Fatal Toxic Epidermal Necrolysis Induced by Carbamazepine Treatment in a Patient Who Previously had Carbamazepine-induced Stevens-Johnson Syndrome

Abstract

Toxic epidermal necrolysis (TEN) is a rare but life-threatening skin disease that is most commonly drug-induced. It has recently been suggested that Stevens-Johnson syndrome (SJS) belongs to the same group of skin disorders, although it has a lower mortality rate than TEN. We report the case of a 26-year-old male schizophrenic patient with a history of carbamazepine-induced SJS 5 years earlier. At the time of his current admission, he was admitted to our psychiatry department with acute agitation due to schizophrenia. However, the patient and his family denied history of drug allergy. After 3 days of carbamazepine treatment, the patient developed TEN (body surface area > 90%). He was transferred to the burn center, but despite appropriate treatment, including intravenous hydrocortisone 200 mg q6h and being covered with sterile biological material, he died. It is important to note that re-administration of a drug that previously caused SJS may lead to TEN, which has a very high mortality rate.

Stevens-Johnson Syndrome Induced by Carbamazepine Treatment in a Patient Who Previously Had Carbamazepine Induced Pruritus - A Case Report -

“…We assumed that SJS did not occur on the first administration of carbamazepine because the patient stopped taking the medication after a single dose, which is not enough dosage to trigger hypersensitivity reaction. Huang et al also reported a case of fetal toxic epidermal necrolysis induced by carbamazepine treatment in a patient who previously had carbamazepine-induced SJS [12]. It has been reported that higher daily doses of some drugs are associated with an increased risk of SJS compared to lower doses, as is the case for allopurinol [13].…”

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“…The other 3 patients (1 with EM and 2 with TEN) had attacks of similar severity when compared with the first episode [17]. Huang et al [18] reported a case of TEN induced by carbamazepine in a patient who previously experienced SJS induced by the same drug. However, there is no evidence that EM may recur as SJS/TEN.…”

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“…The earliest signs are fever and malaise. The mortality rate is 30% and the morbidity is higher (9)(10)(11)(12)(13)(14)(15). Approximately 85% of patients develop a skin rash that is usually exanthematous but may include blistering eruptions such as erythema multiforme, Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and perifollicular ⁄ non-follicular pustular eruptions.…”

“…The incidence is 0.4-1.2 cases per million per year. The mortality rate is 30% and the morbidity is higher (9)(10)(11)(12)(13)(14)(15).…”

“…The most frequently prescribed antiepileptics in older patients are carbamazepine (CBZ), phenytoin (PHY), phenobarbital (PB) and valproic acid (VPA) for monotherapy or combination therapy (16). The use of polypharmacy increases the risk of adverse reactions (11)(12)(13)16,17).…”