Med League Legal Nurse Consultant was involved in review of a case involving Stevens-Johnson syndrome (SJS) which is a rare, but life-threatening disorder of the skin and mucous membranes. It’s usually a reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters. Then the top layer of affected skin dies, sheds, and begins to heal after several days. Our legal nurse consultant had identified the relation between Cabamazepine as a cause of Stephen-Johnson Syndrome after review of the medical chart of this patient.

Carbamazepine

Symptoms of Stephen-Johnson Syndrome (SJS):

One to three days before a rash develops,  early signs of Stevens-Johnson syndrome may appear, including:

• Fever
• A sore mouth and throat
• Fatigue
• Burning eyes

Stephen-Johnson Syndrome

As the condition develops, other signs and symptoms include:

• Unexplained widespread skin pain
• A red or purple rash that spreads
• Blisters on your skin and the mucous membranes of the mouth, nose, eyes and genitals
• Shedding of skin within days after blisters form

https://www.mayoclinic.org/diseases-conditions/stevens-johnson-syndrome/symptoms-causes/syc-20355936

Seek Medical Care:

Stevens-Johnson syndrome requires immediate medical attention.  Drug-induced reactions may occur during the use of a medication or up to two weeks after discontinuing it.

Causes of Stephen-Johnson Syndrome (SJS):

Stevens-Johnson syndrome is a rare and unpredictable illness. Your health care provider may not be able to identify its exact cause, but usually the condition is triggered by medication, an infection or both. You may react to medication while you’re using it or up to two weeks after you’ve stopped using it.

Drugs that can cause Stevens-Johnson syndrome include:

• Anti-gout medications, such as allopurinol
• Medications to treat seizures and mental illness (anticonvulsants and antipsychotics)

Refer to CASE SPECIFICS

• Antibacterial sulfonamides (including sulfasalazine)
• Nevirapine (Viramune, Viramune XR)
• Pain relievers, such as acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve)

Risk Factors:

• An HIV infection
• A weakened immune system
• Cancer
• A history of Stevens-Johnson syndrome.
• A family history of Stevens-Johnson syndrome
• Genetic factors Refer to CASE SPECIFICS

Case Specific Scenario :

Patient expired on 14^th day after starting Carbamazepine prescribed for trigeminal neuralgia.  Patient expired from sepsis.

• Carbamazepine [Tegretol] is an anticonvulsant medication used in the treatment of epilepsy and neuropathic pain. Severe side effects include serious and sometimes fatal dermatologic reactions [including Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis].
• Failure to screen susceptible individuals for human leucocyte allele B*1502 leads to the onset of SJS. No testing was performed in this case prior to issuing this prescription.
• In 2007, the US Food and Drug Administration issued a post market Alert “Carbamazepine significantly increases the risk of dangerous or even fatal skin reactions [SJS and TEN] in certain patient populations…the allele is almost exclusively found in patients with ancestry across broad areas of Asia, including South Asian Indians.”

The FDA warning is that Carbamazepine is not to be started in those patients carrying the gene unless the benefits clearly outweigh the risks.

How our Legal Nurse Consultants can help Attorneys:

Med League can assist on similar cases where identification of drug related reactions is in question.  Med League has assist attorneys nationwide with similar types of cases for over 30 years.  Contact us today to discuss your next case!