3. DISCUSSION
The case presented in this report highlights the importance of monitoring patients closely for adverse effects of antiepileptic drugs, particularly carbamazepine, and promptly recognizing and managing such effects to prevent further complications.
Carbamazepine is a widely used antiepileptic drug that can cause a range of adverse effects, including skin reactions, hepatotoxicity, and hematologic abnormalities. Among these, SJS/TEN is a rare but potentially life-threatening skin reaction that can occur with carbamazepine use. This adverse reaction is characterized by a widespread rash, blistering, and mucosal involvement and can progress rapidly to involve large areas of the body, leading to significant morbidity and mortality. Therefore, early recognition and discontinuation of the offending drug are critical to prevent further damage.
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous reactions characterized by widespread skin detachment and mucosal involvement. The condition is often caused by exposure to certain medications, particularly antiepileptic drugs (AEDs) and antibiotics.
In the present case, the patient had a previous history of epilepsy and was taking carbamazepine from past 9 day for the same before admission. The development of the rash and mucosal involvement after exposure to carbamazepine strongly suggests a drug-induced hypersensitivity reaction.
The patient was admitted to the emergency ward with symptoms of fever, sore throat, and widespread rash, which were consistent with a diagnosis of SJS/TEN. Carbamazepine was immediately discontinued, and the patient was managed with supportive care, including nutritional support, eye care, wound care, and intravenous fluids. The patient was also started on the tablet Valproate for his epilepsy, which was continued.
The management of SJS/TEN requires a multidisciplinary approach involving dermatologists, intensivists, ophthalmologists, and nutritionists. Patients with SJS/TEN require close monitoring in the intensive care unit, and the management should be tailored to the individual patient’s needs. In this case, the patient received multidisciplinary care, which contributed to the favorable outcome.
SJS-TEN is a spectrum of disease, with SJS representing the milder end and TEN representing the more severe end. The condition is diagnosed based on clinical features and a history of medication exposure. The characteristic rash begins as erythematous macules that rapidly progress to form bullae and detachments of the epidermis. Mucosal involvement is common and can occur in the eyes, mouth, and genitalia. In the present case, the patient had extensive blistering with mucous membrane involvement and crusting over the lips. The presence of the Nilkolsky sign is a characteristic finding of SJS-TEN and is defined as the separation of the epidermis from the dermis with slight pressure. Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) belongs to type B class of adverse drug reactions [8], and It is a hypersensitivity reaction of type IV (subtype C) that typically affects the skin and mucous membranes [9].
The management of SJS/TEN requires a multidisciplinary approach involving dermatologists, intensivists, ophthalmologists, and nutritionists. Patients with SJS/TEN require close monitoring in the intensive care unit, and the management should be tailored to the individual patient’s needs. In this case, the patient received multidisciplinary care, which contributed to the favorable outcome.
The management of SJS/TEN involves a multidisciplinary approach, with close monitoring of vital signs, fluid and electrolyte balance, nutritional status, wound care, and pain management. In addition, systemic corticosteroids and immunoglobulins have been used in the treatment of SJS/TEN, although their efficacy remains controversial. The use of topical agents such as corticosteroids, antibiotics, and analgesics can also be helpful in managing skin and mucosal symptoms.
In the present case, the patient was given 4 milligrams of dexamethasone intravenously once daily along with an antihistaminic drug (for itching) in the form of 22.75 milligrams of pheniramine maleate intravenously twice daily for 7 days. The patient showed improvement with this treatment, and after 13 days, he was discharged in good general condition.