Steven-Johnson syndrome due to unknown drugs [corrected].

Steven-Johnson syndrome may be considered as a cytotoxic immune reaction to drugs, infections etc. This is a case report of Steven-Johnson syndrome due to an ayurvedic preparation which was used in the treatment of mental retardation in a young girl.

Introduction

Steven–Johnson syndrome (SJS) is an uncommon mucocutaneous disorder usually presenting as erythematous macules evolving to epidermal detachment and mucous membrane erosions. Above 50% of the cases of SJS are attributed to drugs and more than hundred different drugs have been reported to cause SJS. Ayurvedic drugs are also known to cause this syndrome. Some other causes of SJS are herpes, mycoplasma infections etc.[12]

Case Report

A female aged 17 years presented to the outpatient department of the skin, JJM Medical College, Davanagere, with the history of skin lesions and fever for three days. The lesions were insidious in onset, started appearing first on oral mucosa which gradually turned into ulcers on the third day. Patient complained of difficulty in swallowing. There was history of delayed mile stones and mental retardation for which she was being treated with an ayurvedic medication since twelve years. There was no history of intake of any other medications.

On examination, lesions were found on the oral mucosa, lips and vaginal mucosa. They ranged from erythematous macules to dusky red erosions associated with pain [Figure 1]. There was a minimal involvement of other parts of body. The ayurvedic medication was found to be dispensed in a small bottle without labeling. The medication was in form of small white balls. The patient was advised to stop the medication. She was treated with tab cetirizine, injection cefixime, tab paracetamol and topical emollients. The patient was photographed but skin biopsy or laboratory investigations were not done. The diagnosis of Steven–Johnson syndrome was made on the basis of clinical findings. The possible association between the drug and SJS was made based on modified Naranjo algorithm.

Figure 1

Picture of patient before treatment

Discussion

There is often a misconception that “natural” means “safe” and many consumers believe that remedies of natural origin carry no risk. Some of the ayurvedic drugs causing adverse drug reactions are guggul, svarnabhasma, ras manikya, godanti, ginko echinacae, St. Johns wort, ginseng, lavanabhaskar, parad preparations etc. The popular ayurvedic preparations for mental retardation include extracts from Centella asiatica and Bacopa monierri. Herbal medicines usually contain multiple ingredients and it is not possible to identify them all.[34] However, in our case, the product name could not be identified due to absence of labeling.

Traditional medicines are now used outside the confines of traditional cultures and far beyond the traditional geographical areas without proper knowledge of their use and the underlying principles. They are also being used in different ways and for non-traditional indications. The concomitant use of traditional medicines with other medicines which is now frequent, is quite outside the traditional context and has become a particular safety concern. Adverse events reported in association with herbal products are attributable to problems of quality. Major causes of such events are adulteration of herbal products with undeclared other medicines and potent pharmaceutical substances such as corticosteroids and nonsteroidal antiinflammatory drugs (NSAIDs). Adverse events may also result from the mistaken use of wrong species of medicinal plants, incorrect dosing, and errors in the use of herbal medicines both by health care providers and consumers, interactions with other minerals and use of products contaminated with potentially hazardous substances such as toxic metals, pathogenic micro-organisms and agrochemical residues etc.[34]

Conclusion

Steven–Johnson syndrome can be caused due to ayurvedic drugs. Further studies are required to prove that ayurvedic preparations used in treatment of mental retardation in children may cause this syndrome. Stringent policies toward specifying the actual ingredients and method of purification used in extracting the ayurvedic drug need to be defined. In this case, the causation can be proposed but not firmly established. It was only a series of credible questionnaire that led us to the possible etiology.