Case presentation on toxic epidermal necrolysis

1. PRESENTED BY
RUMANA HAMEED
ROLL NO: 170310820021
PHARM D VTH YEAR

2. SUBJECTIVE
NAME: XYZ D.O.A: 6-4-15
SEX: Female REG.No.: 12954/15
AGE: 30yrs DEPT: DVL1,FM1
ADDRESS: Ranga Reddy.
OCCUPATION: Housewife.

3. CHIEF COMPLAINTS: Watery elevated lesions over
the right side of chest,inside and around mouth
since 3 days.
HISTORY OF PRESENT ILLNESS :
A 30yrs old female patient was admitted with the
complaints of fever and watery lesions over the right side of
chest, inside and around mouth since 3 days.
Bullous erupted over the trunk and mouth.
Spontaneous rupture of blisters seen.
Pain present over the lesions.

4. PAST HISTORY:
History of Drug intake (phenytoin) present 8 days back for
one episode of seizure.
History of UTI(Treated).
FAMILY HISTORY:
No significant family history.

6. VITALS
VITALS DAY 1 DAY 2 DAY3 DAY 4
BP/mmhg 110/70 110/80 110/80 110/80
Pulse
rate/min
80/min 80/min 80/min 80/min
Temp-erature 101°F 99°F 98.6°F 98.6°F

7. LABORATORY DATA
 RBS: 72mg/dl
 Serum Urea: 32mg/dl
 Serum Creatinine: 1.4mg/dl
 SERUM ELETROLYTES
 Sodium: 130meq/l
 Potassium:3.0meq/l
 Serum Total Bilirubin: 0.6mg/dl

8. COMPLETE BLOOD PICTURE:
 Hemoglobin: 13gms/dl
 W.B.C: 3200 Cells/Cmm
 NEUTROPHILS: 64%
 LYMPHOCYTES: 29%
 EOSINOPHILS: 03%
 BASOPHILS: 00%
 PLATELETS: 2.5Lacs/cmm
 BLOOD PICTURE: Normocytic,normochromic.

9.  USG ABDOMEN:
IMPRESSION: Normal study.
 CHEST X-RAY:
IMPRESSION: Normal study
 SKIN BIOPSY:
Findings: Keratocyte cell death(apoptosis)

10. GENERAL EXAMINATION
 Patient is conscious
and febrile
 Conjunctivitis - present.
Conjunctivial congestion - +
CCC - +
 Adhesions noted in the
right eye.
 Ectropion – present.
 EOM : Full
 Early petrygium.

11. CUTANEOUS EXAMINATION
 Discreet maculopapular rashes present all over the
body.
 No confluent rashes present.
 Erosions present.
 Eroded mucous membrane over the lower lip.
 Nikolsky’s sign - ++ (both direct and indirect).
 Denuded skin present over the back.
 No EMF lesions seen.

12. CUTANEOUS EXAMINATION
DENUDED SKIN OVER THE
BACK
MACULOPAPULAR
RASHES ALL OVER THE
BODY

13. ASSESMENT:
Maculopapular rashes all over the body and the
detachment of the epidermal layer of the of the skin
and the mucosa.
Bullous erupted over trunk and mouth.
Involvement of more than 30% of the body surface
area.
FINAL ASSESMENT:
TOXIC EPIDERMAL NECROLYSIS

15. GOAL OF THE TREATMENT
 Identify the causative agent and withdraw it for
better outcome.
 To prevent and reduce fluid and skin loss.
 To reduce and prevent infection.
 To reduce inflammation and pain.
 To improve survival and quality life of the patient.

16. PLAN
FORMULA-
TION
DRUG GENERIC DOSE ROUTE FREQ,
IV FLUIDS 2 NS +1 25%
2 RL DEXTROSE
INJ Monocef Ceftriaxone 1gm IV BD
INJ Decadron Dexamethasone 2cc IV BD
INJ Rantac Ranitidine 2cc IV BD
Tab. B.C B Complex 1 tab P/O OD
Tab. Calcium Calcium 1 tab P/O OD
Tab. Rantac Ranitidine 150mg P/O BD
Ointment TESS Triamcinolone
acetonide
Oral Application
Gargle
(mouth)
Betadine Povidone-iodine Oral Application
Eye drop Moisol Hydroxypropyl
methyl cellulose,
Nacl,kcl.borax
0.5% 3-4
times a
day

18. DISEASE CONDITION
 Toxic epidermal necrolysis also known as lyell’s
syndrome is a rare life threatening skin condition
that is usually caused by reaction to drugs.
 The disease cause the top layer of the
skin(epidermis) to detach from the lower layers of
the skin(dermis) all over the body resulting in
exfoliation,possible sepsis or death.

19. MEDICATIONS
 MONOCEF: Antibiotic to treat and prevent infections.
 DECADRON: Used to treat and prevent severe skin
skin inflammation.
 RANTAC: H2RA,reduces the acidity.
 BETADINE MOUTH GARGLE:
Oral antiseptic for relief of painful infections and
inflammatory conditions of mouth and pharynx.
 TESS OINTMENT: Anti-inflammatory, Anti-pruritic, and
Vaso-constructive properties. To cure mouth ulcers.

20. LIFESTYLE MODIFICATIONS
 Intake of large amount of fluids as there is a skin loss.
 Avoid spicy food.
 Have proper and timely diet.
 Stop the causative drug and avoid it in future.
 Cool wet compresses will help it to soothe the blisters
while they heal.
 Keep the eye hydrated by using the eye drops and
ointment.
 Maintaining fluid and electrolytes homeostasis.
 Mitigating temperature loss.
 Take medications regularly.

21. DRUG INFORMATION QUERY
ACUTE
COMPLICATIONS
 Similar to burns, depends
extent of occular
complications
 Massive fluid and electrolyte
loss
 Prerenal failure
 Hyper catabolism
 Mucous membrane
involvement.
 Bacterial infection,
septicaemia.
CHRONIC
COMPLICATIONS
 Occular complications
(upto 30%)
 Conjuntivitis, ectropion,
entropion, corneal scarring.
 Wound infection
 Nail dystrophy
 Scarring alopecia
 Oesophageal stricture
What are the complications of TEN?