Medical Negligence Leading to the Onset of Stevens-Johnson Syndrome: A Case Report

INTRODUCTION AND IMPORTANCE Stevens-Johnson Syndrome (SJS) is a life-threatening, drug-induced hypersensitivity reaction with high morbidity and mortality. This case report demonstrates the critical importance of thorough history-taking and antibiotic stewardship, as a preventable drug-drug interaction between lamotrigine and azithromycin led to SJS in a young patient. The case exposes dangerous shortcomings in standard practice protocols that jeopardize patient outcomes. CASE PRESENTATION A 16-year-old female on lamotrigine for depressive episodes presented to the emergency room with fever (40°C), extensive mucocutaneous erosions, and respiratory distress after taking azithromycin for flu-like symptoms. Clinical diagnosis of SJS (<10% total body surface area involvement) was confirmed by Nikolsky’s sign, bullae, and mucosal lesions. She required intubation and multidisciplinary management, including ophthalmologic intervention for corneal involvement. CLINICAL DISCUSSION The case reveals two critical errors: (1) failure to reconcile the patient’s lamotrigine use (a known SJS trigger) before prescribing azithromycin, and (2) inappropriate antibiotic use for a likely viral infection. Comparable cases emphasize lamotrigine’s interaction risks and the need for clinician education. CONCLUSION This preventable case calls for strict adherence to medication reconciliation protocols, antibiotic stewardship, and patient education about high-risk drugs. Systemic interventions, such as electronic health record alerts for drug interactions, could mitigate future occurrences.