(Kiosk 4) Managing Potential Triggers of Diffuse Rash in Brain Abscess Patient: A Case Report

Case Diagnosis: 67-year-old woman with diffuse rash

Case Description or Program Description: Patient with history of CRPS presented with AMS and was found to have a left parieto-occipital mass. Her course was complicated by status epilepticus refractory to lorazepam, levetiracetam, lacosamide, and valproic acid. Termination of seizures was achieved with a phenobarbital and phenytoin regimen. Patient underwent excision of the mass which revealed an abscess growing strep viridans requiring intravenous ceftriaxone. In acute inpatient rehabilitation, she developed a diffuse pruritic maculopapular rash.

Setting: Acute inpatient rehabilitation facility

Assessment/Results: Phenytoin and phenobarbital levels were in therapeutic ranges. Medication changes tried included discontinuation of pregabalin and switching ceftriaxone to vancomycin. Symptoms were managed with oral diphenhydramine, topical hydrocortisone, hydroxyzine, and oral steroids with no improvement. Phenytoin was halved then discontinued and replaced with levetiracetam with substantial improvement in symptoms. Notably the rash began 22 days after initiation of phenytoin in the acute care hospital. Prior to discharge the phenobarbital was discontinued and the patient was able to continue only on Keppra.

Discussion (relevance): New-onset generalized rash in the inpatient setting is commonly medication induced (cutaneous adverse drug reactions (cADRs)) and occurs closely timed with the start of inciting agent. The majority of cADRs are neither severe or life-threatening. Symptom management and prompt discontinuation of the medication are important to minimize patient suffering. Isolating the cause can prove difficult as cutaneous reactions are common with many classes of medication including antibiotics, antiepileptics (AED), pain medications, chemotherapy, and psychotropic medications. Among AEDs, incidence of rashes range from 1.7 to 8.8%. Maculopapular rash from phenytoin usually occurs 3 to 20 days after initiation. As with this patient, when multiple medications are potential triggers of rash it is prudent to exercise a tiered approach for alternatives by considering the harm-benefit ratio of each agent.

Conclusions: This is a case of maculopapular rash management complicated by multiple medication risk factors. Physiatrists need to familiarize with the differential and management of cADRs.