Jawt 11 I 2 P 48

Case Report
STEVEN JOHNSON SYNDROME IN PREGNANCY
SUCHI JAIN*, AP JAIN**, S PALAPARTHY***, S SAMAL****
ABSTRACT
Steven Johnson Syndrome (SJS) is a lifethreatening allergic reaction to medications

affecting the skin and mucous membranes. A 23 year old G2A1 37 weeks gestation, reported to us
with features of SJS after receiving Inj Cefotaxime. She was put on topical steroids, analgesics and
antacids. She delivered a term female child of weight 2.5kg vaginally. Postpartum she was put on
systemic steroids. Both mother and baby were discharged in a good condition.
Introduction : Fever subsided after treatment. Since the past 4

Steven Johnson Syndrome(SJS) is a severe days, she again developed fever and was started
and lifethreatening condition. It is thought to on injectable Cefotaxime after which she had
be a hypersensitivity reaction to certain drugs redness of eyes, swelling of lips, iris lesions which
and vaccines affecting the skin and the mucous were becoming congruent all over the body, on
membranes. Altered drug metabolism in some the palms and soles and oral ulcers and was
patients causes formation of reactive metabolites unable to take anything orally. There was no history
that bind to and alter cell proteins, triggering a of cough, cold, jaundice, or bleeding tendencies,
T-cell-mediated cytotoxic reaction to drug antigens or any allergy to drugs and food products. There
in keratinocytes. Another possible mechanism was no history of similar complaints in the past.
involves interactions between Fas, a cell-surface On examination, patient was toxic,
death receptor, and its ligand. Other causes like dehydrated, febrile (temperature - 39 0C), pulse -
viral infections and malignancies are also known. 110/min, BP - 110/80 mm Hg, not pale, anicteric,
It is the most severe form of erythema multiforme maculopapular eruptions present all over the
known as erythema multiforme major. It is a rare body, with involvement of the palms and soles.
condition with a reported incidence of one case Mouth was oedematous and inflamed and there
per million people per year. Such a rare case of were ragged ulcers on the buccal mucosa, hard
SJS in pregnancy is reported. and soft palate and on the lips. No cervical
lymphadenopathy, no pedal edema. Cardiorespiratory
Case Report :
examination was normal. Abdominal examination
A 23-year-old G2A1 with 37 weeks of
revealed a term size uterus, relaxed. A diagnosis
gestation reported in emergency with features
of SJS was made and she was put on intravenous
suggestive of SJS. She had consulted a private
hydration and patient was kept nil by mouth. Oral
practitioner 14 days back for high grade fever with
toileting was carried out every 2 hrly, topical
chills for which she was put on oral Cefixime.
steroids, analgesics and antacids were started.
* Associate Prof., *** Resident, **** Prof. Deptt. of
Initial investigations showed a haemoglobin
Obstetric & Gyneology, ** Professor & Head Deptt. of
Medicine, MGIMS, Sevagram (Wardha) MS - 442 102. of 10 gm/dl, with total counts of 9.2 x 103 cu mm
48
J MGIMS, September 2011, Vol 16, No (ii), 48-50

Suchi Jain & et al
and normal kidney and liver function tests. Swabs disturbance and may result in death from
from the mouth were sterile. pneumonia, septicaemia, myocarditis or renal
The potential precipitating factor could failure. Erosive changes may occur in the
be antibiotics, which was aggravated in the genitalia. Severe scarring of the genital tract may
presence of pregnancy. also occur occasionally, however there is no
On 2 nd day of admission, patient had mention of permanent damage to the female
Premaline Rupture of Membranes (PROM) and genital tract.
delivered a female child vaginally of weight 2.5kg. There has been one case report of vaginal
The intra-partum period was uneventful. stenosis following SJS in pregnancy, which was
Following delivery, she developed new active discovered 6 weeks after cesarean section for
lesions for which she was put on systemic breech presentation1 1 . However, our patient
Prednisolone which was gradually tapered. The delivered baby vaginally and there was no
lesions subsided gradually over a period of 10 problem on follow up.
days. Mother and baby were well on discharge
The management includes prompt
and follow up.
withdrawal of all potential causative drugs,
intravenous fluid replacement. Symptomatic
Discussion :
treatment are careful and aseptic handling,
SJS is marked by the rapid attack of fever,
maintenance of venous peripheral access distant
skin lesions and sores on the mucous membranes
from affected areas, initiation of oral nutrition
of eyes, mouth, nasal passage, lips and genitals.
by nasogastric tube, anticoagulation, prevention
Clusters last for about 2-4 weeks. The skin lesions
of stress ulcer.
may look like target lesions or bubble like. The
diagnosis is often obvious by the appearance of Topical antiseptics (0.5% silver nitrate
lesions and rapid progression of symptoms. or 0.05% chlorhexidine) are used to paint, bathe,
Histologic examination of sloughed skin shows or dress the patients. New dressings with
necrotic epithelium, a distinguishing feature. The Apligraft ® , Biobrane ® , TransCyte ® etc are
condition is charecterised by severe constitutional being tried. Corticosteroid use is highly debated.
Fig 1 a :Maculopapular eruptions over legs Fig 1 b : Maculopapular eruptions over hands
49

Steven Johnson Syndrome in Pregnancy
Tegelberg used 400 or 200 mg prednisone/ However, early diagnosis and prompt management
day, gradually diminished over a 4 to 6 week saved the mother and the child.
period, and observed a single death among eight
patients 2 . Disclosure of Interest :
It's difficult to prevent an initial attack No conflicts of interest.
of Stevens-Johnson syndrome because what
triggers it is not known. However, if Steven- References :
1. Graham R.A.C., Cochrane G.W., Swihone J.R.,
Johnson syndrome occurred once, which was
Sarkany. I., Epsztein L.J., "Vaginal Stenosis due to
caused by medication, the drug is to be avoided
Bullous Erythema Multiforme ( Steven Johnson
to prevent another attack. A recurrence is usually Syndrome)" Br J Obstet Gynaecol 1981; 88: 1156-57
more severe than the first episode and, may be
2. Tegelberg-Stassen MJ, van Vloten WA, Baart de la
fatal. Faille. Management of nonstaphylococcal toxic
Attack of SJS developing in pregnancy epidermal necrolysis: follow-up study of 16 case
can be fatal because immunity is compromised. histories. Dermatologica 1990;180:124-129.
50

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Case Report

STEVEN JOHNSON SYNDROME IN PREGNANCY

SUCHI JAIN, AP JAIN, S PALAPARTHY, S SAMAL****

Steven Johnson Syndrome (SJS) is a lifethreatening allergic reaction to medications

Introduction : Fever subsided after treatment. Since the past 4

J MGIMS, September 2011, Vol 16, No (ii), 48-50

J MGIMS, September 2011, Vol 16, No (ii), 48-50

J MGIMS, September 2011, Vol 16, No (ii), 48-50

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