Rapid onset of Stevens-Johnson syndrome and toxic epidermal necrolysis after ingestion of acetaminophen
A 43-year-old woman visited our hospital with an erythematous skin rash involving bullae throughout the body. Oropharyngeal ulceration and conjunctivitis developed within just two days after medication with acetaminophen to treat an infection of the upper respiratory tract (). The patient had a history of asthma, which had been controlled for five years by inhalation of a corticosteroid or long-acting beta-2 agonist, and had reported an incident of immediate drug hypersensitivity, urticaria to acetaminophen one year earlier. On examination, the patient was alert and appeared acutely ill. Her body temperature was 39.4℃, blood pressure was 115/90 mmHg, pulse rate was 140 beats per minute, and respiratory rate was 24 breaths per minute. Macular rash and epidermal detachment was evident on approximately 20% of the body surface. Nikolsky's sign was positive. Tenderness was evident, especially in parts of the skin affected by the rash. The white blood cell count was 2.900/mm3, the hemoglobin concentration was 13.2 g/dL, and the platelet count was 160,000/mm3. Her C-reactive protein was increased to 16.64 mg/dL, and the level of procalcitonin was 0.34 ng/mL. The level of total protein was 5.9 g/dL, the level of albumin was 3.1 g/dL, the level of blood urea nitrogen was 8 mg/dL, and the level of serum creatinine was 0.6 mg/dL. The level of aspartate aminotransferase was 102 IU/L, and the level of alanine aminotransferase was 40 IU/L. Levels of sodium, potassium and calcium levels were slight decreased. There was no eosinophilia.\nThe skin lesions rapidly progressed to bullous skin lesions covering the whole body, with epidermal detachment apparent over more than 30% of the body surface with time in spite of administration of high dose systemic corticosteroid (). After diagnosis of TEN, we administered intravenous immunoglobulin G (IVIG) at 2 g/kg/day for 3 days. After the treatment with IVIG, the epidermal detachment of the skin ceased and the severity of the skin lesions decreased. Empirical antibiotic use was continued for three weeks. The patient was discharged from the hospital 33 days after admission.\nWe thoroughly investigated other causes of the pathology, including viral infection. Nonetheless, there was no evidence of other causes besides ingestion of acetominophen.