Intracerebral Hemorrhage in the Setting of Lamotrigine-Induced Stevens-Johnson Syndrome: A Case Report

Abstract

Stevens-Johnson syndrome is a rare but life-threatening severe cutaneous adverse reaction that may involve multiple organ systems and is commonly associated with medication exposure. Although clinicians are familiar with complications such as sepsis, shock, and multiorgan dysfunction, rare neurological complications may be overlooked. We report the case of a 41-year-old Saudi male with epilepsy who developed Stevens-Johnson syndrome following recent initiation and dose escalation of lamotrigine. The patient presented with fever, generalized malaise, and a rapidly progressive diffuse erythematous maculopapular rash associated with painful oral erosions and systemic symptoms. Examination demonstrated widespread skin involvement with mucosal lesions consistent with Stevens-Johnson syndrome. The patient was admitted for close monitoring due to the severity of the reaction and risk of rapid deterioration. During hospitalization, he developed sudden severe headache, repeated vomiting, fluctuating level of consciousness, and objective unilateral weakness. These findings prompted urgent neurological evaluation, and non-contrast computed tomography of the brain revealed an acute intracerebral hemorrhage with intraventricular extension. The patient was subsequently managed in an intensive care setting with multidisciplinary involvement from dermatology, neurology, neurosurgery, and critical care teams. Supportive management of Stevens-Johnson syndrome was continued alongside neurological monitoring and management of the intracranial hemorrhage. The patient's neurological status gradually improved, with concurrent clinical improvement of the cutaneous manifestations following discontinuation of the suspected medication. This case highlights an uncommon but important complication of Stevens-Johnson syndrome and emphasizes that neurological deterioration should not automatically be attributed to sepsis or systemic inflammation. New focal neurological deficits, severe headache, vomiting, or unexplained decline in consciousness should prompt urgent investigation for intracranial pathology. Maintaining diagnostic vigilance and recognizing atypical disease progression may facilitate early diagnosis and improve outcomes in patients with severe drug-induced reactions.