(131) Lamotrigine-induced drug reaction with eosinophilia and systemic symptoms (DRESS) exacerbated by COVID-19 infection

Abstract: Background/Significance:

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a rare but potentially life-threatening drug reaction syndrome characterized by delayed-onset skin eruption, fever, hematologic abnormalities, and internal organ involvement. Mortality is estimated at 10% (Cacoub, 2011). This case report of DRESS syndrome was caused by a psychotropic medication and was exacerbated by COVID-19, leading to concerns about multisystemic inflammatory syndrome in children (MIS-C).



Case:

S is a 12 year old male with autism spectrum disorder, anxiety, depression, and gender dysphoria. Medications include lamotrigine 50MG and risperidone 1.5MG, started 1 month prior and increased after recent hospitalization. After discharge, he developed fever to 102F and rash that began on his chest and bilateral arms. He was seen by his psychiatrist, who suspected a drug reaction and discontinued lamotrigine. One week later, S presented to ED for continued rash and new upper respiratory symptoms.

In ED, S’s physical exam was notable for cervical lymphadenopathy, hepatomegaly, and facial edema. He had a diffuse, erythematous, blanching, maculopapular rash spanning the body, sparing palms, soles of feet, mucosal surfaces, face, and genitals. Labs were significant for leukocytosis, eosinophilia, elevated transaminases, and prolonged INR. He was also positive for COVID. There was concern that COVID might have exacerbated the drug reaction.

His presentation was concerning for DRESS syndrome caused by lamotrigine. He was managed with prednisone 1mg/kg daily.





Discussion:

Lamotrigine is a high-risk drug for DRESS (Lin, 2021). The most common psychotropic drugs linked to DRESS syndrome include Carbemazepine, Lamotrigine, Phenytoin, Valproate, and Phenobarbital (Bommersbach, 2016). Up to 35% of cases of DRESS are caused by antiepileptic drugs (Kardaun, 2013). Given the mortality associated with this syndrome and highly variable clinical presentation, DRESS should be considered in any patient who is started on a high-risk medication with recent rash and systemic symptoms. COVID infection may exacerbate these symptoms (Novak, 2021).

Conclusion/Implications:

Psychiatrists are essential to the recognition of DRESS and management of co-morbid psychiatric conditions with new, non-offending medications.



References:

Bommersbach TJ, Lapid MI, Leung JG, Cunningham JL, Rummans TA, Kung S. Management of Psychotropic Drug-Induced DRESS Syndrome: A Systematic Review. Mayo Clin Proc. 2016;91(6):787-801.

Cacoub P, Musette P, Descamps V, et al. The DRESS syndrome: a literature review. Am J Med. 2011;124(7):588-597.

Kardaun SH, Sekula P, Valeyrie-Allanore L, et al. Drug reaction with eosinophilia and systemic symptoms (DRESS): an original multisystem adverse drug reaction. Results from the prospective RegiSCAR study. Br J Dermatol. 2013;169(5):1071-1080.

Novak N, Peng W, Naegeli MC, et al. SARS-CoV-2, COVID-19, skin and immunology - What do we know so far?. Allergy. 2021;76(3):698-713. doi:10.1111/all.14498

Lin CH, Lin SS, Hong SY, Chen CH, Chou IC. Lamotrigine Induced DRESS Syndrome in Child: A Case Report and Literature Review. Child (Basel, Switzerland). 2021;8(11).