Eslicarbazepine induced toxic epidermal necrolysis
To the Editor: Eslicarbazepine acetate (ESL) member of the dibenzazepine family which also includes carbamazepine (CBZ) and oxcarbazepine (OXC) is a new antiepileptic drug approved in 2009 by the European Medicines Agency and in 2013 by the U.S. Food and Drug Administration as adjunctive therapy in adults with partial onset seizures with or without secondary generalization. The incidence of rash, which is the most common idiosyncratic reaction with all antiepileptic drugs, seems to be lower in patients treated with ESL relative to CBZ and OXC. In fact, since ESL was approved, reports on severe cutaneous adverse drug reactions (cADRs) with this antiepileptic have not been accumulating, with only one case of eslicarbazepineinduced erythema multiforme major reported to date. To our knowledge, we report the first case of toxic epidermal necrolysis (TEN) following treatment with ESL. An 85year old man with a longstanding history of hypertension treated with captopril, was admitted with fever (38.8degC) stinging eyes, pain upon swallowing, and painful cutaneous lesions on day 19 after taking ESL at doses of 800 mg/day for partial onset seizures. On physical examination, we observed coalescing dusky red macules over >30% of the body surface, with blisters and detachment of large sheets of necrolytic epidermis all over his chest (Fig. 1A) back (Fig. 1B) and face. The conjunctiva and oral (Fig. 2) and genital mucosa were also involved, and tense blisters were seen in the palmoplantar surfaces. The diagnosis of TEN was confirmed by histopathologic examination of lesional skin. Laboratory examination showed markedly elevated C reactive protein levels, with renal and hepatic enzymes within normal limits. ESL was withdrawn. The patient was treated with intravenous immunoglobulin at a dose of 2 g/kg/day for 3 days, intravenous corticosteroids (tapered methylprednisolone starting with 125 mg daily) and cyclosporine at a dose of 4 mg/kg for 10 days, and then tapered over another 10 days; He showed a slow but progressive improvement both in symptoms and cutaneous manifestations. Reepithelization of the skin was achieved in 4 weeks. Stevens Johnson syndrome (SJS) and TEN are rare, acute, and life threatening mucocutaneous diseases that are nearly always drug related. Compelling evidence suggests that SJS/TEN is associated with an impaired capacity to A
Epilepsia