Post on 18-Feb-2018
7/23/2019 Jurnal Maju
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CARBAMAZEPINE-INDUCED
STEVENS JOHNSON SYNDROME: ACASE SERIES OF THREE CASE
REPORTS
Maria Yosephina
03011176
FK Trisakti
7/23/2019 Jurnal Maju
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PENDAHULUAN
Stevens Johnson syndrom (SJS) dan toxic
epidermal necrolysis (TEN) didefinisikan sebagai
luka lecet yang timbul diatas makula,
merupakan penyakit dengan karakteristik klinis
homogen dan berpotensial menyebabkankematian.
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SJS <10% LBP
TEN >30% LBP
Penyebab tersering: reaksi obat/alergi diantaranya
antikonvulsan (carbamazepine, lamotarigine,
phenobarbital, phenytoin, and asam valproat)
CBZ kejang, trigerminal neuralgia, gangguan
bipolar.Efek samping jangka panjang: mengantuk, ataxia,
vertigo, penglihatan kabur, mual-muntah, intoksikasi
darah (anemia aplastic, dll)
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Angka insidensi CBZ – SJS/TEN 14/100.000
Klinis: eritema, nekrosis, dan pengelupasan
epidermis secara luas, melibatkan mukosa,
gejala sistemik.
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CASE 1
1,5 bulan
lalu
15 hari
pengobatan
10 haripemberian
CBZ
S: Kejang (+)
P:
- Tab. Phenytoin
3x100mg- Tab. Acyclovir
100mg- Tab.Cefixime
Tab.Carbamazepine
2x100mg
S: kulit kemerahan
pada lengan
menjalar cepat ke
seluruh tubuh, nafsumakan <<
O: febrile (101F),
pucat (+), edema (+),
kongesti mata (+),
bibir edema (+)
Perempuan, 18 th, Microcephaly dengan retardasi
mental
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St. Dermatologis:
-lokasi: seluruh tubuh
-UKK: makulopapular, eritema, purpuraP:
CBZ di stop
Cairan infus
Inj. Dexamethasone 12mg (pagi), 4mg (malam) im tapering off oral Tab. Prednisolone stop
Inj. Pantoprazole 2x40mg iv
Antibiotik
Mucain gel 3x Cth2 Tab. Paracetamol 500mg prn
Terapi lokal: Clotrimazole 1% + Beclomethasone 0,01% +
benzocaine 1% + glycerine
10 hari perawatan perbaikan + acc pulang
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Hematologi
Hemoglobin 9,0 g%
Leukosit 32,300
Diff count N45/L23/M2/E30
Trombosit 105/cumm
S. Na 132 mEq/l
S. K 4.9 mEq/l
Fungsi ginjal
Ureum 69 mg/dl
Creatinine 1.4 mg/dlFungsi hati
Alkalin fosfatase 220 IU
SGOT/PT 68 IU/122 IU
Urinalisa
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Figure 1: Carbamazepine induced lesions on forearm
and palm of the 18-year-old female being treated for
epilepsy.
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Figure 2: Drug-induced maculopapular lesions on face
along with swelling lips and face in the 18-year-old
female being treated for epilepsy.
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Figure 3: Maculopapular lesion due to carbamazepine
hypersensitivity of the18-year-old female being treated
for epilepsy.
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CASE 2
3 minggu lalu Saat pemeriksaan
S: plenting di daerah kulit
kepala, dahi, dan kepala
belakang, sensasi terbakar(+)
O: demam naik turun (+),
lesi vesikopapular di scalp,
dahi, regio oksipital
A: Herpes zosterP: Tab. CBZ 1x200mg
(malam)
Inj. Vit B1,6,12.
S: muntah, nyeri uluhati,
gatal seluruh tubuh, bengkak
pada belakang telinga dan
wajah, kulit kemerahan, BAB
warna oranye.
O: BP 128/82, HR 28x/mnt
Limpadenopati inguinal 2-3
nodus limfe, uk 1-3cm ,splenomegali ringan
St. Lokal: lesi berisi cairan
pada wajah kiri, bengkak di
dahi, periorbital bilateral,
tangan kiri
Perempuan, 32 tahun, Herpes Zoster
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A: Reaksi hipersensitivitas terhadap CBZ
P:
Omnacortil 40mg (j.8 pagi pc) dan 20mg (malam)
Tab. Pantoprazole 2x40mg Tab. Hydroxyzine 25mg
Simptoms membaik acc pulang
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Hematologi
Hb 13 g%
Diff count N58/L33/E9/M0/B0
Trombosit 291,000/mm3LED 28mm/jam
Kimia darah
GDS 89 mg%
Ureum/Creatinine 35 mg/dl/0.68 mg/dl
Elektrolit
Na/K 128.8 mEq/l / 4.9 mEq/lRBC normositik normokrom, limfositosis reaktif akibat reaksi
hipersensitivitas terhadap obat, urinalisa dbn, USG: splenomegali ringan.
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Figure 4: Resolving lesions on the forearm and palm of
the patient who was being treated with carbamazepine
for post herpetic neuralgia.
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Figure 5: Healing lesions on forehead of the patient
who was being treated with carbamazepine for post
herpetic neuralgia.
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CASE 3
2 tahun lalu 6 bulan lalu1 bulanpemberianCBZ 3x200mg
Laki-laki, 41 tahun
Orthopedics
Department
nyeri kronik
panggul kiri
dan lutut
Reported to Skin
Department ruam
kemerahan seluruh tubuh,
mulai dari wajah, leher,
dada,punggung, tungkai
bawah, sensasi terbakar(+), gatal (+), demam
menggigil, badan kaku-
kaku
O: BP 108/70, PR: 88x/mnt
Reffered to
Neurologiy
Department
nyeri neuropati
P: Tab. CBZ
2x100mg
2x200mg
3x200mg (1 bln
terakhir)
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St dermatologis:
Lokasi: seluruh tubuh
UKK: eritema, papul
P:
CBZ stop
Cairan infus Inj. Dexamethasone 8mg (pagi), 4mg (malam)
tapering off oral Tab. Omnacortil 40mg (pagi), 20mg
(malam) stop
Inj. Pantoprazole 2x40mg
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Hematologi
Hb 12 mg%
Leukosit 12,000/dl
Diff count N58/L35/E2/M5/B0Kimia darah
S. Na/S.K 135.56 / 4.5 mEq/l
SGOT/PT 186/294 IU
Alk PO4 509 IU
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Figure 6: Maculopapular and target lesions on the
trunk of the patient being treated with carbamazepine
for chronic neuropathic pain.
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Figure 7: Maculopapular and target lesions on the arm
and forearm of the patient being treated with
carbamazepine for chronic neuropathic pain
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Figure 8: Maculopapular and target lesions on the
back of the patient being treated with carbamazepine
for chronic neuropathic pain.
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DISKUSI
CBZ sudah diakui di US sebagai anti kejang
pada 1974, terapi untuk trigerminal neuralgia
sejak 1960.
Konsentrasi terapeurik 6-12 ug/ml (variasi)
Salah satu yang biasa menimbulkan reaksi
hipersensitivitas (SJS)
Meskipun SJS memiliki banyak etiologi, secara
umum dicetuskan oleh infeksi virus dan
neoplasia, paling sering karena penggunaan obat
(allopurinol, antibiotik, anti konvulsan, NSAID.
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Devi et al 7 tahun studi antikonvulsan paling
sering menyebabkan SJS t/u 8minggu pertama
pengobatan, 80% nya CBZ
Meningkatnya pemberian CBZ untuk kontrol nyeri
neuropati dan herpetik dapat menjadi penyebab
meningkatnya insiden SJS.
3 kasus, indikasi CBZ berbeda, memberi reaksi yg
serupa maculopapular rash seluruh tubuh,
hipotermia ringan, eosinofilia, penurunan fungsi hati
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Mekanisme reaksi hipersensitivitas belum jelas.
Wu et al limfosit dan sel-T berproliferasi saatterekspos oleh CBZ.
Proliferasi berlangsung variatif 5 mnt- 4 jam
Manifestasi klinis: demam, maculopapular rash
progresif
Dx ditentukan scr klinis; penunjang: skin biopsy
Prinsip terapi: mengenali dini ruam yang muncul, stop
penggunaan obat yang berkaitan, dan berikan obat
simptomatik.
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