Reactions 1462, p14-15 - 27 Jul 2013

SCarbamazepine

Dry erythroderma in an elderly patient following adispensing error: case report

A 74-year-old woman developed dry erythroderma whilereceiving carbamazepine [Taver; dosage and route not stated]following a dispensing error.

The woman was hospitalised with a 15-day history of dryerythroderma. She reported mild pruritus. She had a history ofheart failure, and was being treated with aspirin, captopril,atenolol and atorvastatin [Trova]. Upon examination, she hadcontinuous erythema affecting almost her entire body, withpapular or vesicular lesions. She also had cutaneousdesquamation and oedema in her extremities and face. Testsrevealed leucocytosis, with a WBC of 12 800/mm3.

The woman received corticosteroids and antihistamines.Her symptoms improved in 4 days, with fine desquamationand regression of oedema and pruritus. A detailed historyrevealed that she had started receiving Taver instead of Trova9 days before onset of symptoms, due to a dispensing error.One week after discharge, she was readmitted with the sameclinical symptoms. Tests showed a leucocytosis andeosinophilia. After symptomatic treatment, her conditionslowly improved.

Author comment: The imputability score calculatedaccording to the French pharmacovigilance system wasprobable for carbamazepine (C3 S2 I3). The bibliographicscore was B3 (known effect, well described in theliterature). . . our patient developed severe dry erythroderma-type toxidermia after taking carbamazepine, owing to adispensing error.Amouri M, et al. A medication error: who’s responsible? Therapie 68: 55-6, No. 1,Jan-Feb 2013. Available from: URL: http://dx.doi.org/10.2515/therapie/2013001[French; summarised from a translation] - Tunisia 803090321

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Reactions 27 Jul 2013 No. 14620114-9954/13/1462-0001/$14.95 Adis © 2013 Springer International Publishing AG. All rights reserved