  

 

 

 

Acute pain  

 

ACETAMINOPHEN/OXYCODONE HYDROCHLORIDE  

Adults: Oxycodone 5 to 20 mg/acetaminophen 325 to 1,000 mg orally every 4 hours as needed (maximum 4 g acetaminophen/day)

Pediatrics: 0.05 to 0.15 mg/kg of the oxycodone ingredient orally every 4 hours as needed

 

HYDROCODONE BITARTRATE/ACETAMINOPHEN  

Adults: Hydrocodone 5 to 20 mg/acetaminophen 325 to 1,000 mg orally every 4 hours as needed (maximum 4 g acetaminophen/day)

Pediatrics (2-13 years): 0.27 mL/kg (0.135 mg/kg hydrocodone and 9 mg/kg acetaminophen) orally every 4 hours as needed (maximum 6 doses/day)

 

ACETAMINOPHEN/CODEINE PHOSPHATE  

Adults: Codeine 15 to 60 mg/acetaminophen 325 to 1,000 mg orally every 4 hours as needed (maximum 360 mg codeine and 4 g acetaminophen/day)

Pediatrics (3-6 years): 5 mL (12 mg codeine/120 mg acetaminophen per 5 mL) orally every 6 to 8 hours as needed

Pediatrics (7-12 years): 10 mL (12 mg codeine/120 mg acetaminophen per 5 mL) orally every 6 to 8 hours as needed

 

MORPHINE SULFATE  

Adults: 2 to 10 mg IV every 5 to 10 minutes titrated to effect OR 10 mg IM or subQ every 3 to 4 hours as needed

Pediatrics: 0.1 to 0.2 mg/kg subQ, IM, or IV every 2 hours as needed (maximum 15 mg/dose)

 

HYDROMORPHONE HYDROCHLORIDE  

Adults: 1 mg IV every 10 minutes titrated to effect OR 1 to 2 mg subQ or IM every 3 to 4 hours as needed

Pediatrics: 10 to 20 mcg/kg IV every 3 to 4 hours as needed

 

FENTANYL  

Adults: 1 mcg/kg IV slowly every 3 to 5 minutes titrated to effect

Pediatrics: 0.5 to 1 mcg/kg IV every 30 to 60 minutes as needed

 

 

Fever  

 

ACETAMINOPHEN (Related toxicological information in ACETAMINOPHEN-ACUTE, ACETAMINOPHEN-REPEATED SUPRATHERAPEUTIC)  

Adults: 650 to 1,000 mg orally every 4 to 6 hours as needed (maximum 4 g/day)

Pediatrics: 10 to 15 mg/kg orally or rectally every 4 to 6 hours as needed (maximum 5 doses or 4 g/day)

Neonates: 10 to 15 mg/kg orally or rectally every 6 to 8 hours as needed

 

 

Risk of thrombosis due to immobility  

 

Heparin  

Adults: 5,000 units subQ every 8-12 hours

 

ENOXAPARIN SODIUM  

Adults: 40 mg subQ once a day for up to 14 days

 

DALTEPARIN SODIUM  

Adults: 5000 international units subQ once daily for 12-14 days

 

 

Hyperglycemia  

 

INSULIN HUMAN REGULAR  

 

 

Procedural Therapy  

 

Suspected or known drug-induced rash with severe manifestations  

* Recommendation to stop drug treatment: Prompt cessation of the suspect drug(s) is essential in patients with a severe drug eruption .

 

Bullous eruption in Stevens-Johnson syndrome, toxic epidermal necrolysis, and staphylococcal scalded skin syndrome  

* Wound care, Epidermolysis: Bullous eruptions with epidermolysis require meticulous skin care with protection of exposed, eroded areas and prevention of secondary infection .

 

Conjunctivitis due to a mucocutaneous disorder such as Stevens-Johnson syndrome and toxic epidermal necrolysis  

* Eye care management: Meticulous eye care is essential to lessen or prevent permanent ophthalmic complications in Stevens-Johnson syndrome and toxic epidermal necrolysis .

 

Dehydration  

* Intravenous fluid replacement: Intravenous fluid replacement is indicated for patients with dehydration when oral replacement cannot be accomplished .

 

Prevention and treatment of pulmonary complications due to Stevens-Johnson syndrome and toxic epidermal necrolysis  

* Respiratory therapy: Respiratory therapy is necessary to reduce and treat pulmonary complications of Stevens-Johnson syndrome and toxic epidermal necrolysis .

 

Stomatitis  

* Mouth care management: Oral mucosal lesions are treated with analgesics, soothing mouth rinses, topical anesthetics, a soft diet, and avoidance of spicy or acidic foods .

 

Stevens-Johnson syndrome with oral mucous membrane involvement  

* Nasogastric feeding: In patients with mucosal lesions that interfere with oral intake, a nasogastric tube may be used to maintain fluid balance and nutritional support .

 

Stevens-Johnson syndrome in young children and in patients with acute urinary retention or difficulty voiding  

* Insertion of catheter into urinary bladder: A urinary catheter may be necessary in young children to monitor fluid balance and in patients with urinary retention or difficulty voiding .