STEVENS-JOHNSON SYNDROME

By:
Nurlela 12.16.777.14.133
Rahmatia Anwar 12.16.777.14.147
I Made Ageng Pramana 12.16.777.14.144
Putri Endang 11.16.777.14.123

CLINIC ADVISER:
dr. Nur Rahmah. S.M, M.Kes, Sp.KK
 CASE
IDENTITY
Name : Mr. R
Age : 30 years
Sex : Male
Adress : Ds. Korobokan Sari
Marriage status : Single
Date of examination : August, 19th 2017
 ANAMNESIS
Main Complaints:
Comprise skin

History of present illness :

A man 30 years old goes into Anutapura hospital with complaint a
comprise skin since 8 days before in. At the begining, there is retspost
in a face area then spreads to the whole body. Day by day, it is going
bigger then before and contains liquid, then it brokes an expell a
pure/clear liquid. Moreover, the red spots that had broke, is becoming a
painful injury and the color is becoming black. Besides, patients family
said that, he complains about his eyes which become red, injury in the
mouth, dry lips, injury in some parts of his body, and he feels painful
when he moves his body. In addition, his family also said that, before
the red spots has appear, patient had consume some medicines from
Madani hospital, such as Carbamazepine for 3 days.
ANAMNESIS

History of previous disease :

Patient had 3 times entered the Madani
Hospital with mental disorder gripe since 2016.
History of diabetes (-)
History of hypertension (-)
History of alergy, denied.
ANAMNESIS

History of medicinal treatment

Patient routine consumes medicine from
Madani hospital.

Family history
There are no family members with the same
complaint with the patient
PHYSICAL EXAMINATION
General status:
1. General situation: Severe
2. Awareness : Compous Mentis
3. Nutritional status : Normal
4. Vital signs:
- Blood pressure : 120/80 mmHg
- Pulse : 76 x/minutes
- Temperature : 36,7C
- Breathing : 19x/minutes
5. Head
Sclera : Jaundice (-)
Conjungtiva :Conjungtivitis (+)
Lips : Cyanosis (-)
6. Thorax : not checked
7. Abdomen : not checked
LOCATED STATUS
Head : crust and erotion has appear
Neck : vesicle and erotion has appear
Chest : bula and erotion has appear
Stomach : eritema, vesicle, and bula has
appear
Back : eritema and vesicle has appear
Genitalia : erotion has appear
Buttock : vesicle accompanied by erotion
and ulcus has appear
Upper Extremity : vesicel and erotion has appear
Lower Extremity: eritema, bula and erotion has
appear
STATUS DERMATOLOGY
Location : Regio Facialis, thorax anterior and
posterior, abdomen,extremitas superior and
inferior.

Size : Miliar-plakat

Effloresensi : Skin disorder such as eritema,

vesicle, bula and erotion accompined by ulcer at
the buttock has appear.
RESUME
Patient (Mr. R) 30 years old come to Anutapura
hospital with complaint an erotion skin since 8 days
before. The first sign was eritema appeared at facialis
and spread to the whole body. Eritema become
vesicle, bulla and become erotion after tear, and ulcer
feels painful and become black crust. Besides, his
family said that he also complaint conjungtivitis,
odinofagia, stomatitis, dry lips, anorexia, there are
ulcer in some parts of his body, and myalgia. In
addition, before eritema, he is also consume
carbamazepin medicine from Madani hospital for 3
days.
 On physical examination: for generalics status
of patients; consciousness (compos mentis), blood
pressure (120/80), pulse (76x/minutes),
temperature (36,7 c), respiration (19x/minutes).
On dermatology status has detected skin
disorder, such as crust has detected in lips area,
eritema accompined by vesicle, bulla, erotion and
ulcer has detected in the other parts of body.
 LABORATORY EXAMINATION
WBC : 6,2 x 103/mm3 HbsAG : Non Reaktif
RBC : 4,95 x 106/mm3 ANTI HCV : Non Reaktif
HGB : 12,8 g/dL Ureum : 33 mg/dl
HCT : 38,4 % Creatinin : 0,85 mg/dl
PLT : 177 x 103/mm3 Kalium : 3,63 mmol/L
GDS : 125 mg/dl
Natrium : 143,96 mmol/L
SGOT : 91 U/L
Clorida : 87,89 mmol/L
SGPT : 75 U/L
WORKING DIAGNOSIS

STEVENS-JOHNSON SYNDROME (SJS)

DIFFERENTIAL DIAGNOSIS

TEN (Toxic Epidermal Necrolysis)

Fixed drug eruption
 TREATMENT
Non-medicamentose:
- Compresed NaCL 0.9%
- Repair general situation
- Repair nutrition
Medicamentose
Systemic:
- IVFD RL 24 tpm
- Inj. Dexamethasone 5mg/8H/IV
- Inj. Gentamicin 8mg/8H/IV
- Cetirizine 10 mg
Topical :
- Fulson cr 5g
- Kenalog oral base
 Follow Up Day Care 1
Date August 21th 2017 (Day care 1)
S Erotion at face area, bula at chest area, vesicle at upper extremity
eritema at upper and lover extremity, and ulcer at buttock area.

O Vital Sign
BP 110/80 mmHg
Pulse 81x/minutes
Temperature 36,8 C
Respiratory rate 19x/minutes
Head : eyes : Conjungtivitis
Universal : vesicel, bula dan erotion

A Sindrom Steven Johnson

P Non-Medicamentose
Compresed NaCL 0.9% (for injury in lips and genitalia)
Repair general situation

Medicamentose
Systemic
IVFD RL 24 tpm
Inj. Dexamettasone 5 mg/8 H/ iv
Inj. Gentamicin 8 mg/12 H/ iv
Ranitidin amp/12 H/iv
Cetirizine 10 mg ( 1 dd 1)

Topical
Fulson cr 5g the injury of the body
Kenalog oralbase the injury of the lips
 Day Care 1, August 21th 2017

Picture 1. conjungtivitis, lip erotion difuse, erythematous, ulcer

 Follow Up Day Care 2
Date August 22th 2017 (Day care 2)
S Erotion at face, chest, back, erythema at upper and lower extremity
and ulcer at buttock.

O Vital Sign
BP. 120/70 mmHg
Pulse 78x/minutes
Temperature 37,0 C
Respiratory rate 20x/minutes
Head : eyes : Conjungtivitis
lips : diffuse erotion
Universal : erythema, erotion, and ulcer

A Sindrom Steven Johnson

P Non-Medicamentose
Compresed NaCL 0.9% (for injury in lips and genitalia)
Repair general situation

Medicamentose
Systemic
IVFD RL 24 tpm
Inj. Dexamettasone 5 mg/8 H/ iv
Inj. Gentamicin 8 mg/12 H/ iv
Ranitidin amp/12 H/iv
Cetirizine 10 mg ( 1 dd 1)

Topical
Fulson cr 5g the injury of the body
Kenalog oralbase the injury of the lips
 Day Care 2, August 22nd 2017

Picture 2. conjungtivitis, lip erotion difuse, erythematous, ulcer

 Follow Up Day Care 3
Date August 23th 2017 (Day care 3)
S Erotion and erythema at the face, chest, upper and lower extremity
also ulcer at the buttock

O Vital Sign
BP. 110/80 mmHg
Pulse 81x/minutes
Temperature 36,8 C
Respiratory rate 19x/minutes
Regio occipital : Ulcer
Generalisata : erythema with erosi

A Sindrom Steven Johnson

P Non-Medicamentose
Compresed NaCL 0.9% (for injury in lips and genitalia)
Repair general situation

Medicamentose
Systemic
IVFD RL 24 tpm
Inj. Dexamettasone 5 mg/8 H/ iv
Inj. Gentamicin 8 mg/12 H/ iv
Ranitidin amp/12 H/iv
Cetirizine 10 mg ( 1 dd 1)

Topical
Fulson cr 5g the injury of the body
Kenalog oralbase the injury of the lips
 Day Care 3, August 23th 2017

Picture 3. ulcer on regio occipital, shoulder, back, and regio coxygeus

 Follow Up Day Care 4
Date August 24th 2017 (Day care 4)
S Erotion and erythema at the face, chest, upper and lower
extremity, also ulcer at the buttock

O Vital Sign
BP. 120/80 mmHg
Pulse 82x/minutes
Temperature 36,3 C
Respiratory rate 22x/minutes
Generalisata : erythema with erosi

A Sindrom Steven Johnson

P Non-Medicamentose
Compresed NaCL 0.9% (for injury in lips and genitalia)
Repair general situation

Medicamentose
Systemic
IVFD RL 24 tpm
Inj. Dexamettasone 5 mg/8 H/ iv
Inj. Gentamicin 8 mg/12 H/ iv
Ranitidin amp/12 H/iv
Cetirizine 10 mg ( 1 dd 1)

Topical
Fulson cr 5g the injury of the body
Kenalog oralbase the injury of the lips
 Day Care 4, August 24th 2017

Picture 3. ulcer on regio occipital, shoulder, back, and regio coxygeus

 DISCUSSION

In this case the diagnosis of Steven Johnson

syndrome based on history and clinical features.
The history and clinical symptoms of Steven
Johnson syndrome found in this case.
 FROM ANAMNESIS AND THE
CLINICAL FINDING
Complaints of scale whole of body 8 days ago, after he
was consumed carbamazepine. On the first sign, Erythema at
facialis was appear and spread to the whole body, erythema
became vesicle, bulla was broke and became erotion and
ulcer feels painful and became black crusta. Besides, patients
family said that he complaint for conjungtivities, odinofagia,
stomatitis, dry lips, anoreksia, there are ulcer at some parts
of his body, and also he complaint for mylagia.
 DISCUSSION
Theory
StevensJohnson syndrome
(SJS) are acute life-
threatening mucocutaneous
reactions characterized by
extensive necrosis and
detachment of the epidermis.
(Fitzpatrick's, 2008)
Case
In this patient steven
johnson syndrome has found
erythema, erotion, ulcer
whole of body.
Necrosis and epidermis has
peeled off in this patient. At
the beginning, erythema has
appear and erotion in a
whole body is happen, and
continuous to become ulcer
at the buttock.
 DISCUSSION

Theory Case
Steven Johnson syndrom case In this case, Mr. R as the
rise based on the increase of patient is a male and now
age, especially at the age close he is 30 years old.
to and above 40 years old.
There is no differences between
male or female. (Fitzpatricks,
2008)
 Learning Case
Theory Case
The factors of Steven Johnson In this patient, the symptom
syndrom disease is not figure was appeared after 8 days
out yet, but the consumption he consumed
of medicines is most often carbamazepine
becoming one of the factors.
(Fitzpatricks, 2008)
Ini tidak usah
 Learning Case
Theory Case
Mucous membrane When the second day of
involvement (nearly always on treatment in hospital care
at least two sites) is observed in in the first days of
approximately 90% of cases erythema with thick
and can precede or follow the skuama whole of body.
skin eruption. It begins with
erythema followed by painful
erotions of the oral, ocular, and
genital mucosa.( Fitzpatrick's.
2008)
 DISCUSSION

From the results of the history and physical

examination and an explanation theory in case
then this diagnosis patients with steven johnson
syndrome. Steven johnson syndrome is caused by
the pathophysiology of epydermal necrolysis is
still unclear; however, drugs are the most
important etiologic factors. (Fitzpatrick's, 2008).
DISCUSSION

Figure 1. The human body sensory dermatomes

DISCUSSION

Figure 2. Clinical finding

DIFFERENTIAL DIAGNOSIS

-Toxic Epidermal Necrolysis

-Fixed Drug Eruption
THERAPY IN PATIENTS

The first principal to treat steven johnson

syndrom is to stop the consumption of the medicine
which became the factor of symptom.

ANTIHISTAMIN. used to handle pruritus symptom.

We can give antihistamin H2 reseptor generation 2,
if pruritus symptom is appear.
CORTICOSTEROIDS. The use of systemic corticosteroids
is still controversial. Some studies found that such therapy
could prevent the extension of the disease when
administered during the early phase, especially as
intravenous pulses for a few day.

INTRAVENOUS IMMUNOGLOBULIN. The proposal to

use high-dose intravenous Ig was based on the hypothesis
that Fas-mediated cell death can be abrogated by the anti-
Fas activity present in commercial batches of normal
human Ig.
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