A 15-year-old girl was brought by her mother to a behavioral health clinic for a psychiatric assessment. The patient admitted to suicidal ideation occurring every other day for the past year, as well as a plan to overdose with pills, and having multiple pills at her bedside. She also had been cutting her arms with a box-cutter.
The patient was admitted for an involuntary hold, during which she was prescribed Wellbutrin XL, 150 mg per day for depression, and melatonin, 10 mg at bedtime for sleep. The patient was not on any other medications at the time, and had never been prescribed an antidepressant before. On the fourth day, 6/17/2022, the patient was discharged home to her mother with a prescription to continue the Wellbutrin, and a follow-up appointment set for 6/21/2022. It's not clear whether the patient made it to the follow-up.
On 7/5/2022, the patient's mother took her to an urgent care center for an itchy rash that had been present for the past 2 days, along with nausea. The patient had a temperature of 100.2, BP of 100/62, HR 137, and respiratory rate 18. She was COVID-negative, and a urinalysis was abnormal but in line with a long-time history of glucosuria and proteinuria, for which no cause had ever been found. The patient was diagnosed with folliculitis and prescribed Bactrim and a Medrol dosepack. Her mother was suspicious that the Wellbutrin was causing the rash, so the patient stopped taking it around this time. During a telehealth visit that same day to discuss previous labwork results, the patient and her mother informed her regular pediatrician about the rash and urgent care visit.
On 7/7/2022, the patient followed up in person with her pediatrician, who ordered a rapid strep test and allergy testing. On 7/8/2022, the patient's mother took her to the emergency room for the rash, which was described as maculopapular, consistent with an allergic reaction, and present on the trunk and all extremities. The patient's vital signs were all normal. The patient was given IV Benadryl, Pepcid, and Solu-Medrol with mild improvement of itching. She was discharged home with a referral to a dermatologist and instructions to take oral Benadryl as needed and not to restart the Wellbutrin.
On 7/13/2022, the patient's mother took her back to the emergency room. The rash was still present, and now the patient also complained of fever, decreased appetite, diarrhea, weakness, joint pain, and enlarged lymph nodes. Her vitals in the ER were BP 101/56, HR 120, RR 20, O2 sats 96%, and temperature 36.8. On physical exam, she was found to have "hives all over upper extremities and back with signs of excoriation" and swollen bilateral submandibular lymph nodes. Labwork results included WBC 12.9, H/H 13.5/14, sodium 132, AST 90, ALT 138, and albumin 2.5.. Testing for mononucleosis and a viral and bacterial panels were negative. A chest x-ray was negative, and a gallbladder ultrasound showed mild hepatomegaly. The patient was given IV fluids and Benadryl and discharged home again.
On 7/15/2022, the patient followed up with her pediatrician, reporting a continuing fever, and rash on her entire body. Her mother was advised to take her to the emergency room at a local children's hospital, which she did. In the ER, the patient reported a 4-week history of rash, cough, progressive fatigue, weakness, myalgias and arthralgias, lymphadenopathy, and left-sided facial swelling that had begun earlier in the day. Blood pressure was found to be low for her age, but other vitals were normal. Lab results included: WBC 21, eosinophils normal, CRP 3.6, ESR 121, RVP negative, AST 378, ALT 394, calcium 7.9, albumin 3.1, sodium 130, procalcitonin 6.02, PT/INR 22.5/2, D-dimer 5629, ferritin 1150, and normal troponin and BNP. Ultrasound showed hepatomegaly with the liver measuring 18.3 cm with normal parenchyma, gallbladder wall thickening without stones seen, and reactive appearing periportal lymph nodes. The patient was admitted and eventually diagnosed with DRESS, felt to be most likely from the Wellbutrin. She spent 8 days in the hospital and was treated with Vitamin K, high-dose solumedrol, cyclosporine, and ursodiol, among other things. She continues to have ongoing related health problems.
I would be interested in opinions on whether Wellbutrin was an appropriate first-line drug to prescribe, whether the patient should have been hospitalized sooner, and anything else you think is relevant. Thank you!
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Do you believe there might have been medical error?
The patient was depressed, and she was admitted for her health and safety. She was started on an antidepressant medication that is very commonly prescribed to adults and teens for the treatment to major depressive disorder. There was nothing presented in the medical history that indicated an error was made in the type of medication selected. DRESS is an exceedingly rare reaction to a variety of different medications, and the medical history did not raise concern that the patient was at some usually elevated risk for experiencing DRESS from bupropion (Wellbutrin XL).
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There was no evidence of an error causing injury. It appears more likely that an unfortunate reaction occurred that could not have been predicted by the prescriber.
What makes you a good expert for this case?
I’ve treated over 15,000 patients. I’m board certified in both psychiatry and child and adolescent psychiatry.
How often do you encounter cases similar to this one in your practice?
I’ve prescribed Wellbutrin XL to teens and adults more times than I can count over the past decade and never had a case of DRESS.
Do you believe there might have been medical error?
Regarding the initial prescription of Wellbutrin: Review of records may shed light on why Wellbutrin was chosen over an SSRI. Although Wellbutrin would not have been my first choice given the relative safety and efficacy of an SSRI, the development of DRESS syndrome in such a case would not be reasonably foreseen and therefore the Wellbutrin prescription does not appear, based on the information provided, to have been a dereliction of duty.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the limited information provided, it seems more likely than not that DRESS syndrome was caused by Wellbutrin. Further records might change this likelihood.
What makes you a good expert for this case?
I am triple board certified in Psychiatry, Child / Adolescent Psychiatry, and Forensic Psychiatry. I have testified dozens of times in Court (more criminal cases than civil cases). Having stated this, I may or may not be a good expert for the case. That would depend on many factors, including state licensure requirements.
How often do you encounter cases similar to this one in your practice?
Treatment of DRESS Syndrome: Never treated it Treatment of children and adolescents w/ depression: Have treated hundreds over the years
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