Levetiracetam, phenytoin
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DRESS syndrome in an adolescent patient: case report An 18-year-old man developed DRESS syndrome while receiving levetiracetam and phenytoin for seizures. The man presented with a 5-day history of a pruritic, maculopapular rash that had started on his extremities and spread to his back, chest and face. Associated periorbital swelling, fever and transaminitis were present. He had a history of seizures that started 35 days previously, and were treated with levetiracetam 500mg twice per day and extendedrelease phenytoin 100mg daily [routes not stated]. On examination, he exhibited fever (40.2°C), a non-productive cough and tea-coloured urine. Profound periorbital oedema prevented eye-opening. Laboratory tests revealed the following values: free phenytoin level 0.4 mcg/mL (therapeutic level 1.0–2.0), AST 778 U/L (0–37), ALT 1274 (0-41). The man was admitted with a presumptive diagnosis of drug-induced hypersensitivity and all drugs were withdrawn. His condition worsened on hospital day 1, with increased facial swelling and progression of the rash. Signs of liver synthetic dysfunction began, with an elevated prothrombin time and INR in addition to increasing transaminitis. Complete blood count demonstrated an atypical lymphocytosis and eosinophilia at 8%. He was commenced on dexamethasone, and showed marked clinical recovery on day 2. His transaminases started to improve on day 3, and had substantially resolved by day 8. He was discharged home receiving prednisone. At 5 months’ follow-up, there was no recurrence in his rash or other symptoms, and his serum transaminases were normal. Author comment: "Given the significant mortality attributed to DRESS syndrome, clinicians should be aware of the potential for this severe hypersensitivity reaction particularly in starting any new anti-epileptic medication". Hall DJ, et al. Drug reaction with eosinophilia and systemic symptoms syndrome in a patient taking phenytoin and levetiracetam: A case report. Journal of Medical Case Reports 7: No. 2, 2013. Available from: URL: http:// 803085948 dx.doi.org/10.1186/1752-1947-7-2 - USA
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Reactions 20 Apr 2013 No. 1448
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