Är fenytoin inducerad lymfadenopati ett reversibelt tillstånd. Vilket preparat är lämpligt att byta

Fråga: Är fenytoin inducerad lymfadenopati ett reversibelt tillstånd. Vilket preparat är lämpligt att byta till vid fenytoininducerad lymfadenopati.

Sammanfattning: Lymphadenopathy is a documented side effect of phenytoin. The drug also seems to impair immunological reactivity.

Svar: The phenytoin lymphadenopathy is a fairly well documented side effect and you find some copies enclosed (1,2,3). The Swedish adverse effect committee has got 9 reports about lymphadenopathy and one report on malignant lymphoma during the 70-ties. Interestingly there have also been 4 cases of carbamazepine in monotherapy suspected to cause this syndrome. The mechanism behind this effect seems to be a drug induced depression of the immunological function. E.g. Sorrell and collaborators (1971; 4) report about 63 patients on long term phenytoin therapy. About 20 per cent of these had low immunoglobulin A levels and a decreased response to various antigens by skin-test. In an article by Fontana et al 1977 (5) it is stated that predisposing factors are needed for the development of IgA depression. Charlesworth (1977; 3) presents a case of phenytoin induced pseudolymphoma. Initially there was no skin reactions to tuberculin and a variety of other antigens. Half a year after stopping the treatment the patient developed normal and positive reactions to these antigens. Scully and associates (1980; 6) report a case of "angioimmunoblastic lymphadenopathy" where phenytoin medication was probably of importance for induction of these disease. This patient recovered and her antiepileptic therapy was changed from phenytoin to phenobarbital.<br><br>I can get no hard data on the reversibility of phenytoin induced lymphadenopathy and e.g. Reynolds (1975; 7) does not specifically comment on this issue.<br><br>I think that one is allowed to guess that the lymphadenopathy is reversible as the closely related depression of various immunological parameters seems to be reversible. Your case is difficult to handle, if valproate works this is great but in a longer perspective we are somewhat uneasy about the side effect profile. A change to carbamazepine would be highly questionable as this drug might also induce the syndrom. An alternative approach would be to use phenobarbital and carefully adjust the minimum level that controls the seizures. Of course this student needs all his mental capacity to manage. I assume that you have taken the simple measures to reduce the seizure frequency, things like abstention from alcohol (I am sure about that in your country) getting enough sleep and possibly avoiding exhausting experiences.<div id="referenser" style="display:none;">1 Björnberg A, Holst R: Generalized lymphadenopathy as a drug reaction to hydantoin. Acta Neurol Scand 1967; 43: 399-402<br>2 Greene MDA: Localized cervical lymphadenopathy induced by diphenylhydantoin sodium. Arch Otolaryngol 1975; 101: 446-448<br>3 Charlesworth EN: Phenytoin-induced pseudolymphoma syndrome: an immunolic study. Arch Dermatol 1977; 113: 477-480<br>4 Sorell TC, Forbes IJ, Burness FR, Rischbieth RHC: Depression of immunological function in patients treated with phenytoin sodium (sodium diphenylhydantoin). Lancet 1971; II: 1233-1235<br>5 Fontana A, Sauter R, Grob PJ, Joller H: IgA deficiency, epilepsy and hydantoin medication. Lancet 1976; II: 228-231<br>6 Scully RE, Galdabini JJ, Mcneely BU: Weekly clinicopathological exercises. Case 11-1980. N Engl J Med 1980; 302: 678-84<br>7 Reynolds EH: Chronic antiepileptic toxicity: a review. Epilepsia 1975; 16: 319-352</div>