Pleural Effusion Associated With Use of Lamotrigine

Analysis of the clinical characteristics of lamotrigine-induced haemophagocytic lymphohistiocytosis

WHAT IS KNOWN AND OBJECTIVE

Lamotrigine is currently known to be related to haemophagocytic lymphohistiocytosis (HLH). Knowledge regarding the association between HLH and lamotrigine is mainly based on case reports. The purpose of this study was to evaluate the clinical characteristics of lamotrigine-induced HLH.

METHODS

We collected literature from 1994 to 31 August 2020 in Chinese and English on HLH induced by lamotrigine for retrospective analysis.

RESULTS AND DISCUSSION

A total of 17 patients (12 men and 5 women) from 15 studies were included, with a median age of 29 years old (range 4-47). Symptoms of lamotrigine-induced HLH were reported to have occurred within 6-24 days following treatment initiation. Six cases reported doses that ranged from 25 mg every other day to 800 mg once daily. The major clinical features of lamotrigine-induced HLH are fever, cytopenia, rash and hyperferritinaemia. Bone marrow showed haemophagocytosis. Fifteen patients improved with drug discontinuation, and 2 patients eventually died.

WHAT IS NEW AND CONCLUSION

Hemophagocytic lymphohistiocytosis is a potentially serious adverse reaction to lamotrigine (LTG). Patients should be informed that if they experience any symptoms of HLH while taking lamotrigine, they should immediately seek medical attention.

Overlap between hemophagocytic lymphohistiocytosis and drug reaction and eosinophilia with systemic symptoms: a review

Drug reaction and eosinophilia with systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome (DIHS), shares features with hemophagocytic lymphohistiocytosis (HLH), most notably fever, rash, and internal organ involvement. However, there is increasing recognition of drug-induced (secondary) HLH and biopsy-proven hemophagocytosis in DRESS, suggesting that HLH and DRESS not only overlap but also may be diseases on the same spectrum of immune dysfunction. To characterize existing literature on HLH/DRESS overlap, we queried the PubMed/MEDLINE database for 23 cases of HLH-DRESS codiagnosis. Average time-to-onset of rash after exposure to inciting drug was 2.7 weeks. Fourteen cases (61%) clinically worsened despite initial therapy, prompting a workup with diagnosis of HLH on average 2.3 weeks after diagnosing DRESS. Nine cases met HLH diagnostic criteria and had a RegiSCAR score ≥4. Nine cases met one set of criteria with a presentation suggestive of the other. Five cases met neither criteria. A patient presenting with fever, generalized rash, bicytopenia, and internal organ involvement after drug exposure was most predictive of meeting diagnostic criteria for both HLH and DRESS. Treatment was highly variable, although most initiated systemic corticosteroids with/without IVIG, plasmapheresis, or etoposide. Patients with poor outcomes in this review were treated using steroid monotherapy and had viral reactivation. Dermatologists should consider the possibility of HLH in any patient presenting with fever, rash, internal organ involvement, and cytopenia. Additional studies will be necessary to further characterize HLH and DRESS overlap and determine optimal management.