(1610) Antimicrobial Stevens-Johnson Syndrome in an ICU Patient With Multisystem Organ Failure and Sepsis

Introduction: Stevens-Johnson Syndrome (SJS) is a rare, life-threatening drug reaction involving severe blistering and desquamation of skin and mucosal surfaces. Early recognition and cessation of inciting agents is crucial for preventing progression and mortality. Other treatments include intravenous immunoglobulin (IVIg), high-dose corticosteroids, and tumor necrosis factor-alpha (TNF-alpha) blockade with etanercept. We report a case of an ICU patient with multisystem organ failure and sepsis due to fungal pneumonia who developed SJS after exposure to voriconazole and cefepime.

Description: A 30-year-old immunosuppressed woman with type 1 diabetes, IgA deficiency, and systemic lupus erythematosus complicated by lupus nephritis presented with subacute malaise, dyspnea, and dry cough. She developed acute hypoxic respiratory failure requiring intubation and ICU admission. Imaging revealed pulmonary cavitations; she was treated empirically with cefepime but was later found to have aspergillus fungal pneumonia and switched to voriconazole. She had a prolonged ICU stay due to continued respiratory and acute renal failure, requiring dialysis. On hospital day 17, she developed blistering lesions, progressing to extensive skin desquamation and mucosal involvement. SJS was confirmed on biopsy. Based on the algorithm for assessment of drug causality in epidermal necrolysis (ALDEN), cefepime and voriconazole were identified as probable inciting agents and replaced immediately with meropenem and amphotericin B. Treatment for SJS was initiated with IVIg, methylprednisolone, and etanercept, along with expansive wound care measures. Her SJS progressed from 9% of total body surface area (BSA) to 25% BSA, and she was transferred to the nearest burn unit for a higher level of specialized care.

Discussion: Early diagnosis and prompt discontinuation of inciting agents, alongside supportive care, are vital in SJS management. Treatments such as IVIg and corticosteroids are controversial but may be considered in the acute phase. Etanercept is a new approach but carries risks, especially in immunocompromised patients and those at risk of disseminated fungal infection such as the subject of this case. Mortality can be predicted with validated SJS scoring systems, such as Score of TEN (SCORTEN) or ABCD-10.