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Painless thyroiditis in drug‐induced hypersensitivity syndrome with prolonged reactivation of herpesviruses

Drug-induced hypersensitivity syndromze (DIHS) is a rare disease with a severe drug eruption usually characterized by fever, rash, and eosinophilia associated with reactivation of human herpes simplex virus 6 (HHV-6). Multiple organ failures and autoimmune diseases sometimes appear during the course of DIHS. Herein we report a case of carbamazepine-induced DIHS with prolonged reactivation of HHV-6 and human cytomegalovirus (CMV) causing painless thyroiditis after one year. A 51-year-old Japanese man started carbamazepine therapy for manic-depressive psychosis in March 2008. Four weeks after starting carbamazepine, he developed a fever (39 C) and widespread rash. The diagnosis of toxic eruption was made and he was treated with antibiotics in a local hospital. However, his condition deteriorated and he was referred to our hospital because of general malaise, high fever, liver disorder, and skin rash over his entire body. Physical examination revealed a maculopapular erythematous rash involving most of his body (Fig. 1a–c). He also had facial edema with small pustules (Fig. 1d) and lymphadenopathy involving bilateral cervical nodes. The mucous membrane was intact. Nikolsky’s sign was negative. Laboratory data were significant for a white blood cell count of 9200/ll with 5% atypical lymphoid cells. Aspartate aminotransferase and alanine aminotransferase were elevated at 69 and 159 U/l. Elevated antibody titer against HHV-6, HHV-7, and CMV were observed (Fig. 2). A skin biopsy specimen from the abdomen revealed interface alterations with vacuolar degeneration of the basal cells with infiltration of lymphocytes in the upper dermis (Fig. 1e). The patient was diagnosed as