Stevens-Johnson Syndrome and Hyperbaric Oxygen Therapy: A Case Report

Abstract

A 20-year-old male patient was admitted to emergency department with complaints of being unable to swallow and urinate and wounds in his hands, feet, mouth and penis. He had purulent conjunctivitis, hyperemia in nasal mucosa, pseudomembranous stomatitis in his mouth, inflammation in external urethral orifice, vesiculobullous lesions in both hands and feet. Nikolsky sign was positive. The patient was diagnosed as Stevens- Johnson syndrome and hospitalized in intensive care unit. Intravenous fluid replacement treatment, ceftriaxone sodium, ranitidine, nystatin and methylprednisolone were started. In addition, he received five sessions of hyperbaric oxygen therapy (at 2.5 atmospheres absolute for 90 minutes/day). The lesions were markedly improved after three days and he was completely healed after five days of treatment. In this case report, the potential role of hyperbaric oxygen therapy in the treatment of cutaneous and mucosal manifestations of Stevens-Johnson syndrome was discussed. Turkish Başlık: Stevens-Johnson Sendromu ve Hiperbarik Oksijen Tedavisi: Bir Olgu Sunumu Anahtar Kelimeler: Stevens-Johnson sendromu; stomatit; hiperbarik oksijenasyon; vezikülobüllöz Yirmi yaşında bir erkek hasta iki gün önce başlayan tükürüğünü yutamama, idrar yapamama, ellerde, ayaklarda, ağızda ve peniste yara şikayetleri ile acil servise başvurdu. Her iki gözde pürülan konjunktivit, burun mukozasında hiperemi, ağızda erode, psödomembranlı, yer yer kanamalı stomatit vardı. Üretra çıkışı inflamasyonluydu. Her iki el ve ayakta hedef tarzı vezikülobüllöz lezyonlar vardı. Hastada Nikolsky bulgusu pozitifti. Hastaya Stevens-Johnson sendromu tanısı konularak yoğun bakıma yatırıldı. Hastaya intravenöz sıvı replasman tedavisi, seftriakson sodyum, ranitidin, nistatin ve metilprednizolon başlandı. Bu tedavilere ek olarak 2.5 mutlak atmosfer basınçta 90 dakika/gün, toplam beş seans hiperbarik oksijen tedavisi uygulandı. Üçüncü günde hastanın belirtilerinde fark edilir düzelme gözlendi. Beş günlük tedavi sonunda hasta tamamen iyileşti. Bu olgu sunumunda hiperbarik oksijen tedavisinin Stevens-Johnson sendromunda görülen cilt ve mukoza bulgularının tedavisindeki rolü tartışılmaktadır.

Keywords

• Stevens-Johnson syndrome; stomatitis; hyperbaric oxygenation; vesiculobullous

Stevens-Johnson Sendromu ve Hiperbarik Oksijen Tedavisi: Bir Olgu Sunumu

Öz

Yirmi yaşında bir erkek hasta iki gün önce başlayan tükürüğünü yutamama, idrar yapamama, ellerde, ayaklarda, ağızda ve peniste yara şikayetleri ile acil servise başvurdu. Her iki gözde pürülan konjunktivit, burun mukozasında hiperemi, ağızda erode, psödomembranlı, yer yer kanamalı stomatit vardı. Üretra çıkışı inflamasyonluydu. Her iki el ve ayakta hedef tarzı vezikülobüllöz lezyonlar vardı. Hastada Nikolsky bulgusu pozitifti. Hastaya Stevens-Johnson sendromu tanısı konularak yoğun bakıma yatırıldı. Hastaya intravenöz sıvı replasman tedavisi, seftriakson sodyum, ranitidin, nistatin ve metilprednizolon başlandı. Bu tedavilere ek olarak 2.5 mutlak atmosfer basınçta 90 dakika/gün, toplam beş seans hiperbarik oksijen tedavisi uygulandı. Üçüncü günde hastanın belirtilerinde fark edilir düzelme gözlendi. Beş günlük tedavi sonunda hasta tamamen iyileşti. Bu olgu sunumunda hiperbarik oksijen tedavisinin Stevens-Johnson sendromunda görülen cilt ve mukoza bulgularının tedavisindeki rolü tartışılmaktadır.

Anahtar Kelimeler

• Stevens-Johnson sendromu, stomatit, hiperbarik oksijenasyon, vezikülobüllöz.

References

1. Bastuji-Garin S, Rzany B, Stern RS, Shear nH, naldi L, Roujeau JC. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syn- drome, and erythema multiforme. Arch Dermatol 1993;129:92-6.
2. Sane SP, Bhatt AD. Stevens-Johnson syndrome and toxic epidermal necrolysis-challenges of recognition and management. J Assoc Physicians India 2000; 48:999-1003.
3. Lam nS, Yang YH, Wang LC, Lin YT, Chiang BL. Clinical characteristics of childhood erythema mul- tiforme, Stevens-Johnson syndrome and toxic epi- dermal necrolysis in Taiwanese children. J Microbiol Immunol Infect 2004;37:366-70.
4. Turhan V, Adam e, Can M, Haznedaroğlu T, Beşirbellioğlu B. Stevens Johnson sendromu. Klinik Bilimler & Doktor 2000;6:33-6.
5. Léauté-Labrèze C, Lamireau T, Chawki D, Maleville J, Taïeb A. Diagnosis, classification, and manage- ment of erythema multiforme and Stevens-Johnson syndrome. Arch Dis Child 2000;83:347-52.
6. Rappersberger K, Foedinger D. Treatment of ery- thema multiforme, Stevens-Johnson Syndrome, and toxic epidermal necrolysis. Dermatologic Therapy 2002;15:397-408.
7. Roujeau JC, Stern RS. Severe adverse cutaneous reac- tions to drugs. n engl J Med 1994;331:1272-85.
8. Ruocco V, Bimonte D, Luongo C, Florio M. Hyperbaric oxygen treatment of toxic epidermal necrolysis. Cutis 1986;38:267-71.

9. Garcia-Doval I, LeCleach L, Bocquet H, Otero XL, Roujeau JC. Toxic epidermal necrolysis and Stevens- Johnson syndrome: does early withdrawal of causa- tive drugs decrease the risk of death? Arch Dermatol 2000;136:323-7.
10. Wong KC, Kennedy PJ, Lee S. Clinical manifesta- tions and outcomes in 17 cases of Stevens-Johnson syndrome and toxic epidermal necrolysis. Australas J Dermatol 1999;40:131-4.
11. Serdaroğlu S, Uysal S. eritema multiforme. Dermatose 2002;1:9-15.
12. Tripathi A, Ditto AM, Grammer LC, Greenberger PA, McGrath KG, Zeiss CR, et al. Corticosteroid therapy in an additional 13 cases of Stevens-Johnson syndrome: a total series of 67 cases. Allergy Asthma Proc 2000;21:101-5.
13. Patterson R, Dykewicz MS, Gonzalzles A, Grammer LC, Green D, Greenberger PA, et al. erythema mul- tiforme and Stevens-Johnson syndrome. Descriptive and therapeutic controversy. Chest 1990;98:331-6.
14. Dalli RL, Kumar R, Kennedy P, Maitz P, Lee S, Johnson R. Toxic epidermal necrolysis/Stevens- Johnson syndrome: current trends in management. AnZ J Surg 2007;77:671-6.
15. Prendiville JS, Hebert AA, Greenwald MJ, esterly nB. Management of Stevens-Johnson syndrome and toxic epidermal necrolysis in children. J Pediatr 1989;115:881-7.
16. Prins C, Vittorio C, Padilla RS, Hunziker T, Itin P, Förster J, et al. effect of high-dose intravenous immu- noglobulin therapy in Stevens-Johnson syndrome: a retrospective, multicenter study. Dermatology 2003; 207:96-9.
17. Hehenberger K, Brismar K, Lind F, Kratz G. Dose- dependent hyperbaric oxygen stimulation of human fibroblast proliferation. Wound Repair Regen 1997;5:147-50.
18. Hopf HW, Gibson JJ, Angeles AP, Constant JS, Feng JJ, Rollins MD, et al. Hyperoxia and angiogenesis. Wound Repair Regen 2005;13:558-64.
19. Hopf HW, Humphrey LM, Puzziferri n, West JM, Attinger Ce, Hunt TK. Adjuncts to preparing wounds for closure: hyperbaric oxygen, growth factors, skin substitutes, negative pressure wound therapy (vacu- um-assisted closure). Foot Ankle Clin 2001;6:661-82.
20. Mader JT, Brown GL, Guckian JC, Wells CH, Reinarz JA. A mechanism for the amelioration by hyperbaric oxygen of experimental staphylococcal osteomyelitis in rabbits. J Infect Dis 1980;142:915-22.
21. Walden WC, Hentges DJ. Differential effects of oxygen and oxidation-reduction potential on the multiplication of three species of anaerobic intestinal bacteria. Appl Microbiol 1975;30:781-5.
22. Farr SB, Touati D, Kogoma T. effects of oxygen stress on membrane functions in escherichia coli: role of HPI catalase. J Bacteriol 1988;170:1837-42.
23. Hassan HM, Fridovich I. Superoxide radical and the oxygen enhancement of the toxicity of paraquat in escherichia coli. J Biol Chem 1978;253:8143-8.
24. Chen SY, Chen YC, Wang JK, Hsu HP, Ho PS, Chen YC, et al. early hyperbaric oxygen therapy attenuates disease severity in lupus-prone autoimmune (nZB x nZW) F1 mice. Clin Immunol 2003;108:103-10.