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Ibuprofen/methylprednisolone/moxifloxacin Toxic epidermal necrolysis and tonic-clonic seizure: case report

A 22-year-old woman developed toxic epidermal necrolysis (TEN) during treatment with ibuprofen for fever and headache. Additionally, she developed tonic-clonic seizure during treatment with methylprednisolone and moxifloxacin for TEN [not all routes and dosages stated]. The woman without any underlying medical history, presented to the hospital with a 1-day history of painful multiple erythematous bullae and plaques of various sizes on her entire body. Five days prior to the presentation, she had taken nortriptyline and paracetamol [acetaminophen] for headache. Two days prior to the presentation, she had taken amoxicillin/clavulanic acid [amoxicillin/clavulanate] and ibuprofen for headache and fever. Viral laboratory test and punch biopsy from the bullous lesion were performed. Histopathologic examination revealed spongiosis and inflammatory infiltrates in the dermis and perivascular area. Immunofluorescence staining showed no specific findings. On hospital day 2, the bullae progressively coalesced and detachment of the epidermis was observed. Nikolsky’s sign was positive, and about 60% of the body surface area was involved. She was diagnosed with TEN. She received methylprednisolone 2 mg/kg, and the areas of epidermal detachment were treated with foam dressing. On hospital day 4, IV moxifloxacin 400mg was administered because of dysuria and pyuria. On hospital day 5, she had a tonic-clonic seizure with eyeball deviation for 5 minutes. Subsequently, the woman was transferred to the ICU where she received lorazepam and levetiracetam. Investigations revealed elevated levels of ALT and low levels of serum creatinine. The levels of AST, blood urea nitrogen, serum sodium, serum potassium and serum chloride were found to be normal. Brain CT, MRI and CSF examination revealed no abnormality. She experienced seizures on hospital day 7 and again on hospital day 10. The two episodes of seizures were well controlled by lorazepam. On hospital day 16, the seizures completely stopped following treatment with levetiracetam alone, and the skin lesions completely healed. She was transferred to the general ward; however, her Mini-Mental State Examination (MMSE) score was 20 points. Levetiracetam was discontinued on hospital day 21, and the MMSE slightly improved to 24 points; however, she developed retrograde amnesia and did not remember being treated in the ICU. She was discharged on hospital day 25. She had no complications or sequelae after 5 weeks of follow-up. Kim MS, et al. A case of generalized seizure after toxic epidermal necrolysis. Annals of Dermatology 32: 334-336, No. 4, Aug 2020. Available from: URL: http:// doi.org/10.5021/ad.2020.32.4.334

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Reactions 17 Oct 2020 No. 1826