Stevens-Johnson Syndrome Induced by Carbamazepine Treatment in a Patient Who Previously Had Carbamazepine Induced Pruritus - A Case Report -
A 68-year-old male presented with left mandibular area pain due to third trigeminal neuralgia. He had underdone conventional radiofrequency lesioning in the left third branch of the trigeminal nerve for trigeminal neuralgia one year previously. Following the procedure he had been without pain until quite recently. However, at the time of his presentation, he was reporting pain in the same area of 40/100 using the VAS (Visual Analogue Scale) score. We decided to proceed with medical treatment including carbamazepine 200 mg three times a day, tramadol (37.5 mg)/acetaminophen (325 mg) combination three times a day, and nortriptyline 10 mg one time a day because his pain was mild. On his second day of medication, a mild fever and general weakness had occurred. On his fourth day after beginning the medication, an oral rash and bullae on the cheek, neck, forearm and leg were found. On the fifth day, the patient visited the emergency room and was admitted with a presumptive diagnosis of SJS. Further history revealed that he had discontinued medication including carbamazepine 200 mg one year previously on his own due to pruritus after taking the medication once. The medical history was otherwise unremarkable. On physical examination, the patient displayed pruritic and stinging erythema and painful crursted erosions on both lips, with several flaccid and ruptured bullae on the left cheek, neck, forearm, and leg (). Pharyngitis was present but he was able to swallow some food. Eye discomfort and genital mucosa involvement were not present. Nikolsky's sign was positive. Laboratory examination revealed mild leukocytosis, and alanine aminotransferase, C-reactive protein, and potassium were mildly elevated. Carbamazepine was withdrawn and prednisolone 125 mg/day was started. A skin biopsy performed on the third day after admission, demonstrated subepidermal bullae formation with epidermal necrosis and minimal perivascular lymphohistocytic infiltration in the upper dermis and the correct diagnosis of SJS was established. Steroid treatment was given for 5 days and gradually withdrawn. On the eighth day the patient was discharged in good condition, with generalized desquamation and incomplete peeling of the skin on the neck, forearm, and face. Two weeks after discharge, he underwent conventional radiofrequency lesioning of the left third branch of the trigeminal nerve. Two weeks later, his pain was nearly gone.