Stevens-Johnson Syndrome A Case Presentation

Patient Profile Name: 王O芬 Age: 49 years old Gender: female Marriage: divorced Occupation: working in printing-related factory

Chief complaint Multiple oral ulcers since one week ago.

Present Illness-1 This patient is a 49 years old female. She had low back pain onset since last Monday (11/14) and went to LMD for help on last Wednesday morning(11/16). Two kinds of NSAIDs along with some other medications were prescribed for her. After taking the medication, she had multiple oral ulcers onset on 3 P.M.. The ulcer was with sharp pain and was progressively worsening till this Wednesday. There was no fever, chills, cough, stiff nose, nausea, vomiting, diarrhea, tarry stool, dysuria, nor hematuria ever since the onset of oral ulcer episode. There was difficulty and discomfort during swollowing liquid. Such discomfort started many years ago.

Present Illness-2 Then on this Monday (11/21) she visited our ENT for help. Mycostatin, colchicine, and some other medications were prescribed for her. She didn’t take the medicine and in turn went to our ER for feeling great discomfort. A small ulcer in the vulva was found as well. She denied any skin rash over trunk or extremities. At ER, blood routine and CRP were done and the results were normal. Under the impression of oral ulcers and suspicious drug-allergy reaction , she was admitted into our ward for further survey and treatment.

Past History 1. Medical history: GERD with medication control. 2. Surgical history: left herniarrhaphy in 2008 in our hospital. 3. Depression and other psychiatric disorders for years and are now being treated in the LMD with mesyrel, zompidem, and alpraline.

Personal History Allergy: NSAIDs: aceclofenac or ketoprofen. (Stevens-Johnson Syndrome) Alcohol: nil. betelnets: nil. Smoking: nil. Special environmental contacts: The patient works in a factory with high possibilities of contacting various types of chemical agents, especially organic-solvants. Family history: no DM. no hypertension, no AIR disease

Review of system 1. General: Weight loss(+) poor appetite(+), general malaise(+). 2. HEENT: oral ulcer(+), neck mass(+), dysphagia(+). 3. Respiratory: chest tightness(+). 4. Cardiovascular: Palpitation(+). 5. Gastrointestinal: dysphagia(+). 6. Cutaneous:nail change(+). Vital sign: BT: 35.8 BP: 134/84 R: 18 P: 84

Physical Examination 1. General appearance: acutely ill 2. Consciousness: clear 3. Peripheral perfusion: Normal 4. Skin : normal 5. HEENT: Head, Eyes, and Ears: normal Mouth & Throat: oral ulcers(+) Neck: one thyroid nodule on the right lobe. Trachea, carotid artery, and Jugular vein: normal Thyroid gland : one nodule found in the right lobe region 6. Chest and abdomen, and extremities: normal 7. Nervous system: normal 8. Genitalia area: one shallow ulcer found on the vulva.

Lab findings: 11/21 T3, TSH, free T4:normal ANA, CRP, TPHA: normal RF: normal Uric Acid: normal CBC: normal profile Electrolyte: K[3.06 mEq/L] IGE: normal

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

Exam: 11/21 At ENT OPD: Nasopharyngoscopy: No specific findings beside multiple oral ulcers. In the ER: chest X-ray: Rt & Lt CP angle blunting, probably pleural effusion or pleural change. Bilateral apex pleural thickening Mild Increased bronchovascular lung markings of both lungs.

Exam: 11/23 EKG: no specific finding

Progress Medication Prescribed by ENT on 11/21: Colchicine: 1 tab BID for 5 days Mycostatin: 3 c.c. TID for 5 days Gascon: 1 tab TID for 5 days Mopride: 1 tab TID for 5 days Kolantyl: 1 tab TID for 5 days

Progress S: 11/23 oral ulcer with pain, no further worsening. 11/24 oral ulcer with pain, feeling much improved. O: 11/23~11/24 Consciousness: Normal. Vital signs: normal. PE: oral ulcer. 1 thyroid mass found in the right lobe region. No other specific finding. A: 11/23 Stevens-Johnson Syndrome. Stationary 11/24 Stevens-Johnson Syndrome. Improving Plan: Medication: Prescribed in our ward on 11/23: Vitapoly 1 tab QID 11/23~11/25 Panadol 1 tab QID 11/23~11/25 MgO 1 tab BID 11/23~11/25 Periactin 4mg 1 tab TID 11/23 Broen-C 1 Tab QID Parmason 漱口水 prn, Kenalog 口內膠 Morphine 3mg IM prn for oral ulcer pain control. 11/24~11/25