Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942010000400011
Brazilian Journal of Anesthesiology
Clinical Information

Reação cutânea grave induzida por carbamazepina no tratamento da neuralgia pós-herpética: relato de caso

Severe carbamazepine-induced cutaneous reaction in the treatment of post-herpetic neuralgia: case report

João Batista Santos Garcia; Letácio Santos Garcia Ferro; Anamada Barros Carvalho; Rosyane Moura da Rocha; Livia Maria Lima de Souza

http://dx.doi.org/10.1590/S0034-70942010000400011 Braz J Anesthesiol, vol.60, n4, p.433-437, 2010
PDF Português
PDF English
Downloads: 0
Views: 1964

Resumo

JUSTIFICATIVA E OBJETIVOS: O herpes zoster tem como principal complicação a neuralgia pós-herpética (NPH). Utiliza-se para o tratamento a carbamazepina (CXB), um anticonvulsivante bem tolerado, porém frequentemente associado a reações Cutâneas graves, como, por exemplo, a síndrome de Stevens-Johnson (SSJ) e a necrólise epidérmica tóxica (NET). O objetivo deste trabalho é relatar um caso de SSJ/NET secundário ao uso de CBZ em paciente com NPH. RELATO DO CASO: Paciente do sexo feminino, com dor contínua em região torácica e dorso, intensa, em queimação, fisgada, choque, alteração de força de membro superior ipsilateral e sudorese. Apresentava lesões crostosas e eritematosas em região dorsal do tórax, com alodinia e disestesias em dermátomo acometido. Iniciou-se CBZ 300 mg.dia-1, amitriptilina (AMT) 12,5 mg à noite e infiltração com anestésico local na região afetada. Após 15 dias, referia mal-estar, febre, dores musculares e artralgias com rash cutâneo leve e inespecífico. Retirou-se a carbamazepina imediatamente. Uma semana depois, foi internada com urticária e exantema generalizados, erupções Cutâneas eritematosas, bolhosas e máculas purpúricas por todo o corpo. A impressão era de SSJ/NET induzida por carbamazepina. Houve progressiva piora do quadro, com aumento do número e do tamanho das lesões Cutâneas, além de rash eritematoso macular generalizado, áreas de necrose e erosões, com destacamento simétrico da epiderme em face, pescoço, tórax, dorso e membros acometendo mais de 50% da área de superfície, além de envolvimento da mucosa bucal, conjuntival e genital com erosões vesiculares. Apresentou piora funcional progressiva, evoluindo com choque séptico e falência múltipla de órgãos, indo a óbito. CONCLUSÕES: A SSJ/NET é uma reação Cutânea grave com potencial para morbidade e mortalidade elevadas e que demanda intervenção rápida e tratamento adequado. Fica também o alerta para o uso da carbamazepina, que deve sempre ser supervisionado, especialmente em idosos.

Palavras-chave

COMPLICAÇÕES, doenças, Viral, DROGAS, Anticonvulsivante

Abstract

BACKGROUND AND OBJECTIVES: Post-herpetic neuralgia (PHN) is the main complication of herpes zoster. Carbamazepine (CBZ), a well-tolerated anticonvulsant, but frequently associated with severe cutaneous reactions, such as the Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) is used in the treatment of this complication. The objective of this article was to report a case of SJS/TEN secondary to CBZ in a patient with PHN. CASE REPORT: This is a female patient with continuous severe, burning, chock-like pain in the thoracic region and dorsum associated with reduced strength in the ipsilateral upper limb and diaphoresis. She had crusty and erythematous lesions in the dorsal region of the thorax with allodynia and dysesthesia in the affected dermatome. She was treated with CBZ 300 mg.day-1, amitriptyline (AMT) 12.5 mg at bedtime, and infiltration with local anesthetic in the affected region. After 15 days, she developed malaise, fever, muscle pain, and arthralgia with a mild non-specific cutaneous rash. Carbamazepine was discontinued immediately. One week later, she was hospitalized with urticaria, generalized exanthema, erythematous cutaneous eruptions, bullae, and purpuric maculae all over her body. The impression was of carbamazepine-induced SJS/TEN. She evolved with progressive worsening of her symptoms, with increase in the number and size of cutaneous lesions, besides generalized erythematous macular rash, areas of necrosis, and erosions with symmetrical loosening of the epidermis in face, neck, thorax, dorsum, and limbs, affecting more that 50% of her body surface, besides involvement of buccal, conjunctival, and genital mucosa with vesicular erosions. She had progressive functional worsening, evolving to septic shock and multiple organ failure followed by death. CONCLUSIONS: Stevens-Johnson syndrome and toxic epidermal necrolysis are severe cutaneous reaction with potential for elevated morbidity and mortality that requires immediate intervention and adequate management. In addition, we would like to alert that the use of Carbamazepine should be supervised, especially in the elderly.

Keywords

COMPLICATIONS, DISEASES, Viral, DRUGS, Anticonvulsant

References

Klassen BD, Sadler RM. Induction of hypersensitivity to a previously tolerated antiepileptic drug by a second antiepileptic drug. Epilepsia. 2001;42:433-435.

Durán-Ferreras E, Mir-Mercader J, Morales-Martínez MD. Síndrome de hipersensibilidad por antiepilépticos con repercusión cutánea y renal grave por carbamazepina. Rev Neurol. 2004;38:1136-1138.

Johnson RW, Wasner G, Saddier P. Herpes zoster and postherpetic neuralgia: optimizing management in the elderly patient. Drugs Aging. 2008;25:991-1006.

Gilden DH, Kleinschmidt-DeMasters BK, LaGuardia JJ. Neurologic complications of the reactivation of varicella-zoster virus. N Engl J Med. 2000;342:635-645.

Kennedy PG, Grinfeld E, Bell JE. Varicella-zoster virus gene expression in latently infected and explanted human ganglia. J Virol. 2000;74:11893-11898.

Stankus SJ, Dlugopolski M, Packer D. Management of herpes zoster (shingles) and postherpetic neuralgia. Am Fam Physician. 2000;61:2437-2444.

McCrary ML, Severson J, Tyring SK. Varicella zoster virus. J Am Acad Dermatol. 1999;41:1-14.

Straus SE, Ostrove JM, Inchauspe G. NIH conference: Varicellazoster virus infections. Biology, natural history, treatment, and prevention. Ann Intern Med. 1988;108:221-237.

Dubinsky RM, Kabbani H, El-Chami Z. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004;63:959-965.

Wu CL, Raja SN. An update on the treatment of postherpetic neuralgia. J Pain. 2008;9(1^s1):s19-s30.

Attal N, Cruccu G, Haanpää M. EFNS guidelines on pharmacological treatment of neuropathic pain. Eur J Neurol. 2006;13:1153-1169.

Schmader KE, Dworkin RH. Natural history and treatment of herpes zoster. J Pain. 2008;9(^s1):s3-s9.

Johnson RW, Wasner G, Saddier P. Herpes zoster and postherpetic neuralgia: optimizing management in the elderly patient. Drugs Aging. 2008;25:991-1006.

Argoff CE, Katz N, Backonja M. Treatment of postherpetic neuralgia: a review of therapeutic options. J Pain Symptom Manage. 2004;28:396-411.

Douglas MW, Johnson RW, Cunningham AL. Tolerability of treatments for postherpetic neuralgia. Drug Saf. 2004;27:1217-1233.

Rowbotham M, Harden N, Stacey B. Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial. JAMA. 1998;280:1837-1842.

Roujeau JC, Stern RS. Severe adverse cutaneous reaction to drugs. N Engl J Med. 1994;331:1272-1285.

Nirken MH, High WA. Stevens-Johnson syndrome and toxic epidermal necrolysis: Clinical manifestations, pathogenesis, and diagnosis. .

Fritsch PO, Ruiz-Maldonado R. rythema Multiforme, Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Fitzpatrick's Dermatology in General Medicine. 2003:543-559.

Parrillo SJ. Stevens-Johnson syndrome and toxic epidermal necrolysis. Curr Allergy Asthma Rep. 2007;7:243-247.

Letko E, Papaliodis DN, Papaliodis GN. Stevens-Johnson syndrome and toxic epidermal necrolysis: a review of the literature. Ann Allergy Asthma Immunol. 2005;94:419-436.

Bastuji-Garin S, Rzany B, Stern RS. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme. Arch Dermatol. 1993;129:92-96.

Roujeau JC. Stevens-Johnson syndrome and toxic epidermal necrolysis are severity variants of the same disease which differs from erythema multiforme. J Dermatol. 1997;24:726-729.

Auquier-Dunant A, Mockenhaupt M, Naldi L. Correlations between clinical patterns and causes of erythema multiforme majus, Stevens-Johnson syndrome, and toxic epidermal necrolysis: results of an international prospective study. Arch Dermatol. 2002;138:10191024.

Assier H, Bastuji-Garin S, Revuz J. Erythema multiforme with mucous membrane involvement and Stevens-Johnson syndrome are clinically different disorders with distinct causes. Arch Dermatol. 1995;131:539-543.

Criado PR, Criado RFJ, Vasconcellos C. Reações cutâneas graves adversas a drogas aspectos relevantes ao diagnóstico e ao tratamento: Parte I Anafilaxia e reações anafilactoides, eritrodermias e o espectro clínico da síndrome de Stevens-Johnson & necrólise epidérmica tóxica (Doença de Lyell). An Bras Dermatol. 2004;79(4):471-488.

Klein PA. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. .

French LE. Toxic epidermal necrolysis and Stevens Johnson syndrome: our current understanding. Allergol Intern. 2006;55:9-16.

Gomez-Criado MS, Ayani I, Leon-Colombo T. Sindrome de Stevens-Johnson, necrolisis epidermica toxica y fenitoina: Factores asociados a un aumento del riesgo. Rev Neurol. 2004;38:1056-1060.

Mockenhaupt M, Schöpf E. Epidemiology of drug-induced severe skin reactions. Sem Cutan Med Surg. 1996;15:236-243.

Lin MS, Dai S, Pwu RF. Risk estimates for drugs suspected of being associated with Stevens-Johnson syndrome and toxic epidermal necrolysis: a case-control study. Intern Med J. 2005;35:188-190.

Roujeau JC, Kelly JP, Naldi L. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;333:1600-1607.

Halevy S, Ghislain P-D, Mockenhaupt M. Allopurinol is the most common cause of Stevens-Johnson syndrome and toxic epidermal necrolysis in Europe and Israel. J Am Acad Dermatol. 2008;58:25-32.

Rzany B, Correia O, Kelly JP. Risk of Stevens-Johnson syndrome and toxic epidermal necrolysis during first weeks of antiepileptic therapy: a case-control study. Lancet. 1999;353:2190-2194.

Devi K, George S, Criton S. Carbamazepine the commonest cause of toxic epidermal necrolysis and Stevens-Johnson syndrome: a study of 7 years. Indian J Dermatol Venereol Leprol. 2005;71:325-328.

Mockenhaupt M, Viboud C, Dunant A. Stevens-Johnson syndrome and toxic epidermal necrolysis: assessment of medication risks with emphasis on recently marketed drugs. The EuroSCAR-study. J Invest Dermatol. 2008;128:35-44.

Sharma VK, Sethuraman G, Minz A. Stevens Johnson syndrome, toxic epidermal necrolysis and SJS-TEN overlap: a retrospective study of causative drugs and clinical outcome. Indian J Dermatol Venereol Leprol. 2008;74:238-240.

Mockenhaupt M, Messenheimer J, Tennis P. Risk of Stevens-Johnson syndrome and toxic epidermal necrolysis in new users of antiepileptics. Neurology. 2005;64:1134-1138.

Revuz JE, Roujeau JC. Advances in toxic epidermal necrolysis. Semin Cutan Med Surg. 1996;15:258-266.

Lonjou C, Thomas L, Borot N. A marker for Stevens-Johnson syndrome: ethnicity matters. Pharmacogenomics J. 2006;6:265-268.

Lonjou C, Borot N, Sekula P. A European study of HLA-B in Stevens-Johnson syndrome and toxic epidermal necrolysis related to five high-risk drugs. Pharmacogenet Genomics. 2008;18:99-107.

FDA Information for Healthcare Pro fessionals. Dece.

Pirmohamed M, Arbuckle JB, Bowman CE. Investigation into the multidimensional genetic basis of drug-induced Stevens-Johnson syndrome and toxic epidermal necrolysis. Pharmacogenomics. 2007;8:1661-1691.

Garcia-Doval I, LeCleach L, Bocquet H. Toxic epidermal necrolysis and Stevens-Johnson syndrome: does early withdrawal of causative drugs decrease the risk of death?. Arch Dermatol. 2000;136:323-327.

Ghislain PD, Roujeau JC. Treatment of severe drug reactions: Stevens-Johnson syndrome, toxic epidermal necrolysis and hypersensitivity syn drome. Dermatol Online J. 2002;8:1087-1108.

5dceb6c30e8825cf02bf58f2 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections