The prevalence of Stevens Johnson Syndrome caused by antiretroviral in hospitalized patients at Dr . Hasan Sadikin General Hospital Bandung

Stevens Johnson Syndrome is a mucocutaneous disease caused by allergic drug eruption.��ntiretroviral (�RV) therapy for HIV/�IDS patient may cause allergic drug eruption such as Stevens Johnson Syndrome.� The aim of this research was to find out the prevalence of Stevens Johnson Syndrome caused by ARV in hospitalize patient at Dr.� Hasan Sadikin General Hospital Bandung from January to December 2008.� It was a descriptive research by taking the secondary data from patient’s medical record.� �he result of this research showed that from 20 Stevens Johnson Syndrome patients, 12 persons of them (60%) are men.� Most of the patients were between the age of 20-29 (45%).� �ral manifestation of Stevens Johnson Syndrome seen in 100% patients.� Prevalence of Stevens Johnson Syndrome caused by �RV was 28.�6% which seen in 8 HIV/�IDS patients.� �RV combination consist of nevirapine, lamivudine, and zidovudine was the most (50.�0%) �RV which suspected causing Stevens Johnson Syndrome.� �he conclusion of this research showed that the prevalence of Stevens Johnson Syndrome caused by �RV in hospitalize patient at Dr.� Hasan Sadikin General Hospital Bandung 2008 was 28.�6% seen in 8 HIV/�IDS patients.�


INTRODUCTION
Stevens Johnson Syndrome (SJS) is a hypersensitivity reaction of immune complex at mococutaneous mostly caused by medications and infections.�Stevens-Johnson Syndrome symptoms are the spread of macular skin eruption, with a typical target lesion (flat, irregular) and involve more than one of mucosa (oral cavity, conjunctivitis and genital).� 1,2ntiretroviral (�RV) is one of the medications caused SJS which were given for Human Immunodeficiency Virus (HIV)/Acquired Immunodefi-ciency Syndrome (�IDS) infection therapy.� 3 �nanworanich et al.� in their research stated that nevirapine made two of HIV infected patients suffered from Stevens-Johnson Syndrome.� 4 Nevirapine is a non-nucleoside reverse transcriptase inhibitor, used in combination with others antiretroviral medications for the treatments of HIV infection.�Mococutaneous disorder such as Stevens-Johnson Syndrome firstly occurred in oral.The early anticipation gave much help to prevent the further spread of skin eruption.� 6Dentists played the vital roles in identifying patients with druginduced oral ulcers and facilitating patients for  �he literature described that based on sex, the comparative amount of SJS patients, men to women were 2:1.� 10 �he literature's research showed the same outcome, means more men suffered from SJS predilection than women did.��pproved by �able 2, SJS were diagnosed in 2008 at RSHS by the amount of 12 men (31.�6%) which were more than women patients; 8 (21.�1%).� 10 From 20 SJS patients, prevalence was mostly occurred between the ages of 20-29 years old, i.�e.� 9 persons (45%).�SJS incident based on age criterion in this research, had almost the same result with former researches all over the   the SJS patients were between the ages of 20-40 years old, even though there was an SJS report on 3 month-old baby.�Noel et al.� 8 also offered the equivalent result that the SJS patients' in India was mostly between the ages of 21-40 years old.��he research on prevalence of antiretroviral medications as the caused of SJS resulted in 28.�6%.��he type of antiretroviral that had the biggest prevalence is the combination of Nevirapine, Lamivudine and Zidovudine, which found at four persons (50%).�Meechan and Seymour said that Nevirapine (NVP) and Efavirenz (EFV) were the caused of Stevens Johnson Syndrome; moreover, Zidovudine can caused the swell of the lips and tongues.� 11It was reported to the US Food and Drug �dministration that there were 19 cases of SJS and �EN caused by Nevirapine since the approvement of nevirapine used, on June 1996.��he biggest risk of mucocutaneous reaction at Nevirapine therapy on HIV infected patients became the most occurred cases than other medication.� 12Fagot et al.� 13 found that from 18 patients infected by HIV, 15 of them were diagnosed as SJS patients caused by Nevirapine.� �he researchers from Uganda report two cases of SJS in a mother and an 8 years old son, in which both of them were used Nevirapine combined with Stavudine and Lamivudine.� 2 The major toxicity of the first-line antiretroviral in the combinations of Zidovudine, Lamivudine and Nevirapine, and the combinations of Stavudine, Lamivudine, and Nevirapine was the heavy skin eruption because of Nevirapine.�If it was not a life threatening condition, with clinical symptoms of no pustule, and didn't reach mucosa, then Nevirapine therapy can be substituted with Efavirenz.�Meanwhile, if there was a heavy skin eruption, which was threaten the life (Stevens Johnson Syndrome) because of Nevirapine therapy, then the medications can be substituted by protease inhibitor.� 4 patient with a heavy skin eruption from Nevirapine should be discontinued the medication and should not be substituted by Efavirenz.��he used of Efavirenz in substituting Nevirapine at the patient with smaller skin eruption, remained risked the patient for suffering the same skin eruption.In the case of ARV failed in the first-line which contained NNR�I (Nevirapine or Efavirenz), the switch of both medications was not suggested because of the high resistance across NNR�I.�Viruses at the patients, which failed on therapy of Efavirenz, proved to be résistance to Efavirenz and Nevirapine.�Some others observational studies also showed the unresponded therapy to Efavirenz after the failing nevirapine.� 4 �he second-line antiretroviral for HIV/ �IDS infected adult, in the case of failed therapy at first line regime or in other words the failed on Stavudine or Zidovudine or Lamivudine and Nevirapine or Efavirenz therapies, they can be replaced by �enofovir Disoproxil Fumarate (�DF) or Abacavir, Didanosine and Lopinavir or Saquinavir.�o substitute medications from non-nucleoside reverse transcriptase inhibitor (NNR�I) group depended on the reason of the discontinuity, for example in hard or fatal toxicity case, then all the usage of these medications should be stopped immediately.�CONCLUSION �he prevalence of Stevens Johnson syndrome caused by antiretroviral in hospitalized patients at Dr.� Hasan Sadikin Bandung in 2008 was 28.�6%.��he antiretroviral that suspected to be the caused of Stevens Johnson Syndrome was the combinations of Nevirapine, Lamivudine and Zidovudine.�Dentists have major roles on the treatment of Steven Johnson Syndrome patients and consequently they had to have enough knowledge on disorder oral mucosa caused of medications side-effects.� combination therapy, i.�e.� 4 persons (50.�0%).�DISCUSSION During the research, there are 38 patients from hospitalized patients' morbidity data at Dr.� Hasan Sadikin Bandung in 2008.��here were 20 patients (52.�6%) diagnosed as suffered from Steven Johnson Syndrome, and 8 persons or 21.�1 % were suffered from SJS + �EN.� �he result of the research indicated the bigger prevalence, if compared with others researches.��n the Noel, et al.�'s research, out of 56 patients, 15% of them suffered from SJS and 35% suffered from maculopapular skin eruption.� 8�thers researches found that the SJS incident in Spain is approximately 1-2 cases per a million population.� 9

Figure 1 .Figure 2 .
Figure 1.Manifestation of SJS e.c.Neviral suspect on oral of 52 years old man patient.

Figure 3 .
Figure 3. Manifestation of SJS e.c.Neviral suspect on skin, The patient is 52 years old man.

Table 1 . The distribution of patients diagnosed as Bulbous and Toxic Epidermal Necrolysis based on sex and age Age (year)
-29 years old were 12 persons (31.� 6%) regarded as the biggest amount of patients, and the lowest one was only person (2.�6%) at the age of 50-59 years old.��he distribution of data based on Bullous and �oxic Epidermal Necrolysis found that the numbers of patients which were diagnosed of SJJ were 20 persons (52.�6%) (Fig.� 1), furthermore, it also found that 8 people (21.�1%) diagnosed as suffering from SJJ and �EN.� �able 3 above described that all of Steven Johnsons Syndrome

Table 5 . The patients' percentage of SSJ and SSJ syndrome overlap toxic epidermal necrolysis based on medications etiologyTable 6 . The kinds of ARV predicted as the caused of Steven Johnson Syndrome in HIV patients
patients (100%) had clinical symptoms on oral, eyes and skin.�Meanwhile, the clinical symptoms on genital only occurred in 35% the patients.��able 4 showed that all the patients of Steven Johnson Syndrome overlap Epidermal Necrolysis have clinical symptoms on oral, eyes and skin, and only 50% on genital.��able 5 showed that the prevalence of Steven Johnson Syndrome Patients caused by �RV reached 28.�6%.�Based on the above table, Steven Johnson Syndrome found frequently in patients, who was treated by Neviral and Duviral world.��ccording to Parillo et al.� 10 in Philadelphia,