Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are severe cutaneous adverse reactions (SCAR) differentiated by degree of skin detachment. Common triggers include anticonvulsants, sulfonamides, antibiotics (penicillin, cephalosporin, quinolones) and acetaminophen. Reports of clindamycin causing cutaneous complications are rare with only 6 published reports, none of which were reported in the Philippines. Though uncommon, it is an important consideration in patients presenting with erythematous to violaceous purpuric macules that progress to full thickness epidermal exfoliation.

A 59-year-old female who presented with erythematous maculopapular rash on both hands, dry crusted lesions on the mouth and positive Nikolsky sign within 28 days of administration of Clindamycin. Algorithm for assessment of drug causality in SJS and TENS (ALDEN) was done and Clindamycin scored 6 points, which points to a definite drug causality of SJS/TEN.

A female in her late 50s presented with fatigue, malaise, and sore throat. Initially managed as a case of sepsis peritonsillar abscess right but later in the course of admission, presented with erythematous maculopapular rash on both hands and dry crusted lesions on the mouth. Patient was clinically diagnosed with Steven-Johnson syndrome and toxic epidermal syndrome and was given a course of intravenous hydrocortisone. Patient unfortunately expired due to overwhelming sepsis.

Severe cutaneous adverse reaction induced by clindamycin are rare but important life-threatening conditions which needs prompt recognition and treatment. SJS/TEN as a secondary diagnosis leads to a delay in management, therefore a high index of suspicion and the utility of validated scoring tools should be maintained throughout the course of treatment.

Keywords: Steven Johnson Syndrome-Toxic Epidermal Necrolysis Overlap, Clindamycin

1. Fulghum DD, Catalano PM. Stevens-Johnson Syndrome From Clindamycin: A Case Report. JAMA. 1973;223(3):318–319. doi:10.1001/jama.1973.03220030052013
2. Saiag P, Caumes E, Chosidow O, Revuz J, Roujeau JC. Drug-induced toxic epidermal necrolysis (Lyell syndrome) in patients infected with the human immunodeficiency virus. J Am Acad Dermatol. 1992 Apr;26(4):567-74. doi: 10.1016/0190-9622(92)70082-q. PMID: 1597543.
3. Paquet P, Schaaf-Lafontaine N, Piérard GE. Toxic epidermal necrolysis following clindamycin treatment. Br J Dermatol. 1995 Apr;132(4):665-6. doi: 10.1111/j.1365-213 1995.tb08730. x. PMID: 7748763.
4. Meiss F, Helmbold P, Meykadeh N, Gaber G, Marsch WCh, Fischer M. Overlap of acute generalized exanthematous pustulosis and toxic epidermal necrolysis: response to antitumour necrosis factor-alpha antibody infliximab: report of three cases. J Eur Acad Dermatol Venereol. 2007 May;21(5):717-9. doi: 10.1111/j.1468-3083.2006.02026.x. PMID: 17448012.
5. Sahagún Flores JE, Soto Ortiz JA, Tovar Méndez CE, Cárdenas Ochoa EC, Hernández Flores G. Síndrome de Stevens Johnson más colestasis intrahepática inducido por clindamicina o clorfeniramina [Stevens-Johnson syndrome plus intrahepatic cholestasis caused by clindamycin or chlorpheniramine]. Dermatol Online J. 2009 May 15;15(5):12. Spanish. PMID: 19624990.
6. Chan, Benson, & Plemel. (2018, June). A diagnosis of Stevens-Johnson Syndrome (SJS) in a patient presenting with superficial keratitis. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6098186/#bib16
7. Oakley, & Krishnamurthy, K. (2022, August 21). Stevens Johnson Syndrome. National Ceter for Biotechnology. https://www.ncbi.nlm.nih.gov/books/NBK459323/
8. Stern RS, Divito SJ. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: Associations, Outcomes, and Pathobiology-Thirty Years of Progress but Still Much to Be Done. J Invest Dermatol. 2017 May;137(5):1004-100 doi: 10.1016/j.jid.2017.01.003. PMID: 28411832; PMCID: PMC5567821.
9. Bastuji-Garin S, Rzany B, Stern RS, Shear NH, Naldi L, Roujeau JC. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme. Arch Dermatol. 1993 Jan;129(1):92-6. PMID: 8420497.
10. Roujeau, J. C., & Stern, R. S. (1994). Severe adverse cutaneous reactions to drugs. New England Journal of Medicine, 331(19), 1272-1285.
11. Onishi ECC, Roa FDC. Stevens-Johnson syndrome and toxic epidermal necrolysis at the Philippine General Hospital: A seven-year retrospective study (January 2004 to December 2010). 2013. JPDS.
12. Johnson, & Hooper. (n.d.). Clindamycin: An Overview. Uptodate. Retrieved December 16, 2012, from https://www.uptodate.com/contents/clindamycin-an-overview#H1
13. Mockenhaupt M, Viboud C, Dunant A, Naldi L, Halevy S, Bouwes Bavinck JN, Sidoroff A, Schneck J, Roujeau JC, Flahault A. Stevens-Johnson syndrome and toxic epidermal necrolysis: assessment of medication risks with emphasis on recently marketed drugs. The EuroSCAR-study. J Invest Dermatol. 2008 Jan;128(1):35-44. doi: 10.1038/sj.jid.5701033. Epub 2007 Sep 6. PMID: 17805350.
14. Kumar, R., Das, & Das. (2018, March). Management of Stevens-Johnson Syndrome-Toxic Epidermal Necrolysis: Looking Beyond Guidelines! Indian Journal of Dermatology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903040/
15. Creamer D, Walsh SA, Dziewulski P, Exton LS, Lee HY, Dart JKG, Setterfield J, Bunker CB, Ardern-Jones MR, Watson KMT, Wong GAE, Philippidou M, Vercueil A, Martin RV, Williams G, Shah M, Brown D, Williams P, Mohd Mustapa MF, Smith CH. UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016. J Plast Reconstr Aesthet Surg. 2016 Jun;69(6):e119-e153. doi: 10.1016/j.bjps.2016.01.034. PMID: 27287213.
16. Creamer, Walsh, & Exton, L. (2016, June 18). U.K. guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults 2016. Wiley Online Library. https://onlinelibrary.wiley.com/doi/10.1111/bjd.14530
17. Sassolas, B. S., Haddad, C., & Mockenhaupt, M. (2010, April 7). ALDEN, an Algorithm for Assessment of Drug Causality in Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis: Comparison With Case–Control Analysis. Wiley Online Library. https://ascpt.onlinelibrary.wiley.com/doi/full/10.1038/clpt.2009.252
18. Hsu DY, Brieva J, Silverberg NB, Silverberg JI. Morbidity and Mortality of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in United States Adults. J Invest Dermatol. 2016 Jul;136(7):1387-1397. doi: 10.1016/j.jid.2016.03.023. Epub 2016 Mar 30. PMID: 27039263.
19. Nakshabandi, A., Naryanan, A., Nandakumar, & Ajemian. (2018). A Case of disappearing toxic epidermal necrolysis after cessation of cefepime. Open Journal of Clinical & Medical Case Reports. http://jclinmedcasereports.com/articles/OJCMCR-1445.pdf
20. Onishi ECC, Roa FDC. Stevens-Johnson syndrome and toxic epidermal necrolysis at the Philippine General Hospital: A seven-year retrospective study (January 2004 to December 2010). 2013. JPDS.
21. Guégan, S. (2006, February 1). Performance of the SCORTEN During the First Five Days of Hospitalization to Predict the Prognosis of Epidermal Necrolysis. Journal of Investigative Dermatology. https://www.jidonline.org/article/S0022-202X(15)32753-6/fulltext