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Fitzgerald Health Education Associates, Inc., April 2015 fhea.com
For most drugs, the onset of Stevens-Johnson syn-
drome is a few days to a month after the drug is start-
ed. The reaction usually develops within the first week
of antibiotic therapy, but onset can be up to 2 months
after starting an anticonvulsant. Other causes of
Stevens-Johnson syndrome may include:
• radiation therapy
• herpes virus infection (herpes simplex or herpes
zoster)
• pneumonia
• HIV infection
• hepatitis
Signs and symptoms of Stevens-Johnson syndrome
include:
• widespread erythematous or purpuric macules or
flat atypical targets (Figure 1)
• painful red or purple skin rash that spreads within
hours or days; may look burned and peels off
• blisters on skin, mouth, nose, and/or genitals (Figure 2)
• red, painful, watery eyes
• facial swelling
• tongue swelling
• hives
• skin pain
Several days before the rash develops the patient
may experience fever, sore mouth and throat, fatigue,
cough, and burning eyes. There is usually mucosal in-
volvement, though without actual blisters. Usually at
least two mucosal surfaces are affected, including:
• eyes (conjunctivitis) (Figure 3)
• lips/mouth (cheilitis, stomatitis)
• esophagus, causing difficulty eating
• upper respiratory tract, causing cough and respira-
tory distress
• ulcers of the genital area and urinary tract
• gastrointestinal tract, causing diarrhea
Don't diagnose rashes by telephone
While fully developed Stevens-Johnson syndrome has dis-
tinctive skin signs that are difficult to forget, an early-on-
set Stevens-Johnson rash can look like the more benign
form of dermatitis caused by antibiotics. Even though an
early Stevens-Johnson rash may be indistinguishable from
a more benign rash, a third thing to learn from this case is
to have a patient complaining of rash come to the clinic
rather than attempt to diagnose by telephone.
Become familiar with Stevens-Johnson syndrome
I urge all NPs to put "Stevens-Johnson syndrome" and
"images" into their favorite search engine so that all
NPs are familiar with how that rash and other typical
lesions look.
•
*This case is cited as Huelskamp v. Patients First, 2014 WL
5840020 (Mo. App., November 12, 2014) and was reported in the
Legal Eagle Eye Newsletter, EK Snyder, editor, December 2014.
Carolyn Buppert is an attorney and
nurse practitioner whose law practice
focuses on the legal and business
issues affecting nurse practitioners
and their employers. Her website is
www.buppert.com .
References
DermNetNZ website. Stevens Johnson syndrome & toxic epidermal
necrolysis. Available at http://dermnetnz.org/reactions/sjs-ten.html.
Mayo Clinic website. Stevens-Johnson syndrome. Available at
www.mayoclinic.org/diseases-conditions/stevens-johnson-syndrome/
basics/symptoms/con-20029623.
WebMD.com. Stevens-Johnson syndrome (SJS). Available at
www.webmd.com/skin-problems-and-treatments/stevens-johnson-
syndrome.
Resource
Fitzgerald MAF. Uncommon Drug Reactions: The Zebra in Your
Office.
Online course .
NP Firsts Avoiding Malpractice: A Case Analysis
All NPs should be able to recognize the
potential for and presentation of
Stevens-
Johnson syndrome, as it can be
activated by many medications.
C
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