\documentclass[twocolumn,twoside]{article}
\makeatletter\if@twocolumn\PassOptionsToPackage{switch}{lineno}\else\fi\makeatother

\usepackage{amsfonts,amssymb,amsbsy,latexsym,amsmath,tabulary,graphicx,times,xcolor}

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
% Following additional macros are required to function some 
% functions which are not available in the class used.
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
\usepackage{url,multirow,morefloats,floatflt,cancel,tfrupee}
\makeatletter


\AtBeginDocument{\@ifpackageloaded{textcomp}{}{\usepackage{textcomp}}}
\makeatother
\usepackage{colortbl}
\usepackage{xcolor}
\usepackage{pifont}
\usepackage[nointegrals]{wasysym}
\urlstyle{rm}
\makeatletter

%%%For Table column width calculation.
\def\mcWidth#1{\csname TY@F#1\endcsname+\tabcolsep}

%%Hacking center and right align for table
\def\cAlignHack{\rightskip\@flushglue\leftskip\@flushglue\parindent\z@\parfillskip\z@skip}
\def\rAlignHack{\rightskip\z@skip\leftskip\@flushglue \parindent\z@\parfillskip\z@skip}

%Etal definition in references
\@ifundefined{etal}{\def\etal{\textit{et~al}}}{}


%\if@twocolumn\usepackage{dblfloatfix}\fi
\usepackage{ifxetex}
\ifxetex\else\if@twocolumn\@ifpackageloaded{stfloats}{}{\usepackage{dblfloatfix}}\fi\fi

\AtBeginDocument{
\expandafter\ifx\csname eqalign\endcsname\relax
\def\eqalign#1{\null\vcenter{\def\\{\cr}\openup\jot\m@th
  \ialign{\strut$\displaystyle{##}$\hfil&$\displaystyle{{}##}$\hfil
      \crcr#1\crcr}}\,}
\fi
}

%For fixing hardfail when unicode letters appear inside table with endfloat
\AtBeginDocument{%
  \@ifpackageloaded{endfloat}%
   {\renewcommand\efloat@iwrite[1]{\immediate\expandafter\protected@write\csname efloat@post#1\endcsname{}}}{\newif\ifefloat@tables}%
}%

\def\BreakURLText#1{\@tfor\brk@tempa:=#1\do{\brk@tempa\hskip0pt}}
\let\lt=<
\let\gt=>
\def\processVert{\ifmmode|\else\textbar\fi}
\let\processvert\processVert

\@ifundefined{subparagraph}{
\def\subparagraph{\@startsection{paragraph}{5}{2\parindent}{0ex plus 0.1ex minus 0.1ex}%
{0ex}{\normalfont\small\itshape}}%
}{}

% These are now gobbled, so won't appear in the PDF.
\newcommand\role[1]{\unskip}
\newcommand\aucollab[1]{\unskip}
  
\@ifundefined{tsGraphicsScaleX}{\gdef\tsGraphicsScaleX{1}}{}
\@ifundefined{tsGraphicsScaleY}{\gdef\tsGraphicsScaleY{.9}}{}
% To automatically resize figures to fit inside the text area
\def\checkGraphicsWidth{\ifdim\Gin@nat@width>\linewidth
	\tsGraphicsScaleX\linewidth\else\Gin@nat@width\fi}

\def\checkGraphicsHeight{\ifdim\Gin@nat@height>.9\textheight
	\tsGraphicsScaleY\textheight\else\Gin@nat@height\fi}

\def\fixFloatSize#1{}%\@ifundefined{processdelayedfloats}{\setbox0=\hbox{\includegraphics{#1}}\ifnum\wd0<\columnwidth\relax\renewenvironment{figure*}{\begin{figure}}{\end{figure}}\fi}{}}
\let\ts@includegraphics\includegraphics

\def\inlinegraphic[#1]#2{{\edef\@tempa{#1}\edef\baseline@shift{\ifx\@tempa\@empty0\else#1\fi}\edef\tempZ{\the\numexpr(\numexpr(\baseline@shift*\f@size/100))}\protect\raisebox{\tempZ pt}{\ts@includegraphics{#2}}}}

%\renewcommand{\includegraphics}[1]{\ts@includegraphics[width=\checkGraphicsWidth]{#1}}
\AtBeginDocument{\def\includegraphics{\@ifnextchar[{\ts@includegraphics}{\ts@includegraphics[width=\checkGraphicsWidth,height=\checkGraphicsHeight,keepaspectratio]}}}

\DeclareMathAlphabet{\mathpzc}{OT1}{pzc}{m}{it}

\def\URL#1#2{\@ifundefined{href}{#2}{\href{#1}{#2}}}

%%For url break
\def\UrlOrds{\do\*\do\-\do\~\do\'\do\"\do\-}%
\g@addto@macro{\UrlBreaks}{\UrlOrds}



\edef\fntEncoding{\f@encoding}
\def\EUoneEnc{EU1}
\makeatother
\def\floatpagefraction{0.8} 
\def\dblfloatpagefraction{0.8}
\def\style#1#2{#2}
\def\xxxguillemotleft{\fontencoding{T1}\selectfont\guillemotleft}
\def\xxxguillemotright{\fontencoding{T1}\selectfont\guillemotright}

\newif\ifmultipleabstract\multipleabstractfalse%
\newenvironment{typesetAbstractGroup}{}{}%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
\AtBeginDocument{\let\citet\cite\let\citep\cite}
\usepackage[numbers,sort&compress,numbers,sort&compress]{natbib}



\newif\ifnokeywords\nokeywordsfalse
\def\abbrvJournalTitle{Future J. Pharm. Health. Sci.}
\def\jrnlurlname{fjphs}
\usepackage{balance}

\makeatletter\input{size10-pointfive.clo}\makeatother%
\definecolor{kwdboxcolor}{RGB}{242,242,242}
\usepackage[hidelinks,colorlinks=true,allcolors=blue]{hyperref}
\linespread{1}                 
\def\floatpagefraction{0.8}

\usepackage[paperheight=11.69in,paperwidth=8.26in,top=1in,bottom=1in,left=1in,right=.75in,headsep=24pt]{geometry}

\usepackage{multirow-custom}

\makeatletter

\def\hlinewd#1{%
  \noalign{\ifnum0=`}\fi\hrule \@height #1%
  \futurelet\reserved@a\@xhline}
\def\tbltoprule{\hlinewd{1pt}\\[-14pt]}
\def\tblbottomrule{\noalign{\vspace*{6pt}}\hline\noalign{\vspace*{2pt}}}
\def\tblmidrule{\hline\noalign{\vspace*{2pt}}}



\let\@articleType\@empty
\let\@journalDoi\@empty
\let\@journalVolume\@empty
\let\@journalIssue\@empty
\let\@crossMarkLink\@empty
\let\@receivedDate\@empty
\let\@acceptedDate\@empty
\let\@revisedDate\@empty
\let\@publishedDate\@empty
\let\@copyrightYear\@empty
\let\@firstPage\@empty
\let\@eISSN\@empty
\let\@pISSN\@empty
\def\eISSN#1{\gdef\@eISSN{#1}}
\def\pISSN#1{\gdef\@pISSN{#1}}
\def\articleType#1{\gdef\@articleType{#1}}
\def\journalDoi#1{\gdef\@journalDoi{#1}}
\def\crossMarkLink#1{\gdef\@crossMarkLink{#1}}
\def\receivedDate#1{\gdef\@receivedDate{#1}}
\def\acceptedDate#1{\gdef\@acceptedDate{#1}}
\def\revisedDate#1{\gdef\@revisedDate{#1}}
\def\publishedDate#1{\gdef\@publishedDate{#1}}
\def\copyrightYear#1{\gdef\@copyrightYear{#1}}
\def\journalVolume#1{\gdef\@journalVolume{#1}}
\def\journalIssue#1{\gdef\@journalIssue{#1}}
\def\firstPage#1{\gdef\@firstPage{#1}}


\def\author#1{%
  \gdef\@author{%
    \hskip-\dimexpr(\tabcolsep)\hskip5pt%
    \parbox{\dimexpr\textwidth-1pt}%
    {\fontsize{11}{13}\selectfont\raggedright #1}%
  }%
}


\usepackage{pharmascope-abs}
\usepackage{caption}
\usepackage{lastpage}
\usepackage{fancyhdr}
\usepackage[noindentafter,explicit]{titlesec}
\usepackage{fontspec}

\setmainfont[%
BoldFont=cambriab.ttf,%
ItalicFont=CAMBRIAI.TTF,%
BoldItalicFont=CAMBRIAZ.TTF]{Cambria.ttf}

\usepackage{qrcode}

%\def\abbrvJournalTitle{Future J. Pharm. Health. Sci.}
\def\jshort{fjphs}

\def\title#1{%
  \gdef\@title{%
%      \vspace*{-20pt}%
       \vspace*{-48pt}
       \ifx\@articleType\@empty\else{\fontsize{10}{12}\scshape\selectfont\hspace{8pt}\@articleType\hfill\mbox{}\par\vspace{2pt}}\fi%
       \minipage{\linewidth}
         \hrulefill\\[-0.7pt]%
         \parbox{.1\linewidth}{\includegraphics[width=4.2cm]{pharmasprings_logo.png}}\hfill
%         \fcolorbox{kwdboxcolor}{kwdboxcolor}{\parbox{.792\linewidth}{%
         \fcolorbox{kwdboxcolor}{kwdboxcolor}{\parbox{.729\linewidth}{%
          \begin{center}
          \vskip-4pt 
          \scshape\fontsize{18}{20}\selectfont\journalTitle\hfill\end{center}%
          \vspace*{-16pt}{\vspace*{-3.1pt}\fontsize{8}{9}\selectfont Published by Pharma Springs Publication\hfill  Journal Home Page: \href{https://pharmasprings.com/index.php/\jrnlurlname}{\color{blue}\underline{\smash{https://pharmasprings.com/\jrnlurlname}}}}\hspace*{4pt}\mbox{}}}%
       \par\rule{\linewidth}{1.3pt}%
       \endminipage%
    \par\vspace*{9.2pt}\parbox{.98\linewidth}{\linespread{.9}\raggedright\fontsize{14}{17}\selectfont #1}%
    \vspace*{-8pt}%
  }
}


\setlength{\parindent}{0pt}
\setlength{\parskip}{0.4pc plus 1pt minus 1pt}


\fancypagestyle{headings}{%
  \renewcommand{\headrulewidth}{0pt}%
  \renewcommand{\footrulewidth}{0.3pt}
  \fancyhf{}%
  \fancyhead[R]{%
    \fontsize{9.12}{11}\selectfont\RunningAuthor,\ \abbrvJournalTitle\ \@copyrightYear;\space\ifx\@journalVolume\@empty X\else\@journalVolume\fi%
    \ifx\@journalIssue\@empty\else(\@journalIssue)\fi%
    :\ \ifx\@firstPage\@empty 1\else\@firstPage\fi-\pageref*{LastPage}%
  }%
  \fancyfoot[RE]{\fontsize{9.12}{11}\selectfont\textcopyright\ Pharma Springs Publication\ $|$\space \journalTitle}%
  \fancyfoot[LO]{\fontsize{9.12}{11}\selectfont\textcopyright\ Pharma Springs Publication\ $|$\space \journalTitle}%
  \fancyfoot[RO,LE]{\fontsize{9.12}{11}\selectfont\thepage}
}\pagestyle{headings}


                                                         
\fancypagestyle{plain}{%
  \renewcommand{\headrulewidth}{0pt}%
  \renewcommand{\footrulewidth}{0.3pt}%
  \fancyhf{}%
  \fancyhead[R]{%
    \fontsize{9.12}{11}\selectfont\RunningAuthor,\ \abbrvJournalTitle\ \@copyrightYear;\space\ifx\@journalVolume\@empty X\else\@journalVolume\fi%
    \ifx\@journalIssue\@empty\else(\@journalIssue)\fi%
    :\ \ifx\@firstPage\@empty 1\else\@firstPage\fi-\pageref*{LastPage}%
  }%
  \fancyfoot[RE]{\fontsize{9.12}{11}\selectfont\textcopyright\ Pharma Springs Publication\ $|$\space \journalTitle}%
  \fancyfoot[LO]{\fontsize{9.12}{11}\selectfont\textcopyright\ Pharma Springs Publication\ $|$\space \journalTitle}%
  \fancyfoot[RO,LE]{\fontsize{9.12}{11}\selectfont\thepage}
  \ifx\@firstPage\@empty\else\setcounter{page}{\@firstPage}\fi
}


\def\NormalBaseline{\def\baselinestretch{1.1}}
\usepackage{textcase}
\setcounter{secnumdepth}{0}

\titleformat{\section}[block]{\bfseries\boldmath\NormalBaseline\filright\fontsize{10.5}{13}\selectfont}
{\thesection}
{6pt}
{\MakeTextUppercase{#1}}
[]
\titleformat{\subsection}[block]{\bfseries\boldmath\NormalBaseline\filright\fontsize{10.5}{12}\selectfont}
{\thesubsection}
{6pt}
{#1}
[]
\titleformat{\subsubsection}[block]{\NormalBaseline\filright\fontsize{10.5}{12}\selectfont}
{\thesubsubsection}
{6pt}
{#1}
[]
\titleformat{\paragraph}[block]{\NormalBaseline\filright\fontsize{10.5}{10}\selectfont}
{\theparagraph}
{6pt}
{#1}
[]
\titleformat{\subparagraph}[block]{\NormalBaseline\filright\fontsize{10.5}{12}\selectfont}
{\thesubparagraph}
{6pt}
{#1}
[]

\titlespacing{\section}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\subsection}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\subsubsection}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\paragraph}{0pt}{.5\baselineskip}{.5\baselineskip}  
\titlespacing{\subparagraph}{0pt}{.5\baselineskip}{.5\baselineskip}

\captionsetup[figure]{skip=1.4pt,font=bf,labelsep=colon,justification=raggedright,singlelinecheck=false}
\captionsetup[table]{skip=1.4pt,font=bf,labelsep=colon,justification=raggedright,singlelinecheck=false}

\def\bibyear#1{#1}
\def\bibjtitle#1{#1}
\def\bibauand{}
\setlength\bibsep{3pt}
\setlength\bibhang{8pt}
\lefthyphenmin = 3
\makeatother
\date{}
\makeatletter
\usepackage{mdframed}
%\usepackage{balance}
\definecolor{unitednationsblue}{RGB}{222,234,246}
\definecolor{cpboxcolor}{RGB}{211,211,211}
\definecolor{citeboxcolor}{RGB}{242,242,242}
\def\printBio{%
  %\noindent\begin{mdframed}[innerbottommargin=7pt,backgroundcolor=unitednationsblue,hidealllines=true,frametitle={ABOUT AUTHORS},innerleftmargin=7pt,leftmargin=2pt,skipabove=1pt,innertopmargin=2pt,innerbottommargin=1pt,skipbelow=1pt]%
  \noindent\begin{mdframed}[innerbottommargin=7pt,backgroundcolor=unitednationsblue,hidealllines=true,frametitle={ABOUT AUTHORS},innerrightmargin=20pt,rightmargin=4,innerleftmargin=7pt,leftmargin=2pt,skipabove=1pt,innertopmargin=2pt,innerbottommargin=1pt,skipbelow=1pt]%
   \@tempcnta=0
    \loop
      \advance \@tempcnta by 1
      \def\aubioCnt{\the\@tempcnta}
      \vskip1pt
%      \noindent\hspace{-2pt}%\fbox{
%     \vspace*{1pt}
      \raisebox{62pt}%{\begin{minipage}[t]{.35\linewidth}%
      \expandafter\ifx\csname authorImage\aubioCnt\endcsname\relax%
       \else%
         \includegraphics[height=60pt,width=60pt]{\csname authorImage\aubioCnt\endcsname}%height=145pt
       \fi%
      %\end{minipage}
      %}%}
      \hskip 4pt%\fbox{
      \raisebox{52pt}{\begin{minipage}[t]{.74\linewidth}%
        {\fontsize{8}{10}\selectfont{\csname authorName\aubioCnt\endcsname\\[5pt]}}
        \fontsize{8}{10}\selectfont\csname authorDetails\aubioCnt\endcsname\\
      \end{minipage}}
%      }
%     \vskip10pt%
    \ifnum\@tempcnta < \theaubio
    \repeat
%     \vspace*{-16.5pt}%
  \end{mdframed}
}


\makeatother


\def\citeauthor{~Bushra~Unisa}
\def\citetitle{A Case Report: Lamotrigine Induced Steven Johnson Syndrome}
\def\copyrightstmt{This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial- ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.}
\publishedDate{}
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
% Feature enabled:
%citation-style: unsrt
%citation-type: numbered
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

\usepackage{float}

\begin{document}


\def\RunningAuthor{Bushra Unisa}
\firstPage{215}
\articleType{Case Report}
\receivedDate{07 Oct 2021}
\acceptedDate{22 Oct 2021}
\revisedDate{20 Oct 2021}
\journalVolume{1}
\journalIssue{4}
\journalDoi{fjphs.v1i4.203}
\copyrightYear{2021}
\eISSN{2583-116X}
\journalDoi{fjphs.v1i4.203}
\def\authorCount{1}
\def\affCount{1}

\def\journalTitle{Future Journal of Pharmaceuticals and Health Sciences}

\title{A Case Report: Lamotrigine Induced Steven Johnson Syndrome}
\author{Bushra~Unisa\textsuperscript{*}\textsuperscript{\href{https://orcid.org/0000-0003-0570-8107}{\XeTeXLinkBox{\includegraphics[height=7pt]{orcid-logo-pharmascope.pdf}}}}~\\[5pt]{Department of Clinical Pharmacy Practice, MRM College of Pharmacy, Ibrahimpatnam {\textendash} 501510, Ranga Reddy district, Telangana, India}}

\begin{abstract}
A 21 years old male with complaints of erythematous erosive lesions, itchy and burning sensation all over the body for 5 days and multiple erythematous maculopapular lesions on palms and soles, erosive mucosal lesions in oral mucosa, erosive erythematous lesions on the scrotum, discharge from the eye, blurring of vision and redness in both the eyes. The patient was evaluated by three local doctors but not fully diagnosed. The lesions started after taking antidepressant selective serotonin reuptake inhibitor (SSRI'S) which was Lamotrigine, along with this Aripiprazole-Atypical antidepressant and Desfenlafaxine-a serotonin and norepinephrine reuptake inhibitor (SNRI'S) was taken, it was prescribed by a psychologist who thought the patient is depressed, but the patient was inactive due to anemia. The initial dose of Lamotrigine is 25mg per day which can be managed further based on symptoms, but the patient was directly started with 100mg half tablet for 8days along with one 200mg of lamotrigine at night. The patient was not made aware of drug-related information like it's side effects, improper drug usage and what if dose is missed. After taking patient history and examination the diagnosis was made to be Lamotrigine induced Steven Johnson syndrome (SJS). The patient was not depressed and he was not active as he was anemic. After correct diagnosis, the management was done with a corticosteroid, antihistamines, Pantoprazole, and antibiotic along with mouthwash and eye drops. The recovery period was of 40 days. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Erythematous Lesions,\newline Erosive Mucosal Lesions,\newline Corticosteroid,\newline Steven-Johnson Syndrome,\newline Anti-Depressant,\newline Anti-Histamines
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright{\Large$^\ast$}Corresponding Author\par Name:\ Bushra~Unisa~\\ Phone:\ +91 9398347312~\\  Email:\ meher3579@gmail.com
        \par}\vspace*{-13pt}\hrulefill\par\ifx\@eISSN\@empty\else{\fontsize{12}{14}\selectfont eISSN: \@eISSN\hfill pISSN: \@pISSN}\par\fi% 
        \textsc{DOI:}\ \href{https://doi.org/10.26452/\@journalDoi}{\textcolor{blue}{\underline{\smash{https://doi.org/10.26452/\@journalDoi}}}}\par%
        \vspace*{-12pt}\hrulefill\\[5pt]\hypersetup{allcolors=black}\qrcode[version=4,height=1.5cm]{https://doi.org/10.26452/\@journalDoi}\hypersetup{allcolors=blue} \hspace*{10.5pt}\parbox[t]{5cm}{\raisebox{19pt}{\fontsize{9.12}{10.12}\selectfont Production and Hosted by}\\[-13pt]{{\fontsize{12}{14}\selectfont  Pharmasprings.com \\[-1pt]{\fontsize{9.12}{10.12}\selectfont\textcopyright\ \@copyrightYear\ $|$ All rights reserved.}\\[-8pt]\hspace*{-1pt}\rule{.762\columnwidth}{1.2pt}}}}\hypersetup{allcolors=blue}%{\fontsize{12}{14}\selectfont Pharmasprings.com}\par%
        \makeatother
        
    
\section{Introduction}
Steven Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN) is a severe skin reaction that is caused by a particular medication. Previously SJS and TEN were considered to be different disorders, but now it is concluded that they are part of a continuum. SJS represents the acute condition and TEN the more severe \unskip~\cite{1239177:23421964}. The two begin with fever and flu-like symptoms, followed by blistering, peeling of skin with erosions that look like a severe hot water burn. Skin lesions begin with a face to the chest following to the body. The more the reaction to the skin the more damage to mucous membranes, including the lining of the mouth and airways which results in inconvenience in swallowing and breathing. The blisters affect the urinary tract and genitals as well. The eyes are also affected, causing irritation, redness of the conjunctiva, and damage to the corner as seen well. Serious complications include pneumonia, bacterial infections (Sepsis), shock, multiple organ failure, and even death \unskip~\cite{1239177:23421965}. About 10 percent of individuals die from SJS, while the fatal condition is seen in 50 percent of individuals with TEN. The survival persons also suffer from long term effects like skin coloration, skin dryness, xerosis, hyperhidrosis, alopecia, and abnormal growth or loss of fingernails and toenails.

\textbf{Case Presentation}

A 21-year-old male patient consulted the physician with chief complaints of erythematous erosive lesions, itchy and burning sensation on body and mouth since 5days. At the presentation, there were multiple erythematous maculopapular and papular lesions on palms and soles. There are erosive mucosal lesions in the mouth and erosive erythematous lesions on the scrotum \unskip~\cite{1239177:23422011}. The medical history of medications includes- Lamotrigine- 100mg half tablet at night for 8 days followed by 200mg (SSRI), Desvenlafaxine-100mg at night (SNRI), and Ariprapazole- 2.5 mg (Atypical antidepressant) half tablet for 4 days at night followed by 2.5mg from 6\ensuremath{^{th}} day to continue till 1 month. The symptoms started in the patient after 5-6 days of treatment. The physical examination discloses the patient is anemic along with fever, body pains, erythematous erosive lesions on palms and soles, erosive mucosal lesions in the mouth with difficulty in swallowing, erosive erythematous lesions on the scrotum which was causing difficulty in walking, and redness of eyes with creamy discharge \unskip~\cite{1239177:23422055}. The lesions were reddish, painful, and were spreading in nature. All vital signs were completely normal. On examination of social history, the patient was on liquids, bowel and bladder habits were normal, sleep duration and appetite seemed to be normal. Three local doctors examined the patient previously but haven't diagnosed the condition as Steven Johnson Syndrome but treated it as a skin disorder this has continued for 2-3 days and later on the final diagnosis was made correct at Princess Esra hospital at Shah Ali banda after taking complete drug history, physical examination and evaluation of vitals \unskip~\cite{1239177:23422078}.

The standard treatment started with tablet Prednisolone-20mg twice daily for 5days, tablet Pan-40mg twice daily for 1 week, Tablet fexofenadine hydrochloride- 180mg in the morning for 1 week, tablet levocetirizine dihydrochloride-5mg at night for 1 week, CHLORHEX mouthwash thrice a day, fudic cream twice a day for local application on the scrotum, Tess oral gel twice a day for local application in mouth and on lips, clop cream for application on lesions around fingernails, tablet Azithromycin-500mg twice a day for 5days, lacryl gel every 2hours for eyes and FML eye drop thrice for 1 week followed by twice for 2\ensuremath{^{nd}} week and once daily for 3\ensuremath{^{rd}} week. After 5days of treatment continuation the symptoms gradually lowered down and the patient seemed to be improved as the drug-induced effect was getting controlled [Figure~\ref{f-5c22e08c5b53} and Figure~\ref{f-731a95aba7f0}]. The lesions were dried up and peeled off slowly, the discoloration of skin was also improved \unskip~\cite{1239177:23422121}. There is no intervention in this case and the progression of the lesion happened due to lack of drug dose usage and also improper guidance to the therapy. The best instruction to every physician is proper guidance of dose according to the patient situation. The complete recovery took 45 days with gradual recovery from all symptoms and the recovery was fully reclaimed. Lifestyle modification, in this case, includes proper hydration to the body, a healthy diet including iron-rich foods, and protein intake as the patient was underweight \unskip~\cite{1239177:23422169}.
    
\section{DISCUSSION }
Steven Johnson Syndrome is a serious and life-threatening cutaneous drug allergy although early correct diagnosis and proper management help in ruling out in saving the life of patients and the best can be done by cessation of the offending drug [Table~\ref{tw-fd0930e4e1d9}]. SJS is characterized by the onset of fever, sore throat, chills, headaches, malaise rapid onset of mucocutaneous lesions [Figure~\ref{f-731a95aba7f0} and Figure~\ref{f-1257aea00a0e}] they may affect lips, oral cavity [Figure~\ref{f-ce92c14ac0e8}], conjunctiva [Figure~\ref{f-5c22e08c5b53}], nasal cavity, urethra, vaginal gastrointestinal tract, and respiratory tract during 9-11 days on the initial onset. 90\% of the affected patients suffer from mucous membrane lesions and the symptoms vary from individuals to individuals based on the usage of the offending drug, the onset of symptoms, and immunity of the patient. 


\bgroup
\fixFloatSize{images/e9261a85-49f0-4e0b-9355-1536fa2d90d5-upicture3.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/e9261a85-49f0-4e0b-9355-1536fa2d90d5-upicture3.png}{\includegraphics{images/e9261a85-49f0-4e0b-9355-1536fa2d90d5-upicture3.png}}{}
\makeatother 
\caption{\boldmath {Effected eye due to SJS}}
\label{f-5c22e08c5b53}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/434baf98-b9f8-471e-ad16-6d3038d93292-upicture4.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/434baf98-b9f8-471e-ad16-6d3038d93292-upicture4.png}{\includegraphics{images/434baf98-b9f8-471e-ad16-6d3038d93292-upicture4.png}}{}
\makeatother 
\caption{\boldmath {Effected limbs due to SJS}}
\label{f-731a95aba7f0}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/a7e91f9d-180d-4e7c-bcf0-b5bf883cb1bc-upicture1.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/a7e91f9d-180d-4e7c-bcf0-b5bf883cb1bc-upicture1.png}{\includegraphics[width=.59\linewidth]{images/a7e91f9d-180d-4e7c-bcf0-b5bf883cb1bc-upicture1.png}}{}
\makeatother 
\caption{\boldmath {SJS Lesions on Palms}}
\label{f-1257aea00a0e}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/04b675de-f416-4a41-b41b-3b684bf6a5d0-upicture2.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/04b675de-f416-4a41-b41b-3b684bf6a5d0-upicture2.png}{\includegraphics{images/04b675de-f416-4a41-b41b-3b684bf6a5d0-upicture2.png}}{}
\makeatother 
\caption{\boldmath {Mucosal mouth lesions affecting mouth and lips}}
\label{f-ce92c14ac0e8}
\end{figure}
\egroup

\begin{table*}[!htbp]
\caption{\boldmath {Drugs Causing Steven Johnson syndrome} }
\label{tw-fd0930e4e1d9}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.5292\linewidth-2\tabcolsep}p{\dimexpr.4708\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack More Frequently & \cAlignHack Less Frequently\\
\tblmidrule 
\cAlignHack Sulphadoxine &
  \cAlignHack Cephalosporins\\
\cAlignHack Sulphadiazine &
  \cAlignHack Fluoroquinolones\\
\cAlignHack Sulphasalazine &
  \cAlignHack Vancomycin\\
\cAlignHack Cotrimoxazole &
  \cAlignHack Ethambutol\\
\cAlignHack Hydantoins &
  \cAlignHack Rifampin\\
\cAlignHack Carbamazepine &
  \cAlignHack Fenbufen\\
\cAlignHack Barbiturates &
  \cAlignHack Tenoxicam\\
\cAlignHack Phenylbutazone &
  \cAlignHack Tiaprofenic acid\\
\cAlignHack Piroxicam &
  \cAlignHack Diclofenac\\
\cAlignHack Chlomezone &
  \cAlignHack Sulindac\\
\cAlignHack Allupurinol &
  \cAlignHack Ibuprofen\\
\cAlignHack Amithiozone &
  \cAlignHack Ketoprofen\\
\cAlignHack Aminopenicillins &
  \cAlignHack Naproxen\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
The correct pathophysiological mechanism of SJS is still unknown but the theories imply both immunological and non-immunological mechanisms. Although it was classified as a type IV delayed hypersensitivity reaction. Current studies have also linked to perforin, a pore monomeric granule released from natural killer T-lymphocyte in the development of SJS, which is believed to initiate keratolysis during the early onset of symptoms. Some evidence also exists linking IgE-mediated mechanisms and mast cell activation contributing to SJS.
    
\section{CONCLUSION}
SJS is a serious skin hypersensitivity reaction. The care should be taken by the physician before the prescription of medications and the dose of every drug should be carefully known and implemented. The on time diagnosis and proper management by withdrawing the offending drug and standard symptomatic treatment help in saving the patient's life. The management and recovery rate depends on the severity of the disease reaction.

\textbf{Funding Support}

The author declares that no funding was supported for this study.

\textbf{Conflict of Interest}

The author declares there was no conflict of interest for this study.

\textbf{Contribution of Authors }

Authors declare that, the Case Report by the names mentioned in the article and all the liabilities and claims related to the content of the article will be borne by the authors.
    

\bibliographystyle{unsrt}

\bibliography{\jobname}\vspace*{20pt} 
\begin{mdframed}[backgroundcolor=cpboxcolor,hidealllines=true,innerbottommargin=7pt,innerrightmargin=1pt,rightmargin=1pt,innerleftmargin=1pt,leftmargin=2pt,skipabove=1pt,innertopmargin=2pt,innerbottommargin=1pt,skipbelow=1pt]%
{\fontsize{8.5}{10}\selectfont\textbf{Copyright:}~\copyrightstmt}	
\end{mdframed}
        
\begin{mdframed}[backgroundcolor=citeboxcolor,hidealllines=true,innerbottommargin=7pt,innerrightmargin=4pt,rightmargin=4pt,innerleftmargin=2pt,leftmargin=2pt,skipabove=1pt,innertopmargin=2pt,innerbottommargin=4pt,skipbelow=2pt]%
{\fontsize{8.5}{10}\selectfont\textbf{Cite~this~article:}~\citeauthor.~\citetitle.\space\makeatletter\abbrvJournalTitle\ \@copyrightYear;\ \ifx\@journalVolume\@empty X\else\@journalVolume\fi\ifx\@journalIssue\@empty\else(\@journalIssue)\fi:\ \ifx\@firstPage\@empty 1\else\@firstPage\fi-\pageref*{LastPage}.\makeatother}	
\end{mdframed}
\vskip-1.1pc

\vskip.5pc
{\includegraphics[width=5cm]{pharmasprings_logo.png}}
~\\
{\fontsize{9.12}{10.12}\selectfont\textcopyright\ \makeatletter\@copyrightYear\makeatother\ Pharma Springs Publication.}

\end{document}
