A 39-year-old HIV seropositive patient reported with breathlessness, fatigue, fever, and abdominal pain of five days' duration. On general examination the patient was well-oriented and conscious. The past medical history revealed that the patient was diagnosed as HIV seropositive (HIV 1 and 2) two months back. He was being treated for pulmonary tuberculosis (rifampacin 150 mg, isoniazid 300 mg) for the past two months. He was also on topical antibiotics for the past one month for the management of otitis media. Two weeks prior to reporting to us, he was started on HAART (lamivudine 150 mg, stavudine 30 mg and NVP 200 mg) and five days following this he developed mucocutaneous rash. There was no previous history of allergic reaction to drugs. Physical examination revealed generalized skin rashes on the neck and the trunk. Abdominal pain was thoroughly evaluated clinically by the physician. On intraoral examination, there was inflammation of the buccal mucosa and the palate. The labial mucosa was erythematous and tender. Oral Candidiasis (OC) was seen on the palate and the tongue [Figure 5].
The routine laboratory investigations showed an ESR of 49 mm/h, hemoglobin-9.2 g/dl and the differential count showed a raised eosinophil count to 6%. A clinical diagnosis of SJS and NVP-induced hepatitis was made based on the history and clinical presentation. HAART was discontinued and 2 ml dexamethasone (4 mg/ml) was given to manage mucocutaneous rashes and intravenous fluids were also administered. OC was treated with topical clotrimazole. Vitamin supplements were also prescribed.
The patient was subsequently followed and discharged after one week, as his condition was stable. He was advised to continue ATT and vitamin supplements. Two months later ART was initiated with oral lamivudine 150 mg and efavirenz 600 mg, without rechallenge of NVP. A follow-up of the patient for six months confirmed that he was responding to ART and had not developed any drug reaction.