toxic epidermal necrolysis ( ten ) is a rare life threatening idiosyncratic mucocutaneous drug reaction characterized by widespread epidermal necrosis followed by epidermal detachment .
drug - induced ten is the commonest cause and antiepileptics , antibiotics , nonsteroidal anti - inflammatory drugs ( nsaids ) and allopurinol are the most commonly implicated agents . here
we report a case of ten which was induced by multiple drugs some of which have been rarely implicated in the causation of ten .
a 42-year - old woman was referred to medical emergency with extensive epidermal detachment and ocular , genital , and oral lesions of 5 days duration leading to a diagnosis of toxic epidermal necrolysis ( ten ) .
seven days prior to this admission , she had presented to a general practitioner with symptoms of vertigo , anxiety , and restlessness . although no provisional or differential diagnosis was found in the documents provided by the patient , she was prescribed antihistamines ( cinnarizine and dimenhydrinate ) , paracetamol / metoclopramide combination and multivitamins .
after 8 - 12 hours , she developed fever , malaise , sore throat , and erythematous maculopapular rash in the perioral region .
she discontinued all medications and was admitted to a general hospital where she was administered piperacillin / tazobactam and dexamethasone . it is unknown whether paracetamol or antihistamines were restarted in the hospital .
her condition deteriorated and she was referred to our hospital . on presentation , she was conscious and afebrile ; her heart rate was 110/min and blood pressure was 190/80 mm hg .
cutaneous examination showed involvement of about 70% total body surface area , with skin necrosis , tenderness , and a positive nikolsky 's sign .
she had a history of hypertension and was on some antihypertensive medication ( unknown ) for a few years .
test reports at three time - points she was administered intravenous fluids , antihypertensive treatment ( amlodipine 5 mg / day ) , injection hydrocortisone ( 50 mg iv twice daily ) , and continued on the same antibiotics .
wound care was given by applying topical antiseptics on eroded areas along with nonadherent dressings .
biochemical reports showed a decrease in blood urea ( from 68 mg / dl on admission to 57.6 mg / dl on the second day after admission ) and a decrease in serum creatinine ( from 1.1 meq / l on admission to 0.78
parenteral therapy was gradually replaced by oral drugs . on the fourth day , she developed herpetic lesions on the oral mucosa and for that tablet acyclovir was advised thrice a day along with chlorhexidine mouthwash , syrup mucaine gel ( antacid ) , and white petroleum jelly for lips . a tzanck smear , done on fifth day after admission , failed to show any giant cells or acantholytic cells ( acc ) [ table 1 ] . this test was done to rule out pemphigus .
the patient showed steady improvement with the therapy given and was discharged , after 8 days , without any sequelae .
this is most likely a case of drug - induced ten as other causes like upper respiratory tract infection , viral infection , or malignancy were not present .
as this was an acute presentation , which occurred right after the drugs were administered , systemic lupus erythematosus ( sle ) and rheumatological disorders were ruled out .
ten was diagnosed from the history and typical clinical features and biopsy was not needed .
the prodrome was shorter ( 8 - 12 hrs ) than the usual 1 - 3 days .
this might have been due to the use of multiple drugs causing an unknown interaction or more likely due to a previous exposure to any or all of these drugs .
causality assessment was done for each of the drugs separately by the method of kramer et al .
paracetamol and metoclopramide were categorized as probable ( score 5 ) and antihistamines and multivitamins as possible ( score 3 ) causal drugs for this adverse drug reaction .
since this drug intake was uneventful for a long time , the chances of this medication causing this episode of ten are minimal .
there have been two case reports of ten caused by paracetamol and a case control study showing increased risk of sjs or ten with paracetamol use .
there have been no case reports of ten due to a combination of both the drugs , nor have there been any reports regarding ten being caused by antihistamines or multivitamins .
however , the probability of other drugs being responsible could not be ruled out completely .
ten in this patient was probably caused by paracetamol and metoclopramide , but a possibility of an interaction as well as the role of other drugs can not be ruled out .
 toxic epidermal necrolysis ( ten ) and steven - johnson syndrome ( sjs ) are serious disorders commonly caused as idiosyncratic reactions to drugs , the most common ones being oxicams , anticonvulsants , allopurinol , and sulfonamides . 
 we present a case of ten in a patient who developed the lesions after ingesting multiple drugs including paracetamol , metoclopramide , antihistamines , and multivitamins . 
 these drugs have rarely been implicated in this disorder . 
 the suspected drugs in this case were paracetamol and metoclopramide . 
 however , the role of other drugs could not be ruled out definitely . 
 the patient was managed with antibiotics , corticosteroids , and parenteral fluids and recovered well . 
Introduction
Case Report
Discussion
Conclusion