Sir,

Lyell’s syndrome is a serious, acute, life-threatening condition, rare in the pediatric population [1], characterized by skin detachment of more than 30% of the body surface area, with at least two mucous membranes involved [1,2]. It is considered a hypersensitivity reaction to numerous types of drugs, primarily anticonvulsants, antibiotics, and nonsteroidal anti-inflammatory drugs [2]. Infections particularly with Mycoplasma pneumoniae may also act as potential co-factors in the pediatric population [2,3]. The diagnosis is often clinical [1]. A skin biopsy is not always required in young children or if the diagnosis is obvious and encounters complete epidermal necrosis [3]. Treatment is based on the immediate discontinuation of the offending drug, prompt admission to the intensive care unit, and local care [3]. Specific treatment in children is controversial, with a lack of clinical trials, and includes systemic corticosteroids and intravenous immunoglobulin [1,3,4]. Short-term sequelae are often related to mucosal involvement dominated by synechiae [4]. Long-term complications may occur, mainly ocular, such as dry eye syndrome, genitourinary, pulmonary, and renal. Thus, long-term monitoring must be instituted [5]. Finally, raising public awareness and educating the public about the harmful effects of self-medication may help decrease the occurrence of severe cutaneous drug reactions in children [6].

Herein, we report the case of a nine-month-old infant followed for epilepsy secondary to congenital hydrocephalus. Five days before the admission, he presented a pruritic cutaneous eruption with the appearance of liquid lesions 48 hours later on the lower limbs and the face, following treatment with sodium valproate and carbamazepine with a delay of one month for the former and fifteen days for the latter. A general examination revealed an apyretic infant. A dermatological examination revealed multiple vesicular bullae and blisters on the legs, thighs, and cheeks with a positive Nikolsky sign and maculo-papular exanthema on the rest of the body (Fig. 1a). The skin area affected was initially estimated to be 25%. The ocular, oral, nasal, and genital mucosa were affected as well (Figs. 1a – 1c). After hospitalization, a biological checkup revealed creatine phosphokinase (CPK) three times the normal value, CPK mb five times the normal value, with C-reactive protein (CRP) at 33 mg/L and negative procalcitonin. A skin biopsy was not taken. Both drugs were stopped immediately and replaced by levetiracetam and clobazam. On the next day, the skin surface area was extended to 35% with a wet linen appearance (Fig. 1d). The diagnosis of Lyell’s syndrome was retained. The infant was put on rehydration, josamycin, local care, dermocorticoids for the skin lesions, a healing cream for the mucous lesions, and an antihistamine. A pharmacological investigation revealed the imputability of carbamazepine treatment. The evolution was favorable, with regression of the lesions without the appearance of short-term complications such as synechiae.

Figure 1: (a) Maculo-papular exanthema with multiple vesicular bullae and blisters on the legs and thighs. (b-c) Severe mucosal damage.(d) Skin detachment with a wet linen appearance.

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