Necrotizing Lymphadenitis Associated with the Phenytoin-induced Hypersensitivity Syndrome

Abstract

A 32-year-old black female was started on phenytoin for seizure prophylaxis following the clipping of an aneurysm. This was stopped after 3 weeks when she developed a generalized skin rash. Over the next week she developed fever, sore throat, dysphagia, and headache. She had an erythematous throat with white exudates on the right tonsil and 1 to 3 cm firm, tender lymphadenopathy in multiple regions. Blood, throat swab and cerebrospinal fluid studies were negative for bacterial or viral infections, except for elevated liver enzymes. CT scan of chest, abdomen, and pelvis showed no lymphadenopathy. Lymph node biopsy suggested necrosis but no evidence of infection, granuloma, or lymphoma. Her lymphadenopathy resolved spontaneously and liver enzymes normalized in 3 weeks. Hypersensitivity syndrome due to antiepileptics manifests as fever, rash, generalized lymphadenopathy, and probably represents a T-cell mediated drug reaction. This reaction may persist despite cessation of the drug, and it may engender expensive evaluation. Careful observation up to 3 weeks after drug cessation may be the best management.

Morphologic Spectrum of Lymphadenopathy in Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome

“…In Table 3, we summarize the morphologic patterns described in previous cases and the 5 cases reported here. [16][17][18][19][20][21][22][23][24][25] Over half of all cases reported previously had Tcell lymphoma-like morphologic features, perhaps because of the selection bias of accepted reports. The most frequent morphologic features of DRESS-associated lymphadenopathy, mimicking T-cell lymphoma, include marked expansion of the paracortex with distortion of lymph node architecture and the presence of a mixed inflammatory background with eosinophils.…”

Safety of Long-Term Benzodiazepine Therapy; Topiramate and Reversible Anorgasmia; Lymphadenitis and Phenytoin-Induced Hypersensitvity; Syndrome Seeing Double with Your Antidepressant?; Cabergoline and Heart Valve Pathology; Toxicity with Rectal Fentanyl; Tardive Dystonia with Ziprasidone; Prescription of Teratogenic Medications in the US

“…A 32-year-old female recently underwent a surgical procedure to “clip” a ruptured intracranial aneurysm. 3 She was placed on phenytoin, as a prophylactic anticonvulsant measure, after the surgery. When she developed a generalized body rash 3 weeks later, the phenytoin was stopped.…”