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\begin{document}

\title{Ibuprofen Unveiled: A Middle-Aged Odyssey through Stevens-Johnson
Syndrome}



\author[1]{Ahmed Alhatemi}%
\author[2]{Hashim Talib Hashim}%
\author[1]{Mohammed  Abdul Rahman }%
\author[3]{Rand Abdulhussain }%
\author[4]{Ali Talib Hashim}%
\affil[1]{Al Nasiriyah Teaching Hospital }%
\affil[2]{University of Warith Al Anbiyaa}%
\affil[3]{University of Huddersfield Department of Pharmacy}%
\affil[4]{Golestan University of Medical Sciences and Health Services}%


\vspace{-1em}



  
  \date{May 16, 2024}


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\subsection*{Ibuprofen Unveiled: A Middle-Aged Odyssey through
Stevens-Johnson
Syndrome}

{\label{ibuprofen-unveiled-a-middle-aged-odyssey-through-stevens-johnson-syndrome}}

Ahmed Qasim Mohammed Alhatemi1, Hashim Talib Hashim2, Mohammed Abdul
Rahman 3, Rand K Abdulhussain 4. Ali Talib Hashim5.

\begin{enumerate}
\tightlist
\item
  Al Nasiriyah Teaching Hospital, Thi Qar,
  Iraq.\emph{dr.ahmedqasim95@gmail.com}
\item
  Warith Al Anbiyaa university, Karbala,
  Iraq.\emph{hashim.talib@uowa.edu.iq}
\item
  Al Nasiriyah Teaching Hospital, Thi Qar,
  Iraq.\emph{m.shyea95@gmail.com}
\item
  University of Huddersfield, Huddersfield,
  UK.\emph{randkabdulhussain@gmail.com}
\item
  Golestan University of medical sciences, Gorgan,
  Iran.\emph{talibhashim42@gmail.com}
\end{enumerate}

*\textbf{Corresponding Author}: Ali Talib Hashim, Golestan University of
medical sciences,
Gorgan,Iran.\emph{talibhashim42@gmail.com}\textbf{Consent statement}:
Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy

We declare that we have no conflict of interest

No source of funding receive

\textbf{Data availability statement} The data that support the findings
of this study are available from the corresponding author upon
reasonable request.

\subsection*{Clinical key message}

{\label{clinical-key-message}}

Ibuprofen, a common NSAID, may unravel unexpected dangers like
Stevens-Johnson Syndrome. This case underscores the urgency of
recognizing adverse drug reactions, urging vigilance in both healthcare
and public spheres for safer medication
practices.\textbf{Introduction:}Ibuprofen, a widely used nonsteroidal
anti-inflammatory drug (NSAID), has long been a stalwart in the realm of
pain relief and inflammation management. However, behind its commonplace
presence in medicine cabinets, there lies a potential peril that, though
rare, demands our attention and understanding. This narrative unfolds as
a middle-aged individual embarks on an unexpected journey through the
harrowing landscape of Stevens-Johnson Syndrome (SJS) -- a severe and,
at times, life-threatening skin disorder (1,2). As the story begins, it
beckons us to consider the seemingly innocuous act of reaching for an
over-the-counter pain reliever. In this case, ibuprofen serves as the
unwitting protagonist, a common choice for those grappling with the
discomforts of everyday ailments (3). The unsuspecting middle-aged
protagonist, seeking respite from a routine headache or muscular ache,
unwittingly triggers a chain of events that will unfold into a rare and
alarming medical ordeal (4). Stevens-Johnson Syndrome, characterized by
the abrupt onset of a painful rash and blistering, often involves the
mucous membranes, including the eyes, nose, and mouth. It can be
triggered by various medications, and ibuprofen, despite its ubiquity
and perceived safety, is not exempt from this list (5). The narrative
explores the unfolding symptoms, the perplexing escalation from mild
discomfort to severe skin involvement, and the subsequent medical
odyssey that ensues (5). This exploration delves into the broader
implications of drug safety, shedding light on the delicate balance
between the benefits and risks of widely used medications. It
underscores the importance of vigilance, both on the part of healthcare
providers and the public, in recognizing potential adverse reactions
(6). Through this journey, we navigate the intricacies of drug-induced
skin disorders and the critical role of prompt medical intervention in
steering the narrative towards recovery (7). ''Ibuprofen Unveiled''
invites readers to contemplate the uncharted territories that can emerge
from seemingly routine decisions and prompts a reconsideration of our
relationship with common medications that weave seamlessly into the
fabric of our daily lives.\textbf{Keywords}Acute medicine, Dermatology,
Immunology, Critical care medicine, pharmacology and pharmacy.

\subsection*{Case presentation}

{\label{case-presentation}}

A middle-aged female presented to the emergency room with a sudden onset
of severe facial swelling, red painful eyes with discharge, crusting and
erosion of lips, and a generalized non-blanching purpuric rash,
predominantly on the chest, upper, and lower limbs. Upon thorough
history-taking, it was revealed that she had taken ibuprofen for
flu-like symptoms three days prior. She had no past medical history of
chronic diseases and was not taking any medications. She is a non-smoker
and non-drinker. During examination, the patient, an average-built
female, appeared in distress but was fully conscious, oriented to time,
place, and person. Cardiac, respiratory, and neurological examinations
were unremarkable. Her vital signs were as follows: BP 133/88 mmHg, RR
22, SpO2 95\%, HR 88 bpm, and a temperature of 38.4\selectlanguage{ngerman}°C. Head, neck, and
eye examination revealed conjunctivitis with discharge, coalescing deep
red erythematous targeted macules with central blister formation on the
face, and swelling, erosion, and yellowish discharge of the lips
(chelitis) as depicted in figure 1.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

figure 1.conjunctivitis with discharge. Coalescing red erythematous
macules with central blister formation in the face. Chelitis and
yellowish discharge. Musculoskeletal examination showed a non-blanching
purpuric rash with target lesions on the chest, as well as both upper
and lower limbs, illustrated in figure 2.. Figure 2.Non blenching
purpuric rash with target lesions in lower and upper limbs. Blood
samples were collected for a complete blood count, renal and liver
function tests, and serum electrolytes (see table 1).\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Test\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Results\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Units\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Normal value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Hb\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
11.2\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
g/dl\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
12-14\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Wbc\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
15.9\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
10\textsuperscript{10} /l\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
4-10\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Plt\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
155\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
10\textsuperscript{10}/l\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
150-400\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
B. Urea\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
56\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
mg/dl\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
15-40\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
S.\\
Creatinine\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.3\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
mg/dl\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.6-1.2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
ALT\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
50\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
U/L\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
10-130\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
AST\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
U/L\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
10-34\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
T. Bilirubin\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.4\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
mg/dl\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0-0.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
S. Albumin\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
3.2\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
g/dl\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2.4-4\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
PT\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
10.2\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Seconds\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
9.5-12.5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
INR\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.4\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1-2\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Sodium\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
139\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
mmol/l\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
135-145\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Potassium\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
3.8\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
mmol/dl\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
3.5-5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Chloride\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
101\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
mmol/dl\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
96-106\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 1. Blood tests showing anaemia, leucocytosis and mild renal
impairment. A comprehensive review of history and examination raised a
high suspicion of Steven Johnson syndrome. The patient was subsequently
admitted to the Intensive Care Unit for strict management under aseptic
conditions. Treatment included intravenous fluids, prophylactic
antibiotics, lubricating eye drops, and dexamethasone 8mg IV once daily.
After seven days of admission, the patient's condition improved, and she
was discharged for regular follow-up with a dermatologist and
immunologist. Facial and mucocutaneous rash and ulcers decreased, as
observed in figure 3.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

figure3. Decrease in size and colour of facial rash with minimal ulcers.
Normal lips appearance\textbf{Discussion}: Ibuprofen, a widely used
nonsteroidal anti-inflammatory drug (NSAID), is generally considered
safe for pain relief and inflammation. However, in rare cases, its use
has been associated with severe adverse reactions, including
Stevens-Johnson Syndrome (SJS), a potentially life-threatening skin
condition (8). SJS is characterized by a severe and painful rash that
can lead to the detachment of the outer layer of the skin (9). While it
is more commonly linked to certain infections and other medications,
including some antibiotics and anticonvulsants, cases of SJS associated
with ibuprofen use have been reported. Middle-aged individuals, who
might assume they are beyond the susceptibility to severe drug reactions
often associated with younger populations, can find themselves facing
unexpected challenges (5,7). The onset of SJS is typically abrupt,
starting with flu-like symptoms and a rash that progresses rapidly. The
severity of SJS requires immediate medical attention (9). The link
between ibuprofen and SJS is not fully understood, and the reaction
seems to be idiosyncratic, occurring in only a small percentage of
individuals. Genetic factors may play a role in predisposing certain
people to such severe reactions. Given the widespread use of ibuprofen
for various conditions, including arthritis and pain management,
understanding the potential risks is crucial. Patients, especially those
in middle age, should be aware of the signs and symptoms of severe
adverse reactions and seek medical attention if they experience unusual
skin rashes, blistering, or mucosal involvement (10). Healthcare
providers must weigh the benefits of ibuprofen against the potential
risks, particularly in individuals with a history of adverse reactions
or known risk factors. Communication between patients and healthcare
professionals is vital to ensure informed decision-making regarding
medication choices (10).

\section*{Conclusion:}

{\label{conclusion}}

While ibuprofen is generally safe, the rare occurrence of severe
reactions such as SJS serves as a reminder that no medication is
entirely without risk. Middle-aged individuals, like any other age
group, should be vigilant about their health, be aware of potential side
effects, and consult with healthcare professionals if they experience
unexpected symptoms during ibuprofen use.

\section*{References:}

{\label{references}}

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(FQAD)-Pathogenesis, Diagnostics, Therapy and Diagnostic Criteria:
Side-effects of Fluoroquinolones. Springer Nature, 2021.

Fazeli, Seyed Amirhossein, et al. ''Bullous fixed drug eruption
following ibuprofen ingestion.''

\emph{Journal of research in pharmacy practice} 7.1 (2018): 51.

\begin{enumerate}
\tightlist
\item
  Mawson, Anthony R., Ike Eriator, and Sridhar Karre. ''Stevens-Johnson
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\item
  Mancano, Michael A. ''ISMP Adverse Drug Reactions: Propofol-Related
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  Pharmacy} 53.4 (2018): 220-222.
\item
  Rainsford, K. D. ''Ibuprofen: pharmacology, efficacy and
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\item
  Vassileva, Snejina. ''Drug-Induced Pemphigoid:: Bullous and
  Cicatricial.'' \emph{Clinics in dermatology}
\end{enumerate}

16.3 (1998): 379-387.

Anderson, Hannah J., and Jason B. Lee. ''A review of fixed drug eruption
with a special focus on generalized bullous fixed drug eruption.''
\emph{Medicina} 57.9 (2021): 925.

Larrieu-Jimenez, Patricia, et al. ''Diffuse Rash Followed by Erosions on
the Lips and Mouth.'' \emph{The}

\emph{Journal for Nurse Practitioners} 19.10 (2023): 104802.

Muchnick, Bruce G. ''Identify the ocular side effects of systemic
medications: dozens of mainstream systemic drugs produce a broad range
of ocular side effects. Here is a review of numerous systemic
medications and the associated side effects you should be aware
of.''\emph{Review of Optometry} 145.1 (2008): 60-70.

Kantardjiev, Vessel, Elena Stoikova, and Valentina Broshtilova.
''Drug-induced rowell syndrome in a male patient.'' \emph{Scripta
Scientifica Medica} 50.4 (2018): 39-42.

\selectlanguage{english}
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