Lamotrigine-induced severe cutaneous adverse reaction in a patient with N-methyl-D-aspartate receptor autoimmune encephalitis

Omkar Sonavane; Suneel Majagi

doi:10.18203/2319-2003.ijbcp20261971

Authors

Omkar Sonavane Department of Pharmacology, K. H. Patil Institute of Medical Sciences, Gadag, Karnataka, India https://orcid.org/0009-0003-4131-0590
Suneel Majagi Department of Pharmacology, K. H. Patil Institute of Medical Sciences, Gadag, Karnataka, India https://orcid.org/0009-0006-7654-2262

DOI:

https://doi.org/10.18203/2319-2003.ijbcp20261971

Keywords:

Autoimmune, Cutaneous, Encephalitis, Reaction, Lamotrigine, Valproate

Abstract

Current case report is regarding a 20-year-old female patient presenting with N-methyl-D-aspartate (NMDA) receptor antibody-positive autoimmune encephalitis and new-onset seizures who developed rapidly progressive erythematous pruritic rash after administration of tablet lamotrigine followed by escalation of its dose and which was combined with tablet sodium valproate and tablet lacosamide. Cutaneous involvement was diffuse but mucosal surfaces were spared. Laboratory investigations revealed mild transaminitis and monocytosis without systemic involvement. A probable lamotrigine‑induced severe cutaneous adverse drug reaction was diagnosed based on temporal association and Naranjo causality assessment. Prompt discontinuation of lamotrigine and initiation of systemic corticosteroids resulted in complete clinical resolution. Present case highlights risk of occurance of severe cutaneous adverse drug reactions caused by oral lamotrigine when co-administered with sodium valproate which is known to cause enzyme inhibition as well as in the presence of immune dysregulation. There is a need to take precautions where these conditions exist. Early recognition and timely withdrawal of the offending drug are critical to prevent progression to Steven Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN).

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References

Mockenhaupt M, Messenheimer J, Tennis P, Schlingmann J, Langbein K, Sturkenboom M, et al. Risk of Stevens–Johnson syndrome and toxic epidermal necrolysis in new users of antiepileptics. Neurology. 2005;64(7):1134-8. DOI: https://doi.org/10.1212/01.WNL.0000156354.20227.F0

Arif H, Buchsbaum R, Weintraub D, Pierro J, Resor SR Jr, Hirsch LJ. Comparison and predictors of rash associated with 15 antiepileptic drugs. Neurology. 2007;68(20):1701-9. DOI: https://doi.org/10.1212/01.wnl.0000261917.83337.db

Hirsch LJ, Weintraub DB, Buchsbaum R, Spencer HT, Straka T, Hager M. Predictors of lamotrigine-associated rash. Epilepsia. 2006;47(2):318-22. DOI: https://doi.org/10.1111/j.1528-1167.2006.00423.x

Yip VL, Alfirevic A, Pirmohamed M. Genetics of immune-mediated adverse drug reactions. Clin Rev Allergy Immunol. 2015;48(2-3):165-75. DOI: https://doi.org/10.1007/s12016-014-8418-y

Harr T, French LE. Stevens–Johnson syndrome and toxic epidermal necrolysis. Orphanet J Rare Dis. 2010;5:39. DOI: https://doi.org/10.1186/1750-1172-5-39

Chung WH, Hung SI, Yang JY, Su SC, Huang SP, Wei CY, et al. Granulysin as mediator of keratinocyte death in Stevens–Johnson syndrome and toxic epidermal necrolysis. Nat Med. 2008;14(12):1343-50. DOI: https://doi.org/10.1038/nm.1884

Phillips EJ, Sukasem C, Whirl-Carrillo M, Müller DJ, Dunnenberger HM, Chantratita W, et al. CPIC guideline for HLA genotype and use of carbamazepine and lamotrigine. Clin Pharmacol Ther. 2018;103(4):574-81. DOI: https://doi.org/10.1002/cpt.1004

Dalmau J, Armangué T, Planagumà J, Radosevic M, Mannara F, Leypoldt F, et al. Anti-NMDA receptor encephalitis-update. Lancet Neurol. 2019;18(11):1045-57. DOI: https://doi.org/10.1016/S1474-4422(19)30244-3

Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. Estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981;30(2):239-45. DOI: https://doi.org/10.1038/clpt.1981.154

Bastuji-Garin S, Fouchard N, Bertocchi M, Roujeau JC, Revuz J, Wolkenstein P. SCORTEN severity score for toxic epidermal necrolysis. J Invest Dermatol. 2000;115(2):149-53. DOI: https://doi.org/10.1046/j.1523-1747.2000.00061.x

Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med. 1994;331(19):1272-85. DOI: https://doi.org/10.1056/NEJM199411103311906

Schneck J, Fagot JP, Sekula P, Sassolas B, Roujeau JC, Mockenhaupt M. Impact of treatments in Stevens–Johnson syndrome/toxic epidermal necrolysis. J Am Acad Dermatol. 2008;58(1):33-40. DOI: https://doi.org/10.1016/j.jaad.2007.08.039

García-Doval I, Le Cleach L, Bocquet H, Otero XL, Roujeau JC. Effect of early causative-drug withdrawal on mortality. Arch Dermatol. 2000;136(3):323-7. DOI: https://doi.org/10.1001/archderm.136.3.323

Creamer D, Walsh SA, Dziewulski P, Exton LS, Lee HY, Dart JK, et al. UK guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults. Br J Dermatol. 2016;174(6):1194-27. DOI: https://doi.org/10.1016/j.bjps.2016.01.034

Roujeau JC, Kelly JP, Naldi L, Rzany B, Stern RS, Anderson T, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;333(24):1600-7. DOI: https://doi.org/10.1056/NEJM199512143332404

Chatterjee M, Hemdani R, Rajput GR. Stevens-Johnson syndrome and toxic epidermal necrolysis. In: Gupta LK, Khurana A, Sharma VK, editors. IADVL’s Textbook on Cutaneous Adverse Drug Reactions. Mumbai: Bhalani Publishing House. 2018;266-79.