Steven Johnson Syndrome: A case report
R. Shanthi
Nursing Incharge, Kauvery Hospital, Tirunelveli
Abstract
Early stage Steven-Johnson syndrome can include flu-like symptoms, such as fever, sore throat, cough or joint pain. A few days later, a skin rash may appear on any part of the body and may feel like sunburn or lesions. Other symptoms, which appear shortly after the initial issues, may include:
- Blisters on the skin, mouth, eyes, nose and genitals
- Shedding skin after the blisters form
- Unexplained pain on the skin
- Swelling of the mouth, lips, throat, tongue or face
Background
A 60 years old female was admitted with complaints of fever for 10 days associated with tingling and numbness in both upper limbs, and foot swelling with redness of both feet, palms and face. Also, difficulty in swallowing and throat pain for past 2 days. Treatment was taken out side hospital in OPD.
- No history of previous surgery
- Not a known case of HT/ DM/Thyroid /CAD
Examination
Patient Conscious, Oriented.
- HR – 88/mts
- BP – 150/80mmHg
- TEP – 98.6
- RR – 18
- SPO2 – 96%
- CVC – S1, S2 present
- RS – Bilateral air entry is present
- P/A – Soft
- CNS – NFND
Investigation
| S. No | Vitals | Results |
| 1 | HB | 11.7 |
| 2 | PCV | 36.8% |
| 3 | Platelet | 95000 |
| 4 | RBC count | 4.22 |
| 5 | Total WBC count | 9820 |
| 6 | Urea | 54.64.8mg/dL |
| 7 | Creatinine | 1.00mg/dL |
| 8 | RBS | 174mg/dL |
| 9 | Potassium | 4.26mEq/L |
| 10 | Sodium | 135.8mEq/L |
| 11 | ESR | 22 mm/1hr |
| 12 | Bilirubin total: | 0.44mg/dL |
| 13 | Bilirubin Direct | 0.24mg/ dL |
| 14 | Bilirubin indirect | 0.20mg/dL |
| 15 | SGOT | 29.95 |
| 16 | SGPT | 35.70 |
| 17 | ALP | 35.71 |
| 18 | Total protein | 6.49g/dL |
| 19 | Albumin | 3.04g/dL |
| 20 | AG Ratio | 0.88g/dL |
| 21 | RA Factor | >150.0IU/ml |
| 22 | Uric acid | 2.93mg/dL |
| 23 | HIV | Negative |
| 24 | HbsAg | Negative |
| 25 | HCV | Negative |
Discussion
- A 60 Years old female, Euglycemic and normotensive, came with complaints of fever associated with tingling and numbness in both upper limbs with a history of foot swelling. Patient was evaluated outside and diagnosed as carpal tunnel syndrome and treated.
- After that patient had chest discomfort and cough with oral ulceration, difficulty in swallowing, throat pain and was admitted outside and diagnosed as acute pneumonitis and referred here for further evaluation.
- On examination, patient had pruritic rash over the face, both ears, neck and lower back, and both feet, and with whitish patches over the tongue.
- All relevant blood investigations were done and found to be normal. RA factor was elevated.
- Patient was shifted to ICU for observation. She was treated with IV steroids, IV fluids and Candid mouth paint.
- ENT opinion was obtained and nil intervention was suggested.
- Dermatologist opinion obtained and the patient was suspected of Steven Johnson syndrome with oral candidiasis.
- The patient was started on antivirals, high dose steroids and on Cyclosporine. Skin lesion started to subside gradually. Oral fluids started gradually. Patient was hemodynamically stable. Urea was mildly elevated. Patient started on semi solid diet. Ulcers over the eyelids and mouth started healing. Patient was shifted to room. CBG was monitored daily. Steroids were tapered slowly and stopped. Patient general condition improved.
Medications
| Drug | Dose | Frequency |
| Inj. Pantocid | 40 mg | OD |
| Inj. Syscon | 100ml- | OD |
| Inj. Dexa | 8 mg | BD |
| Inj. Solumedral | 1 gm | OD |
| Tab. Cyclosporin | 50 mg | BD |
| Syp Polybion | 10 ml | BD |
Nursing management
Frequent monitoring of vital signs is an essential part of management as they offer the first sign of a worsening systemic condition. Monitoring (both initially at baseline and subsequently at periodic intervals) includes parameters such as pulse rate, blood pressure, respiratory rate, fluid intake and urine output chart, blood glucose, serum electrolytes, serum creatinine and specific cultures.
Completing all necessary documentation including patient notes and discharge documents.
- Barrier nursing and sterile handling of the patient
- Regular hand hygiene with chlorhexidine hand rubs and hand washes to be practiced by health-care workers and caregivers
- Avoid unnecessary insertion of urinary catheters, intravenous lines or central lines
- If used, urinary catheters, intravenous lines and central lines must be handled minimally and changed regularly
- Monitor for foci of sepsis in the body, features of septicemia and disseminated intravascular coagulation
- Environmental controls for dependency units (air exchanges, humidity and temperature control) and intensive care unit
- Activate sepsis protocols early.
Topical antiseptics and dressing of denuded skin
For denuded areas, dressing can be done with paraffin or petrolatum gauze, with or without antibiotic impregnation. Adhesive dressings should be avoided. Frequent changes in patient position and an air-fluid bed/water bed help in early healing of lesions, prevention of bed sores and reduce patient
Oral and ophthalmic care
Oral hygiene should be maintained with normal saline swishes or antiseptic or anesthetic mouth washes. Saline compresses followed by the application of lubricants can be advised for the lips. This also helps soften hemorrhagic lip crusts. Daily examination by an ophthalmologist and vigorous treatment reduce the risk of long-term ocular complications. Lubrication and antibiotic eye drops/ointments with or without corticosteroids are needed frequently (every 2 h). Lid globe adhesions should be cautiously removed with a glass rod daily. Recently, the application of amniotic membranes was reported to be effective in preserving visual acuity and an intact ocular surface
Respiratory care
Hypo-static pneumonia should be prevented by frequent change of posture and mobilization of the patient as early as possible. The nose may require attention in the form of miniaturization with saline and removal of adherent crusts.
Psychological care
Providing emotional support and maintaining a continual dialogue with the patient and his/her family is a vital part of supportive care and addresses the patient’s fears/anxieties, improves compliance with daily nursing care and gives an opportunity for patient education about self-care after discharge and prevention of future episodes.
Diet
Eat small, frequent meals and avoid spicy or fried food. Probably feel very fatigued for the first 2 weeks then notice a gradual increase in energy thereafter. Fruits and vegetables and high protein diet.
Health education
- Diet
- Drink plenty of liquids
- Rest
Outcome of the patient
General condition was good, Vitals stable, hence Discharged.
R. Shanthi
Nursing in charge