Abstract
We report a case of Mr. R, a 23-year-old male admitted to the hospital with a diagnosis of mania with psychotic symptoms. His Young mania rating scale (YMRS) score at the time of admission was 53. Because of his extremely disruptive behaviour, ECT was started on the third day; he received a total of 10 bilateral ECTs, and showed good response. After stopping his ECT, carbamazepine (CBZ) was started, increased to a dose of 900 mg with olanzapine 15 mg/day. While on carbamazepine he showed a deterioration in his symptoms, so lithium was added as a second mood stabilizer after 15 days of starting CBZ. His YMRS score was 43 and was disruptive and aggressive.
After 2 days of the addition of lithium, physical examination in the morning revealed extensive mucosal ulceration of lip and buccal mucosa. After 3 hours, the patient had developed inflammation of conjunctiva and erythematous macular rash on his face and chest; temperature was 99.5 °F with sore throat. A diagnosis of SJS was confirmed by a dermatologist. In view of the severity of the symptoms all the previous medication were stopped and he was commenced on dexamethasone injection (4mg) twice daily, cefotaxime injection 1 g twice daily, bland diet and ciprofloxacin eye drops.
A day later, he started showing improvement and within 3–4 days his rash and mucosal ulceration disappeared. After the onset of SJS his manic symptoms showed significant and very rapid improvement. Within 4 days of the onset he showed a total resolution of manic symptoms, his affect was euthymic, with normal speech and motor behaviour and gained an insight into his illness. His YMRS score was 4 from a previous score of 43 prior to the onset of rash.
He remained well without any medication and later olanzapine 10 mg/day was added. He is currently asymptomatic after 2 months of discharge from the hospital.
SJS is a rare life-threatening intolerance reaction of the skin; the majority of SJS cases are thought to be drug induced [1]. In this case the diagnosis of SJS had a strong clinical basis. The clinical presentation described is most consistent with self-limited, exanthematous mucocutaneous disorder and has a temporal connection with the initiation of carbamazepine [2].
There have been previous reports of psychosis improving with onset of life-threatening disease and delirium [3]. To our knowledge this is the first case is which SJS led to the resolution of a case of severe mania and that too within a span of 3 days.
Though this life-threatening condition cannot be recommended for the treatment of any disease, further observation of such a phenomenon might lead to a better understanding of the aetiology and treatment of mania.