YO18 - Challenges in Provision of Patient centered care with a Practical approach in a Resource-limited setting - Steven Johnson Syndrome – Toxic Epidermal Necrolysis (SJS-TEN) overlap related to Phenytoin use and review of logistical challenges related to care provision - a Case Report.

Case summary

Case Details - A 47-year-old female, a known case of multicentric Glioblastoma multiforme (grade four) who had received concurrent chemoradiotherapy followed by palliative Temozolomide on tapering doses of Levetiracetam and had been commenced on Phenytoin presented (during the peak of the second wave of Pandemic) with complaints of new-onset maculopapular lesions involving legs, arms, and lower back. She subsequently developed a worsening Rash with the development of vesico-bullous lesions, oral mucosal lesions, acral involvement, and systemic symptoms (Fever) 2 days later. Arrangements were made to obtain a Tele Dermatology consult (from a Private setting) following which a diagnosis of SJS TENS Overlap was made. A consult with the Medical Oncology department was sought in order to provide ICU admission which was refused. She was subsequently admitted under Palliative Medicine after obtaining high-risk consent. Her lesions regressed with supportive management comprising Cyclosporin, and intravenous antibiotics, however, her general condition deteriorated. She was discharged as she had expressed a wish to meet her mother (at home). However, she was unable to obtain a fitness for Air travel. She was re-admitted and re-started on supportive treatment (symptom-directed medications via intravenous route). A subcutaneous line was inserted in the anterior chest wall and pre-filled syringes containing essential pain medication, anti-seizure medication (sc bolus levetiracetam), and dexamethasone for three days were provided to the Patient’s husband who had volunteered to take her back home via Train.

Discussion - Important Issues included Logistical - Lack of infrastructure, Medical - use of boluses of subcutaneous medication at end of life (without syringe drivers).

Conclusion - Practical Issues related to Travel, Finances, and Continuity of care may assume more importance than Spirituality underlining the importance of formulating a comprehensive management plan most suited to the Patient and their Family members.

Clinical trial identification

Editorial acknowledgement