STEVENS‐JOHNSON SYNDROME PRESUMABLY INDUCED BY CIPROFLOXACIN

A 32‐year‐old black man was admitted for severe sore throat, fever, and eruptions. Ten days before admission, the patient noted a sore throat that became progressively worse. Seven days before admission, he went to a local health center and was given ciprofloxacin. Although he was taking the ciprofloxacin daily, his sore throat was getting worse and he noticed the development of eruptions on the extremities. The patient also developed dyspnea, dysphagia, and fever. He denied any cough, chest pain, nausea, vomiting, and urticaria. His past medical history revealed recurrent tonsillitis every 2–3 years for the last 10 years. His last episode, a year ago, was treated with ampicillin. He denied any skin and mouth lesions associated with his previous episodes of tonsillitis. He had no known drug allergy. The patient smoked cigarettes, one pack per day for 10 years; drank alcohol occasionally; and denied any intravenous drug abuse, homosexuality, blood transfusion, and sexual promiscuity. On physical examination in the emergency department, his initial blood pressure was 80/50, but rose to 110/80 after infusion of 2 L of normal saline intravenously. His pulse was 120, respiratory rate 22, and temperature 40.4°C (104.8°F). He was lying in bed with moderate distress from soreness in the throat; unable to talk due to pain; alert and oriented to time, place, and person. The patient had injected conjunctiva with exudates. The tongue was coated with white plaques. There were excoriations on the gums with ulcerations on the buccal mucous membranes. The tonsils were enlarged, erythematous, and congested, with exudate. There was severe tenderness of the tongue during use of the tongue depressor. The lips were excoriated (Fig. 1). The neck was supple with mild submandibular lymphadenopathy; no jugular vein distension or tracheal deviation was noted. The heart rate was rapid and regular; heart sounds unremarkable and no murmur or gallop were noted. Lungs were clear on auscultation, both anteriorly and posteriorly, without rales, wheezes, or egophony. The abdomen was flat with normal bowel sounds on auscultation and no organonrvegaly or tenderness were noted. The extremities showed large bullae (5–6 cm) on each forearm. There were 1–2 cm crops of bullae resembling “target” or “iris”‐like lesions with a rim of erythema surrounding areas on the palms and soles (Fig. 2). No crusted lesions were found. Neurologic examination was unremarkable. Laboratory studies revealed a total protein of 8.1 g/dL, albumin 4.1 g/dL, calcium 9.6 mg/dL, phosphorus 2.0 mg/dL, uric acid 6.2 mg/dL, glucose 97 mg/dL, cholesterol 145 mg/dL, total bilirubin 0.7 mg/dL, alkaline phosphatase 102 lU/L, lactate dehydrogenase (LDH) 673 lU/L, AST 47 lU/L, triglyceride 58 mg/dL. Electrolytes showed a sodium 139 mEq/L, potassium 3.4 mEq/L, chloride 99 mEq/L, and bicarbonate 25 mEq/L. BUN was 10 mg/dL and creatinine 1.3 mg/dL. Complete blood count showed white cells 10.1 × l0 3 /mL (10 lymphocytes, 15 monocytes, 55 segmented neutrophils, and 19 band forms), hemoglobin of 16.1 g/dL, hematocrit of 48.4%, and platelets 229 × 10 3 /mL. Rapid plasma reagin (RPR) was negative. Chest x‐ray was unremarkable. The initial diagnoses were acute tonsillitis secondary to Group A betahemolytic Streptococcus and Stevens‐Johnson syndrome (sjs), probably secondary to ciprofloxacin. The patient was admitted to the hospital and was started on intravenous penicillin G, 2 million units every 4 hours to cover the possibility of a streptococcal infection. Further laboratory studies included a negative monospot test. X‐rays of the soft tissue of the neck revealed no epiglottitis. Blood cultures and throat cultures were negative. A test for human immunodeficiency virus was obtained after consent was given, and was negative. Although the temperature on the following hospital day dropped to 40°C (104°F), the patient subjectively felt better with less dysphagia and sore throat and he was able to tolerate a soft diet. On the subsequent days the patient's temperature returned to normal and his general condition improved. The skin, lips, and throat lesions started to resolve approximately 4 days after admission, whereas his discomfort improved from the first full hospital day. He was discharged home in good condition after 10 days of intravenous antibiotics.