While the flu season is about to end, it is leaving with us some bad memories.

During the early days of the flu season, a lot of patients developed respiratory failure.

However, over the past few weeks, the medical department of PIMS is receiving patients who developed serious allergic reactions to antibiotics especially amoxicillin, prescribed by doctors for flu, fever and a sore throat.

Most patients who developed serious allergic reactions to antibiotics had Steven-Johnson Syndrome and Toxic epidermal necrolysis

Toxic epidermal necrolysis[/caption]

Over the last few weeks, an increasing number of patients are coming to our emergency with skin rash, swelling, and redness of the eyes, sore throat, crusting, skin exfoliation and bleeding from the oral and nasal cavity.

Most of these patients have received amoxicillin, a few patients also received tetracyclines and one patient developed the rash after hemodialysis.

One patient was received in a very critical state and developed severe mucosal bleeding and bleeding into the airways followed by respiratory distress.

The patient, while being intubated, was seen to be bleeding into the airways and lungs and died due to asphyxia and hypoxemia.

What are some uncommon but serious side effects of Amoxicillin?

Amoxicillin is a commonly used antibiotic prescribed for the treatment of a variety of infections caused by gram-positive bacteria and anaerobes.

It is used to treat sore throat, pharyngitis, sinusitis, bronchitis, pneumonia, and skin & soft tissues infections caused by susceptible organisms.

It can result in side effects some of which may be very serious.

Serious side effects of amoxicillin include:

1. Allergic reactions and anaphylaxis
2. Opportunistic infections like pseudomembranous colitis
3. Acute hepatitis and liver failure
4. Anemia, agranulocytosis, and hemolytic anemia
5. Agitation and seizures
6. Skin-related side effects

Amoxicillin is especially notorious for causing serious skin-related adverse reactions like erythema multiforme, Steven Johnson syndrome and toxic epidermal necrolysis especially if given in patients with a viral fever.

What is Erythema multiforme?

• It is an acute immune-mediated disease characterized by target lesions over the skin.
• Erythema multiforme minor does not involve the mucosa while erythema multiforme major also involves the mucosa ie the oral and nasal cavity, conjunctiva, the gastrointestinal tract, and the genital tract.
• It commonly follows infections and medications but may also be seen after vaccination, in malignancies and autoimmune diseases.

Target lesions are the hallmark of the disease.

Steven Johnson syndrome and Toxic epidermal necrolysis

• It is characterized by skin sloughing and necrosis. Mucosal involvement occurs in 92 to 100 % of the patients.
• The disease starts abruptly after the ingestion of medications especially allopurinol, penicillins, and carbamazepine.
• Patients develop a skin rash followed by skin necrosis, sloughing of the skin and involvement of the oral, genital, nasal and gastrointestinal mucosa.
• Lesions may evolve into blisters and bulla and may extend into the pharynx and larynx.
• When the skin area involved is greater than 30% of the body surface area, it is labeled as TEN or Toxic epidermal necrolysis.

Lesions appear over a course of 3 to 5 days and resolve within 2 weeks.

Ocular involvement may lead to keratitis, conjunctivitis, and visual impairment.

Treatment is aimed at limiting fluid losses, antibiotics, steroids, and antihistamines.

Local emollients and nonadherent gauze coated with silver sulfadiazine are applied. In severe cases, intravenous immunoglobulins and immune-modulators may be given.

Since diagnostic facilities are lacking, most of the patients with viral fevers are being treated as bacterial pharyngitis and bronchitis usually with amoxicillin.

How to differentiate a viral fever from a bacterial sore-throat?

• Sore-throat is caused by viruses in 80% of the times. However, almost every patient in Pakistan gets antibiotics for a sore throat.
• Thus 80% of the times, the patient does not need treatment with antibiotics and is over treated.
• Patients with bacterial pharyngitis usually have a high-grade fever (102 F or more). On the other hand, in viral fever,  most of the patients usually have feverish feelings but the fever is either not documented or low grade. Although this is not a hard sign in the absence of fever, antibiotics are seldom required.
• Viral fevers usually start with flu and systemic symptoms like body aches and a rash.
• Contrary to that, patients with bacterial pharyngitis complain of pain in the throat, difficulty in swallowing and have enlarged tonsils with exudates.

Physicians are advised to limit the use of antibiotics especially amoxicillin, tetracyclines and potent NSAIDs in patients with flu-like symptoms, sore throat, rash, and body aches.