Successful use of carbamazepine in a patient with drug rash with eosinophilia and systemic symptoms.

Drug rash with eosinophilia and systemic symptoms (DRESS) is a serious adverse drug reaction with a high mortality rate. Discontinuation of the causative agent is the primary treatment. History of DRESS may put patients at higher risk of future episodes; however, cross-reactivity between various medications is not well established. An 18-year-old African American male with a history of bipolar I disorder with psychotic features was admitted for mania on his home dose of divalproex. After 1 week, olanzapine was added for refractory symptoms, but due to elevated creatinine phosphokinase (CPK), it was subsequently discontinued, and he was started on lorazepam and lithium. One week later, the patient was transferred to the intensive care unit with elevated CPK, fever, thrombocytopenia, elevated serum creatinine, hypotension, diarrhea, mild rigidity, bilateral inducible ankle clonus, and a rash. All medications were discontinued except for lorazepam. The skin pathology report was consistent with a drug eruption, and he was started on prednisone. Given continued symptoms of mania, carbamazepine was initiated. After clinical and laboratory improvement, the patient was discharged on hospital day 59 with instructions to continue carbamazepine and lorazepam. A MEDLINE search revealed no published case reports of the successful use of carbamazepine in a patient with a history of DRESS. Information regarding cross-reactivity between medications is limited primarily to aromatic antiepileptics. In our case report, carbamazepine was successfully used in a patient with a recent episode of DRESS during olanzapine, lithium, and valproate use.

Screening for depression in the primary care population.

Despite strong efforts, the diagnosis and treatment of depression bring many challenges in the primary care setting. Screening for depression has been shown to be effective only if reliable systems of care are in place to ensure appropriate treatment by clinicians and adherence by patients. New evidence-based models of care for depression exist, but spread has been slow because of inadequate funding structures and conflicts within current clinical culture. The Affordable Care Act introduces potential opportunities to reorganize funding structures, conceivably leading to increased adoption of these collaborative care models. Suicide screening remains controversial.