Morning Report

Steven Johnson Syndrome due to

Capecitabine and Ulcus Decubitus
Grade II
Ahmad Bayu Ajie
Counselor : dr. Arif Widiatmoko Sp.KK
Identity
• Name : Ny. S
• Sex : Female
• Age : 52 years old
• Address : Dadaprejo, Batu
• Race : Javanece
• Religion : Muslim
• Occupation : Housewife
• Registered : 114270**
• Consulted : 12nd Februari 2019
History Taking
(Alloanamnesis Patient’s son and daughter)

• Chief Complaint :
Wound on the several parts of body
Present Ilness history :
Since 12 days ago (January 31), complaints of fever, chills, reccurent mouth
ulcers, sore throat, watery eyes, dusky red spots on the left and right breast
folds, lower abdominal folds, inguinal fold, and genitals.
since 8 days ago the dusky red spots right breast folds and inguinal folds
became wound and given a gentamicin ointment (all wounds) and covered
with gauze (under the left breast) for 2 days, after being opened, appears
pus.
- Since 5 days ago, complaining urinating pain
- Since 2 days ago complaining reddish and watery eyes
Present Illness History
• Patient also complained, Since 4 months ago (October 16, 2018), the
second session of chemotherapy (due to breast cancer), patient
began to receive docetaxel IV and Capecitabine oral. After 5 days
appeared reddish erosion partly covered with brown crusting in
mouth, 2 weeks later after stopping capecitabine mouth complaints
improved, but reappeared after taking capecitabine in subsequent
chemotherapy.
• 2 weeks after taking capecitabine, skin at fingertips, face, armpit
became blackish, but there was no peel or blister. Patient also
complaining wheal on the chest, stomach, upper limbs and neck
treated by calamin powder, itching complaints are reduced
Present Illness History
Since 3 months ago (november 2018) a week after 2nd chemoterapy (due to
Breast Cancer) complained blackish skin increased in the area of ​the face of
the hands and feet, appeared thrush and sore throat. Patient also having
fever and chills but don’t remember the pattern of fever.
Since a years ago there was a small abberations at sacrum region, by the
time the aberration became wider and deeper. Sometimes the wound
improved and driying, but sometimes become wet. Since 3 weeks ago the
wound in buttock area relapsed and felt pain.
Patient also complained nausea and vomiting since 12 days ago and become
worsen 2 days ago. Because of Poor intake and weakness condition family
bring patient to ER RSSA. Patient was consulted by Internal department in ER
RSSA
Past Illness history
• since 18 months ago a complaint of a right breast lump was
diagnosed with breast cancer St IV
• Since 11 months ago (March 2018) treated at RSSA received
chemotherapy therapy Brexel and carboplastin 6x every 3 weeks
(March - June 2018) no complaints on the skin and mukosa
• Similiar skin complaint was denied
• Hystory of uncontrolled HT(+) diabetes (-)

Family History
Similar skin and mucosal complaint was denied
Medication History
• Paracetamol, MST, Codein, alternately starting on february 2018
• Duragesic (fentanil) patch after chemotherapy since 3 month ago
• VCO oil, sirih leaf water gived to all wound since a week ago
• March 2018 - june 2018 khemoterapy every 21 days: IV braxtel
(docetaxel) dan carboplastin. Every Hospitalized patient got ranitidine,
ondansetron, diphenhydramine, dexamethasone (there is no skin and
mucosal complaint)
• October 2018 - January 31st 2019 chemoterapy every 21 days: IV
doxitacel (for a day) dan capecitabine tab 500 mg: 4 tablets in the
morning, 3 tablets evening for 2 weeks. No medication for 6 days
after.
Medication History
• Last Chemoterapy (31-1-2019) : IV Docetaxel and oral
Capecitabine
• There is no history of jamoo, and self medication.

Medication on Desember 2018-January 2019

Duragesic patch November 2018- January
Capecitabine Oktober 2018- January
IV Ranitidine June 2018 Desember
IV Ondansetron June 2018- Desember 2019
NAC October 2018-January 2019
IV Dexamethason June 2018-Desember 2019
IV DiphenhydramineJune 2018-Desember 2019
IV Docetaxel March 2018-Januari 2019
Cetirizine June 2018-Desember

Sosial History
• Patient is a housewife and have 3 children
 Course of Illness
18 months before 11 months before consulted 4 months before consulted
consulted (August 2017) (march 2018) (October 16th 2018)

complaint of a right Treated at RSSA received the second cycle of

breast lump was chemotherapy (1st Cycle)
therapy Brexel (docetaxel)
diagnosed with breast and carboplastin 6x every 3
cancer weeks (March - June 2018)
no complaints on the skin
and mukosa
chemotherapy began to
receive docetaxel 80 & 20
mg IV and Capecitabine
500 mg tab, morning 4
tablets, night 3 tablets
taken for 14 days.

2 weeks : skin at fingertips, face, armpit
appears black, but there is no peel or blister.
Patient also complaining wheel on the chest,
stomach, upper limbs and neck treated by
calamin powder, itching complaints are
reduced
5 days : reddish erosion appeared partly
covered with brown crusting in mouth (like
now, but not this much) 2 weeks later after
stopping capecitabine mouth complaints
improved, but reappeared after taking
capecitabine in subsequent chemotherapy

3 months before consulted
(November 2018)
one week after 2nd
chemoterapy complaints of
black skin increased in the
area of ​the face of the hands
and feet, appeared thrush
and sore throat, fever and
chills but don’t remember the
pattern of fever.
Course of Illness
3 weeks before consulted 12 days before consulted
( January 2019) (February 1th 2019)
The wound in buttock area Complaints of fever, chills,
relapsed and felt pain. mouth ulcers, sore throat,
watery eyes, dusky red spots
on the left and right breast
folds, lower abdominal folds,
inguinal fold, and genitals.
Nausea and vomiting,
 Course of Illness
8 days before consulted ( 5 days before consulted 2 days before consulted
February 4th 2019) ( February 7th 2019) (February 10 th 2019)

Dusky red spots right breast complaining urinating pain reddish and watery eyes,
folds and inguinal folds purulent and crusted secret
became wound and given a Nausea and vomiting worsen
gentamicin ointment (all
wounds) and covered with
gauze (under the left breast)
Hospitalized and consulted on February 12th 2019
for 2 days, after being
opened, appears pus.
General Examination
General condition : GCS 456, BW: 68 kg
Vital Sign :
BP 136/65 N 97 RR 20 Tax 36SpO2: 99 % RA
Head and Neck :
ODS Conjungtiva anemis(-/-), sclera icteric (-/-), conjunctiva hyperemis
(+/+), secret purulent (+/+).
Lymph node enlargement (-), pain (-)
Thorax : Pulmo: Rh -/-, Whe -/-
Heart : S1S2 single, irregular
Abdomen : flat, soefl, liver and lien was unpalpable
Extremities : oedem (+) right arm (+), cyanosis (-)
Dermatological Examinations
L: Face, scalp
D: Generalisata
R: macule and patches hyperpigmentation,
Vary in shape and size, multiple, well defined

L: ODS
D: -
R: hyperemis(+), purulent secretions (+),
blackish brown crusts in the conjunctiva,
Lagophthalmos (+) , ectropion (+)

L: lip mucosa and mouth

D: localized
R: erythematous base erosion, with blackish
brown crusta, irregular shape
Tongue is difficult to evaluated
Dermatological Examinations
L: inframammae Sinistra,
D: localized
R: Patches dusky red well
defined erosion with the
erythematous base, well
defined, discharge
purulent and blackish
brown crust

L: dextra inframammae,
abdominal folds
D: localized
R: Patches dusky red,
multiple, well defined,
Vary in size and shape,
blackish brown crust,
L: Palmar and dorsum manus dextra et sinistra
D: Localized
R: macule and Patches hyperpigmentation, well definead,
multiple, vary in size and shape,
L: Plantar pedis dextra et sinistra
D: Localized
R: macule and Patcthes
hyperpigmentation, well defined,
multiple, vary in size and shape
L: Inguinal dextra sinistra, genitalia
D: Localized
R: patches hyperpigmentation,Erotion with erythematous base, Blackish brown crust, purulent
discharge,
L : Sacrum
D: Localized
R: ulkus soliter with erythematous base, well defined, no echoic and rising
edge, dermal layer depth, necrotic tissue (+), blackish brown crust,
Diascopy nonblanchable
Nikolski sign (-)
Ulcus Decubitus:
PMN(+) coccus (+) Vagina : PMN(+) coccus (+) Tongue : PMN (+), Coccus (+)
Laboratory Finding
• Hb 10,00 ↓ • Alb 2.30 ↓ • GDS : 117mg/dL
• Rbc 3.38 • Ur 76.10
• Wbc 13,43 ↑ • Cr 0.63 • BGA:
• Hct 29.60% • Electrolite Na/K/Cl • Ph 7.40
• Plt 77.000 ↓ 141/2.99↓/105 • P.CO2 30.8 ↓
Diff Count Urinalisis • P.O2 117.3 ↑
• Eosinofil 0.0% • Keton +1 • HCO3 19.1 ↓
• Basofil 0.5% • Urobilinogen 66 • BE -6.0 ↓
• Neutrofil 75.0% ↑ Kimia Klinik • Sat 99.9%
• Limfosit 12,7% ↓ • BJ plasma 1,024 ↓ • Conclusion : acidosis metabolic
• Monosit 11.8% ↑ • Faal Hati fully compensated
• Bilirubin total 2,49mg/dL ↑
• OT 59 ↑ • Bilirubin direk 1,22 mg/dL ↑
• PT 18 • Bilirubin indirek 1,27 mg/dL ↑
RO Thorax
Conclusion :
Right Pleural Effution
SCORTEN and SOFA score
• SCORTEN
• age >40 thn : 1
• Malignancy :1
• BSA>10% :0
• HR>120 : 0
• Bun >28 mg/dl :1 (pasien ureum 76,10 ekuivalen Bun 35,51)
• Serum glucosa >250 : 0
• Serum bicarbonate < 20 meq/L : 0
• Total Scorten 3 (mortality 35%)

• Sofa score: 3 (bilirubin 1, platelet 2) --> sepsis

DV Departement
Assesment :
1. SJS ec drug induced susp
Capecitabine
Dd/ eritema multiforme major
Dd/ pemfigus paraneoplastik
2. Ulkus decubitus grade 2 regio
sacrum
3. Septic condition
Ptx
1. Stop culprit drug (capecitabine)
2. metyl prednisolone 62,5 mg-0-0 (BW 8. Joined care
68 kg, Prednisone 1mg/kgBB = 68 mg
 54,4 mg metil prednisolone)
2. Wet dressing NS 3x 10’ for erotion
3. Asam fusidat cream 2 ddue for
erotion of abdomen, inguinal, and
genetalia
4. Softratule dressing 1 ddue for
erotion inframammae sinistra and
ulcus buttock area
5. Suggest : consultation Ophtalmology
and ENT department
6. Regulary change right and left
Posiotion
7. Decubitus Bed
Internal Department
- Assessment
- 1. Ulkus+crust at mucosa oral, eyes, and skin
- 1.1 SJS
- 1.2 Capecitabine induced
- 2. Ca mammae D st 4 (metastasis paru) on chemo docataxel+capecitabine 2 4/6
- 3. Nausea + vomitting
- 4. Hipokalemia moderate

- Ptx O2 NRBM 8lpm

- NGT --> Liquid diet 6x200cc
- IVFD NS 20 tpm
- Inj lansoprazole 1x30mg
- Inj. Metocloperamide 3x10mg
- Inj. Metil prednisolone 62,5-0-0
- Hipokalemia Correction 2 Cycle --> WIDA KN2 @ 3 jam /cycle
Follow UP February 13th 2019
February 13th 2019
DV Department
wound pain (+) especially when moving, VAS is difficult to
evaluate, itching (-), new lesions (-), pain in the lips
and mouth (+), difficult to talk (+), can sleep (+),
L: inframammae Sinistra,
D: localized
R: Patches and plaques dusky red well defined
erosion with the erythematous base, well defined , discharge
purulent and blackish brown crust

O: L: dextra inframammae, abdominal folds

TD 165/80 N 88 RR 20 Tax 36.7 D: localized
E4V5M6 GCS R: Patches dusky red, well defined, blackish brown crust
Lymph node enlargement (-)
Dermatological status L: Palmar and dorsum manus dextra et sinistra
L: Face, scalp D: Localized
D: Generalisata R: macule and Patcthes hyperpigmentation, well definead,
R: Patches hiperpigmentation multiple

L: ODS L: Plantar pedis dextra et sinistra

D: localized D: Localized
R: hyperemia (+), purulent secretions (+), blackish brown R: macule and Patcthes hyperpigmentation, well defined,
crusts in the conjunctiva, Lagophthalmos (+) , ectropion (+) multiple

L: lip mucosa and mouth

D: localized
R: erythematous base erosion, with blackish brown crusta
Tongue is difficult to evaluate
L: Inguinal dextra sinistra, genitalia
D: Localized
R: patches hyperpigmentation,Erotion with
erythematous base, Blackish brown crust, yellowish
pus,
L : Sacrum
D: Localized
R: ulkus with erythematous base, well defined,
necrotic tissue (+), blackish brown crust
Assesment :
1. SJS ec drug induced susp Capecitabine
Dd/ eritema multiforme major
Dd/ pemfigus paraneoplastik
2. Ulkus decubitus grade 2 regio sacrum
3. Septic condition
Ptx
1. Stop culprit drug (capecitabine)
2. metyl prednisolone 62,5 mg-0-0 Day 1 (BW 68 kg,
Prednisone 1mg/kgBB = 68 mg  54,4 mg metil
prednisolone)
2. Wet dressing NS 3x 10’ for erotion
3. Asam fusidat cream 2 ddue for erotion of
abdomen, inguinal, and genetalia
4. Softratule dressing 1 ddue for erotion
inframammae sinistra and ulcus buttock area
5. Regulary change right snd left Position
6. Decubitus Bed
7. Joined care
Opthalmology department - 1.2 Capecitabine induced
Assesment : - 2. Ca mammae D st 4 (metastasis paru) on
- ODS blepharoconjunctivitis + ectropion chemo docataxel+capecitabine 2 4/6
sikatrika dt. SjS - 3. Nausea + vomitting
- OS Lagoftalmus - 4. Hipokalemia moderate
- Terapi:Levocin ed 6x1ODS
- Fluorometholon ed 6x1ODS - Ptx O2 NRBM 8lpm
- C-lyteers ed gtt 1 /jam - NGT --> Liquid diet 6x200cc
- Chloramphenicol eye ointment 4xue - IVFD NS 20 tpm
- Secret cleaning - Inj lansoprazole 1x30mg
- Inj. Metocloperamide 3x10mg
Internal Department - Inj. Metil prednisolone 62,5-0-0
- Assessment - Hipokalemia Correction 2 Cycle --> WIDA
- 1. Ulkus+crust at mucosa oral, eyes, and KN2 @ 3 jam /cycle
skin
- 1.1 SJS
ENT Department
Assesment
1. Steven-Johnson Syndrome
2. CA Mammae Std 4 Pulmonary
Metastase

Ptx
1. Wet dressing for lip and mouth
2. Gargle with Nacl 3X1
3. Optimize Pain terapy from Internal
department
Follow Up February 14th 2019
February 14th 2019
DV Department L: inframammae Sinistra,
S : pain (+) especially when movie, VAS is difficult to D: localized
evaluate, itching (-), new lesions (-), pain in the lips R: Patches and plaques dusky red well defined
and mouth (+), difficult to open mouth talk (+), sleep (+), erosion with the erythematous base, well defined ,
Difficult to open eyes (+) discharge purulent and blackish brown crust
O:
TD 165/80 N 88 RR 20 Tax 36.7 L: dextra inframammae, abdominal folds
E4V5M6 GCS D: localized
Fluid balance = -415 R: Patches dusky red, well defined, blackish brown crust
Lymph node enlargement (-)
Dermatological status L: Palmar and dorsum manus dextra et sinistra
L: Face, scalp D: Localized
D: Generalisata R: macule and Patcthes hyperpigmentation, well definead,
R: Patches hiperpigmentation multiple

L: ODS L: Plantar pedis dextra et sinistra

D: localized D: Localized
R: hyperemia (+), purulent secretions (+), blackish brown R: macule and Patcthes hyperpigmentation, well defined,
crusts in the conjunctiva, Lagophthalmos (+) , ectropion (+) multiple

L: lip mucosa and mouth

D: localized
R: erythematous base erosion, with blackish brown crusta
L: Inguinal dextra sinistra, genitalia
D: Localized
R: patches hyperpigmentation,Erotion with erythematous
base, Blackish brown crust, yellowish pus,
L : Sacrum
D: Localized
R: ulkus with erythematous base, well defined, necrotic
tissue (+), blackish brown crust
Assesment :
1. SJS ec drug induced susp Capecitabine
Dd/ eritema multiforme major
Dd/ pemfigus paraneoplastik
2. Ulkus decubitus grade 2 regio sacrum
3. Septic condition
Ptx
1. Stop culprit drug (capecitabine)
2. metyl prednisolone 62,5 mg-0-0 Day 2 (BW 68 kg,
Prednisone 1mg/kgBB = 68 mg  54,4 mg metil
prednisolone)
2. Wet dressing NS 3x 10’ for erotion
3. Fusidic acid cream 2 ddue for erotion of abdomen,
inguinal, and genetalia
4. Softratule dressing 1 ddue for erotion inframammae
sinistra and ulcus buttock area
5. Regulary change right and left Position
6. Decubitus Bed
7. Joined Care
Internal Departement (14/02/19) 4. IV ceftriaxone 2x1gr (d-2)
Assesment : 5. IV lansoprazole 1x30mg
1. Ulcus + crus in oral mukosa, eyes, and skin 6. IV metoclopramide 3x10mg
1.1 SJS 7. PO amlodipine 1x10mg
1.2 Capecitabine 8. Wet dressing NS 3x10cc
2. Steven Johnson Syndrome 9. fusidic acid 2 x 1 ue
3. Septic condition dt no 1 and secondary infection 10. Inj methylprednisolon 1x62.5mg D-2
4. DOC dt no.3 11. ODS c-liters 3tts/jam
5. Ca mammae st IV pulmonary matastase on chemo 2nd 12. Cloramphenicol 4x1 tts
series 13. Levocin 8x1tts
6. Anemi HM 14. Flurometholone 6 dd 1 gtt
6.1 chronic disease
6.2 Malignancy
7. Hipoalbuminemia
7.1 Wound Loss
7.2 Hypercatabolic State
8. Nausea vomiting (resolve)
Ptx :
1. Bedrest, Decubitus bed, regulary change position
2. Liquid diet 6x200cc
3. IVFD NS 2000cc/day
Lab 14-2-2019

Na : 148 ↑
K : 3,36↓
Cl : 113 ↑
Ur : 85,9 ↑
cr : 0.62
Follow Up February 15th 2019
February 15th 2019
DV Department L: inframammae Sinistra,
S : pain (+) especially when movie, VAS is difficult to D: localized
evaluate, itching (-), new lesions (-), pain in the lips R: Patches and plaques dusky red well defined
and mouth (+), difficult to open mouth talk (+), sleep (+), erosion with the erythematous base, well defined ,
Difficult to open eyes (+), NRBM felt uncomfort discharge purulent and blackish brown crust
O:
TD 165/80 N 88 RR 20 Tax 36.7 L: dextra inframammae, abdominal folds
E4V5M6 GCS D: localized
Fluid balance R: Patches dusky red, well defined, blackish brown crust
Lymph node enlargement (-)
Dermatological status L: Palmar and dorsum manus dextra et sinistra
L: Face, scalp D: Localized
D: Generalisata R: macule and Patcthes hyperpigmentation, well definead,
R: Patches hiperpigmentation multiple

L: ODS L: Plantar pedis dextra et sinistra

D: localized D: Localized
R: hyperemia (+), purulent secretions (+), blackish brown R: macule and Patcthes hyperpigmentation, well defined,
crusts in the conjunctiva, Lagophthalmos (+) , ectropion (+) multiple

L: lip mucosa and mouth

D: localized
R: erythematous base erosion, with blackish brown crusta
L: Inguinal dextra sinistra, genitalia
D: Localized
R: patches hyperpigmentation,Erotion with erythematous
base, Blackish brown crust, yellowish pus,
L : Sacrum
D: Localized
R: ulkus with erythematous base, well defined, necrotic
tissue (+), blackish brown crust
Assesment :
1. SJS ec drug induced susp Capecitabine
Dd/ eritema multiforme major
Dd/ pemfigus paraneoplastik
2. Ulkus decubitus grade 2 regio sacrum
3. Septic condition
Ptx
1. Stop culprit drug (capecitabine)
2. metyl prednisolone 62,5 mg-0-0 Day 3 (BW 68 kg,
Prednisone 1mg/kgBB = 68 mg  54,4 mg metil
prednisolone)
2. Wet dressing NS 3x 10’ for erotion
3. Fusidic acid cream 2 ddue for erotion of abdomen,
inguinal, and genetalia
4. Softratule dressing 1 ddue for erotion inframammae
sinistra and ulcus buttock area
5. Regulary change Position
6. Decubitus Bed
Internal Departement (14/02/19) 4. IV ceftriaxone 2x1gr (d-2)
Assesment : 5. IV lansoprazole 1x30mg
1. Ulcus + crus in oral mukosa, eyes, and skin 6. IV metoclopramide 3x10mg
1.1 SJS 7. PO amlodipine 1x10mg
1.2 Capecitabine 8. Wet dressing NS 3x10cc
2. Steven Johnson Syndrome 9. fusidic acid 2 x 1 ue
3. Septic condition dt no 1 and secondary infection 10. Inj methylprednisolon 1x62.5mg D-2
4. DOC dt no.3 11. ODS c-liters 3tts/jam
5. Ca mammae st IV pulmonary matastase on chemo 2nd 12. Cloramphenicol 4x1 tts
series 13. Levocin 8x1tts
6. Anemi HM 14. Flurometholone 6 dd 1 gtt
6.1 chronic disease
6.2 Malignancy
7. Hipoalbuminemia
7.1 Wound Loss
7.2 Hypercatabolic State
8. Nausea vomiting (resolve)
Ptx :
1. Bedrest, Decubitus bed, regulary change position
2. Liquid diet 6x200cc
3. IVFD NS 2000cc/day