Stevens–Johnson syndrome progressing to toxic epidermal necrolysis with haloperidol and carbamazepine combination
A 27-year-old unmarried Asian male diagnosed with bipolar affective disorder, presented with 5 years of cannabis (ganja) intake in dependence pattern and increased talk, disturbed sleep, hyperactivity for past 3 years. He had one past episode of mania 10 years back and one episode of depression 4 years back that remitted following treatment with carbamazepine without any adverse reaction. There was no family history of any psychiatric or medical illness or drug reactions. Mental status examination showed domineering attitude, voluble speech, euphoric affect, and delusion of grandiosity. He was administered intramuscular haloperidol injection 10 mg and promethazine injection 50 mg twice a day for 2 days to control agitation that was changed to oral haloperidol 5 mg twice a day. Considering his previous response he was started on carbamazepine tablet 400 mg per day; dose was increased by 100 mg every 3 days to 700 mg per day. On 13th day, patient developed fever (temperature 101.3 °F), sore throat along with flushing of face, and subsequently developed maculopapular rashes, starting from the face spreading to the neck and then to the trunk. Within 6 to 8 h vesicular eruptions were noted in the lips along with conjunctival congestion. There were no rashes below the trunk or presence of target lesions. Within 24 h of development of rashes, vesico-bullous eruptions developed in the face and neck with involvement of mucosa of lips, palate and throat []. There was rapid spread of lesion and within next 24 h more than 30% of body surface area had vesico-bullous eruptions with positive Nikolsky sign. A diagnosis of drug-induced Stevens–Johnson syndrome progressing to toxic epidermal necrolysis was made after dermatologist consultation. Laboratory investigations revealed high erythrocyte sedimentation rate (ESR) titers (50 mm in the first hour), white blood cell (WBC) count 7000 per mm3, and neutrophil count 74.5%; rest were within the normal range. All his medications were stopped and referred to dermatology department for further management. He was treated with dexamethasone injection 4 mg b.i.d., ceftriaxone injection 1 gm b.i.d., topical betamethasone, and ciprofloxacin eye drops along with supportive care and after 7 days his condition improved. He was subsequently managed with sodium valproate 1000 mg and olanzapine 10 mg per day with complete resolution of manic symptoms and without any emergent adverse effect.