A 67-year-old man comes to an urgent care clinic with skin rash and malaise over the last several days. He has a history of hypertension and suffered an ischemic stroke 2 years earlier. One month ago, he had an episode of new-onset tonic-clonic seizures and was hospitalized for 2 days. MR imaging of the brain during that admission showed no intracranial mass lesion. Electroencephalogram done at that time was normal. His current medications include aspirin, rosuvastatin, valsartan, amlodipine, and phenytoin. He does not use tobacco, alcohol, or illicit drugs.
The patient's temperature is 38.2 C (100.8 F), blood pressure is 120/80 mm Hg, and pulse is 85/min. Oral examination shows mild pharyngeal erythema but no mucosal ulcerations. There are numerous and diffuse erythematous macules and papules present on the trunk and proximal extremities. Enlarged lymph nodes are palpated in the cervical, axillary, and inguinal areas. The remainder of the examination is within normal limits.
Laboratory results are as follows:

What is the best next step in management of this patient?

Question

A 67-year-old man comes to an urgent care clinic with skin rash and malaise over the last several days.  He has a history of hypertension and suffered an ischemic stroke 2 years earlier.  One month ago, he had an episode of new-onset tonic-clonic seizures and was hospitalized for 2 days.  MR imaging of the brain during that admission showed no intracranial mass lesion.  Electroencephalogram done at that time was normal.  His current medications include aspirin, rosuvastatin, valsartan, amlodipine, and phenytoin.  He does not use tobacco, alcohol, or illicit drugs.
The patient's temperature is 38.2 C (100.8 F), blood pressure is 120/80 mm Hg, and pulse is 85/min.  Oral examination shows mild pharyngeal erythema but no mucosal ulcerations.  There are numerous and diffuse erythematous macules and papules present on the trunk and proximal extremities.  Enlarged lymph nodes are palpated in the cervical, axillary, and inguinal areas.  The remainder of the examination is within normal limits.
Laboratory results are as follows:

What is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9882_5a83_853d_5dc5e1718568_MD0002_00 This patient's presentation of fever, rash, lymphadenopathy, eosinophilia, and elevated transaminases suggests anticonvulsant hypersensitivity syndrome (AHS) (a form of drug-induced hypersensitivity syndrome or drug reaction with eosinophilia and systemic [DRESS] syndrome), a rare but serious disorder with a mortality rate of 10%. AHS occurs in about 1/1000 to 1/10,000 patients treated with phenytoin or other aromatic anticonvulsant drugs (eg, carbamazepine, phenobarbital). Other implicated agents include nonaromatic anticonvulsants (eg, lamotrigine), allopurinol, angiotensin-converting enzyme inhibitors, antidepressants, and beta-blockers. Patients usually present within 2 months of starting anticonvulsant therapy with fever, rash, pharyngitis, lymphadenopathy, facial edema, and systemic organ involvement (eg, hepatitis, nephritis). Rash can present as classic erythematous papules, pustules, or possible toxic epidermal necrolysis. Eosinophilia and anemia are common, and severe cases may present with megaloblastic anemia, hepatitis, and rhabdomyolysis. Diagnosis requires a high index of suspicion. AHS management includes supportive care and prompt discontinuation of the offending drug. Systemic corticosteroids are frequently used as they may help with faster recovery. AHS patients are at risk for recurrence and development of similar reactions to other anticonvulsants. Family members should also be counseled as there may be a genetic susceptibility. (Choice B) Contact isolation is usually recommended for patients colonized with multidrug-resistant bacteria (eg, methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus), enteric infections, scabies, impetigo, zoster, and draining abscesses or decubitus ulcers. (Choices A, D, and E) Hepatitis viral panel and lumbar puncture would not be of much help in identifying this patient's illness. Bone marrow biopsy can be considered to rule out malignancy if this patient does not improve after discontinuing phenytoin and starting systemic glucocorticoids. Educational objective: Anticonvulsant hypersensitivity syndrome is a rare but serious disorder that usually occurs within 2 months of initiating anticonvulsant therapy. Clinical manifestations include fever, rash, pharyngitis, lymphadenopathy, facial edema, and systemic organ involvement (eg, hepatitis, nephritis). Management includes discontinuation of the offending drug and systemic glucocorticoids. __________ References: Anticonvulsant hypersensitivity syndrome: an update. (http://www.ncbi.nlm.nih.gov/pubmed/22794330) Anticonvulsant hypersensitivity syndrome: clinical and laboratory features. (http://www.ncbi.nlm.nih.gov/pubmed/18986457)

A 67-Year-Old Man Comes to an Urgent Care Clinic with Skin