Case Presentation
A 32-year-old female patient complained of sore throat and was prescribed IM cefoperazone/sulbactam 1500 mg. One day post-initiation, the patient started to complain of itchy rashes over the hands, she sought medical advice, Cefoperazone/sulbactam was immediately discontinued and was prescribed conservative treatment in the form of IM dexamethasone every 12 hours. 6 days post-initiation, the patient presented to ER with sever itchy rash. On examination she had a generalized symmetrical, erythematous rash more marked on the face, upper limbs, chest and back with violaceous colour of both hands and feet. In addition, she had an associated buccal ulceration and conjunctival injection. Her temperature was 37°C, with SpO2 of 98%, a blood pressure recording of 100/60 mmHg and a regular pulse of 80 beats/min. Vesiculobullous lesions were observed over the course of the admission, with sloughing of skin, especially on the chest and face around the lips. Routine laboratory assessments showed normal blood counts (7500 cells/uL) without hyper eosinophilia (0.02%). Hepatic enzyme levels, renal function, and serum electrolyte levels were all within normal limits and a serological test was negative for HIV. CRP was high (55 mg/l) with low serum Albumin (3.1 g/dl). A diagnosis of TEN secondary to cefoperazone/sulbactam exposure was made. Evaluation of the SCORE of Toxic Epidermal Necrosis (SCORTEN) score on day 1 indicated a score of 1. The patient was admitted to intensive care unit and received intravenous fluid resuscitation and urinary catheter was inserted. Blood and urine cultures were conducted. Dermatological, ophthalmological and burn unit consultation were done. Skin punch biopsy was done which confirmed the diagnosis of TEN. Supportive treatment was formed; the patient was kept warm, had careful protection of the eroded areas, tetracycline eye ointment, antiseptic mouth wash and both Intravenous and non-intravenous hydration. Immunosuppressive treatment was initiated on the second day of admission; IvIG 2 gm/kg divided by 5 days by infusion over 6 hours. The patient recovered considerably after 5 days of immunosuppressive, symptomatic and supportive management and was transferred to the ward for further follow up and discharged and was asked to follow up at OPC basis.