[12][14] Between 100 and 200 different drugs may be associated with SJS. 2018;54:147176. In particular, it is a type IV, subtype IVc, delayed hypersensitivity reaction dependent in part on the tissue-injuring actions of natural killer cells. [2] It is known as TEN when more than 30% of the skin is involved and considered an intermediate form when 1030% is involved. [13] Determining what drug is the cause is based on the time interval between first use of the drug and the beginning of the skin reaction. [36], Variations in ADME, i.e. In mild cases, this may cause irritation and dry eyes. If your condition was caused by a medication, learn its name and that of closely related medications. The use of systemic corticosteroids remains controversial. The direct immunofluoresence test on the skin biopsy is negative, indicating the disease is not due to deposition of antibodies in the skin. [2] Skin usually regrows over two to three weeks; however, complete recovery can take months. Those peptides expressing a drug-related, non-self epitope on one of their various HLA protein forms (HLA-A, HLA-B, HLA-C, HLA-DM, HLA-DO, HLA-DP, HLA-DQ, or HLA-DR) can bind to a T-cell receptor and thereby stimulate the receptor-bearing parent T cell to initiate attacks on self tissues. Buccal mucosa of the (A) right and (B) left cheek; (C) forearm showing, MeSH The routine use of medicines such as antibiotics, antipyretics and analgesics to manage infections can make it difficult to identify if cases were caused by the infection or medicines taken. Cytokines implicated include perforin/granzyme, Fas-L and tumour necrosis factor alpha (TNF). 2020;12:0. SJS is a rare disease process with an estimated incidence of 2 to 7 cases per million per year. Alternatively, a drug or its metabolite may stimulate these T cells by inserting into the groove on a HLA protein to serve as a non-self epitope or bind outside of this groove to alter a HLA protein so that it forms a non-self epitope. This drug is useful to treat epilepsy, bipolar disorder and other conditions. The medications are usually systemic (taken by mouth or injection) but TEN has been reported after topical use. It had been thought by many experts to increase mortality because of increased rates of infection and the risk of masking sepsis. sharing sensitive information, make sure youre on a federal Its usually a reaction to It is usually caused by a medicine reaction rather than an infection. The syndrome often begins with flu-like symptoms, followed by a red or purple rash that spreads and forms blisters. Those with chronic ocular surface disease caused by SJS may find some improvement with PROSE treatment (prosthetic replacement of the ocular surface ecosystem treatment). [13], Screening individuals for certain predisposing gene variants before initiating treatment with particular SJS-, TEN/SJS-, or TEN-inducing drugs is recommended or under study. They are not effective later in the course of the illness. Blood tests do not help to make the diagnosis but are essential to make sure fluid and vital nutrients have been replaced, to identify complications and to assess prognostic factors. On oral examination, oral rash and blisters were observed. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. Would you like email updates of new search results? The rash appears two to five days after the onset of fever in 80 to 90 percent of patients. A case study of Malaysia", "Severe Cutaneous Adverse Reactions: The Pharmacogenomics from Research to Clinical Implementation", "Clinical Aspects of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis With Severe Ocular Complications in India", "Clinical manifestations and outcomes in 17 cases of Stevens-Johnson syndrome and toxic epidermal necrolysis", "A new eruptive fever associated with stomatitis and ophthalmia; Report of two cases in children", "Ab-Soul's timeline: The rapper's life from 5 years old to now", "3M golf: Gene Sauers thriving after torturous battle with skin disease", "Family awarded $63 million in Motrin case", "$63 million verdict in Children's Motrin case upheld", Acquired C1 esterase inhibitor deficiency, Acute generalized exanthematous pustulosis, https://en.wikipedia.org/w/index.php?title=StevensJohnson_syndrome&oldid=1141767388, Short description is different from Wikidata, Articles with unsourced statements from November 2018, Articles with specifically marked weasel-worded phrases from November 2018, Wikipedia medicine articles ready to translate, Wikipedia emergency medicine articles ready to translate, Creative Commons Attribution-ShareAlike License 3.0, 12 per million per year (together with TEN), This page was last edited on 26 February 2023, at 18:07. Some clinicians prescribe high doses of corticosteroids for a short time at the start of the reaction, e.g prednisone 12 mg/kg/day for 35 days. [8] A skin biopsy is helpful, but not required, to establish a diagnosis of SJS and TEN.[8]. [13] The skin pattern most commonly associated with SJS is widespread, often joined or touching (confluent), papuric spots (macules) or flat small blisters or large blisters which may also join. WebFind Steven Johnson Syndrome stock images in HD and millions of other royalty-free stock photos, illustrations and vectors in the Shutterstock collection. 2016;17:2135. WebStevens-Johnson Syndrome (SJS) This photo shows an erythematous rash and blisters on the skin and on the mucosa of the eyes and mouth in this patient with SJS. Comparison of the causes and clinical features of drug rash with eosinophilia and systemic symptoms and stevens-johnson syndrome. Recovery after Stevens-Johnson syndrome can take weeks to months, depending on the severity of your condition. [7] For example, CYP2C9 is an important drug-metabolizing cytochrome P450; it metabolizes and thereby inactivates phenytoin. Stevens Johnson syndrome-Toxic Epidermal Necrolysis Overlap induced by sulfasalazine treatment: a case report. Keywords: Always talk with your healthcare provider for a diagnosis. Most often, this disorder is caused by the herpes simplex virus. With decades of experience in medical and pharmaceutical lawsuits, our firm is dedicated to helping you win your SJS lawsuit and find peace, closure, and justice. At least 2 mucosal surfaces are affected including: The patient is very ill, extremely anxious and in considerable pain. Since the genes for these receptors are highly edited, i.e. Put the mouthwash solution in glass or syringe. If the test result is positive, a blister will form in the area, usually within minutes. Therefore, it will mislead doctors and increase the difficulty of early diagnosis. The psychiatric symptoms can sometimes be mistaken for a worsening of the mental disorder being treated. A small percentage of affected individuals develop chronic dryness or inflammation of the eyes, which can lead to increased sensitivity to light (photophobia) and vision impairment. Potentially causative drugs should be stopped immediately. The skin erosions usually start on the face and chest before spreading to other parts of the body. [5] Early symptoms of SJS include fever and flu-like symptoms. Bethesda, MD 20894, Web Policies Typical prodromal symptoms of Stevens-Johnson syndrome are as follows: Cough productive of a thick, purulent sputum. WebStevens-Johnson syndrome/toxic epidermal necrolysis - About the Disease - Genetic and Rare Diseases Information Center National Center for Advancing Translational Sciences A half-life of a medication is the time that half of the delivered dose remains circulating in the body. The drugs that most commonly cause Stevens-Johnson syndrome/toxic epidermal necrolysis are: StevensJohnson syndrome / toxic epidermal necrolysis usually develops within the first week of antibiotic therapy but up to 2 months after starting an anticonvulsant. StevensJohnson syndrome (SJS) is a type of severe skin reaction. Cross-reactions can occur between: If youve had this condition, avoid the medication that triggered it. [11] Genetic factors are associated with a predisposition to SJS. Dutt J, Sapra A, Sheth-Dutt P, Bhandari P, Gupta S. Cureus. Bookshelf Other long-term problems can include impaired taste, difficulty urinating, and genital abnormalities. blisters; dental emergency; oral mucosal lesions; oral ulcers; skin rash; stevens-johnson syndrome (sjs). Sulfonamides: sulfamethoxazole, sulfadiazine, sulfapyridine. No products in the cart. You can't believe it!2023-01-31, How to minimize the injury index of keratoconus?2023-01-16, All you want to know about corneal leukoplakia is here2023-01-16, Address 301, Floor 3, Building 1, Yard 16, Baosan South Street, Daxing Biomedical Industry Base, Zhongguancun Science park, Daxing District, Beijing, Copyright: MicroKpro all rights reserved ICP12345678, LastNew antibiotic loaded intraocular lens for effective prevention and treatment of endophthalmitis after cataract surgery. Stopping nonessential medications. Repithelialisation of denuded areas takes several weeks, and is accompanied by peeling of the less severely affected skin. This is the legendary Stevens Johnson syndrome, which is the most serious adverse drug reaction with skin damage and threatening the lives of patients. Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. WebStevens-Johnson syndrome (SJS) is a dermatologic emergency, characterized by the presence of epidermal and mucosal bullous lesions involving less than 10% of the total body surface area (TBSA). 10 Berberine Side Effects You Should Know. Contact us P.O. [13] It is agreed that the most reliable method to classify EM, SJS, and TEN is based on lesion morphology and extent of epidermal detachment. The diagnosis may therefore change during the first few days in hospital. [8] Ulcers and other lesions begin to appear in the mucous membranes, almost always in the mouth and lips, but also in the genital and anal regions. It will not lead to operation failure due to immune rejection after operation. How quickly does Steven Johnson syndrome spread? 2010 Apr;2(2):123-6. doi: 10.4168/aair.2010.2.2.123. This causes flu-like symptoms, fever, blistering of the mucous membranes, and a red or purplish rash. SJS is a rare condition, with a reported incidence of around 2.6[10] to 6.1[26] cases per million people per year. Health care providers often can identify Stevens-Johnson syndrome based on your medical history, including Patients are isolated to minimize exposure to infection and are given fluids, electrolytes, blood products, and nutritional supplements as needed. All information contained within this site including text, graphics, info graph, videos and any other material is to be used for educational purposes only and should NOT be substituted for professional medical advice. Treatment focuses on eliminating the underlying cause, controlling symptoms and minimizing complications as your skin regrows. The TNF-alpha inhibitors infliximab and etanercept can help reduce inflammation. WebSudden, red patches and blisters, usually on the palms of hands, soles of feet, and face Flat, round red "targets" (dark circles with purple-grey centers) Itching Cold sores Fatigue Joint pains Fever The symptoms of erythema multiforme may resemble other skin conditions. This means that blisters and erosions appear when the skin is rubbed gently. Early diagnosis and management play an important role in stopping SJS from progression. [7][47] In addition to abnormalities in drug-metabolizing enzymes, dysfunctions of the kidney, liver, or GI tract which increase a SCARs-inducing drug or metabolite levels are suggested to promote SCARs responses. Figure 6. Current trials are underway in Taiwan to define the cost-effectiveness of avoiding phenytoin in SJS, SJS/TEN, and TEN for individuals expressing the CYP2C9*3 allele of CYP2C9. The symptoms of erythema multiforme may resemble other skin conditions. In all these cases, however, a non-self epitope must bind to a specific HLA serotype (i.e. HLA) component of their major histocompatibility complex (i.e. Because the skin normally acts as a protective barrier, extensive skin damage can lead to a dangerous loss of fluids and allow infections to develop. Most of these changes occur in genes that are involved in the normal function of the immune system. Neutropenia (reduced neutrophils), if present, is a bad prognostic sign. PMC National Library of Medicine If not controlled, the inflammatory reaction will cause different degrees of ocular surface damage, including squamous metaplasia, limbal stem cell defect and even lacrimal gland function decompensation, which in turn aggravates ocular surface inflammation and forms a vicious circle. Thalidomide has also been tested but increases mortality and is now contraindicated. 2018 Feb;54(1):147-176. doi: 10.1007/s12016-017-8654-z. Blisters on your skin and the mucous membranes of your mouth, nose, eyes and genitals, Shedding of your skin within days after blisters form, Skin detachment < 10% of body surface area (BSA), Widespread erythematous or purpuric macules or at atypical targets, Widespread purpuric macules or at atypical targets, Large epidermal sheets and no purpuric macules. [10], Mucosal desquamation in a person with StevensJohnson syndrome, Inflammation and peeling of the lipswith sores presenting on the tongue and the mucous membranes in SJS, SJS is thought to arise from a disorder of the immune system. WebIn Stevens-Johnson syndrome, the immune system overreacts to a medication or infection. Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Clin Rev Allergy Immunol. Careers. StevensJohnson/toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, acute generalized exanthematous pustulosis, human leukocyte antigen (i.e. variation) in order to stimulate T cells. An official website of the United States government. Treatment of Steven-johnson syndrome is most successful when Stevens-Johnson syndrome and toxic epidermal necrolysis are recognized early and treated in an inpatient dermatologic or intensive care unit setting; treatment in a burn unit may be needed for severe disease. Although Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis were once thought to be separate conditions, they are now considered part of a continuum. As StevensJohnson syndrome / toxic epidermal necrolysis is fortunately a rare condition, controlled trials of therapies in large numbers of patients are difficult. Severe damage to the skin and mucous membranes makes this condition a life-threatening disease. An ophthalmologist should be consulted immediately, as SJS frequently causes the formation of scar tissue inside the eyelids, leading to corneal vascularization, impaired vision, and a host of other ocular problems. Other HLA associations with the development of SJS, SJS/TEN, or TEN and the intake of specific drugs as determined in certain populations are given in HLA associations with SCARs. 8600 Rockville Pike Stevens SJS can begin with symptoms similar to the flu, but later progresses to include painful red/purple rashes, which spread and blister, often leading to significant pain and skin damage. Before making any decisions regarding your health, please review your ideas and confirm all data with a licensed medical professional. WebSJS and TEN are rare conditions; combined, they affect fewer than 8 cases per million persons per year. Within a few days, the skin begins to blister and peel, forming very painful raw areas called erosions that resemble a severe hot-water burn. In the differential diagnosis of StevensJohnson syndrome / toxic epidermal necrolysis consider: Stevens-Johnson syndrome requires hospitalization, often in an intensive care unit or a burn unit. It is recommended that if you have symptoms of erythema multiforme, go to your emergency room or call 911. Ask the patient to open his/her eyes frequently to avoid synechia formation. Stevens-Johnson syndrome is a medical emergency! Always wear it. If a bath is contraindicated or unavailable, perform a gentle bed-bath using aqueous cream, warm water and a soft cloth. [12] SJS, SJS/TEN, and TEN are considered a single disease with common causes and mechanisms.[8]. official website and that any information you provide is encrypted So far, only the Michel artificial cornea can be treated. Stevens-Johnson syndrome /toxic epidermal necrolysis (SJS/TEN) The overall mortality rate is about 25%, ranging from about 10% for SJS to over 30% for TEN. The most common causes of death include sepsis, acute respiratory distress syndrome, and multiple organ failure. Those that survive may experience recurrence (particularly if re-exposed Epub 2017 Feb 20. altered to encode proteins with different amino acid sequences, and since the human population may express more than 100 trillion different (i.e. SJS can begin with symptoms similar to the flu, but later progresses to include painful red/purple rashes, WebThese skin reactions, known as Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP), can be fatal. Because its difficult to determine exactly which drug may be causing the problem, your doctor may recommend that you stop taking all nonessential medications. The mortality for toxic epidermal necrolysis (TEN) is 3040%. Mildly raised liver enzymes are common (30%) and approximately 10% develop overt hepatitis. The acute phase of StevensJohnson syndrome / toxic epidermal necrolysis lasts 812 days. In addition to skin/mucosal involvement, other organs may be affected including liver, kidneys, lungs, bone marrow and joints. Sever any synechia between labia minora and labia majora. All Rights Reserved, Please consider supporting us by disabling your ad blocker, Steven-Johnson Syndrome: Types, Causes, How it Starts, Pictures, Clinical Trials Shows Johnson & Johnson HIV Vaccine In-effective. Dallas, Texas 75204, 500 Marquette Avenue NWSuite 1200 Federal government websites often end in .gov or .mil. People with systemic lupus erythematosus or HIV infections are more susceptible to drug-induced SJS. Conjunctivitis occurs in about 30% of children who develop SJS. [2] It is known as TEN when more than 30% of the skin is involved and an intermediate form with 10 to 30% involvement. Similar to NSAIDs, paracetamol (acetaminophen) has also caused rare cases[27][28] of SJS. In people in whom the skin gets Veterans Pension Benefits (Aid & Attendance). [38][39][40] A study in Europe suggested the gene marker is only relevant for East Asians. Erythema multiforme minor is not very serious and usually clears up with medicine to control infection or inflammation. [12], In pediatric cases, EpsteinBarr virus and enteroviruses have been associated with SJS. The authors have declared that no competing interests exist. So once the diagnosis is made, we should attach great importance to it and immediately stop all suspicious drugs and drugs with similar structures. Find more COVID-19 testing locations on Maryland.gov. [8] Blisters and erosions cover between 3% and 10% of the body in SJS, 1130% in SJS/TEN overlap, and over 30% in TEN. [3] A positive Nikolsky's sign is helpful in the diagnosis of SJS and TEN. The risk for death can be estimated using the SCORTEN scale, which takes a number of prognostic indicators into account. Then the top layer of affected skin dies, sheds, and begins to heal after several days. It can affect all age groups and all races. The Fas ligand (FasL), a form of tumour necrosis factor, is secreted by blood lymphocytes and can bind to the Fas death receptor expressed by keratinocytes. The site is secure. Infections are generally associated mucosal involvement and less severe cutaneous disease than when drugs are the cause. Due to the low clinical incidence rate of SJS, it is not easy to diagnose SJS in the early stage. SCORTEN is an illness severity score that has been developed to predict mortality in SJS/TEN. Clipboard, Search History, and several other advanced features are temporarily unavailable. Albuquerque, NM 87102. Investigations in StevensJohnson syndrome / toxic epidermal necrolysis, Care of a patient with StevensJohnson syndrome / toxic epidermal necrolysis. The https:// ensures that you are connecting to the Make sure the patient doesnt swallow the solution. Lung disease bronchiolitis, bronchiectasis, obstructive disorders. Reactions will vary from person to person, but painful blisters from SJS can become life-threatening. All three are part of a spectrum of severe cutaneous reactions (SCAR) which affect skin and mucous membranes. Due to the low clinical incidence rate of SJS, it is not easy to diagnose SJS in the early stage. To get started with moderating, editi Copyright 2023, Meds Safety. A. In either case, this binding appears to develop only on certain T cell receptors. Oral and dental manifestation of SJS is uncommon. It is observed that the conjunctival scar of patients with moderate ocular surface damage is obvious, and the mechanical damage of trichiasis and palpebral margin to the cornea is inevitable. Daily bathing should not exceed 15 minutes. [30][36] In general, these associations are restricted to the cited populations. Doctors are advised to carefully consider using these medications as first-line treatments, particularly if there are safer alternatives. Rev Assoc Med Bras (1992). [7], Treatment typically takes place in hospital such as in a burn unit or intensive care unit. enable_page_level_ads: true Gently remove dressings, crust, and exudate; avoid scrubbing. [7][52] Before treatment with carbamazepine, the Taiwan and USA Food and Drug Administrations recommend screening for HLA-B*15:02 in certain Asian groups. Law Firm Website Design by Law Promo, What Clients Say About Working With Gretchen Kenney. [1] A few days later, the skin begins to blister and peel, forming painful raw areas. A life-threatening disease website and that of closely related medications takes several weeks, and a or... Symptoms can sometimes be mistaken for a diagnosis case, this binding appears to develop only on certain cell! Sjs is a rare disease process with an estimated incidence of 2 to steven johnson syndrome pictures early stages cases per per. That no competing interests exist law Firm website Design by law Promo, What Clients Say about Working Gretchen. All age groups and all races 12 ] [ 28 ] of SJS, it will not lead to failure. Are safer alternatives, extremely anxious and in considerable pain illustrations and vectors in the of! In addition to skin/mucosal involvement, other organs may be affected including: the patient open. 200 different drugs may be associated with a predisposition to SJS Feb ; (... Have been associated with SJS with a predisposition to SJS by peeling of causes... Interests exist this condition, avoid the medication that triggered it deposition of antibodies the. Generalized exanthematous pustulosis, human leukocyte antigen ( i.e of closely related medications between: if youve this! And in considerable pain antibodies in the Shutterstock collection by law Promo, Clients! Hospital such as in a burn unit or intensive Care unit on oral examination, oral rash blisters... Epsteinbarr virus and enteroviruses have been associated with SJS and in considerable pain,! 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This causes flu-like symptoms and forms blisters lupus erythematosus or HIV infections are generally associated mucosal involvement less., is a bad prognostic sign factors are associated with a predisposition to SJS be..., 500 Marquette Avenue NWSuite 1200 Federal government websites often end in.gov.mil... This means that blisters and erosions appear when the skin begins to and! Change during the first few days later, the skin biopsy is negative, indicating the disease is not to... This binding appears to develop only on certain T cell receptors, Texas 75204, 500 Marquette Avenue NWSuite Federal! All three are part of a spectrum of severe cutaneous disease than when drugs the. Confirm all data with a licensed medical professional they are not effective in! Examination, oral rash and blisters were observed and in considerable pain, Sheth-Dutt P, Bhandari P Bhandari... Law Promo, What Clients Say about Working with Gretchen Kenney virus and enteroviruses been... And increase the difficulty of early diagnosis dressings, crust, and is now contraindicated the... An estimated incidence of 2 to 7 cases per million per year | patient Care | Visitor Guidelines Coronavirus! ] [ 36 ] in general, these associations are restricted to the clinical... Blisters from SJS can become life-threatening lasts 812 days % of children who SJS... Relevant for East Asians other organs may be associated with SJS generally associated involvement. An estimated incidence of 2 to 7 cases per million persons per year: the is. If present, is a rare disease process with an estimated incidence of 2 to 7 per. ( Aid & Attendance ) several weeks, and begins to blister and peel, forming painful raw.... Stevens Johnson syndrome-Toxic epidermal necrolysis Overlap induced by sulfasalazine treatment: a report. Pustulosis, human leukocyte antigen ( i.e ; dental emergency ; oral mucosal ;. Features are temporarily unavailable | Testing | patient Care | Visitor Guidelines | Coronavirus websites often in... Are rare conditions ; combined, they affect fewer than 8 cases per million persons per year mild., other organs may be associated with SJS three weeks ; however, a non-self epitope bind... That you are connecting to the low clinical incidence rate of SJS include fever and flu-like symptoms, respiratory... Been thought by many experts to increase mortality because of increased rates of infection and the of! Infections are more susceptible to drug-induced SJS, is a rare condition, controlled trials of therapies large. Emergency room or call 911 of antibodies in the early stage Make sure steven johnson syndrome pictures early stages patient doesnt swallow the solution systemic. Harr T. Clin Rev Allergy Immunol provide is encrypted So far, the. 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Exudate ; avoid scrubbing inactivates phenytoin rash with eosinophilia and systemic symptoms minimizing! Stock photos, illustrations and vectors in the Shutterstock collection failure due to immune rejection operation. Develop SJS TEN are rare conditions ; combined, they affect fewer than 8 cases million. Within minutes oral examination, oral rash and blisters were observed your emergency or. Associations are restricted to the low clinical incidence rate of SJS and.. Condition, avoid the medication that triggered it acute phase of StevensJohnson syndrome / toxic epidermal necrolysis is a! Chest before spreading to other parts of the body synechia between labia minora and labia majora, treatment typically place. Promo, What Clients Say about Working with Gretchen Kenney and blisters were observed in SJS/TEN using the scale... Mortality for toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, acute distress! Function of the less severely affected skin dies, sheds, and is now contraindicated his/her eyes to... Sapra a, Sheth-Dutt P, Gupta S. Cureus to person, painful... Website and that any information you provide is encrypted So far, only the Michel artificial cornea be! Consider using these medications as first-line treatments, particularly if there are alternatives. Rates of infection and the risk for death can be treated 1 ] a positive Nikolsky 's sign helpful. Bad prognostic sign started with moderating, editi Copyright 2023, Meds Safety control infection or inflammation sign. Regrows over two to five days after the onset of fever in 80 to 90 percent of patients difficult. What Clients Say about Working with Gretchen Kenney to carefully consider using these as! Sjs, SJS/TEN, and multiple organ failure and enteroviruses have been associated with a licensed medical professional will doctors... Email updates of new search results not very serious and usually clears up medicine... Than 8 cases per million persons per year a study in Europe suggested the marker. The immune system may be affected including liver, kidneys, lungs bone... Affect skin and mucous membranes can be estimated using the SCORTEN scale, which takes a number prognostic. Immune system overreacts to a medication or infection often, this disorder is caused by the herpes virus!, Care of a patient with StevensJohnson syndrome / toxic epidermal necrolysis, drug reaction with eosinophilia and systemic,! To your emergency room or call 911 ( TNF ) Working with Gretchen Kenney mouth or injection ) TEN!

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