DRUG ERUPTION

Almahdinur Fuad Reza Antoni Tarigan 070100020 070100100

Supervisor: Prof. dr. H. M. Sjabaroeddin Loebis, Sp.A(K)

Departement of Pediatrics University of North Sumatera Medical Faculty RSUP. H. Adam Malik

Definition
drug-induced reaction The morphologies are myriad and include morbilliform (most common), urticarial, papulosquamous, pustular, and bullous Medications that are known for causing cutaneous reactions include: antimicrobial agents nonsteroidal anti-inflammatory drugs (NSAIDs) Cytokines chemotherapeutic agents Anticonvulsants psychotropic agents.

Etiology
Amoxicillin - 5.1% Trimethoprim sulfamethoxazole - 4.7% Ampicillin - 4.2% Semisynthetic penicillin - 2.9% Blood (whole human) - 2.8% Penicillin G - 1.6% Cephalosporins - 1.3% Quinidine - 1.2% Gentamicin sulfate - 1% Packed red blood cells - 0.8% Mercurial diuretics - 0.9% Heparin - 0.7% Acetaminophen Aspirin

Epidemiology
In United States: approximately 2-5% inpatient, greater than 1% of outpatients International: approximately 2-3% of inpatients Adverse cutaneous reaction: women > men

Patophysiology
Immunologically mediated reactions Type I is immunoglobulin E (IgE)dependent reactions Type II is cytotoxic reactions Type III is immune complex reactions Type IV is delayed-type reactions with cell-mediated hypersensitivity
Nonimmunologically mediated reactions

Clinical Manifestation

Mucous membrane erosions Blisters (Blisters herald a severe drug eruption.) Nikolsky sign (epidermis sloughs with lateral pressure; indicates serious eruption that may constitute a medical emergency) Confluent erythema Angioedema and tongue swelling Palpable purpura Skin necrosis Lymphadenopathy High fever, dyspnea, or hypotension

Differential Diagnosis
1. Drug Eruption 2. SJS 3. TEN

Drug Eruption

SJS

SJS

Fixed Erythem caused by Methampiron

Laboratory Studies
Biopsy CBC count electrolyte balance and renal and/or hepatic function Direct cultures Urinalysis, stool guaiac tests, and chest radiography

Treatment
O2 1-2 Liter per minute (nasal canule) IVFD D5% NaCl 0,45% 20 gtt/min (macro) Diet MB 2200 kcal with 30 gr protein, dont eat saltwater fish, salted fish, MSG Loratadine 1x10 mg Dexamethasone 5 mg/ 8 jam/ IV Eritromisin 4x300 mg Ambulatory Care: Methylprednisolone 2mg/kgBB/hari Body weigth patient: 28 kg Dose of methylprednisolone 4 mg: 15/09/2011 = 5-5-4 16/09/2011 = 5-5-4 17/09/2011 = 4-4-4 18/09/2011 = 4-4-4

STATUS
RS, a nine years old boy, weight 28 kg, height 130 cm, admitted to Adam Malik Hospital on 07th September 2011 with chief complain of reddish spots all over body and itchness since 2 days ago, after taking the drugs from the Puskesmas. Edema was found in the eyes, lips and face in one last day. Fever experienced by patient since 4 days ago, characterized as a low continuous fever, which decreases with consumption of fever medication. History of atopy was found in his father. Itching is felt when eating shrimp, Amoxicillin, CTM, Vit. C, Aspirin have been consumpted by him. RS didnt have allergy with amoxicillin.

FOLLOW UP 08/09/2011 [Day 2] Maculopapular rash (+), erythema (+), fever (+), swallowing pain (+).

Eye: edema superior-inferior palpebra (+). Neck: maculopapular rash (+), erythema (+). Thorax , maculopapular rash (+), erythema (+). Abdomen maculopapular rash (+), erythema (+). Extremities maculopapular rash (+), erythema (+).

Drug Eruption

O2 1-2 Liter per minute (nasal canule) IVFD D5% NaCl 0,45% 20 gtt/min (macro) Diet MB 2200 kcal with 30 gr protein, dont eat saltwater fish, salted fish, MSG Loratadine 1x10 mg Dexamethasone 5 mg/ 8 jam/ IV Eritromisin 4x300 mg

FOLLOW UP (09/09/2011) [Day 3] Loratadine 1x10 mg diganti CTM 3x3 mg FOLLOW UP (10/09/2011) [Day 4] Innerson Cream

FOLLOW UP (11/09/2011) [Day 5] Nothing to Change

FOLLOW UP (12/09/2011) [Day 6] Maculopapular rash (+) () , erythema (+) (), crust (+).

Dexamethasone 5 mg/ 8 jam/ IV> Tapp.off 4mg/ 8 jam/ IV Innersion Zalf

S FOLLOW UP (13/09/2011) [Day7] Nothing to Change

FOLLOW UP (14/09/2011) [Day8] Maculopapular rash (+) ()() , erythema (+) ()(), crust (+).

Prednison 4-4-3

FOLLOW UP (15/09/2011) [Day9] Nothing to Change

Patient could be treated in home with methylprednisolone. Patient have to control on 18/09/2011. Dose of methylprednisolone 4 mg: 15/09/2011 = 5-5-4 16/09/2011 = 5-5-4 17/09/2011 = 4-4-4 18/09/2011 = 4-4-4

 Consultation: Departement of Dermatology (08/09/2011) Differential Diagnose: 1. Drug Eruption 2. Steven Johnson Syndrom Diagnotion: Drug Eruption Therapy: Innersion cream and injection therapy appropriate colleague.

Patient could be treated in home with methylprednisolone. Patient have to control on 18/09/2011. Dose of methylprednisolone 4 mg: 15/09/2011 = 5-5-4 16/09/2011 = 5-5-4 17/09/2011 = 4-4-4 18/09/2011 = 4-4-4