Toxic epidermal necrolysis due to lamotrigine in a pediatric patient
A 12-year-old male patient was admitted in Sir Takhtsinhji General Hospital, Bhavnagar, Gujarat, India, with a history of skin lesions, redness of eye, and shortness of breath for 3 days. Based on detailed history, it was understood that the patient was having a history of intermittent fever since 4 days for which he was prescribed chloroquine, cefixime+potassium clavulanate, paracetamol, and primaquine p.o. The patient consumed only a single dose of the treatment and developed swelling over eyelids with redness of the eye within 4 h. As the time spent, the patient developed multiple blisters and vesicular lesions first over the face and followed by on chest, abdomen, back, and extremities. Initially, lesions were few and then increased in number. The patient consulted the doctor after 1 day of development of lesions. The patient did not consume the other doses of prescribed treatment for fever after the development of reaction. The patient was diagnosed as SJS and referred to our hospital. On evaluation of drug history, the patient was found to be a known case of epilepsy since last 6-7 months. He was on tablet sodium valproate 300 mg/day and tablet Clonazepam 0.25 mg/day. Lamotrigine 50 mg/day p.o. was added in treatment 1–2 months back. He was taking these medicines regularly and stopped them after the emergence of reaction.\nAt the time of admission, the patient was delirious, un-cooperative, and disoriented to time, place, and person. On examination, his vitals were: temperature 101 °F, pulse rate 140/min, blood pressure 100/70 mmHg, and respiratory rate 40/min. There were multiple erythematous, flaccid, clear fluid-filled vesicles, and bullae of varying sizes along with some erosions over the face, chest, abdomen, back, and extremities. Conjunctiva and cornea were congested. Multiple erosions were noted on oral cavity and genitals. Nikolsky sign was positive. Total BSA involvement was of 66%. Diagnosis of drug-induced TEN was made clinically. No skin biopsy was performed.\nOn the day of admission, investigations revealed: Hb 12.0 g% (12–15 g%), total leucocyte count 5600 cells/cmm (4400–11,000 cells/cmm), serum creatinine 1.0 mg% (0.9–1.4 mg%), blood urea 25 mg% (15–40 mg%), and SGPT 30 U/L (upto 45 U/L). Peripheral smear was negative for malarial parasites. On admission, the patient was given humidified oxygen (6 l/min), Inj. dexamethasone, Inj. chlorpheniramine maleate, Inj. ciprofloxacin, Inj. vancomycin, and Inj. metronidazole along with nursing care of skin, eye, and oral cavity. The fluid and electrolyte balance was maintained through intravenous fluids. The patient was intubated due to irregularity in respiration and died within 12 h of admission due to respiratory failure.\nA causality analysis was done using the Naranjo's algorithm, and ADR was found ‘probable’ with lamotrigine.[] The reaction was not preventable according to the modified Schumock and Thornton scale, and the modified Hartwig and Siegel scale showed that the reaction was severe (level 7).[] The SCORTEN score for this patient was 02 (BSA > 10%,, heart rate > 120/min).[]