A 50-year-old male, presented with complaints of fever and extensive rashes on the skin of the face and the neck, ulcerations and erythema of the conjunctiva and the oral cavity and difficulty in swallowing, of ten days' duration. The past medical history of the patient revealed that he had been diagnosed with HIV infection (HIV-1) eight months back. He was initiated on HAART therapy (zidovudine 300 mg + lamivudine 150 mg + NVP 200 mg) a month back when the viral load was 1, 09,000 copies/ml. The patient was also on anti-tuberculosis treatment (ATT) (rifampacin 150 mg, isoniazid 300 mg) and vitamin supplements for the past three months. The patient was well-oriented and on examination, had hyperpyrexia, generalized, maculopapular and bullous eruptions on the neck, face and the trunk [Figures 1 and 2]. Intraorally, the patient was completely edentulous and had multiple oral ulcers of the buccal mucosa, soft palate and buccal vestibule. The ulcers were hemorrhagic and tender on palpation. Hemorrhagic erosions were also seen on both the upper and lower lips [Figures 1 and 2]. Ophthalmic examination showed acute conjunctivitis and subconjunctival hemorrhages. There was no history of previous hypersensitivity reaction to drugs. The pruritis involving the oral and the ocular region was followed by vesicles and ulcerations four days after the initiation of HAART therapy.
The laboratory investigations at the time of admission to our referral centre showed a CD4 count of 470 cells/microliter (normal range 200-1347 cells/microliter), total white blood cell (WBC) count was 4860-cells/cu mm (normal range 4000-11000 cells/cu mm), hemoglobin 11.9 g/dl (normal range 12-17 g/dl) and erythrocyte sedimentation rate (ESR) 36 mm/h (normal range 0-14mm/h). The platelet count was 208 x 109/L (normal range 137-367 x 109/L) and random blood glucose was 186 mg/dl (normal range 80-120 mg/dl). Urine analysis and serum chemistry were within normal limits. A chest radiograph of the patient did not show any active tuberculous lesion.
On the basis of the history and clinical presentation a diagnosis of SJS was made. As the first line of treatment HAART was discontinued and the patient was administered intravenous 5% dextrose and 2 ml dexamethasone (4 mg/ml). Supportive therapy with oral topical anesthetic gel (lignocaine 2%) for the oral ulcers was prescribed. The ocular lesions were managed with dexamethasone (0.1%) eye drops and crusting dry lesions were managed with liquid paraffin. The skin and the oral lesions healed over a period of two weeks. The patient was subsequently followed up and after 12 weeks the oral mucosal lesions resolved completely [Figures 3 and 4].