Felicia Paramita,1 Febrina Rahmayanti,2 Endi Novianto,3 Endah Ayu Tri Wulandari4
Oral Medicine Residency Program, Oral Medicine Department, Faculty of Dentistry, Universitas Indonesia, Jakarta
Oral Medicine Department, Faculty of Dentistry, Universitas Indonesia, Jakarta
Dermatovenerology Department, Cipto Mangunkusumo General Hospital/Faculty of Medicine, Universitas Indonesia, Jakarta
Oral Medicine Division, Dentistry Department, Cipto Mangunkusumo General Hospital/Faculty of Medicine, Universitas Indonesia, Jakarta
Stevens-Johnson Syndrome (SJS) is common in HIV patients. SJS results from a hypersensitivity reaction to certain drugs. Oral manifestation of SJS includes erosions, ulcers, and bullae of the oral mucosa and hemorrhagic crusts of the lips. This case report will discuss a case of SJS in an HIV patient, whose management was complicated by the presence of pseudomembranous candidiasis. A 40-year-old HIV positive male inpatient who had already been diagnosed with nevirapine-induced SJS (by the dermato- veneorologist) was referred to the oral medicine division of Cipto Mangunkusumo General Hospital because of crusted lips and erosions inside the oral cavity. He was already on intravenous corticosteroid.
On examination, we found hemorrhagic crusts of the lips, multiple erosions and erythema of the oral mucosa, which was consistent with oral manifestation of SJS, and pseudomembranous candidiasis under the upper removable denture. The patient was in advanced immunosuppression (CD4 level 5 cells/µL) with cytomegalovirus (CMV) and hepatitis C virus (HCV) coinfection, marked by the presence of anti CMV and anti HCV antibody. The presence of pseudomembranous candidiasis complicated the management of the oral manifestation of SJS in this patient. The oral manifestation of SJS had to be treated with a corticosteroid mouthwash, even though corticosteroid itself can be a risk factor for oral candidiasis.
The patient had an upper and lower denture, HIV positive, and being treated with high dose systemic corticosteroid, which were all risk factors for oral candidiasis. Therefore, we not only treated the patient for the oral manifestation of SJS, but also gave antifungal to control the oral candidiasis. In an immunocompromised patient with two different conditions whose treatment appears contradictory, the right management decision can be challenging. Careful consideration should be made and the holistic treatment of the patient should not be overlooked.
Keywords: Stevens-Johnson syndrome, HIV patient, cytomegalovirus, hepatitis C, pseudomembrane candidiasis, management