M.J.

, a 58 years old female, widowed, from Candaba, Pampanga was admitted for
the first time at Jose B. Lingad Memorial Regional Hospital due to generalized
maculopapular rash.

Present condition started 2 weeks prior to admission as limitation of motion

accompanied by pain to touch, swelling, warmth and redness of the left knee. No skin
discoloration and ulcerations observed. No other symptoms noted. Consultation to a
primary clinic was done. An initial impression of Acute Gouty arthritis was made. BUA
was requested revealing high result (7.5mg/dL). Colchicine 1mg/tab initially followed by
500mcg q2° until relief of pain, vomiting, diarrhea or abdominal pain was given.
However, due to persistent abdominal pain, a follow-up was made. Colchicine
was replaced with Diclofenac 50mg/tab TID taken for 3 days then BID until acute attack
disappears. Symptoms improved. Above medication was continued.
1 week prior to admission, intermittent fever accompanied by body malaise,
soreness of throat and burning sensation of both eyes were noted. No blurring of vision
and itchiness were experienced. No consultation was done. Paracetamol 500mg/tab, 3x a
day was taken.
3 days prior to admission, still with the above condition, patient noted pain upon
swallowing of food accompanied by vomiting. Appearance of painful, non-pruritic,
erythematous rashes on the face and upper torso were also observed. There were no
difficulty in breathing, diarrhea and signs of bleeding. Prompt consultation to our
institution was done, hence the admission.

Patient is a diagnosed hypertensive for 10 years taking Amlodipine 10mg/tab,

O.D. No other medical condition was noted.
No history of travel noted. No wadding in floods mentioned.
Patient is a housewife with 2 children living in a well lighted, screened
windows/doors bungalow type of housing. Potable water source is from NAWASA.
There were no history of smoking and alcohol consumption. Diet includes fish,
poultry and rice with preference to canned goods, legumes, beans and crustaceans.

Review of systems was unremarkable

Physical examination was as follows:

Vital signs: BP: 160/100 mmHg

PR: 110 bpm
Temp.: 39°C
UO: 40mL/hr
BMI: 24

Skin: (+) poorly defined, non-pruritic, tender, flat, erythematous macules

with darker purpuric centers symmetrically seen on the face and
upper trunk and lower extremities
(+) tender edematous erythema on both palms and soles
(-) discoloration, (-) abscess formation, (-) ulceration
 HEENT: VA: 20/20 OU
(-) ptosis, (+) tearing, (+) erythematous bulbar conjunctiva, OU
(+) direct and consensual papillary reflex to light, OU
(+) intact EOM, OU
(-) corneal opacities, ulcerations

Fundoscopic examination:
(+) red reflex, OU
(+) yellowish orange optic disc with
blurred nasal border cup, OU
(+) focal narrowing of retinal arteries, OU
(+) A-V tapering at 4:30 o’clock, 2 disc diameters
from the disc, OS
(+) punctuate hard exudates, OD
(+) deep hemorrhages, OU
(+) multiple ulcerations with reddish base and irregular borders
measuring approximately 5mm distributed on both right and left
buccal mucosa
(+) <1cm, palpable, tender posterior auricular and submandibular
lymph nodes, bilaterally

Chest/Lungs: Symmetrical chest expansion, (-) retraction, (-) lagging

Breath sounds vesicular with no added sounds

Cardiovascular: Adynamic precordium, (-) thrills, PMI at 5th ICS LMCL

Normal rhythm with tachycardia, (-) murmur

Abdomen: Flabby, normal bowel sounds, liver span 7cm in RMCL;

smooth edge and palpable 1cm below right costal margin
(-) tenderness upon palpation

Genitourinary: (-) ulcerations, (-) masses

Rectal: (-) masses, (+) brown stool on examination finger

Peripheral vascular: (-) edema. (-) calf tenderness

Neurologic: unremarkable

Admitting Impression: Stevens-Johnson Syndrome secondary to Diclofenac intake

Hypertension Stage II, uncontrolled
t/c Asymptomatic Hyperuricemia
 Upon admission, venoclysis was started with D5NSS as IV fluids. Vital signs
were taken and recorded q1°. CBG was taken then monitored q24°. Clear liquid diet was
started.

Problem #1: Stevens-Johnson Syndrome secondary to Diclofenac intake

Diagnostic examinations: CBC with platelet count

Serum Na/K
BUN/Crea, u/a
SGOT/SGPT
PT/PTT
Chest X-ray
Blood GS/CS x 2 sites and oral GS/CS

Treatment: Hydrocortisone 200mg/IV STAT then 100mg/IV q6°

Paracetamol 2mL/IV q°4
Diphenhydramine 25mg/IV q4° (for pruritus)
Famotidine 20mg/IV q12°
Triamcinolone 0.1% dental paste: Apply as thin film qHS
Benzydamine HCL 15mL to be held in the mouth and swirled
around for at least 30sec. at 1-3 hours interval throughout the day
May give Tetanus prophylaxis as follows:
TIG 250 units IM, right deltoid
Tetanus toxoid 0.5mL IM, left deltoid
-referral to an ophthalmologist/ENT for co-management
-referral to an infectious specialist for co-management

Problem #2: Hypertension Stage II, uncontrolled

Diagnostic examinations: total lipid profile

12 lead ECG

Treatment: Nicardipine HCL: Initial 5mg/h slowly then may titrate q15’ by
2.5mg/hr until MAP of 126.7mmHg

Problem #3: t/c Asymptomatic Hyperuricemia

Diagnostic examination: serum BUA

Treatment: Dietary restrictions (low purine diet)

CBG: 80mg/dL
Course in the ward:

DAY1: S: (-) blurring of vision

(+) painful rashes
(+) soreness of throat
(+) difficulty in swallowing
(-) abdominal pain
(-) dysuria

O: VS: BP: 140/80mmHg PR: 100bpm T°: 38°C UO: 35mL/hr

(+) tearing, (+) erythematous bulbar conjunctiva, OU
(+) multiple ulcerations with reddish base and irregular borders measuring
approximately 5mm distributed on both right and left buccal mucosa
(+) poorly defined, non-pruritic, tender, flat, erythematous macules with
darker purpuric centers symmetrically seen on the face and upper trunk
and lower extremities
(+) tender edematous erythema on both palms and soles
CBG: 90mg/dL

A: Stevens-Johnson Syndrome secondary to Diclofenac intake

Hypertension Stage II, uncontrolled
t/c Asymptomatic Hyperuricemia

P: continue medications
Ophthalmology management:
Tobramycin/Dexamethasone 0.3% ophthalmic solution:
Apply 1-2gtts q4°, OU
Solcoseryl 5% ointment: Apply TID, OU

Laboratory results:

CBC with platelet count: Hgb: 142g/l

Hct: 0.56
WBC: 10 x 10 9/L
Neutrophils: 0.64
Lymphocytes: 0.3
Platelet count: 317 x 10 9/L
PT: 12.8 sec
PTT: 27.4 sec

Serum Na: 140mmol/L

Serum K: 3.78mmol/L
Serum BUN: 8.3mmol/L
Serum Crea: 121.7umol/L
Serum SGOT: 121 U/L
Serum SGPT: 98 U/L

u/a: color: yellow-orange

transparency: turbid
Sp. Gravity: 1.030
Protein: +3
Pus cells: 3-5

Chest X-ray: unremarkable

12 lead ECG: sinus tachycardia

DAY2: S: (-) blurring of vision

(+) ulcerative lesions on both palms and soles
(+) soreness of throat
(+) difficulty in swallowing
(-) abdominal pain
(-) dysuria

O: VS: BP: 130/80mmHg PR: 90bpm T°: 37.5°C UO: 42mL/hr

(+) tearing, (+) erythematous bulbar conjunctiva, OU
(+) crusted lesions on both buccal mucosa
(+) erythematous macules with vesicular lesions on upper trunk, forearm
and both lower extremities
(+) ulceration on both palms and soles

Serum BUA: 0.48umol/L

Lipid profile: Total cholesterol: 8.02mmol/L
Triglycerides: 3.10mmol/L
HDL: 1.64mmol/L
LDL: 5.02mmol/L
CBG: 90mg/dL

A: Stevens - Johnson syndrome secondary to Diclofenac intake

Hypertension Stage II, controlled
Hyperlipidemia

P: continue medications and ophthalmic management

Infectious Disease Specialist management:
Start Fusidic acid cream 2%: Apply BID
Follow-up blood and oral GS/CS
DAY3: S: (-) blurring of vision
(+) crusted lesions on both lower extremities
(+) decrease in soreness of throat
(+) intake of liquid to soft diet
(-) abdominal pain
(-) dysuria

O: VS: BP: 130/80mmHg PR: 85bpm T°: 36.5°C UO: 38mL/hr

(+) tearing, (+) decrease in conjunctival erythema, OU
(+) crusted lesions on both buccal mucosa
(+) crusted vesicular lesions on both lower extremities
(+) ulceration on both palms and soles

A: Stevens-Johnson Syndrome secondary to Diclofenac intake

Hypertension Stage II, controlled
Hyperlipidemia

P: Shift Hydrocortisone to Prednisone taken as follows:

Day1: 10mg PO BID (before breakfast and at bedtime)
5mg PO BID (after lunch and dinner)
Day2: 5mg PO TID and 10mg PO at bedtime
Day3: 5mg PO QID
Day4: 5mg PO TID
Day5: 5mg PO BID
Day6: 5mg PO before breakfast then discontinued
Shift Nicardipine drip to Amlodipine 5mg/tab, OD
Shift Famotidine to Omeprazole 20mg/tab, OD
Triamcinolone 0.1% dental paste: Apply as thin film qHS
Benzydamine HCL 15mL to be held in the mouth and swirled around for
at least 30sec. at 1-3 hours interval throughout the day
Fusidic acid cream 2%: Apply BID
Paracetamol IV was discontinued
CBG monitoring discontinued
Ophthalmology management:
Tobramycin/Dexamethasone 0.3% ophthalmic solution:
Apply 1-2gtts q4°, OU
Solcoseryl 5% ointment: Apply TID, OU

For repeat BUN/Crea, SGOT/SGPT

Oral GS/CS: no growth in 3 days of incubation

DAY4: S: (-) blurring of vision
(+) crusted lesions on both lower extremities
(+) decrease in soreness of throat
(+) intake of soft diet
(-) abdominal pain
(-) dysuria

O: VS: BP: 130/70mmHg PR: 80bpm T°: 36.5°C UO: 40mL/hr

(+) tearing, (+) decrease in conjunctival erythema, OU
(+) crusted lesions on both buccal mucosa
(+) crusted vesicular lesions on both upper and lower extremities
(+) scab formation on both palms and soles

Serum BUN: 4.8mmol/L

Serum Crea: 92mmol/L
Serum SGOT: 37 U/L
Serum SGPT: 36 U/L

A: Stevens-Johnson Syndrome secondary to Diclofenac intake

Hypertension Stage II, controlled
Hyperlipidemia

P: continue medications
Start Atorvastatin 80mg/tab, OD

DAY5: S: (-) blurring of vision

(+) crusted lesions on upper trunk, upper and lower extremities
(-) abdominal pain
(-) dysuria

O: VS: BP: 120/70mmHg PR: 78bpm T°: 36.5°C UO: 35mL/hr

(-) tearing, (+) decrease in conjunctival erythema, OU
(+) crusted lesions on both buccal mucosa
(+) crusted vesicular lesions on upper trunk and both upper and lower
extremities with occasional scab formations
(+) increase scab formations on both palms and soles

A: Stevens-Johnson Syndrome secondary to Diclofenac intake

Hypertension Stage II, controlled
Hyperlipidemia

P: continue medications
DAY6: S: (-) blurring of vision
(+) crusted lesions on upper trunk, upper and lower extremities
(-) abdominal pain
(-) dysuria

O: VS: BP: 130/70mmHg PR: 75bpm T°: 37°C UO: 38mL/hr

(-) tearing, (-) conjunctival erythema, OU
(+) appearance of epithelialized surface on both buccal mucosa
(+) increase in scab formations on the upper trunk and both upper
and lower extremities
(+) scab formations on both palms and soles

Blood GS/CS: no growth in 7 days of incubation on both sites

A: Stevens-Johnson Syndrome secondary to Diclofenac intake

Hypertension Stage II, controlled
Hyperlipidemia

P: continue medications

DAY7: S: (-) blurring of vision

(+) intake of low purine diet
(+) scab formations upper trunk, upper and lower extremities
(-) abdominal pain
(-) dysuria

O: VS: BP: 130/80mmHg PR: 82bpm T°: 37°C UO: 35mL/hr

(-) tearing, (-) conjunctival erythema, OU
(+) increase appearance of epithelialized surface on both buccal mucosa
(+) increase in scab formations on the upper trunk and both upper
and lower extremities
(+) scab formations on both palms and soles

A: Stevens - Johnson syndrome secondary to Diclofenac intake

Hypertension Stage II, controlled
Hyperlipidemia

P: continue medications
Discontinue Tobramycin/Dexamethasone 0.3% ophthalmic solution and
Solcoseryl 5% ointment
DAY8: S: (-) blurring of vision
(+) intake of low purine diet
(+) scab formations upper trunk, upper and lower extremities
(-) abdominal pain
(-) dysuria

O: VS: BP: 130/870mmHg PR: 72bpm T°: 36.2°C UO: 35mL/hr

(-) tearing, (-) conjunctival erythema, OU
(+) re-epithelialized surface on both buccal mucosa
(+) scab formations on the upper trunk and both upper and
lower extremities
(+) scab formations on both palms and soles

A: Stevens - Johnson syndrome secondary to Diclofenac intake, improved

Hypertension Stage II, controlled
Hyperlipidemia

P: May go home
Discontinue Fusidic acid cream 2%
Home medications:
Prednisone 5mg PO before breakfast then discontinued
Triamcinolone 0.1% dental paste: Apply as thin film qHS x 3 days
Benzydamine HCL 15mL x 3 days
Amlodipine 5mg/tab, OD
Atorvastatin 80mg/tab, OD
Educating the risks of acquiring Stevens-Johnson syndrome
For repeat Serum BUA after 1 week