Case Presentation
A 32-year-old female patient complained of sore throat and was
prescribed IM cefoperazone/sulbactam 1500 mg. One day post-initiation,
the patient started to complain of itchy rashes over the hands, she
sought medical advice, Cefoperazone/sulbactam was immediately
discontinued and was prescribed conservative treatment in the form of IM
dexamethasone every 12 hours. 6 days post-initiation, the patient
presented to ER with sever itchy rash. On examination she had a
generalized symmetrical, erythematous rash more marked on the face,
upper limbs, chest and back with violaceous colour of both hands and
feet. In addition, she had an associated buccal ulceration and
conjunctival injection. Her temperature was 37°C, with SpO2 of 98%, a
blood pressure recording of 100/60 mmHg and a regular pulse of 80
beats/min. Vesiculobullous lesions were observed over the course of the
admission, with sloughing of skin, especially on the chest and face
around the lips. Routine laboratory assessments showed normal blood
counts (7500 cells/uL) without hyper eosinophilia (0.02%). Hepatic
enzyme levels, renal function, and serum electrolyte levels were all
within normal limits and a serological test was negative for HIV. CRP
was high (55 mg/l) with low serum Albumin (3.1 g/dl). A diagnosis of TEN
secondary to cefoperazone/sulbactam exposure was made. Evaluation of the
SCORE of Toxic Epidermal Necrosis (SCORTEN) score on day 1 indicated a
score of 1. The patient was admitted to intensive care unit and received
intravenous fluid resuscitation and urinary catheter was inserted. Blood
and urine cultures were conducted. Dermatological, ophthalmological and
burn unit consultation were done. Skin punch biopsy was done which
confirmed the diagnosis of TEN. Supportive treatment was formed; the
patient was kept warm, had careful protection of the eroded areas,
tetracycline eye ointment, antiseptic mouth wash and both Intravenous
and non-intravenous hydration. Immunosuppressive treatment was initiated
on the second day of admission; IvIG 2 gm/kg divided by 5 days by
infusion over 6 hours. The patient recovered considerably after 5 days
of immunosuppressive, symptomatic and supportive management and was
transferred to the ward for further follow up and discharged and was
asked to follow up at OPC basis.