JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
evaluation, the patient exhibited altered mental status and left- sided hemiparesis. Computed Tomography (CT) scan performed without intravenous contrast revealed a large right-sided epidural hematoma for which he underwent craniotomy for evacuation of the hematoma. After the operation, the patient received fosphenytoin 100mg every eight hours for seizure prophylaxis. Over the following days, the patient demonstrated improved neurologic function. Fourteen days after initiation of fosphenytoin, the patient developed a rash. The rash progressed and skin began to slough, raising suspicion for toxic epidermal necrolysis (TEN). A biopsy revealed epidermal necrosis with subdermal bullae and sloughing, consistent with the diagnosis of TEN. Three days after the rash began, the treating team transferred the patient to the burn unit at our facility with a diagnosis of TEN secondary to fosphenytoin. Upon his arrival at the burn unit, the intake examination revealed involvement of 85% of his body surface area, including the eyes andmucous membranes of the oral cavity. The affected skin area included the patient’s entire face, scalp, neck, anterior and posterior trunk, bilateral upper extremities, penis, inguinal region, and bilateral lower extremities with sparing of only the calf regions and feet. As per the burn unit protocol, the patient was placed on contact precautions. He received wound care consisting of Topical Mepilex Ag applied to affected areas. Despite these interventions, approximately one week after being transferred to the burn unit, the patient developed severe septic shock and hypotension. He was treated with broad spectrum intravenous antibiotics and continuous infusions of norepinephrine, vasopressin, and epinephrine. Additionally, he developed the acute respiratory distress syndrome (ARDS) and required mechanical ventilation as well as acute kidney injury that required hemodialysis. The patient received tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement in the third week of mechanical ventilation due to his persistent respiratory failure. After 7 weeks in the burn unit, he improved enough to be transitioned to a rehabilitation facility. At the time of his transfer, the patient still had the tracheostomy tube in place, but was no longer ventilator dependent, as well as the PEG tube.
prophylaxis after TBI is a common practice, and prophylaxis for the first seven days carries a level II recommendation by the Brain Trauma Foundation (BTF) despite a lack of evidence associating post-traumatic seizures with worse outcomes. 6 In addition, seizure prophylaxis has no significant impact on the incidence of late post-traumatic seizures (those occurring after the first seven days), and use of antiepileptic drugs after the first seven days following TBI is not recommended. 6 Phenytoin for seizure prophylaxis has been associated with worse neurocognitive outcomes compared to placebo controls. 16 More recently, Bhullar et al. 3 reported that posttraumatic seizure prophylaxis with phenytoin resulted in longer hospital stays and worse functional outcomes compared to a control group. Despite the lack of empirical evidence and potential for adverse outcomes, many physicians, such as those in the current case, continue to order antiepileptic drugs for seizure prophylaxis in patients with traumatic brain injuries beyond the seven day recommended period. 17 The current case illustrates why physicians should use caution when prescribing anticonvulsants for seizure prophylaxis after severe traumatic brain injury, as potential risks may drastically outweigh potential benefits. Although there are multiple case reports of phenytoin-induced toxic epidermal necrolysis, 18 few studies have examined the safety and efficacy of fosphenytoin for seizure prophylaxis. Boucher et al. 7 compared patients receiving intramuscular fosphenytoin and intravenous fosphenytoin to a group that received IV phenytoin, and reported Frequencies of seizures were 5%, 3%, and 7% for patients receiving IM fosphenytoin, IV fosphenytoin, and IV phenytoin, respectively. Of the patients receiving IM fosphenytoin, 1% hadmild irritation at the injection site and 8.5% had an adverse event, mostly central nervous system (CNS) events such as somnolence and nystagmus. One patient developed a skin rash and was withdrawn from the study. Infusion rates were decreased due to adverse events in 14% of patients receiving IV fosphenytoin and 36% of patients receiving phenytoin, with the most common complaints being itching and burning at the infusion site (5% vs. 18%) and hypotension (5% vs. 18%) for fosphenytoin and phenytoin, respectively. The most frequent adverse events in patients receiving either IV fosphenytoin (32%) or phenytoin (39%) included nystagmus, dizziness, and somnolence. The authors concluded that patients tolerate IV fosphenytoin better than phenytoin and that both IV and IM fosphenytoin produce similar adverse events as compared to phenytoin. In addition, seizures were well controlled in all groups. Coplin et al. 19 compared fosphenytoin to phenytoin in 256 emergency department patients. Only 14 of these patients presented to the emergency department with TBI. Administration of anticonvulsants was left to the discretion of the physician, but only 3.2% of patients were actively convulsing uponpresentationtotheED. Therewerenosignificantdifferences in mean time for seizure cessation after administration of phenytoin or fosphenytoin. Two patients in the fosphenytoin group had recurrent seizures after receiving the drug. While the overall incidence of adverse events was not statistically different
DISCUSSION
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but potentially life-threatening, severe cutaneous conditions that result in necrosis of keratinocytes followed by epidermal detachment. Typically considered one of the most feared medication reactions, these conditions are also sometimes associated with infection or malignancy. While all medications have associated risks and toxicity, balancing these risks with potential benefit can be challenging. This is especially true in patients that may be at increased risk for reaction, such as those with certain genetic predispositions or those with immunodeficiencies.
The current case illustrates the potential implications of seizure prophylaxis after traumatic brain injury (TBI). Seizure
120 J La State Med Soc VOL 169 SEPTEMBER/OCTOBER 2017
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