What is the next step in managing a 31-year-old male with a history of delusions and paranoia, who presents 2 weeks after starting a new medication with fever, tachycardia, chills, and oral lesions?

From the Guidelines

The next step in managing this 31-year-old male with delusions and paranoia who has developed fever, tachycardia, chills, and oral lesions after starting a new medication is to immediately discontinue the suspected medication and obtain urgent medical evaluation. This presentation is highly concerning for Stevens-Johnson Syndrome (SJS) or Neuroleptic Malignant Syndrome (NMS), both serious medication reactions. The patient should be hospitalized for close monitoring and supportive care. Laboratory tests including complete blood count, comprehensive metabolic panel, creatine kinase, and urinalysis should be obtained. If SJS is suspected, dermatology consultation is warranted with skin biopsy consideration. For NMS, treatment includes cooling measures, IV fluids, and possibly dantrolene (1-2.5 mg/kg IV every 6 hours) or bromocriptine (2.5-10 mg orally three times daily) 1. The patient should not be restarted on the same medication in the future, and careful documentation of this adverse reaction is essential. These reactions occur because certain psychiatric medications, particularly antipsychotics and mood stabilizers like carbamazepine, lamotrigine, or phenytoin, can trigger severe immune or autonomic responses in susceptible individuals, potentially becoming life-threatening if not promptly addressed. Some key points to consider in the management of such reactions include:

• The importance of immediate discontinuation of the suspected medication and urgent medical evaluation 1
• The need for hospitalization for close monitoring and supportive care
• The consideration of dermatology consultation and skin biopsy for SJS, and the use of cooling measures, IV fluids, and possibly dantrolene or bromocriptine for NMS
• The avoidance of restarting the same medication in the future and the careful documentation of the adverse reaction. Given the potential severity of these reactions, it is crucial to prioritize the patient's safety and take prompt action to address the situation, as supported by the guidelines for managing infusion reactions to systemic anticancer therapy 1.

From the Research

Patient Presentation

The patient presents with fever, tachycardia, chills, and several lesions in his oral cavity, 2 weeks after starting a new medication for delusions and paranoia.

Differential Diagnosis

Given the patient's symptoms, possible diagnoses include:

• Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN), which are severe adverse cutaneous drug reactions 2
• Herpes simplex virus (HSV) infection, which can cause oral lesions and has been implicated in SJS and TEN 3, 4

Next Steps in Management

Considering the potential diagnoses, the next steps in management could be:

• Obtain blood work to rule out infection and assess liver function, as SJS and TEN can cause liver damage 2
• Aspirate and obtain fluid for culture to diagnose HSV infection or other infections 3
• Discontinue the new medication, as it may be the culprit drug causing SJS or TEN 2, 4
• Refer to a specialist, such as a dermatologist or infectious disease specialist, for further evaluation and management

Treatment Options

If SJS or TEN is diagnosed, treatment options may include:

• Supportive care, such as wound care and fluid management
• Immunomodulating agents, such as high-dose intravenous immunoglobulin therapy 2
• Antiviral medication, such as acyclovir, if HSV infection is diagnosed 3, 5

Important Considerations

It is essential to note that SJS and TEN are medical emergencies, and prompt diagnosis and treatment are crucial to prevent mortality and long-term sequelae 2. The patient's symptoms and medical history should be carefully evaluated to determine the best course of action.