Abstract

Background: Epilepsy is a common neurological disorder. The main goal of treatment is to achieve seizure control without adverse effects. Phenytoin is a commonly used sedative antiepileptic medication in many countries. It is used against tonic-clonic and complex partial seizures. Phenytoin is reported to cause a range of deleterious and erratic side effects at therapeutic and toxic doses. Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon but serious hypersensitivity drug reaction most frequently associated with anti-epileptics. Clinical manifestations include rash, fever, eosinophilia and visceral organ involvement, most commonly hepatitis. The mortality rate associated with DRESS syndrome is approximately 10%, the majority due to fulminant liver failure. Case report: We report a case of phenytoin induced DRESS syndrome in a 50 years old female patient who has presented with pruritic, erythematous and maculopapular rashes associated with periorbital swelling, fever, breathlessness (grade-III) and generalized swelling all over the body since 4 days. Vitals are increased. Temperature:103.60 F, BP:110/90 mmHg, respiratory rate 18 cpm, lab investigations shows WBC count is 7.9 thousand/mm3, with 60% neutrophils, 8.0% lymphocytes, and 4.0% eosinophil. Liver function tests revealed increased AST and ALT levels. Patient got admitted in inpatient ward for drug induced hypersensitivity reactions. Four days prior to presentation she noted pruritus and rash over her extremities, which over the next several days progressed to her chest, back, legs and face. She had past history of seizures that began 20 days prior to this admission treated with oral phenytoin 100mg BID daily. Based on the presenting signs and symptoms, her condition was diagnosed as phenytoin induced Dress syndrome. The symptoms improved significantly after the offending drug was withdrawn. Alternatively she was started on oral carbamazepine 200 mg BID. Naranjo’s and WHO causality assessment was done, indicating a probable relationship between the patient’s symptoms and her use of phenytoin. Patient was later managed with IV fluids, dexamethasone injection, and cetirizine tablet. After 5 days of therapy symptomatic relief was observed and patient was discharged. Conclusion: This case report highlights the adverse drug reactions of phenytoin and the need of regular monitoring in patients on long term therapy.

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