Phenytoin induced Stevens-Johnson syndrome exacerbated by cefepime
A 28-year-old female patient with a medical history of left sided pleural effusion was started on anti-tubercular treatment (ATT) [Tablet (tab.) isoniazid, rifampicin, pyrazinamide and ethambutol] at a local hospital for 1 month. Although the patient was non-complaint to therapy, she developed ATT induced hepatitis with aspartate aminotransferase-136 IU/L, and alanine transaminase - 331 IU/L. Following this, ATT was promptly withdrawn. Patient had one episode of generalized tonic clonic seizures (GTCS) 1½ months after the stoppage of ATT medication. She was given a loading dose of phenytoin and was brought to a tertiary care hospital in southern India for further management.\nOn day 1, during the presentation in emergency room, patient developed an episode of seizures and was treated with Tab. phenytoin 300 mg at night. On day 2, patient developed one more episode of GTCS, Tab. Phenytoin 300 mg was continued and pleural effusion was managed with inj. amikacin 500 mg and ethambutol 800 mg. On day 3, patient had a mild fever (39.5°C), itching, and erythematous rash all over her body. Her fever was managed with tab. paracetamol 50 mg, in addition to tab. hydroxyzine 25 mg, calamine lotion and tab. embramine 25 mg for the management of erythematous rashes. Tab. phenytoin was stopped due to rash and tab. levetiracetam 500 mg bid was started.\nOn day 4, patient developed oral ulcers and generalized skin rash that was suspected to be SJS. Tab. paracetamol was stopped and inj. pheniramine maleate 25 mg, inj. hydrocortisone 100 mg were started and oral ulcer was managed with the candid mouth paint and choline salicylate. On day 6, patient's condition remained unchanged. Inj. hydrocortisone 100 mg was replaced with tab. methylprednisolone 6 mg and tab. levetiracetam and tab. embramine 5 mg were also discontinued.\nFrom day 7 to day 19, there were no fresh complaints and rash was improving. Same medications were continued. On day 16 Inj. cefepime 1 g infusion was started for managing urinary tract infection (UTI) caused by multi drug resistance (MDR) Klebsiella/Escherichia coli. On day 20, patient presented with extensive skin peeling all over her body followed by pigmentation and scaling of skin managed with same medicines and was transferred to intensive care unit. Inj. tigecycline 50 mg bid was given for managing MDR Acinetobacter and tab. prednisolone was replaced with inj. methylprednisolone 40 mg.\nOn day 21, inj. cefepime 1 g infusion was stopped. Skin lesions worsened, considering her condition physician planned for tapering of steroids. Possibility of involvement of collagen vascular disease was high hence advised for skin biopsy and antinuclear antibody. On day 22, the patient's condition was unimproved and managed with saline compressor, silver sulphadiazine cream and paraffin gauze dressing. On days 23 and 24, skin lesions persisted and the patient complained of burning sensation over the lesions, chills and rigors, and redness of skin-reduced.\nOn day 25, inj. methylprednisolone 40 mg was changed to 40 mg tablet. Skin lesions and peeling along with desquamation of the skin was present, redness was decreased and lesions on the trunk were dried. On day 28, inj. tigecycline was stopped and inj. polymyxinE 1 million units was started for the treatment of MDR Acinetobacter and MDR Klebsiella. Patient had one episode of fever, skin lesions and peeling were present, redness and new skin eruptions were observed. On day 29, tab. methylprednisolone dose was decreased from 40 mg to 32 mg. Skin lesions showed signs of healing, and no new skin eruptions were observed.\nOn day 30, skin biopsy revealed interface dermatitis with pityriasis versicolor. On day 31, tab. methylprednisolone dose was decreased to 24 mg and to 20 mg on day 34. Patient complained of itching over the face. Facial edema, generalized hyperpigmentation and desquamation were observed. On day 35, Inj. amikacin and tab. ethambutol were stopped, as there was no conclusive evidence of tuberculosis. On day 40, skin peeling was reduced and methylprednisolone dose was decreased to 12 mg. On day 43, polymyxinE was stopped and all other medications were continued. On days 44 and 45, lesions were healed and the dose of methylprednisolone was decreased to 8 mg and to 4 mg on 46th day.\nOn day 48, patient had recurrent UTI and urine culture showed Pseudomonas which was sensitive to cefepime. On day 49, patient was given a test dose of cefepime and was observed for any signs of SJS. When no adverse reactions were observed, a full dose of cefepime 1 g was administered. 2 h later, she developed burning sensation on both upper limb and epigastrium. Patient complained of fever, vomiting (5-6 episodes), generalized weakness, chills and rigors. She was therefore administered inj. pheniramine 1 amp i.v. On day 50, inj. cefepime was stopped. Patient had burning sensation and fever. On day 51, no fresh complaints were observed and patient was better. Hence, she was planned for discharge.