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Stevens–Johnson Syndrome
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     A 22-year-old woman with a history of a seizure disorder presented to the emergency department after having a rash for three days and a fever for one day. The rash began as a maculopapular distribution on the neck and chest and rapidly progressed to target lesions and bullae (Panels A and B) that involved all surfaces of the integument and spared only the scalp. The patient had fevers as high as 40.5°C and painful erosions of the mucosa of the conjunctiva, mouth, and vagina. Since approximately 10 percent of her body surface was involved, a diagnosis of Stevens–Johnson syndrome was made. Five weeks before the development of the rash, the patient had been started on a gradually increasing dose of lamotrigine while therapy with valproate was tapered off. Serum concentrations of lamotrigine are markedly increased when this agent is taken with valproate, owing to an inhibition of lamotrigine metabolism. Both anticonvulsants were discontinued, and the patient received supportive care. In one study, a severe rash requiring hospitalization developed in 0.3 percent of patients receiving lamotrigine. Since the patient had not had a seizure in more than a decade, she was discharged with no anticonvulsant medication and has been free of seizures for more than a year.

    Jordan D. Fein, M.D.

    Kendal L. Hamann, M.D.

    University of California, Davis, Medical Center

    Sacramento, CA 95817