Background & Aims
This case study focuses on acute pain management of rare case of Stevens – Johnson syndrome/Toxic epidermal necrolysis (TEN), who presented to the Emergency Department with severe pain.
Stevens – Johnson syndrome (SJS) is a rare(1) dermatological disorder that causes severe muco-cutaneous responses in the person affected. Although condition is rare but there are significant health hazards to the patient affected by it. This case reports aims to highlight the clinical presentation, management, and outcomes in relation to acute pain management. This case highlights the importance of timely interventions in a multidisciplinary manner to achieve best evidence-based outcomes for patient.
Methods
A 27-year-old male known case of end stage renal disease on regular hemodialysis, presented to Emergency department with severe pain in widespread areas of skin. He had two weeks history of fever of unknown origin with multiple blood cultures coming negative.His antibiotics were changed twice during the course of fever.Within one day of changing his antibiotic to vancomycin he developed generalized erythematous macules and bullae involving widespread areas of his skin. Diagnosis of Stevens – Johnson syndrome/Toxic epidermal necrolysis (TEN) was made by dermatology based on clinical examination and timing of cutaneous reaction. His pain intensity was 10/10 on numeric rating scale.There was widespread distribution of pain in arms and legs. Pain was described as sharp shooting in character with constant burning pins and needle. Patient was already on 25mcg/hr fentanyl patch and 100 mg TID gabapentin from another hospital. Patient was allergic to tramadol.
Results
(MANAGEMENT): Initial plan for pain management included rescue analgesia with intravenous fentanyl boluses of 25 microgram to achieve faster and easily titrated pain relief in acutely severe pain state. Re assessments were done every 5 minutes to repeat further doses of fentanyl IV boluses until his pain score went down to 2/10 intensity. He was moved to intensive care environment where we initiated intravenous fentanyl Patient controlled analgesia, took off his fentanyl patch while continuing gabapentin. Given the predominant neuropathic nature of pain and relative lack of response to strong opioid, he was started on intravenous ketamine infusion(2). We started him on 0.5mg/kg/hr ketamine infusion. He remained on ketamine infusion for 48 hours with dramatic reduction in pain scores (0/10) and improvement in mobility. He experienced mild hallucinations and dissociation with ketamine which was managed with good effect with midazolam boluses.
Conclusions
This case emphasizes the importance of early recognition of diagnosis and swift coordinated medical response to initiate care in an interdisciplinary manner including early involvement of pain team. Healthcare workers should remain vigilant for serious adverse drug reactions. Timely introduction of most suitable pharmacological agent according to type of pain (neuropathic) results in favorable outcomes provided such interventions are carried out in expert hands in suitable clinical environment.
References
1.Hsu DY, Brieva J, Silverberg NB, Silverberg JI. Morbidity and Mortality of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in United States Adults. J Invest Dermatol 2016; 136:1387.
2. Schwenk, E., Viscusi, E., Buvanendran, A., Hurley, R., Wasan , A., Narouze, S., Bhatia, A., Davis, F., Hooten, W., & Cohen, S. (2018). Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Regional anesthesia and pain medicine. https://pubmed.ncbi.nlm.nih.gov/29870457/