Stevens-Johnson syndrome (SJS) following switch to Nevirapine based regimen at Baylor-Uganda´s Paediatric Infectious Diseases Clinic, Mulago Hospital
Background: Nevirapine
toxicities have previously been reported in especially older HIV infected
females with high CD4s or recently improved immunity. This is a report on three
patients managed at the Baylor -Uganda.
Methods: Medical records review.
Results: In the January 2009-2010 period, three patients aged: 13 years
(male, initially on Combivir / Efavirenz but switched to Nevirapine due to
excessive drowsiness at 96 weeks); a 22 year old (female, initially on Combivir
/ Efavirenz but switched to Nevirapine because of pregnancy) and a 9 years
(female, initiated on Combivir / Nevirapine). Their CD4 cell counts prior to
SJS were 24 % (447), 17 % (431), 15 % (335) for the 22, 13 and 9 years old
respectively. About 2.5 weeks after starting Nevirapine, they all developed:
high-grade fever, generalized itchy skin rash, swollen red eyes with photo
phobia, and extensive oral sores. They were agitated, febrile, sore mouth,
conjunctivitis, generalized erythematous maculopapular lesions which developed
into vessiculobulous lessions and ulcers 1-3 days later. Laboratory
investigations were fairly normal (alanine transaminases- 24, 52 and 52.3 U/l)
except for raised Gamma-glutamyl transpeptidase (203.8, Normal range
0-60.0) in the 9year old and thrombocytosis (589x109/ ml) plus lymphocytosis
(5.4%) in the 13 year old. All were hospitalized, HAART completely stopped,
treated with intravenous fluids, antibiotics (ceftriaxone/ amoxyclav) for at
least seven days and fed through a nasogastric tube for the 1-3 weeks hospital
period. Steroids were administered in the initial 5 days of hospitalization,
vitamin A given and saline wet gauze placed over the eyes to minimize eye
damage according to the opthalmologist. They are stable on Nevirapine free
HAART.
Conclusions: Stevens-Johnsons syndrome can present in HAART experienced
stable children switching to a Nevirapine based regimen, therefore extra
caution should be taken when switching and close followup done to detect and
promptly manage reactions.
P. Kasirye Gitta1, S. Bakeera-Kitaka2, A. Kekitiinwa1
1Baylor Uganda (PIDC), Kampala, Uganda, 2Makarere University Medical School/Mulago Hospital, Paediatrics and Child Health, Kampala, Uganda