Rapid onset of Stevens-Johnson syndrome and toxic epidermal necrolysis after ingestion of acetaminophen
A 60-year-old man with a five-year history of diabetes mellitus and hypertension was treated with acetaminophen for three days owing to infection of the upper respiratory tract. He had no history of allergic responses. A erythematous rash throughout the body was evident 3 days after initial exposure to acetominophen. The rash spread and became generalized within a few days, with the appearance of bullae. He was admitted to another hospital 7 days after initial exposure to acetaminophen (day 7) and treated with IVIG delivered at a rate of 1 g/kg/day for 3 days. Skin lesions were accompanied by a fever, with a body temperature > 39℃. A skin biopsy performed on day 8 indicated an early phase of toxic epidermal necrolysis. On day 14 he was referred to our hospital with multiple exfoliations, extensive bullae throughout his body, oral mucositis and ocular involvement (). On examination, the patient was alert and appeared chronically ill. His body temperature was 38.4℃, blood pressure was 144/70 mmHg, pulse rate was 90 beats per minute, and respiratory rate was 20 breaths per minute. Nikolsky's sign was positive. Tenderness was evident, especially in parts of the skin affected by the rash.\nThe patient's white blood cell count was 1.700/mm3, the hemoglobin concentration was 11.9 g/dL, and the platelet count was 183,000/mm3. His C-reactive protein was increased to 6.55 mg/dL and the level of procalcitonin was 0.1 ng/mL. The level of total protein was 4.7 g/dL, the level of albumin was 1.5 g/dL, the level of blood urea nitrogen was 10 mg/dL, and the level of serum creatinine was 0.6 mg/dL. The sodium, potassium, phosphate, calcium and uric acid levels were slightly decreased. There was no evidence of eosinophilia and levels of liver enzymes were within the normal range.\nThe patient was isolated to reduce the risk of secondary infection, and received fluid therapy and parenteral nutrition with high protein content. After treatment of skin lesions by the topical application of mupirocin, 0.9% NaCl and 0.5% AgNO3 three times a day for 7 days, the skin condition gradually improved. The patient was discharged from the hospital on day 30. We are confident that the reaction was caused by acetaminophen, because it appears to be the only drug to which the patient was exposed to within a 30-day period prior to his initial admission.