A nearly fatal reaction to sulfadiazine in a ten-year-old girl, involving skin, eyes, and oropharynx

J G., a 10-year-old female was admitted to the hospital Jan. 11, 1942, critically 9 ill, with a generalized pemphigus-like rash, high fever, and severe toxemia. Fif teen days before admission, tile family physician had started her on sulfadiazine, 7.7 gr. every four hours for an acute follicular tonsillitis with acute bilateral cervical adenitis and high fever. The patient responded satisfactorily to this therapy, and in a few days there was subsidence of the nodes and fever. This dose of the drug was continued for eight consecutive days until Jan. 3, 1942, a total of fifty 7.7-gr. tablets having been given. On this date the mother took the p~tlent to the physician's office, stating that the child was f~le, the appetite was good~ the Cervical swelling had subsided, and the temperature had been normal for four or five days. The mother was then given a prescription for more of the drug and instructed to continue with 1 tablet three times u day. For some reason, she did not s t a r t the drug again until four days later, January 7. On January 9, two days later~ a rash was noted on the child's face, the conjunctiva was somewhat injected, and the drug was stopped. The next day, January 10, the rash spread from the face to the chest, and the child developed a temperature of t03 ~ F. The following day, January 11, the rash became generalized, she complained of a very sore mouth, the fever increased, and the physician sent her to the hospital. On admission physical examination revealed the patient to be critically ill, somewhat drowsy, and very toxic. The skin showed a generalized erythematous maculopapular rash which was confluent in large areas. Almost the entire skin of the body was involved, there being just a few scattered areas of normal skin. There were enormous numbers of vesicles and large bullae present, varying in size from 2 to 3 turn. in diameter to the size of a silver 8o]lar. In some areas, the superficial layer of skin was loosened and could be pulled away easily. The ocular and palpebral conjunctivae wer e markedly injected. The eyelids were swollen shut. The mucous membrane of the oropharynx, including cheeks~ tongue, and pharynx, was covered completely with a thick white membrane and broken bullae. The temperature was 104 ~ F.; pulse, 144, respirations~ 40. The examination of the ears, chest, abdomen, and nervous system was essentially negative. Our clinical impression at this time was a 2emphigus-like rash due to sensitivity to sulfadiazine or some severe overwhelming infection. The patient was seen on the same day by our consulting dermatologist, Dr. :[. J. Eller of New York, who agreed that nmst likely the case was one of a drug reaction, provided acute infectious mononucleosis and an overwhelming infection were ruled out by blood studies. The blood count on admission showed hemoglobin, 84 per cent~ red cells~ 4.6 millions, white cells, 8,000 with 86 per cent polymorphonuclear neutrophiles, 13 per cent lymphoeytes, and 1 per cent monocytes. The pat ient ' s condition was critical during the first week~ the temperature ranging from 101 ~ to 10~ ~ F. and the pulse averaging about 140. She was unable to take anything by mouth for several days and daily large amounts were given of 5 per cent glucose with Hartmann ' s solution, plasma, aseorbic acid, and thiamine chloride, by vein during the first