STEVENS-JOHNSON SYNDROME /TOXIC EPIDERMAL NECROLYSIS (SJS/TEN) ON PATIENT IN THE PERITONEAL DIALYSIS PROGRAM Brigitta Udvardi2, László Kovács1,2, Imre Kulcsár1,2 1B. Braun Avitum Hungary Plc Dialysis Centre No.6. Szombathely 2Markusovszky Teaching Hospital, Szombathely, Hungary

SUMMARY We described a case of TEN/SJS which ended lethal – after the treatment of peritonitis of a PD patient. In our opinion the previous antibiotic therapy was responsible for the symptoms – though in the majority of similar cases (15-45%) the root cause remains unknown.

INTRODUCTION We have treated 379 patients in the peritoneal dialysis (PD) program in our dialysis center since 1978. During this time we have not yet met a clinical picture like this.

SUBJECT A case report

CASE HISTORY In the 20th month of her PD treatment, peritonitis was noticed (due to Staphylococcus epidermidis). We gave her 1,5g vancomycin (i.p.) and 2x500mg ciprofloxacin (p.os). After the result of blood culture, ciprofloxacin stopped, we continued the vancomycin therapy (1,5g i.p. every 5 days – the last one on 27.07). The next day she got admitted to hospital due to fever, confusion and sleepiness. On her skin – body and limbs – hyperemic, papulose in places, in other places connected, vesicular exanthema spurred out, but the mucosa (conjuctivae, lips, pharynx, vulva) show signs of inflammation as well. Based on the symptoms there was a possibility for toxic epidermal necrolysis (TEN), and Stevens-Johnson syndrome (SJS). We thought that the efficient cause was the vancomycin therapy. We started a big dose of steroid, IVIG and other antibiotic therapy, and – due to Candida albicans that cultured from the mucosa – she received antifungal treatment too. The skin changes progressed however and the patient lost consciousness on 10.08, and passed away.

The cause of death was sepsis.

1400 1400

650

400

120 120

30 60 633 12 3 3

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

1300

1400

1500

05.07 06.07 07.07 08.07 10.07 11.07 12.07 13.07 17.07 22.07 27.07 28.07 03.08 10.08

Hospitalisa�on 28.07. – 10.08.

Cell/ml

day/month

exitus

Cell’s count in dialysate and vancomycin therapy (i.p. 1,5g )

PATIENT Elderly female patient. Since 2012 she has known to have chronic kidney disease (CKD) due to hypertension. She had rheumatoid arthritis and gout, also. Her CAPD treatment started in 2016.

PHOTOS The photos were made four weeks after her admission to hospital. At this time less than 10% of skin surface was affected, which is called Stevens-Johnson syndrome (SJS). Later on the status of patient has worsened, and the lesions have covered more than 30% of skin surface at her death (that means toxic epidermal necrolysis – TEN).