Efficacy of Continuous Intravenous Fentanyl for Oral Mucosal Pain in Stevens-Johnson Syndrome: A Case Report

Abstract

The management of oral mucosal pain in Stevens-Johnson syndrome (SJS), known for its severe mucocutaneous reactions, is a significant challenge due to the paucity of effective treatments reported in the literature. This case report aims to help fill this gap by describing the effective use of continuous intravenous fentanyl for the relief of severe oral mucosal pain in a patient with SJS. A patient with postoperative recurrence of cervical cancer developed SJS following chemotherapy. She had severe oral mucosal pain that was not relieved by 12.5 mcg/hour fentanyl transdermal patch, a regular medication. This pain was rated 10/10 on the Numerical Pain Rating Scale (NRS), and the patient had dysphagia and difficulty speaking. On admission, intravenous methylprednisolone (1000 mg/day), oral lip treatment with dexamethasone ointment, and oral rinses with azulene-lidocaine mixture were started. Analgesic treatment consisted of a 12.5 mcg/hour fentanyl transdermal patch of the regular medication and 1000 mg/dose of intravenous acetaminophen twice daily. Due to the inadequate efficacy of the transdermal patch, fentanyl was switched from the transdermal patch to a continuous intravenous fentanyl infusion at 20 mcg/hour on day three of admission. This adjustment significantly reduced pain intensity, which decreased to NRS 5/10 on day six of admission, and the patient was able to drink water and speak. Pain relief preceded clinical improvement of stomatitis. Grade 1 somnolence occurred after the start of intravenous fentanyl, but improved with follow-up. There were no other adverse effects such as respiratory depression. This case highlights the potential of intravenous fentanyl in the treatment of oral mucosal pain associated with SJS, although further studies are needed to confirm these findings and to develop comprehensive pain management protocols.

Keywords: fentanyl; morphine; oral mucosal lesions; stevens-johnson syndrome (sjs); stomatitis medicamentosa.

Figure 1. Changes in pain, examination findings of stomatitis, symptomatic findings of stomatitis, and oral intake.

Figure 2. Microscopic image of an edematous, erythematous area of abdominal tissue taken on day one of admission.

A magnified image of the black frame is shown in Figure 3.

Figure 3. Magnified view of the epidermis and illustration of the lesion.

a. Mild hyperkeratosis; b. Subepidermal bullae; c. Necrotic keratinocytes; d. Interface dermatitis