Behaviour Aspect

in allergic disease
Prof. DR. dr. Endang Sutedja, SpKK (K)
Case Report

A 28-year-old woman, came to

Emergency Unit with chief complain :

 Generalized erythematous macules

and papules
 History

1 week : 3 days:
Cough  GP Generalized
(Community Health Center) erythematous
macules & papules
Medication : Itchy (+), fever (+)
- White tablet 3x/day
- White caplet 3x/day
2 days : 1 day : HOSPITAL

Eye disorder : Pain in swallowing (+)

- Secretion (+) Bleeding at lips (+)
- Foreign body
sensation (+)
Diagnosis

 Steven Johnson Syndrome suspected to

be caused by ingestion of
white tablet and/or
white caplet
Therapy

General :
 Stop suspected medications
 Consult to Dept.Internal Medicine,
Ophthalmology and ENT
Specific :
Topical
Systemic
 Ringer Lactate infusion
 Prednisone 3 mg/kg BW/day  short term
(3 – 0 - 1.5) ampule dexamethasone inj
5th day :

Patient suddenly had respiratory failure

Consult to Internal Medicine

D/ : respiratory failure  apnea

ICU

DEATH
 Her husband and family :
 Did not accept it
 Want to sue the GP and doctor in
hospital
1.During the patient was critically ill
2.Treatment and procedure in hospital
3. If you were the GP who
gave those suspected
medications for the first time
Expectation/answer

1. Treatment and procedure in hospital :

 The treatment and procedure in hospital
were in suitable protocol
 The medical team has provided their
maximal attempt
2. How is the chronology of death in
this patient?
 Drug allergy happens among genetically
prone individuals
 In the progression of the disease, SJS
can cause death, either do to the
deterioration or its complications
3. If you were the GP who gave those
suspected
medications for the first time?

 Ask about drug allergy to the patient.

 Explain about the potential drug allergy
after consuming the medications.
 Explain the sign and symptoms of drug
allergy and what should be done if it
happens
History taking

 Get some information about this disease

(allergic disease or not)
 How it could have happened?
 When it could happen?
 What is the (suspected) etiology?
 What are the subjective symptoms?
 Are there any history of previous
medication?
If there was history about
taking medication
 Why did she take medication?
 When was the last time she took the
medication?
 What happened after she took the medication?
 What kind of medication?
 How many times she consumed the medication?

The woman has history of drug allergy

How to explain to her family
about the drug allergy?
 Hypersensitivity
 Only in individuals with allergic history
 How to prove it?
 Recently, many cases of drug allergy,
why?
 Immunology

Defense mechanism Allergy

Immune response Hypersensitivity

Humoral Cellular
 ALLERGY ALLOS + ERGOS

DEVIATION IN BODY IMMUNE REACTION

(HYPERSENSITIVITY)

Hypersensitivy reactions

4 type of immunological reactions Coombs and

Gell
- type I (immediate)
- type II (cytotoxic)
- type III (antigen-antibody complex)
- type IV (delayed)
Type I (anaphylactic/immediate hypersensitivity)
Type II (cytotoxic)
Type III (antigen-antibody complex)
Tipe IV (delayed hypersensitivity)
Hapten
IK

Hapten carrier Immunogen

I.K agent Hapten

 DRUG ERUPTION
Incidence Increased
Drug/substance Establish
diagnosis

Prophylaxis

Treatment

Port of entry :
- Gastro-intestinal tract
- Respiratory tract
- IV;ID;IM
- Topical
Drug reaction all reaction in the body induced by
drugs
- toxicity
- overdosis
- intolerance
- allergy, etc.
Diagnosis :
1. Accurate anamnesis :
Given medication
Acute onset a few hours
Itching/sub-febrile

2. Cutaneous abnormalities :
Distribution : diffuse & symmetry
Single drug-induced abnormalities,
Multiple drug-induced abnormalities similar
disorders
FORMS :
 Urticaria
 Erythema morbilliform
 Dermatitis
 Purpura
 Exanthema fixtum (Fixed Drug Eruption)
- Hyperpigmentation :
permanent/transient
- Relaps
- Similar sites
Predilection labia (lips); penis
 Erythema nodosum
 Erythroderma
FIXED DRUG ERUPTIONS

Clinical manifestations :
- erytemathous dan vesikel/bula
 hyperpigmentation macule (menetap)
- Many times appear in the same place
- predilections : round the mouth, >> lip
in a man : penis
 STEVENS-JOHNSON’S
Definition : SYNDROME
Syndromes Skin
Orificial and ocular mucosa
Varied general state: mild ---
severe
Synonym : erythema multiforme mayor
Etiology :
Systemic drug-induced allergy
Infection
Neoplasm
Pathogenesis :
type I-IV
DIAGNOSIS :
Mild severe decreased consciousness soporous
coma

TRIAD :
-Skin disorder
-Orificial mucous disorder
-Opthalmic disorder

Skin : erythema , papules, vesicles, bullae, erosion, purpura

Mucosa :
Mouth : 100%
Genitalia : 50%
Anus/nose : 4 - 8 %
Eye Disorder :
• 80% conjuctivitis catarrhalis
• Corneal ulcer
• Iritis, Iridocyclitis

Complication :
• Bronchopneumonia
• Loss of body fluid shock
• Eye blindness, lacrimation
THERAPY :
-Care,General state, Infuse
-Corticosteroid life saving
-4-6 x 5 mg/day critical period (3days)
-Get decreased to be 5mg/day per day 1x5 mg
-Antibiotics (carefully)

PROGNOSIS :
Take action immediately,and appropriately good prognosis
Death 5 – 15 %
 TEN
 More severe than Steven-Johnson’s syndrome
 Epidermolysis
 Mucosa
 Synonym : Lyell’s syndrome
 Etiology : similar with Steven-Johnson’s
 Syndromes : severe death
fluid–electrolyte imbalance

Prodromal :
Severe illness
High fever
Soporo comatous
Skin : erythema generalisata vesicle bulla purpura
With the mucosa of :
Oral/lips
Erosion/excoriation
Crust
Patological anatomy : Epidermolysis
Nikolsky sign (+)
Therapy : similar to Steven-Johnson syndrome
Prognosis :
5 – 7% worse
Infection is better than drugs
Death 28.6%
Steven-Johnson syndrome 1 %
Dermatological Status
Laboratory

 Hb : 13,8 g/dl
 Leukocyte : 10.800 g/dl
 Thrombocyte : 325.000 g/dl
 Gravity index : 1,024
 Liver and kidney function test : normal
 Electrolyte : normal
 Chest X-ray : laryngeal obstruction (-)
Case
 There was a young boy, 10 yr old with
Steven Johnson Syndrome (SJS)
 Anamnesis: 4 days ago  fever

General practice (GP) Blisters

hours
• Syr. Antibiotic
• Analgetic Death

His parents sue the doctor