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.