CASEREPORT ABSTRACT Indian Journal of Psychiatry, 2004, 46(3)270-271 Stevens - Johnson Syndrome Induced by Sodium Valproate P.N. Suresh Kumar*1, S. Kishore Kumar2 A case of Stevens-Johnson syndrome (SJS) following treatment with sodium valproate is presented. A 55-year-old male suffering from manic episode was treated with sodium valproate in addition to haloperidol and trihexiphenidyl. After two weeks he developed cutaneous manifestations of SJS. He was treated with systemic steroids, antihistamines and topical calamine lotion and recovered after a few weeks. Key words: Stevens-Johnson syndrome, sodium valproate Introduction Sodium valproate was initially introduced as an anti epileptic agent in1967, but over the years it has been used to treat a variety of psychiatric disorders. The milder and commonly occurring adverse effects of valproate are nausea, weight gain, hyperammonaemia, menstrual disturbances, tremor, hair loss, lethargy, sedation, behaviour changes, ataxia, dysarthria, incoordination, flushing, and reversible thrombocytopenia (Butler et al, 1999). Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rarely reported side effects valproate (Platin et al, 1995; Tsai & Chen, 1998; Poon & Ho, 2001 & Mishra et al, 2002). Rzany et al (1999), in a case-control study on the risk of SJS and TEN with various antiepileptic agents reported the univariate relative risk as 120 for carbamazepine, 91 for phenytoin, 57 for phenobarbital, 25 for lamotrigine, and 24 for valproate within the first 8 weeks of therapy. The association of SJS with valproate was confounded by concomitant short-term therapy with other causal drugs in many studies. Roujeau et al (1995) conducted a case control study to quantify the risks associated with the use of specific drugs. Drug use before the onset of disease was compared in 245 people who were hospitalized because of TEN or SJS and 1147 patients hospitalized for other reasons. The crude relative risk for SJS or TEN was as follows: carbamazepine, 90; phenytoin, 53; phenobarbital, 45 and valproic acid, 25. Poon and Ho (2001) have reported SJS in a 52-year-old man with inoperable anaplastic astrocytoma of left basal ganglion and neuropathic pain two days after the commencement of sodium valproate. The disease may occur as a primary skin disorder or as a skin manifestation of systemic infections, malignant or chronic disease of internal organs or as a reaction to various drugs (Breathnach, 1992). The principal sign of SJS is a symmetrical distribution of grouped or isolated crops of violaceous papules, macules or nodules of size 0.5 to 1 cm with dome shaped surface. The lesions enlarge and become purplish. There may be vesicles, bullae, pustules, urticarial lesions and hemorrhagic sites. A rather characteristic lesion is erythema iris, also described as “bull’s eye” or “target lesion”. These are concentric erythematous rings with central clearing. The lesions may be present anywhere on the body but extensor surfaces are commonly involved. Mucous membrane ulceration is also a common finding (Breathnach, 1992). We report a case of SJS induced by sodium valproate in bipolar affective disorder because of its rarity. Case report Mr. R, a 55-year-old male was presented with one week history of sudden onset of mental illness, characterised by excessive talk, grandiose ideas of ability, restlessness, excessive happiness and reduced need for the sleep. After a thorough evaluation, diagnosis of manic episode was made. He had a past brief episode of mania 20 years back subsiding spontaneously. All investigations including complete haemogram and blood biochemistry were within normal limits. As an out patient, he was started on sodium valproate 600 milligram per day, haloperidol 10 milligram per day and trihexiphenidyl 4 milligram per day. Prior to our treatment he was not receiving any medications. On the 7th day after starting the therapy, he developed fever, headache and myalgia. Within 24 hours, he developed 1Director, Institute of Mental Health & Neurosciences , Kozhikode-673016 2Medical Officer *Correspondence : M-26-A-62, Malaparamba Housing Colony, Kozhikode-673009. E-mail : dpnsuresh@satyam.net.in 269