A 30 year old African American female with history of Systemic Lupus Erythematosus and secondary Lupus nephritis presented with painful erythematous blisters on her hands and feet along with dysphagia and oral ulcers. It was discovered that 2 weeks prior she was started on mycophenolate mofetil for treatment of her lupus and three days before presentation, she began experiencing oral thrush for which she was given fluconazole. The t following day, she started developing painful lesions on her hands and feet. Other associated symptoms included dyspnea, dysphagia, drooling, diffuse myalgias and pain. Physical examination revealed left conjunctival ocular injection , and hemorrhagic crusting along the lower lip., Additionally, the patient exhibited blistering discoloration and desquamation of skin on the plantar aspect of her bilateral feet. She was tender to palpation on her feet and hands, which showed clear vesicles on palms as well as areas of edema. She subsequently had more progressive sloughing of skin involving the distal upper extremities. In total, about 8% of TBSA was involved. Initial laboratory manifestations demonstrated normal C3 and C4 levels in addition to mildly elevated anti-DSDNA antibodies. The patient was subsequently transferred to the intensive care unit, where Fluconazole was promptly discontinued, and she was started on methylprednisolone and intravenous hydration. In retrospect, there was no other trigger identified for the development of these symptoms, and Fluconazole is believed to be responsible for triggering this episode of SJS since it was the only drug administered prior to the onset of the symptoms.
Discussion:
Steven Johnson syndrome (SJS) is an acute and life threatening manifestation characterized by mucocutaneous lesions, skin blistering and sometimes detachment from the epidermis, involving up to 10% of the total body surface area (TBSA) . Mucous membranes are affected in over 90 percent of patients, usually at two or more distinct sites (ocular, oral, and genital). It is more common in women than in men, with a male to female ratio of 0.6 .This condition is usually triggered by medications including Allopurinol, Carbamazepine, Lamotrigine, Phenytoin, sulfonamides, and NSAIDs. The current literature contains few cases of Steven Johnson syndrome in association with Fluconazole, a commonly prescribed antifungal medication.
Conclusions:
Steven Johnson syndrome is a life threatening condition often associated as an adverse reaction to several commonly used medications. Fluconazole has been rarely associated with SJS, and only a few cases have been reported in the past. Fluconazole is an antifungal agent that is often prescribed to treat superficial and systemic fungal infections. Common side effects of this drug include nausea, vomiting, transaminitis, and mild mucocutaneous manifestations; however, Steven Johnson Syndrome is an important association to keep in mind. Treatment of SJS should include prompt diagnosis and early discontinuation of offending drug and often requires Intensive care management. To conclude, Fluconazole should be considered as one of the drug causing SJS.