Carbamazepine Induced Generalised Erythematous Rash in a Patient of Bipolar Affective Disorder-Case Report

Copyright: © 2016 Pohane P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Carbamazepine Induced Generalised Erythematous Rash in a Patient of Bipolar Affective Disorder Case Report Pohane P*, Jaiswal S, Chandurkar A, Sawant V and Vahia VN

She was assessed on baseline for laboratory investigations which were essentially unremarkable; she was started on Tablet carbamzepine and Tab. Olanzapine as it was best available option considering her reproductive age group and availability of medicine on hospital schedule. Tablet carbamazepine was gradually hiked to 1000 mg with serum level monitoring and olanzapine was hiked to 20 mg. Patient achieved remission within 8-9 days with YMRS score 7. After 7 days maintaining on 1000 mg of Tablet Carbamazepine (serum carbamazepine-14 mg/ ml) patient had maculopapular rash all over the body. Rash were not photosensitive and were present all over body including exposed as well as non-exposed body parts. There were no other physical findings such as lymphadenopathies, arthralgia, osteonecrosis and myopathy which are common in systemic lupus erythematosus present. Her systemic examination was within normal limits.
Maculopapular rash were disappeared gradually after omission of carbamazepine within 5 days with additional treatment of Tablet Prednisolone 40 mg which tapered gradually. After the rash disappeared patient was reintroduced to olanzapine and lithium was started in place of Carbamazepine ( Figure 1).

Introduction
Carbamazepine is primarily used as an anticonvulsant in the treatment of grand mal and focal seizures. Other indications for its use include trigeminal neuralgia, bipolar affective disorder and some off label uses in psychiatry such as impulsive behaviour, disruptive behaviour, substance use disorders to name a few [1][2][3]. Mood disorders are a group of clinical conditions characterized by a loss of the sense of control and a subjective experience of great distress. Patients with elevated mood demonstrate expansiveness, flight of ideas, decreased sleep, and grandiose ideas. Patients with depressed mood experience a loss of energy and interest, feelings of guilt, difficulty in concentrating, loss of appetite, and thoughts of death or suicide. Other signs and symptoms of mood disorders include change in activity level, cognitive abilities, speech, and vegetative functions (e.g., sleep, appetite, sexual activity, and other biological rhythms). These disorders virtually always result in impaired interpersonal, social, and occupational functioning [4].
The common side-effects associated with carbamazepine therapy are dizziness, dipolpia, drowsiness, ataxia, nausea and headaches dry mouth, oedema, hyponatraemia and sexual dysfunction. They can sometimes be avoided by starting with a low dose and increasing slowly, avoiding high peak blood levels by splitting the dose throughout the day, or using a controlled release formulation, may also help [5].
Around 3 percent of patients treated with carbamazepine develop a generalised erythematous rash, serious exfoliative dermatological reaction can rarely occur [6].

Case Report
Miss T. S. 19 years old unmarried female of lower socioeconomic strata presented to outpatient department with complaints of excessive talkativeness, tall claims, irritability and disturbed biological functions for 3 months.
Patient had history of irritability, excessive talking, and making tall claims about having lot of money. There was history of excessive grooming and hypersexuality, she would ask strangers for sexual favour and would go along with them for 1-2 days. Along with these, she had disturbed biological functions such as decreased need for sleep and no treatment was sought for 3 months. Before this episode she had two episodes of similar complaints in last 2 years. Each episode was lasted for 3-4 months period and treated with drugs, details of which are not available. The medications were discontinued soon after she got better by her. In between these two episodes she had one episode of low mood, suicidal ideation, loss of interest at work and disturbed biological functions, which lasted for 5-6 months and no medical attention was received for this episode.
With this patient was presented to outpatient department. She was physically within normal limits. Family and personal history was not contributory. On mental status examination positive findings were Patient was improved after withdrawal of carbamazepine and reinstitution of olanzapine did not produce any adverse reactions. Hence by exclusion, carbamazepine was the causative agent for producing generalised erythematous rash. The main therapeutic action in skin rash is early recognition of the drug reaction and withdrawal of the drug. There is no universally accepted, definitively effective, specific treatment for the skin rash other than supportive care. Glucocorticoid is useful only in early stage of the disease. 8 In our case rapid withdrawal of the offending drug carbamazepine and supportive treatment lead to rapid cure of the patient.

Conclusion
There is increase in the number of prescriptions for carbamazepine in recent years. In this case report there is the "probable" association between carbamazepine and generalised erythematous rash. This case has been reported to highlight the importance of using carbamazepine cautiously keeping in mind its association with skin rash and other serious conditions.