Postoperative Stevens-Johnson syndrome secondary to piperacillin-tazobactam: A case report

Abstract

Introduction: Toxic epidermal necrolysis (TEN) and Stevens–Johnson syndrome (SJS) are severe, potentially fatal cutaneous reactions to medications affecting only 1–2 per million individuals each year. They present as tenderness, erythema and blistering of both the skin and mucus membranes. We describe a case of Stevens–Johnson syndrome linked to piperacillin–tazobactam treatment, which is a previously unreported cause and a rare occurrence in postoperative patients. Case Report: A 37­year­old female with chronic pancreatitis post­total pancreatectomy with auto­islet transplant was re­admitted on postoperative day 12 with abdominal pain and leukocytosis. Her workup revealed a small intra­ abdominal fluid collection suspicious for an abscess and she was empirically started on piperacillin–tazobactam. She developed hives on her extremities with associated itching after four days of treatment. Piperacillin–tazobactam was discontinued, diphenhydramine was administered for symptomatic relief, and she was discharged on an oral regimen of ciprofloxacin and metronidazole. She returned the following day with a rash extending onto her chest, abdomen, feet, face, lips and mouth, with newly appeared bullae covering approximately 35–50% of body surface. A skin biopsy was consistent with SJS, with piperacillin–tazobactam identified as the likely causative agent. Conclusion: The most common medications linked to TEN/SJS are sulfonamide antibiotics (especially sulfamethoxazole/trimethoprim), cephalosporins, quinolones, allopurinol, carbamazepine, phenytoin, phenobarbital, and NSAIDs (oxicam­type). While medications the most common cause, mycoplasma pneumoniae and herpes simplex virus (HSV) have also been linked to SJS. The mortality rate of biopsy­ confirmed SJS ranges from 1–5%, whereas the mortality of TEN ranges from 25–35%. Though many patients experience pruritis and/or rashes as side­effects to medications given post­ operatively, it is important to keep in mind more serious reactions such as TEN and SJS as these conditions as they have a substantial associated morbidity and even mortality.