Early-Stage Stevens–Johnson Syndrome with Oral and Cutaneous Manifestations Following Recent Drug Administration: A Case Report
Keywords:
Stevens–Johnson syndrome, drug eruption, oral ulceration, maculopapular rash, early diagnosisAbstract
Introduction: Stevens–Johnson syndrome (SJS) is a rare, life-threatening, immune-mediated mucocutaneous reaction most frequently triggered by medications (1). Early-stage SJS often presents with fever, oral ulceration, and widespread erythematous macules before blistering or epidermal detachment occurs, making it easily misdiagnosed as a viral exanthem or erythema multiforme major (2). Delayed recognition increases morbidity and mortality (3).
Case Illustration: A 49-year-old female presented with progressive lip swelling, painful oral ulcers, dysphagia, and a rapidly spreading purplish-red maculopapular rash over the entire body, following sequential administration of ketoconazole, prednisone, cetirizine, chloramphenicol eye drops, loratadine, and dexamethasone over 48 hours. On admission, she was febrile (38.2°C), tachycardic (115 bpm), and tachypneic (24 breaths/min). Physical examination revealed multiple erythematous macules on the trunk, extremities, and oropharynx, along with labial crusting and ulceration. No blistering or positive Nikolsky sign was present. A working diagnosis of early-stage SJS versus erythema multiforme major was made. The patient was hospitalized, all suspected drugs were withdrawn, and she received intravenous dexamethasone, diphenhydramine, ranitidine, topical vaseline, saline mouthwash, and topical desoximetasone. By day two, she developed blood-tinged saliva, throat discomfort, vomiting, and bilateral rales, prompting airway monitoring.
Discussion: The temporal relationship between drug administration and symptom onset strongly supported drug-induced SJS (4). The absence of epidermal detachment at presentation confirmed early-stage disease (5). Management focused on immediate drug withdrawal, aggressive supportive care, and daily monitoring for respiratory compromise (6). The use of systemic corticosteroids in early SJS remains controversial but may be beneficial within 48–72 hours (7).
Conclusion: Early recognition, immediate withdrawal of culprit drugs, hospitalization, and vigilant monitoring for airway involvement are essential in suspected early-stage SJS to prevent progression to full-thickness epidermal necrosis and reduce mortality.
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