How would Steven Johnson Syndrome (SJS) present in a patient taking bupropion (Wellbutrin)?

Stevens-Johnson Syndrome from Bupropion: Clinical Presentation

Stevens-Johnson Syndrome (SJS) from bupropion presents with a prodrome of fever, malaise, and upper respiratory symptoms followed by painful mucosal erosions and skin lesions with epidermal detachment. 1

Initial Prodromal Phase

• Flu-like symptoms including fever, malaise, and upper respiratory tract symptoms typically appear 4-28 days after starting bupropion 2
• Cutaneous pain is a prominent early feature and should alert clinicians to incipient epidermal necrolysis 1
• Ocular inflammation may develop before skin signs appear 1

Mucosal Involvement

• Early involvement of mucous membranes is characteristic:
  • Oral: Erosive and hemorrhagic mucositis with painful mouth ulcers
  • Ocular: Purulent keratoconjunctivitis, iritis, eyelid edema
  • Genital: Painful erosions
  • Nasal: Mucosal erosions 1

Skin Manifestations

• Initial presentation includes large areas of confluent erythema
• Lesional skin is tender to touch
• Nikolsky sign: Minimal shearing forces cause epidermis to peel back
• Progression to blistering with necrotic epidermis separating from underlying dermis, producing flaccid bullae
• Extensive necrolysis results in detachment of sheets of epidermis, leaving areas of exposed dermis
• Denuded dermis exudes serum, becomes secondarily infected, and readily bleeds 1

Extent of Involvement

• SJS: Epidermal detachment <10% of body surface area (BSA)
• SJS-TEN overlap: 10-30% BSA involvement
• TEN: >30% BSA involvement 1, 3

Systemic Manifestations

• Fever may persist throughout the acute phase
• Potential for multi-organ involvement:
  • Hepatitis
  • Pneumonitis
  • Myocarditis
  • Pericarditis
  • Nephritis 1
• Risk of septicemia due to compromised skin barrier 3

Laboratory Findings

• Possible eosinophilia
• Elevated inflammatory markers
• Abnormal liver function tests may be present 1, 4

Histopathological Features

• Variable epidermal damage ranging from individual cell apoptosis to confluent epidermal necrosis
• Basal cell vacuolar degeneration
• Subepidermal vesicle or bulla formation
• Mild, predominantly perivascular infiltrate of lymphocytes and histiocytes in the dermis 1

Specific Considerations with Bupropion

Bupropion is specifically listed in its FDA label as having rare reports of SJS 5. A documented case report confirms bupropion-induced SJS 6, highlighting that this medication can trigger this severe reaction.

Key Diagnostic Features

• Temporal relationship: Symptoms typically begin 4-28 days after starting bupropion 2
• Prodromal symptoms followed by mucocutaneous involvement
• Painful skin lesions with epidermal detachment
• Involvement of at least two mucosal sites 1

Differential Diagnosis

• Staphylococcal scalded skin syndrome (SSSS) - lacks mucosal involvement
• Immunobullous disorders (pemphigus, pemphigoid)
• Erythema multiforme major (EMM) - typically has target lesions on extremities 1

Prognosis and Complications

• Mortality rates: SJS <10%, TEN up to 30% 1
• Common complications include ocular, cutaneous, renal, nasopharyngeal, esophageal, and genital issues
• Long-term sequelae may include skin pigmentation changes, scarring, and persistent mucosal problems 1, 7

Early recognition of SJS from bupropion is critical for prompt discontinuation of the medication and initiation of appropriate supportive care to reduce morbidity and mortality. Any patient taking bupropion who develops fever, malaise, and mucosal pain or skin tenderness should be evaluated immediately for this potentially life-threatening condition.