Journal of Postgraduate Medicine April 2011 Vol 57 Issue 2 115

Original Article
Drug-induced Stevens-Johnson syndrome
(SJS), toxic epidermal necrolysis (TEN),
and SJS-TEN overlap: A multicentric
retrospective study
Barvaliya M, Sanmukhani J, Patel T, Paliwal N, Shah H
1
, Tripathi C
ABSTRACT
Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare immune-
mediated severe cutaneous adverse reactions with incidence rate of 0.05 to 2 persons per million populations
per year. Drugs are the most commonly implicated in 95% of cases. Aims: To audit the causative drugs,
clinical outcome, and cost of management in SJS, TEN, and SJS-TEN overlap. Setting and Design: Tertiary
care hospitals-based multicentric retrospective study (case series). Materials and Methods: Indoor case
papers of SJS, TEN, and SJS-TEN overlap admitted between January 2006 and December 2009 in four
tertiary care hospitals of Gujarat were scrutinized. Data were collected for demographic information, causative
drugs, investigations, treatment given, duration of hospital stay, time interval between onset of symptoms
and drug intake, clinical outcome, and complications. Data were analyzed to find out proportion of individual
drugs responsible, major complications, and clinical outcome in SJS, TEN, and SJS-TEN overlap. Total cost of
management was calculated by using cost of drugs, investigations, and consumables used during entire hospital
stay. Statistical Analysis: One-way Analysis of Variance followed by Tukey-Kramer multiple comparison
test was used for comparison of incubation period, duration of hospital stay, and cost of management.
Results: Antimicrobials (50%), nonsteroidal anti-inflammatory drugs (22.41%), and antiseizure drugs
(18.96%) were the most commonly associated groups. Nevirapine (28.12%) was the most common drug.
Antiseizure drugs were more often associated with serious form of adverse reaction (TEN: 81.8%) than
other drugs. Duration of hospital stay (20.6 vs 9.7 days) and cost of management (` 7 910/- vs ` 2 460/-)
were significantly higher in TEN than SJS (P=0.020 and P<0.001, respectively). Time duration between
drug intake and onset of symptoms (17.7 vs 27.5 days) was nonsignificantly lower in TEN as compared with
SJS. Secondary infection (28.12%) was the most common complication noted. Mortality rate was 15.6%
among all cases; 9% in SJS and 26.7% in TEN. Conclusion: Antimicrobial drugs are the most commonly
implicated drugs and cost of managing these adverse drug reactions is higher than other serious ADRs.
KEY WORDS: Adverse drug reaction, Stevens-Johnson syndrome, toxic epidermal necrolysis
Department of
Pharmacology,
Government Medical
College, Bhavnagar,
1
Department of
Dermatology, Venerology
and Leprosy,
Sir Takhtsinhji General
Hospital and Government
Medical College,
Bhavnagar, Gujarat, India
Address for correspondence:
Dr. C.B. Tripathi,
E-mail: cbrtripathi@yahoo.
co.in
Received : 11-10-10
Review completed : 10-12-10
Accepted : 03-01-11
Access this article online
Quick Response Code: Website:
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DOI:
10.4103/0022-3859.81865
PubMed ID:
***
Introduction
A
dverse drug reactions (ADRs) hold special importance
in healthcare as they account for 6% of total hospital
admissions, increase in economic burden on healthcare system,
withdrawal of drugs from market, and death.
[1-3]
Among the
various ADRs, cutaneous adverse reactions like skin rashes,
urticaria, itching, fixed drug eruption, angioedema, erythema
multiforme, Stevens-Johnson syndrome (SJS), and toxic
epidermal necrolysis (TEN) are the common ones.
[4,5]
In this
wide spectrum of cutaneous reactions, SJS and TEN are rare but
serious form of ADRs affecting patients life.
[4]
SJS and TEN are
immune-mediated reactions,

due to various etiological factors
like drugs, infections, malignancy, and radiation therapy.
[5]
Drugs
are the most commonly implicated in 95% of cases.
[5]
Incidence
of SJS and TEN is 0.05 to 2 persons per million populations
per year.
[6,7]
Incidence is higher in HIV patients than general
116 Journal of Postgraduate Medicine April 2011 Vol 57 Issue 2
Barvaliya, et al.: Drug induced SJS, TEN and SJS-TEN overlap
population.
[8]
Clinically, SJS and TEN are characterized by
polymorphic lesions like erythematous macules, papules,
plaque, vesicles, and bullae predilected to distal extremities
with Nikolskys sign positive. Target lesion with bulls eye
appearance is characteristic of SJS and TEN. Oral, genital, and
conjunctival mucosa is often involved in the form of erosion
or ulceration.
[9]
The basic difference between SJS and TEN
is the percentage of body surface area (BSA) involved: <10%
in SJS; >30% in TEN; 10 to 30% in SJS-TEN overlap.
[5,9]
No
confirmatory in vivo or in vitro tests are available for identifying
offending agents in SJS and TEN.
[9]
Moreover, a rechallenge in
a case is not ethically justified as these are the life-threatening
reactions. So, to identify the drugs associated with risk of causing
severe skin reactions, retrospective epidemiological data are
required. This study was aimed to audit the causative drugs,
clinical outcome, and economic burden due to these serious
ADRs. This study also helped us to know the changing pattern
of most common causative agents for SJS and TEN.
Materials and Methods
This multicentric study was started after approval from
Institutional Review Board, Government Medical College,
Bhavnagar, Gujarat. Permission for data collection at other centers
was taken from the head of the respective institutions. Indoor
case papers of SJS, TEN, and SJS-TEN overlap admitted between
January 2006 and December 2009 in Sir Takhtsinhji General
Hospital, Bhavnagar; Pandit Deendayal Upadhyay Civil Hospital,
Rajkot; New Civil Hospital, Surat; and Sir Sayaji General Hospital,
Vadodara were scrutinized. Data were collected for demographic
information, causative drugs, time duration between drug intake
and onset of symptoms, BSA involvement, duration of hospital
stay, treatment given, complications, and clinical outcome. Cases
with doubtful diagnosis and insufficient data were excluded
from the study. Data were analyzed to find out the proportion
of individual drugs involved, major complications, and cost of
management for SJS, TEN, and SJS-TEN overlap. Total cost of
management was calculated by using cost of drugs (average cost of
drugs from IDR-triple i Drug Compendium), investigations, and
consumables used during entire hospital stay.
[10]
Ward and nursing
charges were not included in the management cost. SCORTEN
score was calculated for each case at the time of admission and
its relation with mortality was compared in the study.
[11]
Results are expressed as percentages and mean (95% confidence
interval [CI]). Comparisons between the three groups were
performed by using One-way Analysis of Variance (ANOVA)
followed by Tukey-Kramer multiple comparison test. A P value
of less than 0.05 was considered significant. All statistical analyses
were performed with GraphPad InStat 3 (demo version).
Results
Of the 46 cases scrutinized, 32 cases were included in the
study, whereas 14 cases were excluded from the study. Among
the 32 cases, we found 11 cases of SJS, 15 cases of TEN, and
6 cases of SJS-TEN otverlap. Of the 32, 17 patients were male
and 15 were female between age group of 7 to 60 years. Total
58 drugs were found as suspected causative agent. In 20 cases,
multiple drugs were suspected, whereas in 12 cases, single drug
was implicated. In all the 32 cases, drugs were the probable
cause of eruptions, as determined by Naranjos algorithm.
[12]
Antimicrobials (50%) were the most commonly associated group
followed by nonsteroidal anti-inflammatory drugs (NSAIDs)
(22.41%) and antiseizure drugs (18.96%) [Table 1]. Nevirapine
(9 of 32 cases), paracetamol (8 of 32 cases), cotrimoxazole
(7 of 32 cases), and phenytoin (7 of 32 cases) were found to
be the most commonly associated drugs. Phenytoin (4 of 12
cases) was the most common drug among the single drug
culprit cases. Associated diseases were present in 13 cases (HIV
infection - 12 cases [37.5%] and malignancy - 1 case [3.1%]).
In 12 HIV patients, nevirapine (9 of 12 cases), cotrimoxazole
(6 of 12 cases), zidovudine (1 of 12 cases), and stavudine (1
of 12 cases) were found responsible for causing this reaction.
Antiseizure drugs were more often associated with serious
form of adverse reaction (TEN: 81.8%) than other drugs. Time
duration between drug intake and onset of symptoms was 27.5
days (95% CI: 9.5-45.3) in SJS, 17.7 days (95% CI: 10.2-25.1)
in TEN, and 15.3 days (95% CI: 3.1-27.5) in SJS-TEN overlap.
Table 1: Drug groups and individual drugs responsible for
SJS, TEN, and SJS-TEN overlap
Drugs SJS TEN SJS-TEN
overlap
Total
Antimicrobials 12 (20.7) 10 (17.2) 07 (12) 29 (50)
Cotrimoxazole 02 02 03 07
Amoxicillin 01 00 01 02
Erythromycin 00 01 00 01
Quinine 00 02 00 02
Ampicillin 01 00 00 01
Cefixime 01 00 00 01
Amikacin 00 01 00 01
Gentamicin 00 01 00 01
Levofloxacin 00 01 00 01
Chloroquine 00 01 00 01
Nevirapine 06 01 02 09
Stavudine 00 00 01 01
Zidovudine 01 00 00 01
NSAIDs 03 (5.1) 07 (12) 03 (5.1) 13 (22.4)
Paracetamol 02 04 02 08
Nimesulide 00 03 00 03
Diclofenac 01 00 00 01
Aspirin 00 00 01 01
Antiseizure 01 (1.7) 09 (15.5) 01 (1.7) 11 (19.0)
Phenytoin 01 05 01 07
Carbamazepine 00 03 00 03
Phenobarbitone 00 01 00 01
Others 00 05 (8.6) 00 05 (8.6)
Ondansetron 00 01 00 01
Domperidone 00 02 00 02
Famotidine 00 01 00 01
Pantoprazole 00 01 00 01
Data are expressed in absolute numbers of cases and value expressed
in () is in percentage; SJS: Stevens-Johnson syndrome; TEN: Toxic
epidermal necrolysis; NSAIDs: Nonsteroidal anti-inflammatory drugs
Journal of Postgraduate Medicine April 2011 Vol 57 Issue 2 117
Barvaliya, et al.: Drug induced SJS, TEN and SJS-TEN overlap
Table 2: Comparison of incubation period, duration of
hospital stay, and cost of management between SJS, TEN,
and SJS-TEN overlap
Groups Incubation
period (days)
Duration of
hospital stay (days)
Cost of
management (`)
SJS (n = 11) 27.5 (9.5-45.3) 9.7 (5.8-13.6) 2 460 (1 762-3
158)
TEN (n = 15) 17.7 (10.2-
25.1)
20.6 (14.4-26.8)* 7 910 (5 672-10
147)**
SJS-TEN overlap
(n = 06)
15.3 (3.1-27.5) 16.1 (5.0-27.4) 4 857 (2 118-7
597)
P value
F (df) (ANOVA)
0.33
1.16 (2,29)
0.027
4.15 (2,29)
0.0005
10.45 (2,29)
Data expressed as mean (95% CI); *P=0.020 and **P<0.001 as
compared with SJS by Tukey-Kramer multiple comparisons test; SJS:
Stevens-Johnson syndrome; TEN: Toxic epidermal necrolysis
Table 3: Comparison between SCORTEN score, mortality
rate in present study, and expected mortality rate
SCORTEN score at
admission
No. of cases Mortality rate
in study (%)
Expected mortality
rate
[11]
(%)
00 10 00 3.1
01 11 18.1 3.1
02 09 22.2 12.1
03 02 50 35.3
04 00 00 58.3
05 or more 00 00 >90
In treatment, systemic steroids were given in 8 of 11 cases of
SJS, 12 of 15 cases of TEN, and 5 of 6 cases of SJS-TEN overlap,
whereas intravenous immunoglobulin (IVIG) was given in 1 of
6 cases of SJS-TEN overlap. Duration of hospital stay was 9.7
days (95% CI: 5.8-13.6) in SJS, 20.6 days (95% CI: 14.4-26.8)
in TEN, and 16.1 days (95% CI: 5.0-27.4) in SJS-TEN overlap,
while cost of management was ` 2 460/- (95% CI: 1 762-3 158)
in SJS, ` 7 910/-(95% CI: 5 672-10 147) in TEN, and ` 4 857/-
(95% CI: 2 118-7 597) in SJS-TEN overlap. Duration of hospital
stay and cost of management were significantly higher in TEN
than in SJS (P=0.020 and P<0.001, respectively) [Table 2].
Various complications noted in cases of SJS, TEN, and SJS-
TEN overlap were secondary infection, septicemia, altered liver
function test, electrolytes imbalance, leucocytosis, leucopoenia,
thrombocytopenia, hyperglycemia, respiratory distress, and
acute renal failure. Secondary infection was the most common
complication (9 of 32 cases) noted [Figure 1]. Mortality rate
was 15.6% among all cases; 9% in SJS and 26.7% in TEN. Higher
mortality rate was noticed in patients with higher SCORTEN
score at the time of admission [Table 3].
Figure 1: Complications noted in SJS, TEN, and SJS-TEN overlap (SJS: Stevens-Johnson syndrome; TEN: Toxic epidermal necrolysis;
LFT: Liver function test)
Discussion
We had male preponderance (53.1% male and 46.9% female),
unlike female preponderance in earlier studies.
[13-15]
All the
cases had same frequency of occurrence throughout the year,
no seasonal variation was noted.
[16]
Three most common groups
of drugs causing eruptions were antimicrobials, NSAIDs, and
antiseizure drugs. This is in agreement with the previous
reports.
[13,14,17]
Nevirapine (28.1%) was the most commonly
associated drug in our study, as against phenytoin and
carbamazepine which have been mentioned in previous study.
[14,15]

Antiseizure drugs were the most common drugs causing TEN
in our study. They had the higher chance (81.8%) of causing
severe eruption, that is, TEN than NSAIDs (53.84%) and
antimicrobials (34.48%). This is higher as compared with the
previous report (70%).
[14]
Average number of drugs to be found
as causative for SJS, TEN, and SJS-TEN overlap was 1.81.
Though antimicrobials have been the most common group of
drugs involved, there has been change in the individual drugs
involved. Nevirapine and cotrimoxazole are the most common
antimicrobial associated as compared with cephalosporins in
an earlier study.
[14]
In all, 37.5% patients were HIV positive,
which indicates increase in incidence of SJS and TEN in HIV
patients, which was 7.3% in European study.
[18]
Nevirapine was
the most common causative drug among the HIV patients as
118 Journal of Postgraduate Medicine April 2011 Vol 57 Issue 2
Barvaliya, et al.: Drug induced SJS, TEN and SJS-TEN overlap
compared with the cotrimoxazole.
[8]
However, of 7 culprit cases
with cotrimoxazole, 6 patients were HIV positive. This shows
higher incidence of SJS and TEN with cotrimoxazole in HIV-
positive patients than in general populations.
[8]
In last few years,
HIV infection might have changed the trend of antimicrobials
causing SJS, TEN, and SJS-TEN overlap. In 4 HIV cases,
reaction appeared after change in regimen of antiretroviral
therapy from ZLE (Zidovudine, Lamivudine, Efavirenz) to
ZLN (Zidovudine, Lamivudine, Nevirapine). Arrival of new
drugs like nevirapine and lamotrigine have changed current
scenario of causative drugs for SJS, TEN, and SJS-TEN overlap
and risk of severe skin reaction increases with use of these
drugs.
[19]
However, we did not have lamotrigine as culprit in
our study. This may be due to its limited utilization or different
environmental or genomic factors in our population. However,
highest occurrence with nevirapine suggests the requirement of
monitoring the newer drugs for such type of severe reactions.
[19]
Among NSAIDs, paracetamol was the most common to cause
the reaction in our study and as described in other Indian
study.
[14]
We did not find any oxicam derivative as culprit which
is mentioned as the most commonly responsible among NSAIDs
in American study.
[20]
This may be due to different genomic
factors or drug utility pattern influencing both the populations.
Duration of hospital stay in TEN is higher than in SJS, which is
same as in previous study.
[21]
The risk of SJS, TEN, and SJS-TEN
overlap appears to be greater in the first month of initiation of
treatment as revealed by incubation period. Incubation period
is nonsignificantly lower in the TEN as compared with SJS and
SJS-TEN overlap. In our study, majority of cases were treated
with systemic steroids, and mortality rate was found similar to
previous study in which patients were treated with steroids.
[14]

Though the role of steroids is controversial in treatment of SJS
and TEN, beneficial effect may be there if steroids are started
early in treatment with proper dose.
[22]
IVIG was given in one
patient with SCORTEN score 2 and had recovered within 8
days. We could not make any conclusion about the use of IVIG
in treatment of SJS and TEN as it was used only in one patient
in our study. Complications were seen more frequently in TEN
group (63.4%), the most common being secondary infection
(28.1%). One patient died in SJS group, whereas no mortality
was noted in SJS-TEN overlap. Mortality rate in TEN group
was 26.66%, which is equal to earlier study (26%).
[14]
Our study
showed that mortality rate was higher in patients with higher
SCORTEN score, which shows importance of SCORTEN score
as an important tool for predicting the clinical outcome in
patients of SJS, TEN, and SJS-TEN overlap.
[11]
Average cost of
management of SJS (` 2 460/-) is nearly equal to average cost
of management of other severe ADRs in India (` 2 820/-), but
the cost of management of SJS-TEN overlap (` 4 857/-) and
TEN (` 7 910/-) is much higher.
[10]

Being retrospective in nature, we were not able to calculate direct
nonmedical and indirect costs. Thirty percent cases have been
excluded from the study due to insufficient data or improper
records. Proper record keeping is required for such type of study
involving disease of low incidence rate.
In conclusion, SJS, TEN, and SJS-TEN overlap are serious
cutaneous adverse reactions most commonly caused by
antimicrobials, NSAIDs, and antiseizure drugs. Their cost of
management is higher than other serious ADRs.
Acknowledgement
Our sincere thanks to Dr. Neela Bhuptani, Professor and Head,
Department of Dermatology, Venerology and Leprosy and
Dr. R.B.Deshmukh, Medical Superintendent (P.D.U. Civil Hospital
and Medical College, Rajkot); Dr. N.D.Kanthariya, Professor and
Head, Department of Pharmacology and Dr. M.K.Vadel, Medical
Superintendent (Government Medical College and New Civil Hospital,
Surat) and Dr. Yogesh Marfatiya, Professor and Head, Department of
Dermatology, Venerology and Leprosy and Dr. R.N. Deveshvar, Medical
Superintendent (Medical College and S.S.G. Civil Hospital, Vadodara)
for giving permission for the data collection at their respective centers.
References
1. Patel KJ, Kedia MS, Bajpai D, Mehta SS, Kshirsagar NA, Gogtay NJ.
Evaluation of the prevalence and economic burden of adverse drug
reactions presenting to the medical emergency department of a
tertiary referral centre: A prospective study. BMC Clin Pharmacol
2007;7:8.
2. Brvar M, Fokter N, Bunc M, Mozina M. The frequency of adverse
drug reaction related admissions according to method of detection,
admission urgency and medical department specialty. BMC Clin
Pharmacol 2009;9:8.
3. Suh DC, Woodall BS, Shin SK, Hermes-De Santis ER. Clinical and
economic impact of adverse drug reactions in hospitalized patients.
Ann Pharmacother 2000;34:1373-9.
4. Sharma VK, Sethuraman G, Kumar B. Cutaneous adverse drug
reactions: Clinical pattern and causative agents - a 6 year series from
Chandigarh, India. J Postgrad Med 2001;47:95-9.
5. Sharma VK, Sethuraman G. Adverse cutaneous reactions to drugs:
An overview. J Postgrad Med 1996;42:15-22.
6. Borchers AT, Lee JL, Naguwa SM, Cheema GS, Gershwin ME.
Stevens- Johnson syndrome and toxic epidermal necrolysis.
Autoimmun Rev 2008;7:598-605.
7. Li LF, MaC. Epidemiological study of severe cutaneous adverse drug
reactions in a city district in China. Clin Exp Dermatol 2006;31:642-7.
8. Khambaty MM, Hsu SS. Dermatology of the patient with HIV. Emerg
Med Clin North Am 2010;28:355-68.
9. Mockenhaupt M. Severe drug-induced skin reactions: Clinical pattern,
diagnostics and therapy. J Dtsch Dermatol Ges 2009;7:142-60.
10. Ramesh M, Pandit J, Parthasarathi G. Adverse drug reactions
in a South Indian hospital- their severity and cost involved.
Pharmacoepidemiol drug saf 2003;12:687-92.
11. Bastuji-Garin S, Fouchard N, Bertocchi M, Roujeau JC, Revuz
J, Wolkenstein P. SCORTEN: A severity-of-illness score of Toxic
Epidermal Necrolysis. J Investi Dermatol 2000;112:149-53.
12. Naranjo CA, Busto U, Seller EM, Sandor P, Ruiz I, Roberts EA, et al. A
method for estimating the probability of adverse drug reaction. Clin.
Pharmacol Ther 1981;30:239-55.
13. Schopf E, Stuhmer A, Rzany B, Victor N, Zentgraf R, Kapp JF.
Toxic epidermal necrolysis and Stevens- Johnson syndrome:
An epidemiologic study from West Germany. Arch Dermatol
1991;127:839-42.
14. Sharma VK, Sethuraman G, Minz A. Stevens Johnson syndrome, toxic
epidermal necrolysis and SJS-TEN overlap: A retrospective study of
causative drugs and clinical outcome. Indian J Dermatol Venereol
Leprol 2008;74:238-40.
15. Devi K, George S, Criton S, Suja V, Sridevi PK. Carbamazepine--the
commonest cause of toxic epidermal necrolysis and Stevens-
Johnson syndrome: A study of 7 years. Indian J Dermatol Venereol
Leprol 2005;71:325-8.
16. Wanat KA, Anadkat MJ, Klekotka PA. Seasonal variation of Stevens-
Johnson syndrome and toxic epidermal necrolysis associated with
trimethoprim-sulfamethoxazole. J Am Acad Dermatol 2009;60:589-94.
Journal of Postgraduate Medicine April 2011 Vol 57 Issue 2 119
Barvaliya, et al.: Drug induced SJS, TEN and SJS-TEN overlap
17. Leenutaphong V, Sivayathorn A, Suthipinittharm P, Sunthonpalin
P. Stevens-Johnson syndrome and toxic epidermal necrolysis in
Thailand. Int J Dermatol 1993;32:428-31.
18. Fagot JP, Mockenhaupt M, Bouwes-Bavinck JN, Naldi L, Viboud C,
Roujeau JC. Nevirapine and the risk of Stevens-Johnson syndrome
or toxic epidermal necrolysis. AIDS 2001;15:1843-8.
19. Mockenhaupt M, Viboud C, Dunant A, Naldi L, Halevy S, Bouwes
Bavinck JN, et al. Stevens-Johnson syndrome and toxic epidermal
necrolysis: Assessment of medication risks with emphasis on
recently marketed drugs. The EuroSCAR-study. J Invest Dermatol
2008;128:35-44.
20. Ward KE, Archambault R, Mersfelder TL. Severe adverse skin
reactions to nonsteroidal antiinflammatory drugs: A review of the
literature. Am J Health Syst Pharm 2010;67:206-13.
21. Yap FBB, Wahiduzzaman M, Pubalan M. Stevens - Johnson syndrome
(SJS) and Toxic Epidermal Necrolysis (TEN) In Sarawak: A Four Years
Review. Egyptian Dermatol Online J 2008;04.
22. Kardaun SH, Jonkman MF. Dexamethasone pulse therapy for Stevens-
Johnson syndrome/toxic epidermal necrolysis. Acta Derm Venereol
2007;87:144-8.
How to cite this article: Barvaliya M, Sanmukhani J , Patel T, Paliwal N, Shah
H, Tripathi C. Drug-induced Stevens-J ohnson syndrome (SJ S), toxic epidermal
necrolysis (TEN), and SJ S-TEN overlap: A multicentric retrospective study. J
Postgrad Med 2011;57:115-9.
Source of Support: Nil, Confict of Interest: None declared.
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