When we left off our discussion of Julie, the ED physician who examined her had detected a targetoid lesion with a necrotic, purpuric center—a finding that we described as a diagnostic clue. The second diagnostic clue? The presence of the Nikolsky sign, which the doctor detected by applying slight pressure to the lesion. Julie was admitted to the hospital with a presumed diagnosis of SJS, which skin biopsies and immunofluorescence studies later confirmed.
It wasn’t clear whether Julie had had a reaction to the sulfa (which she’d completed) or to the penicillin (which she’d just begun taking), or whether she had a synergistic reaction to both. Although the exact cause remained uncertain, as it often does, the penicillin was stopped immediately. She received dermatologic treatment without delay and was monitored closely for fluid and electrolyte status. Since Julie had signs of ocular involvement, daily erythromycin and corticosteroid eyedrops were administered to minimize the risk of infection and reduce local inflammation. Given the risk of long-term ocular complications in patients with SJS, we recommended continued ophthalmologic care.
Nine days after she was admitted, Julie’s symptoms resolved, with the exception of persistent complaints of dry eye. At discharge, Julie was given artificial tears to minimize ocular irritation. We suspected that she had dry eyes because of SJS-induced corneal scarring, but we were unable to confirm our suspicion because our patient failed to return for scheduled ophthalmologic appointments. She was subsequently lost to follow up.
Acknowledgement
The authors wish to thank Azita Hamedani, MD, MPH, FACEP, for her critical editing of the text.
Correspondence Ribhi Hazin, MD, 29 Garden Street, Suite 214, Cambridge, MA 02138; Ribhi.hazin@gmail.com
