Recurrent Lamotrigine Induced Meningitis
Introduction.
Lamotrigine induced recurrent aseptic meningitis has been recently reported. We report a second case of recurrent lamotrigine meningitis.
Case presentation.
A 25-year-old female presented with fever, meningism, vomiting, conjunctivitis and myalgia 8 days after starting lamotrigine 25mg daily, and two days after commencing amoxycillin for presumed sinusitis. She had a history of generalised epilepsy, peptic ulcer, and coeliac disease. CSF protein was 1.14g/L, glucose 3.4mmol/L, erythrocytes 22x106/L, leucocytes 112x106/L (67% neutrophils). CSF and blood cultures were negative. Cryptococcus, adenovirus, enterovirus, Herpes Simplex Virus 1 and 2 PCRs, and Neisseria meningitidis serologies were negative.
Her lamotrigine was stopped and she received Ceftriaxone until CSF cultures were negative at day 3. Her headache gradually but incompletely resolved; she was unable to return to work. She recommenced lamotrigine on day 19. An hour later she developed severe headache, photophobia, neck stiffness, vomiting, and dysaesthesiae. She was febrile (39.9ºC), tachycardic, with prominent conjunctivitis, periorbital oedema, a systolic ejection murmur and symmetric hyperreflexia. CSF protein was 0.38g/L, glucose 2.6mmol/L, erythrocytes 2x106/L, leucocytes 32x106/L (98% neutrophils). Culture and PCR examination results were again negative. Lamotrigine was again stopped. Her fever and meningism subsided rapidly, however she developed a mild right abducens nerve palsy which did not completely resolve three weeks later.
Discussion
Our patient represents the second case in which recurrent aseptic meningitis has been observed after lamotrigine ingestion. In each case meningism began 7-10 days after introduction of the drug, resolved several days after it’s withdrawal, and returned 30-60 minutes after its reintroduction.