Case Presentation

DRUG ERUPTION
Preceptor :
dr. Ulynar
Marpaung, Sp.A

UNIVERSITAS YARSI RS SAID SUKANTO

Sri Atika Mayasari Putri 1102011263
Periode Desember 2015 Februari 2016

IDENTITY
Patient

Name
: S.S.
Birth date
: February 2 th 2003
Age
: 13 years old
Gender
: Female
Adress
: Komplek Polri Munjul
Nationality
: Indonesia
Religion
: Moslem
Date of admission : January 25th 2016
Date of examination : January 28th 2016

PARENTS
IDENTITY
Name
Age
Job
Nationality
Religion
Education
Address

Father
Mother
Mr. H
Mrs. N
44 years old
38 years old
Cleaning Service Housewife
Indonesia
Indonesia
Moslem
Moslem
High school
High school
(graduate)
(graduate)
Komplek Polri Munjul RT
009/RW 003

ANAMNESIS
The anamnesis was taken on January 25th 2016, by
autoanamnesis and alloanamnesis (from patient and
patients mother).

Chief complain
rash, itchy in her skin since 4 days before admission to the
hospital.

Additional complain
Fever, dizzy and shiver

History of Present Illness

A 13 years old girl came to Raden Said Sukanto
Police Center Hospital suffering from Rash Itchy
since four days before admission to the hospital.
This complains also followed by intermitten fever
that ever reach normal temperature, patient also
feeling dizzy and shiver since she brought to the
hospital.

History of Present Illness

Patient's mother admitted
that patient got
\
rash in skin since consumption Cefixime 5
days before admission to the hospital, she
also said patient not eat random food before.

History of Present Illness

For the blood test results in emergency
room (25th January 2016) are Hb 14,9 g/dl,
leukocytes 2.700 u/l, hematocrit 41% and
trombocytes 135.000/ul.
On the days of hospital admission, patient
condition was compos mentis, rash, itchy still
exist, and she got fever.

History of Present Illness

On Admission
4 days before
admission
5 days before
admission

Intermittent
fever and
comsumption
Cefixime

Patients
Patients skin skin was
was rash
rash itchy
itchy in her
in her
leg
extremitas,
stomach
and back

History of Past Illness

Pharyngitis
Bronchitis
Pneumonia
Morbili
Pertussis
Varicella
Diphteria
Malaria
Polio
Enteritis

+
+
+
-

Bacillary dysentry
Amoeba dysentry
Diarrhea
Thyphoid
Worms
Surgery
Brain concussion
Fracture
Drug reaction

+
-

Allergic History

The patient have meat Allergy

The patient didn't had cows milk allergy.
The patient didnt have asthma
The patient didnt have allergy to dust,
pollen, etc.

BIRTH HISTORY
Mothers pregnancy history
The mother routinely checked her pregnancy to the hospital. She
denied any problem noted during pregnancy.
Childs birth history
Labor
: Cipto Mangun Kusumo Hospital
Birth attendants : Doctor
Mode of delivery : Pervaginam
Gestation : 38 week
Infant state : Healthy
Birth weight : 3000 grams
Body length : 40 cm

DEVELOPMENT
HISTORY
First dentition

: 6 months

Psycomotor development
Head up
: 1 month old
Smile
: 1 month
Laughing
: 1-2 month old
Slant
: 2,5 month old
Speech initiation
: 5 month old
Prone podition : 5 month old

Prone position : 5 month

old
Sitting
: 6 month old
Crawling : 8 month old
Standing : 1 years old
Walking : 1 years old

Immunization
History of History
Eating

Immunization Frequen
cy

Time

Breast milk: exclusively 6 Months

Formula milk: Bebelac , Pediasure since 6 months old
Hepatitis B 3 times
0,1,6
Baby biscuit: Biscuit Milna and Regal
months old
Fruit and vegetables: Banana, carrots
Polio

4 times

0,2,4,6
months old

BCG

1 time 1 month old

DPT

3 times

2,4,6
months old

Hib

3 times

2,4,6
months old

Measles

1 time

9 months
old

Family History
History of Disease
in
Other
Family
There are no significant
Member
illness or chronic illness
in the family declared.
There is no one living
Patients mother have meat
around their home known
Allergy
for having same
condition as the patient.

Social and Economic History

Patient lived at house with size 30 m x 20 m together with
parents and a brother
There 1 door at the front side,1 toilet near the kitchen and 4
bedrooms, there are 4 windows. The windows are occasionally
opened during the day
Hygiene
The patients mother changes her clothes everyday with clean
clothes.
Bed sheets changed every two weeks.

PHYSICAL EXAMINATION
( JANUARY 10th 2016)

General status
General condition : Mild ill
Awareness
: Compos mentis
Pulse
: 90 x/min, regular, full,
strong
Breathing rate
: 22 x/min
Temperature
: 36 0C

ANTHROPOMETRY
STATUS
Weight : 39 kg
Height : 151 cm
Nutritional status based NCHS
2000
(National Center for Health
Statistic) year 2000
WFA (Weight for Age)
39/45 x 100% = 86 %
HFA (Height for Age)
151/157 x100% = 96 %
Conclusion:

The

nutritional status.

patient

has

good

HEAD TOE EXAMINATION

Head
Normocephaly, hair (black, normal distribution, not
easily removed) sign of trauma (-)
Eyes
Icteric sclera -/-, pale conjuctiva -/-, lacrimation -/-,
pupils 3mm/3mm isokor, direct and indirect light
response ++/++.
Ears
Normal shape, no wound, no bleeding, secretion or
serumen -/ Nose
Normal shape, midline septum, secretion -/-

Head Toe Examination (2)

Mouth
Lips

: Moist

Mucous
Tongue

: Moist

Tonsils
Pharynx

: T1/T1, no hyperemia

: Not dirty
: No hyperemia

Neck
Lymph node enlargement (-), scrofuloderma (-).

Head Toe Examination (3)

Thorax
Inspection : symetric when breathing, retraction (-),
ictus cordis is visible.
Palpation : mass (-), tactile fremitus +/+
Percussion : sonor on both lungs
Auscultation
Cor

: regular S1-S2, murmur (-), gallop (-)

Pulmo : vesicular +/+, wheezing -/-, roncy -/-

Head Toe Examination (4)

Abdomen
Inspection : Convex, epigastric retraction (-), there is
no widening of the veins, no spider nevi, rash (+)
Palpation : supple, liver and spleen not palpable, fluid
wave (-), abdominal mass (-)
Percussion: The entire field of tympanic abdomen,
shifting dullness (-)
Auscultation: normal bowel sound, bruit (-)

Head Toe Examination (5)

Vertebra
There does not appear scoliosis, kyphosis, and lordosis,
do not look any mass along the line of the vertebral
Extremities
Warm,capillary refill time < 2 seconds, rash (+)
Skin
Normal turgor

Neurological Examination
Meningeal sign
Nuchal rigidity

Kernig sign

Lasegue sign

Brudzinski 1

Brudinski 2

MOTORIC EXAMINATION
Power
Hand

5 5 5 5/ 5 5 5 5

Feet

5 5 5 5/ 5 5 5 5

Tonus
Hand

Normotonus / Normotonus

Feet

Normotonus / Normotonus

Trophy
Hand

Normotrophy / Normotrophy

Feet

Normotrophy / Normotrophy

Motoric Examination (2)

Physiologic Reflex

Upper extrimities
Biceps

+/+

Triceps

+/+

Lower extrimities
Patella

+/+

Achilles

+/+

Motoric Examination (3)

Pathologic Reflex
Upper extrimities
Hoffman

-/-

Trommer

-/-

Clonus

Lower extrimities
Babinsky

-/-

Chaddock

-/-

Oppenheim

-/-

Gordon

-/-

Schaeffer

-/-

Patella

-/-

Achilles

-/-

AUTONOM EXAMINATION
Defecation

Normal ( 1-2 times daily)

Urination

Normal ( 4-5 times daily )

Sweating

Normal

LABORATORY INVESTIGATION
HEMATOLOGY JANUARY 25 TH 2016

Hematology

Results

Normal Value

Hemoglobin

14,9

13-16 g/dL

Leukocytes

2.700

5,000

Hematocrytes

41

10,000/L
40 48 %

Trombocytes

135.000

150,000
400,000/L

WORKING DIAGNOSIS
Suspect Drug Eruption, Urtikaria

MANAGEMENT
IVFD RL 24 dpm
Inj. Ceftriaxone 2 x 1 g i.v.
Inj. Rantin 2 x 1 amp i.v.
Inj. Dexamethasone 2 x amp IV
PCT syrp 3 x 1 cth P.O

PROGNOSIS
Quo ad vitam
: dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad bonam

FOLLOW UP

JANUARY 25 2016
TH
JANUARY 28 2016
TH

January 25 th 2016
S : Fever (-)
Dizzy (+)
Rash (+)
Cough (-)
O : General condition : Compos mentis
Blood Pressure
: 110/90 mmHg
Heart Rate : 90x/m
Respiratory Rate : 20x/m
Temperature

: 36 C

Eyes

: Normal

Cardio

: Normal

Pulmonary

: Normal

Extremities

: Rash (+), itchy (+)

A : Susp. Drug Eruption

P : IVFD RL 24dpm

Inj. Ceftriaxone 2 x 1 g i.v.

Inj. Rantin 2 x 1 amp i.v.
PCT syrup 3 x 1 P.O
Calmetasone 2 ml

S.S. (13 yeas old) Day 2

Hematology

Results

Normal Value

Hemoglobin

14,9

13-16 g/dL

Leukocytes

2.700

5,000

Hematocrytes

41

10,000/L
40 48 %

Trombocytes

135.000

150,000
400,000/L

January 26 th 2016
S : Fever (-)
Dizzy (+)
Rash (++)
Cough (-)

Hematology

Results

Normal Value

Hemoglobin

15,6

13-16 g/dL

Leukocytes

4.100

5,000

44

10,000/L
40 48 %

56.000

150,000

Hematocrytes

Trombocytes
O : General condition : Compos mentis
Blood Pressure
: 100/70 mmHg
Heart Rate : 88x/m

400,000/L

Respiratory Rate : 24x/m

Temperature : 36,4 C
Eyes

: Normal

Cardio

: Normal

Pulmonary

: Normal

Extremities

: Rash (+), itchy (+)

A : Drug Eruption, Urtikaria

P : IVFD RL 24dpm

Inj. Ceftriaxone 2 x 1 g i.v.

Inj. Rantin 2 x 1 amp i.v.
PCT syrup 3 x 1 P.O

Consultation with dr. Vitalis

(+) Th/ Dexamethasone 2 amp
(+) if better
2 3 days change to oral
(+) Methyl Prednisolone 1x1 tab

January 27 th 2016
S : Fever (-)
Dizzy (-)
Rash (-)
Cough (-)
O : General condition : Compos mentis
Blood Pressure
: 110/80 mmHg
Heart Rate : 86x/m

S.S. (13 yeas old) Day 4

Respiratory Rate : 24x/m

Temperature

: 36 C

Eyes

: Normal

Cardio

: Normal

Pulmonary

: Normal

Extremities

: Rash (-), itchy (-)

A : Drug Eruption, Urtikaria

P : IVFD RL 24dpm

Inj. Ceftriaxone 2 x 1 g i.v.

Inj. Rantin 2 x 1 amp i.v.
PCT syrup 3 x 1 P.O
Dexamethasone 2 x amp

Hematology

Results

Normal Value

Hemoglobin

14,7

13-16 g/dL

Leukocytes

7.700

5,000

Hematocrytes

42

10,000/L
40 48 %

Trombocytes

81.000

150,000
400,000/L

January 28 th 2016
S : Fever (-)
Dizzy (-)
Rash (-)
O : General condition : Compos mentis
Blood Pressure
: 110/80 mmHg
Heart Rate : 89x/m
Respiratory Rate : 22x/m
Temperature

S.S. (13 yeas old) Day 5

: 36 C

Eyes

: Normal

Cardio

: Normal

Hematology

Results

Normal Value

Pulmonary

: Normal

Hemoglobin

14,5

13-16 g/dL

Extremities

: Rash (-), itchy (-)

Leukocytes

7.700

5,000

Hematocrytes

41

10,000/L
40 48 %

Trombocytes

119.000

150,000

A : Drug Eruption, Urtikaria

P : IVFD RL 24dpm

Inj. Ceftriaxone 2 x 1 g i.v.

Inj. Rantin 2 x 1 amp i.v.
PCT syrup 3 x 1 P.O
Dexamethasone 2 x amp
Methyl Prednisolone 1x1 tab

400,000/L

DRUG ERUPTION
Literature Review

Drug Eruptions

A reaction considered in any patient who is

taking medications and who suddenly develops a
symmetric cutaneous eruption

EPIDEMIOLOG
Y

to occurs in approximately 2-5% of inpatients and in

greater than 1%-3% of outpatients
The serious drug eruptions occur in around 1 in 1000
patients

Drug Reaction mortality : 1.8% percent

Mortality rates for Stevens-Johnson syndrome (SJS)
has a
less than 5%,
whereas the rate for TEN approaches 20- 30%; most
patients die from sepsis

Classification
By appearance
The most common type of eruption is a morbilliform
resembling measles or erythematous rash
By mechanism
The underlying mechanism can be immunological in drug or
non-immunological
By drug
The culprit can be both a prescription drug or an overcounter medication.(antibiotic, analgesic,herbal supplement)

NON - ALLERGIC DRUG REACTION

Over Dose
Side Effects
Cumulative Toxicity
Delayed Toxicity
Facultative Effects
Drug Interaction
Metabolic Changes
Teratogenicity of Fetus
Activation of Effector Pathways
Exacerbation of Diseases
Chromosomal Damage by Drug
Intolerance and Idiosyncrasy
Jarisch herxheimer reaction
Infectious mono - , ampicillin reaction

PATHOPHYSIOLOGY

PATHOPHYSIOLOG
Y
Allergic Reaction
(Immunologic)
less
than 6-10%
Non allergic Reaction (Non
Immunologic) More than . 90%

DRUG ERUPTIONS: CLINICAL APPEARANCE

Drug-induced exanthems
Urticaria
Angioedema/anaphylaxis
Hypersensitivity vasculitis
Exfoliative dermatitis/Erythroderma
Fixed drug eruption

DRUG-INDUCED EXANTHEMS
Account for close to 75% of all drug eruptions.
Morbilliform, maculopapular eruptions.
Most commonly implicated medications are the most
commonly prescribed medications (antibiotics, sulfa).
Usually begin in generalize areas .
Often associated with pruritis, low-grade fever,
eosinophilia.
Onset within 2 weeks of starting a new drug, or
within days of re-exposure.
Delayed (type IV) hypersensitivity is most likely
etiology.
More common in patients with altered immunity,
such as those with HIV or mononucleosis (ampicillin
rash).

Drug-induced
Exanthems

URTICARIA:
Time to onset: immediate, accelerated
(hours), or delayed (days).
Immunological (Type I hypersensitivity
reactions) :antibiotics (especially PCN,
cephalosporins, and sulfonamides), local
anesthetics, radiocontrast media, blood
products, and gamma globulin.
Non-immune urticaria: Mast cell
degranulation by non-IgE mechanisms: opiate
analgesics, anesthetic, muscle relaxants, and
Vancomycin (Red Man Syndrome).

ANGIOEDEMA/ANAPHYLAXIS
May occur along with urticaria (50% of
cases)
Can be life-threatening if it causes laryngeal
edema or tongue swelling.
Can be non-mast cell mediated, as in the
case of ACE-inhibitors.

Angioedema/An
aphylaxis

HYPERSENSITIVITY VASCULITIS(DHS)
American College of Rheumatology proposed the following
five criteria. The presence of three or more had a sensitivity
of 71% and a specificity of 84% for the diagnosis
Age > 16
Use of possible offending drug in temporal relation to
symptoms
Palpable purpura
Maculopapular rash
Biopsy of a skin lesion showing neutrophils around an
arteriole or venule.
Most likely due to drugs that can act as haptens to
stimulate the immune response: PCN, cephalosporins,
sulfonamides, phenytoin, and allopurinol.
Additional findings: fever, urticaria, arthralgias, low
complement (CH50) levels, and elevated ESR .

Hypersensitivity
vasculitis

FIXED DRUG ERUPTIONS

Drug eruption that occurs at the same
location
every
time
a
particular
medication is used.
Begins as an erythematous, edematous
plaque with a grayish center or frank
bullae, then progresses to dark, postinflammatory pigmentation.
Sites include the mouth, genetalia, face,
and acral areas.
Causes
include
phenolphthalein,
tetracyclines, barbituates, sulfonamides,

Fixed drug eruption

DIAGNOSE
1.Anamnesis
2.Physical examination
3.Biopsy e.g. by showing eosinophils in
morbilliform eruptions or numerous neutrophils
without vasculitis
4.CBC count with differential may show
leukopenia, thrombocytopenia, and eosinophilia
in patients with serious drug eruptions

TREATMENT stage
Treatment of a drug eruption depends on the
specific type of reaction
Therapy for exanthematous drug eruptions is
supportive in nature.
First-generation antihistamines are used
mild topical steroids (e.g. hydrocortisone(
moisturizing lotions, especially during the late
desquamative phase

TREATMENT stage
Topical steroids may provide
some relief
If signs and symptoms are
severe, a 2-week course of
systemic corticosteroids
(prednisone, starting at 40- 60
mg) will usually stop the
symptoms and prevent further
progression of the eruption

REFERENCES
Kliegman, R. and Nelson, W. (2007). Nelson textbook of pediatrics.
Philadelphia: Saunders.
Hall, J. and Guyton, A. (2006). Guyton & Hall physiology review.
Philadelphia: Elsevier Saunders.
Kumar, V., Abbas, A., Fausto, N. and Aster, J. (2014). Robbins and
Cotran Pathologic Basis of Disease, Professional Edition. London:
Elsevier Health Sciences.
Tortora, G. and Grabowski, S. (2009). Principles of anatomy and
physiology. New York: Wiley.
Martin, J., Kaul, A. and Schacht, R. (2012). A Manifestation of Immune
Reconstitution Inflammatory Syndrome. PEDIATRICS, 130(3), pp.e710e713.
Vinen, C. (2013).. Postgraduate Medical Journal, 79(930), pp.206-213.
Images provided by the Dermatology Image Atlas - Johns
Hopkins University. http://dermatlas.med.jhmi.edu/derm/

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