Suspected Lamotrigine-Induced Severe Cutaneous Adverse Reaction in Bipolar Disorder Patient

Case at a Glance

A 36-year-old female with Bipolar I disorder developed acute onset facial rash, oral mucosal involvement, and throat symptoms three days after increasing lamotrigine dosage from 25mg to 50mg daily.

Patient's Story

The patient presented with a 3-day history of rapidly developing skin lesions on her face, shoulders, throat, and ears. She reported that the rash appeared shortly after increasing her lamotrigine dose. Associated symptoms included sore throat, tongue numbness with cracking, and severely cracked lips that worsened overnight. The patient expressed concern about a possible drug reaction and had already contacted her psychiatrist and nursing hotline for guidance.

Initial Assessment

Physical examination revealed erythematous, raised lesions consistent with urticarial eruption on facial area, shoulders, and neck. Oral examination showed tongue fissuring, numbness, and severe lip cracking. The patient appeared anxious but was hemodynamically stable with no signs of respiratory distress at initial presentation.

The Diagnostic Journey

Given the temporal relationship between lamotrigine dose escalation and symptom onset, along with the characteristic distribution and rapid progression of the rash, a lamotrigine-induced severe cutaneous adverse reaction was strongly suspected. The presentation raised concerns for potential Stevens-Johnson syndrome or drug reaction with eosinophilia and systemic symptoms (DRESS), warranting immediate evaluation and monitoring.

Final Diagnosis

Lamotrigine-induced severe cutaneous adverse reaction with mucosal involvement, suspected early Stevens-Johnson syndrome

Treatment Plan

Immediate discontinuation of lamotrigine was recommended. The patient was started on high-dose corticosteroids and antihistamines. Close monitoring for progression to more severe cutaneous reactions was instituted. Psychiatric medication regimen required adjustment with alternative mood stabilizer selection in consultation with psychiatry.

Outcome and Follow-up

The patient's symptoms gradually improved following lamotrigine discontinuation and supportive care. Alternative mood stabilization was successfully achieved with a different medication class. Patient was counseled about avoiding lamotrigine in the future and the importance of recognizing early signs of severe drug reactions. Regular dermatologic and psychiatric follow-up was arranged.