More than a rash: lamotrigine-induced hypersensitivity mimicking DRESS in a bipolar patient with early-life trauma
L. Jishkariani, G. Garuchava, G. CheishviliIntroduction
Lamotrigine is effective in bipolar depression but carries a risk of severe cutaneous adverse reactions (SCARs), including Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). Early identification is crucial, especially in vulnerable psychiatric populations. Here, we present a diagnostically complex case of incomplete DRESS in a trauma-exposed adolescent, highlighting the interplay between emotional stress, immune dysregulation, and adverse drug reactions.
Objectives
To (1) describe a rare case of probable lamotrigine-induced DRESS with incomplete criteria; (2) explore how early-life trauma may influence drug reactivity through neuroimmune pathways; and (3) emphasize the role of trauma-informed care in enhancing diagnostic accuracy and treatment safety.
Methods
A 19-year-old female with a history of emotional neglect, early parental separation, and caregiver burden presented with subdepressive symptoms and mixed features. Pharmacological treatment included fluoxetine, quetiapine (PRN), and lamotrigine (titrated from 25 mg QHS). Within two weeks, she developed malaise, low-grade fever, a widespread maculopapular rash, lymphadenopathy, arthralgia, and elevated hepatic transaminases. An extensive workup ruled out infectious and autoimmune etiologies. Clinical photographs were taken to document rash distribution and morphology. RegiSCAR and Japanese criteria were applied to assess DRESS probability.
Results
The patient developed a confluent erythematous maculopapular rash affecting the limbs, trunk, and face, with greater intensity over the knees, forearms, and lower back (see Figures 1–3). Associated symptoms included fatigue, low-grade fever (37.8°C), lymphadenopathy, joint pain, and lab abnormalities (eosinophils 8%, AST 49.6 U/L, ALT 80 U/L). Infectious and autoimmune panels were negative. Although she did not meet full RegiSCAR criteria (fever <38.5°C, eosinophilia <10%), major criteria were fulfilled. Rash and systemic signs resolved after lamotrigine withdrawal and corticosteroid treatment.
RegiSCAR Criteria vs. Patient Presentation Table 1. Long description.