J Korean Med Sci.  2006 Aug;21(4):768-772. 10.3346/jkms.2006.21.4.768.

Drug Hypersensitivity to Previously Tolerated Phenytoin by Carbamazepine-induced DRESS Syndrome

• Kim CW
• Choi GS
• Yun CH
• Kim DI

• KMID: 2157838
• DOI: http://doi.org/10.3346/jkms.2006.21.4.768

Abstract

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome associated with anticonvulsant drugs is a rare but potentially life-threatening disease that occurs in response to arene oxide producing anticonvulsant such as phenytoin and carbamazepine. There have been many reports of cross reactivity among the anticonvulsants upon first exposure to the offending drugs. However, there has been few data describing the development of DRESS syndrome after switching medication from previously well-tolerated phenytoin to carbamazepine, and the induction of hypersensitivity to phenytoin by DRESS to carbamazepine. We experienced a case of a 40-yr-old man who had uncontrolled seizure that led to the change of medication from the long-term used phenytoin to carbamazepine. He developed DRESS syndrome after changing the drugs. We stopped carbamazepine and restored phenytoin for seizure control, but his clinical manifestations progressively worsened and he recovered only when both drugs were discontinued. Patch tests with several anticonvulsants showed positive reactions to both carbamazepine and phenytoin. Our case suggests that hypersensitivity to a previously tolerated anticonvulsant can be induced by DRESS to another anticonvulsant, and that the patch test may be a useful method for detecting cross-reactive drugs in anticonvulsant-associated DRESS syndrome.

Keyword

Carbamazepine; Phenytoin; Hypersensitivity; Cross Reactions; Patch Tests

MeSH Terms

Syndrome
Skin/drug effects/immunology/pathology
Phenytoin/immunology
Male
Humans
Drug Hypersensitivity/*immunology
Drug Eruptions/etiology/*immunology
Carbamazepine/*adverse effects
Anticonvulsants/adverse effects
Adult

Figure

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  Fig. 1 Generalized diffuse maculopapular rashes over the face and trunk with facial edema on the day of admission.

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  Fig. 2 Desquamative facial rash and edema (A), and vesiculation on upper arms (B). Photographs taken at seventh admission day with prednisolone (40 mg/day) treatment.

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  Fig. 3 Results of drug patch testing at day 2. 1, petrolatum; 2, phenytoin 10% aq; 3, phenytoin 1% aq; 4, phenobarbital 10% pet; 5, phenobarbital 1% pet; 6, phenytoin 10% pet; 7, phenytoin 1% pet; 8, carbamazepine 10% aq; 9, carbamazepine 1% aq; 10, carbamazepine 10% pet; 11, carbamazepine 1% pet; 12, carbamazepine 0.5% pet; 13, carbamazepine 0.1% pet; 14, sodium valproate 10% pet; 15, sodium valproate 1% pet; 16, topiramate 10% pet; 17, topiramate 1% pet; 18, gabapentin 10% pet; 19, gabapentin 1% pet; 20, vigabatrin 10% pet. aq, in water; pet, in petrolatum.

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