Toxic Epidermal Necrolysis Due to Lamotrigine Monotherapy for Bipolar Disorder

A Case of Toxic Epidermal Necrolysis Caused by Lamotrigine Combined With Valproic Acid and Literature Review

After suffering from frequent symptomatic seizures secondary to cerebral hemorrhage, a 58-year-old male patient was prescribed a one-time 50 mg dose of lamotrigine, which he took for a week. However, the patient's seizure symptoms were not controlled until a dosage of 500 mg of sodium valproate tablets was taken twice daily, which ultimately resolved his seizures. Unfortunately, about two weeks after the combination, the patient developed a rash. Nine days later, the patient developed new blisters, necrotizing epidermal desquamation, and lesions over 80% of their body surface area. This was diagnosed as toxic epidermal necrolysis (TEN) resulting from the combination of lamotrigine and sodium valproate. The sodium valproate and lamotrigine were discontinued and treated symptomatically for about one month. The patient's condition improved as the fatal rash gradually subsided. However, after the onset of TEN, unexpected psychiatric symptoms such as poor sleep, less than four hours of sleep, irritability, paranoia, crying, fear of rash recurrence, and suspicious hallucinations and delusions emerged in the patient. Surprisingly, after discontinuation of lamotrigine and sodium valproate due to the rash, the patient did not experience any further seizures.

Lamotrigine induced toxic epidermal necrolysis: A case report

Introduction

A wide spectrum of cutaneous adverse reactions ranging from simple maculopapular rashes to more severe and life-threatening reactions like Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis(TEN) have been described after exposure to many antiepileptic drugs. Although the adverse effect following lamotrigine has been reported after a low initial dosage, the risk of developing TEN is relatively rare.

Case report

We present a 23-year-old female, 6 months post-partum, a case of complex partial seizure, who developed TEN after 14 days of monotherapy with lamotrigine. She was put on steroids and other supportive management. After a tempestuous course of 9 days in ICU, she made an eventful recovery.

Discussion

Lamotrigine, a chemically different newer antiepileptic, if rapidly titrated and used in conjunction with valproate can cause exfoliative dermatitis-like TEN, but at lower doses and as a monotherapy, female, post-partum, probably due to hormonal factors and strong association between HLA-B*1502 and AED (Antiepileptic drug)-induced SJS/TEN in patients of Asian ethnicity could be other contributing cause. Also, lesser use of lamotrigine in developing nations might have led to a lesser incidence of serious cutaneous adverse reactions. The SCORTEN (Severity-of-illness score for toxic epidermal necrolysis) is the most widely used system to standardize the evaluation of risk and prognosis in patients with TEN.

Conclusion

Though rare but TEN can occur following lamotrigine monotherapy. Prompt diagnosis, withdrawal of offending agent, and timely proper supportive care might help in lowering the mortality.

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Severe exfoliative dermatitis like SJS and TEN are less reported with lamotrigine as a monotherapy compared to aromatic anticonvulsants.

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The severe adverse cutaneous reaction following lamotrigine use may be overlooked as it is not used that frequently in developing nation.

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Prompt diagnosis, withdrawal of offending agent and proper supportive care can help prevent mortality in such case.

Lamotrigine-induced severe cutaneous adverse reaction: Update data from 1999-2014

We systematically reviewed and analyzed published patients with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) associated with lamotrigine therapy to identify characteristics of these reactions. We identified a total of 70 patients (42 SJS, five SJS/TEN, 23 TEN). The female to male ratio was 2.83:1 in the TEN group and 1.47:1 in the SJS group. Patients in the TEN group were younger than in the SJS group but this difference was not significant (28.35 versus 32.71 years, respectively; p=0.27). The median time to onset was 25.33 versus 18.42 days for SJS and TEN, respectively. The median dosage at onset was 36.46 versus 57.29mg, and final dosage 111.25 versus 97.92mg/day for SJS and TEN, respectively. The median final dosages did not significantly differ. Concomitant use of valproate acid was reported in 54.55% of the SJS patients and 50.00% of the TEN patients. Three fatal reactions were reported, of which two patients deteriorated rapidly and died within 12h of admission, indicating that this disease can develop rapidly before effective treatment. There was no significant difference between the SJS and TEN groups in any of the clinical factors examined which confirmed the opinion that SJS and TEN are part of a single disease spectrum.

A lamotrigine induced toxic epidermal necrolysis in a child

Toxic epidermal necrolysis (TEN) is rare, life-threatening skin disorder that usually is caused by an adverse drug reaction. The exact pathogenesis of TEN is still unknown. Many treatments including prednisolone, cyclosporine and intravenous immunoglobulin (IVIG) can be used to halt the disease process. We present a 12-year-old girl with epilepsy who developed TEN after about 14 days of lamotrigine treatment. Lamotrigine was immediately discontinued. After receiving systemic corticosteroid treatment, the patient had a complete recovery. Antiepileptic-induced TEN can be mortal in some cases. Thus, we would like to point out the importance of early diagnosis and treatment.