A 30-year-old woman presented to the hospital with a morbilliform and pruritic generalized rash [], along with high-grade fever, fatigue, and malaise for 4 days. Physical examination and blood tests revealed enlarged cervical and inguinal nodes, leukocytosis (up to 66,800 white blood cell/mm3), and elevated levels of hepatic transaminases, lactate dehydrogenase, ß-2 microglobulin, and erythrocyte sedimentation rate. Serology results for hepatitis, syphilis, typhoid fever, and brucella were negative. The whole body computed tomography showed multiple neck, chest, and abdominal lymphadenopathy with splenomegaly suggestive of lymphoma []. A skin biopsy specimen revealed epidermotropism of atypical lymphoid cells, with CD30 positive staining as well as a dense perivascular and perifollicular lymphoid infiltrate []. An excisional biopsy of a 1.0 cm cervical node showed diffuse polymorphic lymphoid hyperplasia with effacement of the normal architecture with strong and diffuse staining for CD30 on immunohistochemistry, positive anti-leukocyte common antigen, and high proliferation index (Ki67 80%). All findings were consistent with lymphoma. However, osteomedullary biopsy showed no evidence of lymphoproliferative disorder, was absent for immunomarkers and high eosinophils proliferation rate. T-cell receptor rearrangement studies on the skin, lymph node, and bone marrow biopsies, failed to detect monoclonality. A detailed review of her past medical history revealed that she was started on lamotrigine 50 mg/day for somatization disorder 40 days prior to the onset of symptoms. Blood samples were positive for human herpesvirus 6 DNA. The diagnosis of DIHS/DRESS was made; lamotrigine was discontinued and treatment with oral corticosteroids (prednisolone, 60 mg/day) was started with rapid tapering. The patient made a full recovery with no organ deficit on follow-up visits at 1, 2, 4, and 6 months.
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.