Leukopenia as an unusual component of diphenylhydantoin hypersensitivity. A case with pruritus, rash, fever, lymphadenopathy, but low leukocyte count

Immunologic aspects of phenobarbital hypersensitivity

Seven patients with hypersensitivity reactions to phenobarbital are described. Clinical manifestations consisted of fever and pruritic skin rash, often associated with adenopathy and conjunctivitis. Reexposure to phenobarbital or other anticonvulsants resulted in redevelopment of symptoms. In vitro lymphocyte stimulation studies with anticonvulsant drugs suggested a cell-mediated hypersensitivity reaction to phenobarbital.

Midesophageal web in adults

Stenotic webs in the midesophagus of adults are rare. Including the present patient, only 6 have been described in the literature in English. Clinical presentation is characterized by dysphagia and insidious weight loss in a patient usually over 40 years old. The cause of the lesion is unknown. Based on knowledge of the embryological development of the esophagus and the absence of microscopical inflammatory changes in true webs, a congenital rather than inflammatory basis seems likely. Treatment of midesophageal webs can be accomplished by dilation, divulsion through an esophagoscope, or transthoracic excision.

Diphenylhydantoin-induced serum sickness with fibrin-platelet thrombi in lymph node microvasculature

In this 16 year old boy a syndrome, characterized by high fever, generalized lymphadenopathy, splenomegaly, diffuse skin rash, facial and periorbital edema, neutropenia, thrombocytopenia, elevated serum glutamic oxaloacetic transaminase (SGOT) levels and transient electrocardiographic changes, appeared 2 weeks after the institution of diphenylhydantoin therapy. Lymph node biopsy, performed at the height of the illness, revealed widespread subendothelial fibrin exudation and fibrin-platelet thrombi in the lymph node microvasculature, a finding most consistent with thrombotic thrombocytopenic purpura. Although many types of abnormal lymph node histology have been described with diphenylhydantoin, this appears to be the first instance of this histologic picture. This syndrome may be related to a serum sickness-like illness which triggered an episode of localized coagulopathy.