EMPACT syndrome.
BACKGROUND
Seizure prophylaxis with phenytoin is a common measure in oncologic patients with brain metastases. In these patients, generalized severe adverse drug reactions such as erythema multiforme (EEM) may occur. However, in a subgroup of patients with brain radiation therapy, EEM-like lesions develop particularly in the radiation field. Most recently, the acronym EMPACT (Erythema Multiforme associated with Phenytoin And Cranial radiation Therapy) was proposed to specifically describe this syndrome.


METHODS
Here, we report on EMPACT syndrome in a 46-year-old woman. Therapeutic measures included seizure prophylaxis with phenytoin and total brain radiation therapy of brain metastases from bronchial carcinoma. Three weeks after introduction of phenytoin, the patient presented with EEM-like skin lesions restricted to the original radiation field and facial mucocutaneous involvement. After a few days, the rash spread to the upper part of the body. She was also in poor general condition.


RESULTS
The immediate cessation of phenytoin therapy, combined with administration of systemic corticosteroids and high dose immunoglobulins along with intensive local treatment and pain medications, resulted in complete resolution of the skin eruption. Patch testing to phenytoin was positive after 72 hours.


CONCLUSIONS
EMPACT should be classified as an specific entity among the EEM-like drug reactions as it only appears after radiotherapy and seizure prophylaxis with the anticonvulsant phenytoin. We propose including specific type IV-sensitization to phenytoin into the definition of EMPACT.
Wöhrl
Stefan
S
Division of Immunology, Allergy and Infectious Diseases (DIAID), Department of Dermatology, Medical University of Vienna, Vienna, Austria. stefan.woehrl@meduniwien.ac.at
Loewe
Robert
R
Pickl
Winfried F
WF
Stingl
Georg
G
Wagner
Stephan N
SN
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000927:Anticonvulsants / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D001932:Brain Neoplasms / Q000532:radiotherapy* / Q000556:secondary; D001984:Bronchial Neoplasms; D003875:Drug Eruptions / Q000188:drug therapy / Q000209:etiology*; D004892:Erythema Multiforme / Q000139:chemically induced*; D005260:Female; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000008:administration & dosage / Q000627:therapeutic use; D008875:Middle Aged; D010672:Phenytoin / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D012640:Seizures / Q000517:prevention & control*; D012882:Skin Tests; D013262:Stevens-Johnson Syndrome / Q000139:chemically induced / Q000209:etiology; D013577:Syndrome; D013997:Time Factors
D000305:Adrenal Cortex Hormones; D000927:Anticonvulsants; D016756:Immunoglobulins, Intravenous; D010672:Phenytoin