Stevens-Johnson SyndromeA Case PresentationA Case Presentation

Patient ProfilePatient Profile

Name: Name: 王王 OO 芬芬 Age: 49 years oldAge: 49 years old Gender: femaleGender: female Marriage: divorcedMarriage: divorced Occupation: working in printing-Occupation: working in printing-

related factoryrelated factory

Chief complaintChief complaint

Multiple oral ulcers since one Multiple oral ulcers since one week ago. week ago.

Present Illness-1Present Illness-1

This patient is a 49 years old female. She had This patient is a 49 years old female. She had low back pain onset since last Monday (11/14) low back pain onset since last Monday (11/14) and went to LMD for help on last Wednesday and went to LMD for help on last Wednesday morning(11/16). Two kinds of NSAIDs along morning(11/16). Two kinds of NSAIDs along with some other medications were prescribed with some other medications were prescribed for her.for her.

After taking the medication, she had multiple After taking the medication, she had multiple oral ulcers onset on 3 P.M.. The ulcer was with oral ulcers onset on 3 P.M.. The ulcer was with sharp pain and was progressively worsening till sharp pain and was progressively worsening till this Wednesday. There was no fever, chills, this Wednesday. There was no fever, chills, cough, stiff nose, nausea, vomiting, diarrhea, cough, stiff nose, nausea, vomiting, diarrhea, tarry stool, dysuria, nor hematuria ever since tarry stool, dysuria, nor hematuria ever since the onset of oral ulcer episode. There was the onset of oral ulcer episode. There was difficulty and discomfort during swollowing difficulty and discomfort during swollowing liquid. Such discomfort started many years ago.liquid. Such discomfort started many years ago.

Present Illness-2Present Illness-2

Then on this Monday (11/21) she visited our Then on this Monday (11/21) she visited our ENT for help. Mycostatin, colchicine, and some ENT for help. Mycostatin, colchicine, and some other medications were prescribed for her.other medications were prescribed for her.

She didn’t take the medicine and in turn She didn’t take the medicine and in turn went to our ER for feeling great discomfort. A went to our ER for feeling great discomfort. A small ulcer in the vulva was found as well. She small ulcer in the vulva was found as well. She denied any skin rash over trunk or denied any skin rash over trunk or extremities.extremities.

At ER, blood routine and CRP were done and At ER, blood routine and CRP were done and the results were normal. Under the impression the results were normal. Under the impression of oral ulcers and suspicious drug-allergy of oral ulcers and suspicious drug-allergy reaction , she was admitted into our ward for reaction , she was admitted into our ward for further survey and treatment.further survey and treatment.

Past HistoryPast History

1. 1. Medical history: GERD with Medical history: GERD with medication control.medication control.

2. Surgical history: left 2. Surgical history: left herniarrhaphy in 2008 in our herniarrhaphy in 2008 in our hospital.hospital.

3. Depression and other 3. Depression and other psychiatric disorders for years psychiatric disorders for years and are now being treated in the and are now being treated in the LMD with mesyrel, zompidem, and LMD with mesyrel, zompidem, and alpraline.alpraline.

Personal HistoryPersonal History

Allergy: NSAIDs: aceclofenac or Allergy: NSAIDs: aceclofenac or ketoprofen. (Stevens-Johnson Syndrome)ketoprofen. (Stevens-Johnson Syndrome)

Alcohol: nil.Alcohol: nil. betelnets: nil.betelnets: nil. Smoking: nil.Smoking: nil. Special environmental contacts: The Special environmental contacts: The patient works in a factory with high patient works in a factory with high possibilities of contacting various possibilities of contacting various types of chemical agents, especially types of chemical agents, especially organic-solvants.organic-solvants.

Family history: no DM. no hypertension, Family history: no DM. no hypertension, no AIR diseaseno AIR disease

Review of systemReview of system

1. General: Weight loss(+) poor 1. General: Weight loss(+) poor appetite(+), general malaise(+). appetite(+), general malaise(+).

2. HEENT: oral ulcer(+), neck 2. HEENT: oral ulcer(+), neck mass(+), dysphagia(+).mass(+), dysphagia(+).

3. Respiratory: chest tightness(+).3. Respiratory: chest tightness(+). 4. Cardiovascular: Palpitation(+). 4. Cardiovascular: Palpitation(+). 5. Gastrointestinal: dysphagia(+).5. Gastrointestinal: dysphagia(+). 6. Cutaneous:nail change(+). 6. Cutaneous:nail change(+). Vital sign: BT: 35.8 BP: 134/84 R: Vital sign: BT: 35.8 BP: 134/84 R: 18 P: 8418 P: 84

Physical ExaminationPhysical Examination1. 1. General appearance: acutely illGeneral appearance: acutely ill2. Consciousness: clear2. Consciousness: clear3. Peripheral perfusion: Normal3. Peripheral perfusion: Normal4. Skin : normal4. Skin : normal5. HEENT: 5. HEENT: Head, Eyes, and Ears: normal Head, Eyes, and Ears: normal Mouth & Throat: oral ulcers(+)Mouth & Throat: oral ulcers(+)Neck: one thyroid nodule on the right lobe. Neck: one thyroid nodule on the right lobe. Trachea, carotid artery, and Jugular vein: normalTrachea, carotid artery, and Jugular vein: normalThyroid gland : one nodule found in the right lobe Thyroid gland : one nodule found in the right lobe

regionregion6. Chest and abdomen, and extremities: normal6. Chest and abdomen, and extremities: normal7. Nervous system: normal7. Nervous system: normal8. Genitalia area: one shallow ulcer found on the 8. Genitalia area: one shallow ulcer found on the

vulva.vulva.

Lab findings:Lab findings:

11/2111/21 T3, TSH, free T4:normalT3, TSH, free T4:normal ANA, CRP, TPHA: normalANA, CRP, TPHA: normal RF: normalRF: normal Uric Acid: normalUric Acid: normal CBC: normal profileCBC: normal profile Electrolyte: K[3.06 mEq/L]Electrolyte: K[3.06 mEq/L] IGE: normalIGE: normal

Lab findings:Lab findings:

11/25:11/25: R.B.C.[3.60 10^6/uL]R.B.C.[3.60 10^6/uL] Hct[33.9 %] Hct[33.9 %] Na[140.2 mEq/L] Na[140.2 mEq/L] K[3.60 mEq/L]K[3.60 mEq/L]

Exam: 11/21Exam: 11/21

At ENT OPD: Nasopharyngoscopy:At ENT OPD: Nasopharyngoscopy:No specific findings beside multiple No specific findings beside multiple

oral ulcers.oral ulcers. In the ER: chest X-ray: In the ER: chest X-ray: Rt & Lt CP angle blunting, probably Rt & Lt CP angle blunting, probably

pleural effusion or pleural pleural effusion or pleural change.change.

Bilateral apex pleural thickeningBilateral apex pleural thickeningMild Increased bronchovascular Mild Increased bronchovascular

lung markings of both lungs.lung markings of both lungs.

Exam: 11/23Exam: 11/23

EKG: no specific findingEKG: no specific finding

ProgressProgress

Medication Prescribed by ENT on 11/21:Medication Prescribed by ENT on 11/21:

1.1. Colchicine: 1 tab BID for 5 daysColchicine: 1 tab BID for 5 days

2.2. Mycostatin: 3 c.c. TID for 5 daysMycostatin: 3 c.c. TID for 5 days

3.3. Gascon: 1 tab TID for 5 daysGascon: 1 tab TID for 5 days

4.4. Mopride: 1 tab TID for 5 daysMopride: 1 tab TID for 5 days

5.5. Kolantyl: 1 tab TID for 5 daysKolantyl: 1 tab TID for 5 days

ProgressProgress

S: 11/23 oral ulcer with pain, no further worsening. S: 11/23 oral ulcer with pain, no further worsening. 11/24 oral ulcer with pain, feeling much improved. 11/24 oral ulcer with pain, feeling much improved. O: 11/23~11/24 Consciousness: Normal. Vital signs: normal. O: 11/23~11/24 Consciousness: Normal. Vital signs: normal.

PE: oral ulcer. 1 thyroid mass found in the right lobe region. PE: oral ulcer. 1 thyroid mass found in the right lobe region. No other specific finding.No other specific finding.

A: 11/23 Stevens-Johnson Syndrome. StationaryA: 11/23 Stevens-Johnson Syndrome. Stationary 11/24 Stevens-Johnson Syndrome. Improving11/24 Stevens-Johnson Syndrome. Improving Plan: Medication: Prescribed in our ward on 11/23:Plan: Medication: Prescribed in our ward on 11/23:1.1. Vitapoly 1 tab QID 11/23~11/25Vitapoly 1 tab QID 11/23~11/252.2. Panadol 1 tab QID 11/23~11/25Panadol 1 tab QID 11/23~11/253.3. MgO 1 tab BID 11/23~11/25MgO 1 tab BID 11/23~11/254.4. Periactin 4mg 1 tab TID 11/23Periactin 4mg 1 tab TID 11/235.5. Broen-C 1 Tab QID Broen-C 1 Tab QID 6.6. Parmason Parmason 漱口水 漱口水 prn, Kenalog prn, Kenalog 口內膠 口內膠 7.7. Morphine 3mg IM prn for oral ulcer pain control. Morphine 3mg IM prn for oral ulcer pain control.

11/24~11/2511/24~11/25