25 Indian Journal of Dermatology 2011; 56(1)

Original Article
RETROSPECTIVE ANALYSIS OF STEVENS-JOHNSON SYNDROME AND
TOXIC EPIDERMAL NECROLYSIS OVER A PERIOD OF 10 YEARS
Abarna Devi Sanmarkan, Tukaram Sori, Devinder Mohan Thappa, T J Jaisankar
Abstract
Background: Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN), are the acute emergencies in
dermatology practice. Prompt diagnosis and management may reduce the morbidity and mortality in SJS/TEN patients.
Early identifcation of the offending drug is necessary for early withdrawal and to prevent the recurrences of such a
devastating illness. Aims: To study the demography, offending agents, clinical and laboratory features, treatment,
complications, morbidity and mortality of SJS/TEN in our hospital. Materials and Methods: In this retrospective
study, we reviewed the medical records of SJS, TEN, SJS/TEN overlap of inpatients over a period of 10 years Results:
Maximum number of SJS/TEN cases were in the age group of 1130 years. Males predominated in the SJS group with
a ratio of 1.63:1, whereas females predominated the TEN group with a ratio of 1:2.57. Nonsteroidal anti-infammatory
drugs (NSAIDs) were the commonest group of drugs among the SJS group in 5/21 patients (23.8%). Antimicrobials were
the commonest group of drugs causing TEN in 11/25 patients (44%). Mucosal lesions preceded the onset of skin lesions
in nearly 50%. Our study had one patient each of SJS/TEN due to amlodipine and Phyllanthus amarus, an Indian herb.
The most common morbidity noted in our study was due to ocular sequelae and sepsis leading to acute renal failure
respectively. Kaposis varicelliform eruption was found in three of our patients. Conclusion: Antimicrobials and NSAIDS
are the common offending agents of SJS/TEN in our study.
Key Words: Stevens-Johnson syndrome, retrospective analysis, toxic epidermal necrolysis
Indian J Dermatol 2011:56(1):25-9
From the Department of Dermatology and STD, Jawaharlal
Institute of Postgraduate Medical Education and Research
(JIPMER), Pondicherry - 605 006, India. Address for
correspondence: Dr. Devinder Mohan Thappa, Professor
and Head, Department of Dermatology and STD, JIPMER,
Pondicherry, India. E-mail: dmthappa@gmail.com
Introduction
Stevens-Johnson syndrome (SJS), SJS/TEN overlap, and
toxic epidermal necrolysis (TEN), are variants of acute,
rapidly progressive mucocutaneous reactions which differ
only in their body surface area (BSA) involvement.
[1]

Drugs, infections, vaccines, radiological contrasts, vaginal
suppositories,
[1]
acrylonitrates, graft versus host reaction,
[1]

and lupus erythematosus
[1]
in predisposed individuals result in
immunologically mediated keratinocyte apoptosis, and hence,
extensive necrosis and detachment of epidermis with signifcant
morbidity and mortality. Several studies and case reports on
SJS/TEN have been done in India as well as abroad since the
description of SJS case by Stevens and Johnson in 1922
[1]
and
TEN case by Lyells in 1956.
[1]
A hospital-based retrospective
study was done to study the demography, offending agents,
clinical and laboratory features, treatment, complications,
morbidity and mortality in SJS/TEN in our hospital.
Materials and Methods
Medical records of all inpatients, admitted with a diagnosis
of SJS, TEN, and SJS/TEN overlap over a period of
10 years from June 98 to July 08, in the Department of
Dermatology, at our institute were reviewed. Of the total
56 medical records, 46 with complete data were selected.
Bastugis criteria
[2]
formed the basis for classifying these
severe mucocutaneous reactions into SJS, TEN and
SJS/TEN overlap. Parameters like age, sex, co-morbid
conditions, etiology, clinical features, past history of drug
reactions, period of hospital stay, investigations, treatment
modalities, course and outcome of these 46 patients were
recorded and analyzed.
Results
Age and gender
The number of patients with SJS and TEN was 21 each and
with SJS/TEN overlap was four. Four patients in overlap
group were included in TEN group. Maximum number of
SJS cases was in the age group of 1120 years and the
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DOI:
10.4103/0019-5154.77546
26 Indian Journal of Dermatology 2011; 56(1)
maximum number of TEN cases was in the 2030 years
age group. Males predominated the SJS group with a ratio
of 1.63:1, whereas females predominated in the TEN group
with a ratio of 1:2.57. The youngest patient was a 3-year-
old child and the oldest was a 78-year-old male.
Etiology
Drug as an etiology was established in almost all the cases
except in one case of SJS which was due to herpes labialis.
The implicated drug was identifed in only 36 cases. The
major group of drugs causing SJS/TEN in our study was
antimicrobials 15/46 (32.6%), followed by nonsteroidal
anti-infammatory drugs (NSAIDs) 12/46 (26.08%) and
antiepileptic drugs 8/46 (17.3%). Besides this, there were
two cases of TEN due to paracetamol and one case each
due to nevirapine, isoniazid, fansidar (pyrimethamine
and sulfadoxine), amlodipine, siddha medication, and
Phyllanthus amarus (kizhanelli), a common medicinal
plant used for hepatitis B in south India.
Considering the mucocutaneous reactions individually,
NSAIDs were the commonest group of drugs among
the SJS group in 5/21 patients (23.8%). Antimicrobials
like furoquinolones, penicillin group of drugs were the
commonest group causing TEN in 11/25 patients (44%). At
least more than eight patients (17.3%) developed SJS/TEN
following consumption of over-the-counter medications for
analgesia. Anacin, analgen (contains acetylsalicylic acid,
paracetamol, codeine phosphate, and caffeine) and Vicks
action 500 (contains paracetamol, phenylpropanolamine,
and caffeine) were the common over-the-counter
medications. The drugs which were implicated in causing
SJS/TEN in our patients are shown in Table 1.
Past history of drug reaction was present in seven cases of
TEN. Nature of past and present reaction in patients with
previous history of drug eruption is shown in Table 2.
The co-morbid conditions for which our patients were taking
these offending drugs were seizures (8), diabetes mellitus (5),
hypertension (3), HIV (2), pulmonary tuberculosis (2), enteric
fever (2), one case each of syphilis, non Hodgkins lymphoma,
hypothyroidism, astrocytoma, hemiparesis, carcinoma cervix,
carcinoma breast, lichen planus and hepatitis B.
Reaction time
The mean duration between the drug intake and the onset
of reaction was 6 days. The reaction time was less than a
week in most of our patients [29/46 (63%)].
Clinical features
Fever, sore throat, myalgia and burning sensation were the
major prodromal symptoms experienced by our patients.
Anaphylaxis was observed in one of the SJS patient. SJS
patients had either blanchable or non blanchable purpuric
macules, typical and atypical targets lesions, vesicles,
Table 1: Agents involved in SJS/TEN
Etiology No. of patients %
Antimicrobials 15 32.6
Gatifoxacin 5 10.86
Amoxicillin 3 6.52
Penicillin 1 2.1
Ceftriaxone 1 2.1
Cotrimoxazole 1 2.1
Pyrimethamine and sulfadoxine
(Fansidar)
1 2.1
Isoniazid 1 2.1
Chloramphenicol 1 2.1
Nevirapine 1 2.1
NSAIDs 12 26.08
Anacin

3 6.52
Vicks action 500
*
2 4.34
Paracetamol 2 4.34
Analgen

1 2.1
Voveran

1 2.1
Nimesulide 1 2.1
Unknown analgesics 2 4.34
Antiepileptics 8 17.3
Phenytoin 6 13.04
Carbamazepine 2 4.34
Miscellaneous
Amlodipine 1 2.1
Siddha 1 2.1
P. amarus (kizhanelli) 1 2.1
Unknown drug 7 15.2
Herpes labialis 1 2.1
Total 46 100
*
Paracetamol + phenylpropanolamine + caffeine;

Aspirin +
caffeine;

Acetylsalicylic acid, paracetamol, codeine phosphate,

caffeine;

Diclofenac sodium
Table 2: Nature of past and present reaction in patients with previous history of drug eruption
Present diagnosis Offending drugs (present) Earlier drug eruptions Offending drugs (earlier episodes)
TEN Analgen Maculopapular rash Cotrimoxazole
TEN Cotrimoxazole Fixed drug eruption Colazal
*
TEN Amoxycillin Unknown reaction Sulpha group
TEN Siddha Unknown reaction Cotrimoxazole
TEN Phenytoin Maculopapular rash Carbamazepine
TEN Vicks action 500 Fixed drug eruption Vicks action 500
TEN Carbamazepine SJS Carbamazepine
*
Balsalazide disodium
Sanmarkan, et al.: Retrospective analysis of SJS and TEN
27 Indian Journal of Dermatology 2011; 56(1)
bullae and erosions over erythematous and urticated
plaques, involving <10% of BSA. TEN patients presented
with sudden onset of large sheets of epidermal necrosis
along with severe constitutional features. Nikolskys sign
and skin tenderness were present in all TEN patients. Four
TEN patients had crusted erosions over the scalp.
Mucosal lesions preceded the onset of skin lesions in nearly
50% of our patients. Also, 87% of SJS and 88% of TEN
had oral mucosal involvement. All three (oral, conjunctiva,
genital) mucosa were involved in 20/46 (43.47%) patients.
Oral mucosal involvement was the most common followed
by the conjunctiva. Other mucosal involvement noted
was that of pharyngeal and anal. Abnormal laboratory
parameters noted in our cases are given in Table 3.
Most of our patients had neutrophilic leukocytosis and raised
erythrocyte sedimentation rate (ESR). Eosinophilia was seen in
only three patients. Three TEN patients had thrombocytopenia
and leukopenia. Neutropenia was noticed in two patients.
Elevated liver enzymes were noticed in 18 of our patients.
Systemic complications observed in our study were
acute renal failure (4), septicemia (4, all died, none on
dexamethasone pulse therapy), metabolic encephalopathy
(1), lower respiratory infection (2), congestive cardiac
failure (2), pulmonary edema (2), hyperkalemia,
intracranial bleed, aspirational pneumonia, psychosis, lung
abscess, wound infection commonly due to Staphylococcus
aureus (MRSA), followed by Pseudomonas, Enterococcus,
Klebsiella. One case of herpes labialis and three cases
of Kaposis varicelliform eruption developed during the
regression of the reaction. Post infammatory pigmentation
was noted in almost all cases. Other mucocutaneous
complications that we noticed were oral candidiasis,
gastritis in the form of hematemesis, phimosis parotitis,
tonsillitis, and epiglottitis. The number of patients with
ocular morbidity in our study was 23/46 (50%) comprising
of symblepharon (23), corneal scarring, bacterial, viral
conjunctivitis, blepharitis, and corneal xerosis.
Treatment
Except for seven patients, all other patients received
defnitive therapy in the form of dexamethasone (17),
prednisolone (11), methyl prednisolone pulse (2),
dexamethasone pulse (2) and cyclosporine (7). Pulse
therapy was given along with intravenous broad spectrum
antibiotics. Overall, healing was noticed at 215 days after
the onset of treatment. For dexamethasone pulse therapy,
the onset of healing was on the third day of pulse, and for
methylprednisolone pulse therapy, it was on the second
day of pulse. The period of hospitalization ranged from 5
to 30 days, and it was lowest for methylprednisolone pulse
therapy. Apart from hemoptysis due to gastritis in one
patient, we did not record any other complications including
sepsis and septicemia, in patients on dexamethasone pulse
therapy.
The SCORTEN score for 21 TEN cases ranged from 0 to
5. Five of the SJS/TEN cases died giving a mortality rate
of 10.86% (5/46). The cause for death in all our patients
was sepsis leading to acute renal failure [Table 4].
This study was based on inpatient records; we did not
record long-term sequelae in such patients.
Discussion
Acute disseminated epidermal necrosis (ADEN 1, 2, 3) is
the recently proposed terminology by Ruiz-Maldonado for
SJS, overlap, and TEN, respectively. SJS/TEN are more
common among individuals with lowered ability to detoxify
reactive metabolites or alteration in detoxifying enzymes
due to genetic basis (HLA-B 12, HLA-A29, HLA-DR7),
[3]
or functional basis (enzyme dysfunction due to AIDS or
other disease).
[1]
Drug and/or their reactive metabolites
behave as haptens and render the keratinocyte antigenic
by binding to them. This elicits immune reactions resulting
in extensive keratinocyte apoptosis which is mediated by
cytotoxic T lymphocytes induced caspase cascade through
perforin-granzyme route, FAS (CD95)-FAS ligand pathway,
or nitric oxide synthase route in susceptible individuals.
[1]
We had an equal number of SJS and TEN patients (21
patients each), as the study was done in a tertiary care
hospital. In contrast to the general concept that adverse
events are more common in extremes of age due to
impaired hepatic enzymes and renal functions, our study
had young patients in the frst and second decades in both
groups. This is similar to other studies done in India where
Sharma et al.
[4]
noticed a mean age of 22.3 15.4 years
and Devi et al.
[5]
observed 68% of patients in the 2050
years age group. A study done in West Germany
[6]
showed a
higher age group for TEN (63%) and a lower age group for
SJS (25%). Yamane et al.
[7]
from Japan noticed a mean age
of 45.7 years and Roujeau et al.
[8]
from France observed a
mean age of 46.8 years. Strikingly, there was a difference
in the sex ratio among SJS and TEN patients in our study.
We had more female patients in the TEN group and more
male patients in the SJS group, which is in concordance
with the study from West Germany.
[6]
Table 3: Laboratory parameters
Laboratory parameters No. of patients SJS TEN
Increased alkaline phosphates 18 10 4
Increased amino transferases
(AST, ALT)
15 6 6
Leukocytosis 12 6 3
Neutrophilia 10 4 2
Lymphopenia 4 2 2
Eosinophilia 3 0 3
Leukocytopenia 3 0 3
Thrombocytopenia 3 0 3
Neutropenia 2 1 1
Sanmarkan, et al.: Retrospective analysis of SJS and TEN
28 Indian Journal of Dermatology 2011; 56(1)
Overall, in our study, antimicrobials were the most common
group of drugs causing SJS and TEN. But considering the
mucocutaneous reactions individually, most of our SJS
cases were due to NSAIDs and majority of TEN cases were
due to antimicrobials. This is also in concordance with the
study done in West Germany
[6]
which showed antibiotics
in 42% of TEN cases and analgesics in 33% of SJS cases.
Antibiotics, mainly beta-lactams, were the most common
cause of SJS/TEN in Wong et al.s study.
[9]
Though a
study from France
[8]
showed NSAIDs as the most common
implicated group, some Indian studies
[5]
have shown
anticonvulsants as the most frequently implicated drugs.
Nanda and Kaur
[10]
observed that developing countries
have a higher incidence of TEN due to antituberculous
drugs. Chan et al.
[11]
reported antibacterials such as
aminopenicillins, sulfamethoxazole and trimethoprim as the
commonest causative drugs for SJS and TEN.
Our study had one patient each of SJS/TEN due to
amlodipine and P. amarus (kizhanelli), which is rarely
reported in literature. In the amlodipine induced SJS case,
no other etiology was found than amlodipine which the
patient had taken for 3 months. Calcium channel blockers
are known to have a longer reaction time ranging from 2
weeks to 3 months
[12,13]
as in our case who had a reaction
time of 3 months. A case of TEN induced by kizhanelli
(P. amarus), an Indian herb used more frequently in many
parts of the country for hepatitis, was also observed in our
study. Siddha medication and Chinese herbs induced SJS/
TEN have been reported previously also.
[1]
Past history of
drug reaction was present in seven TEN cases, of which
only two had drug eruption to the same drug in the past
and the rest had reaction to a different group of drug
and the type of drug reaction was also different. Nearly
four of our patients had received radiotherapy for their
malignancy prior to occurrence of SJS/TEN as cancer
and/or radiotherapy increases the risk of SJS/TEN to
anticonvulsants.
[1]
The mean reaction time in our study was 6 days. Majority
of them had manifested within 7 days of drug intake which
is similar to other studies. Noel et al.
[14]
observed 23
weeks for TEN and 13 weeks for SJS, and Devi et al.
[5]

noticed less than 1 week in 44% of cases, between 1 and
2 weeks in 32% of cases, and between 2 and 3 weeks in
the remaining 24% of cases of SJS/TEN. Yamane et al.
[7]

showed that more than half (67.6% of SJS, 80.0% of
TEN) of the patients developed symptoms within 2 weeks.
Roujeau et al.
[8]
observed a reaction time of 10.212 days
for TEN cases. The prodromal symptoms were similar as in
other studies. Anaphylaxis was noticed in one of our SJS
patient. Scalp involvement was noticed in four of our TEN
cases.
Mucosal lesions preceded the onset of skin lesion in
nearly half of our patients. In a Taiwanese study,
[15]

46.7% of patients had mucosal involvement affecting the
buccal mucosa, pharynx, tongue, lips, anogenital region,
esophagus, colon, nasal cavity and conjunctiva.
Most of our patients had raised ESR and leukocytosis due
to neutrophilia. Only three patients had eosinophilia. Three
of our TEN patients developed thrombocytopenia and
leukopenia, and two patients had neutropenia. Increased
liver enzymes were seen in 18 of our cases. As per
Yaman et al.s
[7]
study in SJS/TEN, hepatitis was the most
common complication. Twenty-four cases (46.2%) of SJS
and 41 cases (63.1%) of TEN had hepatitis, suggesting that
SJS could cause more severe hepatitis than TEN. Nearly
50% of the patients had ocular sequelae in the form of
symblepharon, conjunctivitis, corneal scarring and xerosis.
Corneal scarring was treated with amniotic membrane
transplant. Kaposis varicelliform eruption developing
over the lesions of SJS/TEN occurred in three of our
patients, which to our knowledge has not been reported
earlier. Kardaun et al.s
[16]
study has shown that short-term
dexamethasone pulse therapy, given at an early stage of
the disease, may contribute to a reduced mortality rate in
SJS/TEN with out increasing healing time as noticed in our
study. Mortality rate was high in the cases with chronic co-
morbid illnesses like carcinoma, cranial irradiation, diabetes
mellitus, HIV, and abnormal laboratory parameters.
Conclusion
Antimicrobials and NSAIDS are the common offending
agents for SJS/TEN, and hence, patients who have
previous history of drug allergy should strictly avoid
Table 4: The profle of patients who died of complications
Age (years)/
sex
Etiology BSA
(%)
Co-morbid conditions Complications Treatment
32/F Paracetamol 40 Leukopenia, ARF, aspirational
pneumonia, sepsis
Inj. dexamethasone
72/M Siddha 10 Hypothyroidism, bronchial asthma Metabolic encephalopathy,
septicemia, ARF
Prednisolone
78/F Anacin 50 Hypertension, diabetes mellitus ARF, pulmonary edema Inj. dexamethasone
45/F Phenytoin 70 Fibrillary astrocytoma,
diabetes mellitus
ARF, sepsis Inj. dexamethasone
26/F Nevirapine 60 HIV ARF, sepsis Inj. dexamethasone
M= male; F= female; BSA=body surface area; ARF=acute renal failure
Sanmarkan, et al.: Retrospective analysis of SJS and TEN
29 Indian Journal of Dermatology 2011; 56(1)
over-the-counter medications. Drugs like analgen, Vicks
action 500 are banned globally but are available in India
and hence strict regulations are needed. Early withdrawal
of the offending agent and defnitive treatment of SJS/TEN
and multispecialty care may reduce the morbidity, mortality
rates, and thereby, duration of hospital stay.
References
1. Breathnach SM. Erythema multiforme, Stevens-Johnson syndrome
and toxic epidermal necrolysis. In: Burns T, Breathnach S, Cox
N, Griffths C, editors. Rooks Textbook of Dermatology, 7
th
ed.
Oxford: Blackwell Science; 2004. p. 53.1-53.47.
2. Bastuji-Garin S, Rzany B, Stern RS, Shear NH, Naldi L,
Roujeau JC. A clinical classifcation of cases of toxic epidermal
necrolysis, Stevens-Johnson syndrome, and erythema multiforme
Arch Dermatol 1993;129:92-6.
3. Avakian R, PharmD, Flowers FP, Araujo OE, Ramos-Caro FA.
Toxic epidermal necrolysis: A review. J Am Acad Dermatol
1991;25:69-79.
4. 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.
5. 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.
6. Schpf E, Sthmer 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.
7. Yamane Y, Aihara M, Ikezawa Z. Analysis of Stevens-Johnson
syndrome and Toxic epidermal necrolysis in Japan from 2000 to
2006. Allergol Int 2007;56:419-25.
8. Roujeau JC, Guillaume JC, Fabre JP, Penso D, Flchet ML, Girre
JP. Toxic epidermal necrolysis (Lyell Syndrome): Incidence and drug
etiology in France, 1981-1985. Arch Dermatol 1990;126:37-42.
9. Wong KC, Kennedy PJ, Lee S. Clinical manifestations and
outcomes in 17 cases of Stevens-Johnson syndrome and toxic
epidermal necrolysis. Australas J Dermatol 1999;40:131-4.
10. Chan HL, Stern RS, Arndt KA, Langlois J, Jick SS, Jick H,
et al. The incidence of erythema multiforme, Stevens-Johnson
syndrome and toxic epidermal necrolysis. Arch Dermatol
1990;126:43-7.
11. Nanda A, Kaur S. Drug induced toxic epidermal necrolysis in
developing countries. Arch Dermatol 1990;126:125.
12. Ioulios P, Charalampos M, Efrossini T. The spectrum of
cutaneous reactions associated with calcium antagonists:
A review of the literature and the possible etiopathogenic
mechanisms. Dermatol Online J 2003;9:6.
13. Stern R, Khalsa J, Cutaneous adverse reactions associated with
calcium-channel blockers. Arch Intern Med 1989;149:829-32,
14. Noel MV, Sushma M, Guido S. Cutaneous adverse drug
reactions in hospitalized patients in a tertiary care center. Indian
J Pharmacol 2004;36:292-5.
15. Lam NS, Yang YH, Wang LC, Lin YT, Chiang BL. Clinical
characteristics of childhood erythema multiforme, Stevens-
Johnson syndrome and toxic epidermal necrolysis in Taiwanese
children. J Microbiol Immunol Infect 2004;37:366-70.
16. Kardaun SH, Jonkman MF. Dexamethasone Pulse Therapy for
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis . Acta
Derm Venereol 2007;87:144-8.
Received: February, 2010. Accepted: July, 2010.
Source of support: Nil, Confict of Interest: Nil.
Sanmarkan, et al.: Retrospective analysis of SJS and TEN
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