title: Multifocal Bullous Fixed Drug Erruption Due To Phenytoin: A Lesson Learned!
abstract: Antiepileptic drugs (AED) are a common culprit of cutaneous eruptions in clinical practice. Phenytoin, lamotrigine and carbamazepine are the commonest offenders. Maculopapular eruptions are the most frequently reported events. However, multifocal bullous fixed drug eruptions have rarely been described in association with AED use. The risk factors for skin rash including its association with the rate of drug administration are unclear in the literature. We report a case of a young alcoholic man, on long term phenytoin therapy since 3 years, who presented to our emergency department with a breakthrough seizure episode. Patient's routine investigations including serum biochemistry, imaging and toxicology screen were normal. Patient was found to have sub-therapeutic serum phenytoin levels and was prescribed loading with intravenous phenytoin (15mg/kg body weight), which was mistakenly infused at a rapid rate (60mg/minute). Patient developed multifocal bullous lesions over muco-cutaneous regions after 6 hours of drug administration which healed after its discontinuation leaving behind residual hyperpigmentation. Patient was managed conservatively, switched to oral levetiracetam and discharged in a stable condition after one week of hospital stay. Present case highlights a yet uncommon reaction to a commonly used drug and tries to establish the relation between rate of drug infusion and the risk of skin reaction.
authors.affiliation: Post Graduate Student, Department of Medicine, Maulana Azad Medical College , New Delhi, India .
authors.forename: Ankur
authors.initials: A
authors.lastname: Jain
authors.affiliation: Director Professor and Head, Department of Medicine, Maulana Azad Medical College , New Delhi, India .
authors.forename: Naresh
authors.initials: N
authors.lastname: Gupta
keywords: Anti-epileptic drugs; Generalized tonic clonic seizures; Stevens-Johnson syndrome
references.citation: J Clin Psychiatry. 2001;62 Suppl 14:22-6
references.pmid: 11469671
references.citation: Neurology. 2007 May 15;68(20):1701-9
references.pmid: 17502552
references.citation: Dermatol Online J. 2003 Aug;9(3):6
references.pmid: 12952753
references.citation: Indian J Dermatol Venereol Leprol. 2004 Jul-Aug;70(4):217-20
references.pmid: 17642618
references.citation: J Neurol Neurosurg Psychiatry. 1984 Jun;47(6):642-4
references.pmid: 6234378
references.citation: N Engl J Med. 1981 Sep 24;305(13):722-7
references.pmid: 6790991
references.citation: J Dermatol. 1996 Aug;23(8):530-4
references.pmid: 8854584
references.citation: Neurosurgery. 1983 Sep;13(3):272-5
references.pmid: 6225961
references.citation: J Investig Med High Impact Case Rep. 2013 Nov 19;1(4):2324709613512622
references.pmid: 26425589
references.citation: Asian Pac J Allergy Immunol. 1996 Dec;14(2):65-8
references.pmid: 9177818
references.citation: J Assoc Physicians India. 1998 Jul;46(7):595-7
references.pmid: 12152838