Case_Data_Tables (1) new done.docxgty667777

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1. Case Data Summary Tables
DERMOGRAPHICS (Patient Medical Background)
Age 68 years
Gender Female
Past Medical HistoryHypertension, Atrial fibrillation (on anticoagulation), Heart
failure, Epilepsy, Hyperuricemia
Allergy / Hypersensitivity
History
None reported
Recent New MedicationAllopurinol 100 mg/day (started 8 days before symptoms)
Presenting Symptoms
Exanthema Extensive, painful, maculopapular with bullae
Fever Present
Malaise Present
Myalgia Present
Eye SymptomsBilateral purulent conjunctivitis
Oral LesionsHemorrhagic erosions of oral mucosa
Physical Examination Findings
Face Facial erythema
Eyes Purulent conjunctivitis; corneal involvement excluded
Oral Cavity Hemorrhagic erosions on oral mucosa and palate
Skin Diffuse maculopapular rash with bullae on thorax, hands, and limbs
Respiratory Chest radiograph normal
Coagulation Normal
Renal Function Normal
Other Organ InvolveNone documented

2. Laboratory and Microbiological Evaluation
Blood Culture Ordered (results pending/not stated)
Urine Culture Ordered (results pending/not stated)
Infection Screening Bacterial, viral, fungal, parasitic causes
ruled out
Autoimmune & Neoplastic Workup Ruled out
Treatment and Management
Discontinuation of Allopurinol Yes (suspected cause)
Empirical Antibiotics Amoxicillin/Clavulanate 1200 mg every
8 hours
Fluid Therapy Initiated
Ophthalmology Assessment Corneal involvement excluded
ENT Assessment Hemorrhagic erosions confirmed in oral
mucosa and palate
Lab values Interpretation
Parameter Value Reference Range Interpretation
Hemoglobin12.6 g/dl12–15 g/dl Normal
Leucocytes11.7
×10³/µL
3.5–10.5 ×10³/µLHigh (Leukocytosis)
Platelets99 ×10³/µL150–400 ×10³/µLLow (Thrombocytopenia)
Glucose 169 mg/dl70–100 mg/dl High (Hyperglycemia)
Creatinine2.60 mg/dl0.6–1.2 mg/dlHigh (Renal impairment)
Urea 64 mg/dl 10–40 mg/dl High
AST 28 U/L 0–35 U/L Normal
ALT 32 U/L 0–35 U/L Normal
CRP 7.8 mg/dl<0.5 mg/dl High (Inflammation)
aPTT 24.9 sec 24–35 sec Normal
PT 14.6 sec 14.8–16 sec Clinically acceptable
Discussion

3. Allopurinol is widely used for the management of hyperuricemia due to its efficacy and
affordability. Although generally well tolerated, it can cause adverse drug reactions ranging
from mild rash to severe cutaneous adverse reactions (SCARs), including Toxic Epidermal
Necrolysis (TEN), which occurs in about 2% of treated patients. Risk factors for allopurinol-
induced TEN include high starting dose, renal impairment, concurrent diuretic therapy, early
treatment period, and genetic susceptibility, particularly the HLA-B*58:01 allele.
In this case, the patient was initiated on a low dose of allopurinol (100 mg/day), had normal
renal function, and was not using diuretics, which would usually lower the risk. However,
genetic testing for HLA-B*58:01 was not performed. The onset of symptoms typically occurs
between four days and four weeks after starting the drug, consistent with this patient’s
presentation on day eight of therapy.
TEN is a life-threatening dermatologic emergency characterized by widespread epidermal
necrosis and mucosal involvement. The patient presented with fever, painful erythematous
rash, hemorrhagic oral erosions, conjunctivitis, and extensive blistering. A positive Nikolsky
sign and skin detachment affecting approximately 35% of body surface area supported the
diagnosis.
Disease severity was evaluated using the SCORTEN scoring system, which predicts mortality
based on clinical and laboratory findings. The patient’s SCORTEN score was three,
corresponding to a predicted mortality of approximately 35.8%. Early recognition, immediate
withdrawal of allopurinol, supportive care, and multidisciplinary management were essential
to improving the patient’s prognosis.
SCORTEN score.
SCORTEN: Score of TEN, TEN: Toxic epidermal necrolysis, BSA: Body surface area
Factor Points
Age > 40 years 1
Heart rate > 120/min 1
Underlying malignancy 1
Skin detachment >10% of BSA
on day one
1

4. Serum urea > 28mg/dL (10
mmol/L)
1
Serum bicarbonate < 20 mEq/L
(20 mmol/L)
1
Conclusions
Allopurinol is a common drug used to treat hyperuricemia. It usually has innocent side
Allopurinol is widely used to manage hyperuricemia and is generally well tolerated; however,
in rare cases, it can trigger severe adverse reactions such as toxic epidermal necrolysis (TEN).
TEN is a life-threatening dermatological emergency characterized by extensive skin
detachment and systemic involvement, requiring rapid diagnosis and intensive management.
Prior to initiating allopurinol therapy, it is essential to consider patient-specific risk factors,
including renal impairment and genetic susceptibility. Screening for the HLA-B*58:01 allele
is recommended in high-risk populations to minimize the likelihood of severe cutaneous
adverse reactions. In confirmed cases of allopurinol-induced TEN, early assessment using the
SCORTEN severity score is crucial to predict prognosis and guide treatment decisions.
References