A 12 year old boy, with a known case of seizure disorder presented to the casualty with generalized maculopapular rash, fever and facial puffiness. The patient had been operated for gastric perforation when he was 3 days old following which the seizure episodes started. He was treated with phenobarbitone till the age of five. The drug was gradually withdrawn on the advice of a physician. Six months ago he suffered an episode of convulsion. He was started on sodium valproate and levetiracetam. One month back levetiracetam was stopped and lamotrigine was initiated. The patient was taking 1 tablet of 25mg daily for the first 15 days; later the dose was doubled. On the 18th day, patient presented with generalized maculopapular rash, itching and fever and on 20th day he developed colicky abdominal pain and vomiting followed by facial puffiness.\nOn examination, he was alert and oriented, with a temperature of 100°F and pulse was 114/ minutes. There was significant angioedema of his face with edematous lips and swollen ears, and an extensive maculo-papular rash on his entire trunk [], buttocks, extremities and face. The whole body had a red tinge. Examination showed yellow sclera, conjunctival congestion and crusting over his lips. He experienced no joint pain or neurological symptoms, and no abdominal or respiratory complaints. There was no history of any allergies. The birth history and immunization were uneventful. He had 3 siblings: one of them also had history of epileptic disorders for which she was on treatment.\nInvestigations revealed leukocytosis (15,960cells/cmm) with eosinophilia (19%) AEC=2600/cmm. Hemoglobin was 10.8gm%, platelet count 2.53lakhs/cmm; ESR and PCV were normal. Liver enzymes were raised with SGOT=905U/l, SGPT=495U/l, ALP=855U/l and GGT= 155U/l. Total bilirubin was 1.5mg% (direct 0.51mg% and indirect 0.99mg%). Blood urea and creatinine were normal. Routine examination of the urine was normal. Provisional diagnosis of DRESS was made based on the above findings.\nParental cortisteroids and systemic antihistamines were initiated. Lamotrigine was stopped. Within 5 days the rash subsided. Patient's general condition improved. On discharge patient was given oral steroids and antihistaminic's.
A 54-year-old housewife, known case of bipolar disorder with anxiety, presented to the neurology OPD. She was on valproate, fluoxetine, and olanzapine but for the past 3–4 months had worsened despite being on these three medications. Mirtazapine and LTG drugs were added by the psychiatrist, 15 days after which she complained of fever, pain in both ears, and presented to the dermatology OPD with rashes. On examination multiple discrete papules which were erythematous to hyper pigmented were seen all over the body;also seen were mucosal congestion and conjunctival involvement (matted eye lashes with crusting). There was also necrosis in nasal, oral (hemorrhagic crusting on lips), and genital (moist gray-white slough on the vaginal mucosa) areas []. There was no past or family history of any allergies. On the basis of clinical evaluation, the patient was diagnosed with SJS. LTG was stopped immediately and appropriate treatment was initiated. Patient's general condition improved, and on discharge, she was given antibiotic, steroid, and antihistaminic medications.