Fluconazole-induced Stevens-Johnson syndrome in a HIV-negative patient.

Sir, Stevens-Johnson syndrome (SJS) is a rare and severe mucocutaneous disorder, most frequently caused by systemic drugs, with an incidence of 1–6 cases per million person-years (1). It is characterized clinically by a maculopapular and bullous eruption with epidermal necrosis and detachment, mucosal ulcers and erosions and constitutional signs and symptoms. SJS and toxic epidermal necrolysis (TEN) are presently regarded as clinical forms of the same disorder that share common aetiopathogenetic factors but mainly differ in: (i) the extent of epidermal detachment (SJS < 10% body surface vs. TEN > 30%); (ii) the prognosis (SJS = good; TEN = poor); and (iii) the mortality rate (SJS < 5% vs. TEN = 30–40%) (2, 3). Although the exact pathogenetic mechanisms of SJS and TEN at the molecular and cellular level remain to be elucidated, there is evidence suggesting a cytotoxic cell immune response against keratinocytes that is induced by various drugs, mostly sulphonamides, allopurinol, phenytoine, phenobarbital, carbamazepine, lamotrigine, non-steroidal anti-inflammatory drugs and nevirapine (4). Since it is of essential importance to recognize and report drugs capable of inducing severe adverse reactions, we describe herein the first case of SJS occurring in a HIVnegative patient during oral fluconazole treatment. CASE REPORT A 50-year-old Caucasian woman was admitted to the Department of Dermatology at the University of Patras Medical Center with a 3-day history of skin and mucosal lesions accompanied by high fever and malaise. The cutaneous manifestations had developed one week after the onset of treatment of vaginal candidiasis with 200 mg/day oral fluconazole (Flucodrug caps; Med-One, Athens, Greece). Apart from fluconazole, the patient had received no other medication and had no history or evidence of infectious, autoimmune or neoplastic disorders. Physical examination of the patient on admission revealed a confluent erythematoviolaceous, maculopapular and focally bullous pruritic skin rash with large numbers of targeted lesions over her face, upper trunk and the extremities. In a small area on her back, epidermal detachment was clearly seen (Fig. 1A). There were superficial ulcers and erosions in the oral mucosae, erosions and crusts on her oedematous lips (Fig. 1B) and a severe conjunctivitis. Blisters and epidermal detachment affected about 9% of the patient’s body surface. Apart from a vaginal culture positive for Candida albicans, all haematological, biochemical, immunological and serological investigations (including tests for HSV, HIV 1 & 2, hepatitis A, B and C, Toxoplasma, Epstein Barr virus, Fluconazole-induced Stevens-Johnson Syndrome in a HIV-negative Patient