Diagnostic Considerations

Other problems to consider in the differential diagnosis include the following:

Hypersensitivity reactions (eg, dermatitis, eosinophilia, lymphadenopathy, vasculitis, splenomegaly)
Pancytopenia (eg, aplastic anemia, leukopenia)
Drug-drug interactions

In pediatric patients, multisystem inflammatory syndrome (MIS-C) associated with COVID-19 and carbamazepine-induced drug rash with eosinophilia and systemic symptoms (DRESS) syndrome share similar clinical and laboratory findings. It is important to distinguish between them, as DRESS syndrome is potentially life-threatening if left untreated.^[32]

Acute change in mental status

In patients who have a history of seizures despite taking carbamazepine, the postictal state (after an unwitnessed seizure) and an acute mental status change due to carbamazepine overdose are difficult to differentiate.

Child abuse may be a consideration in a pediatric patient with no prior relevant history who presents in coma. Other causes of coma to consider in patients of any age include the following:

Trauma
Infection
Central nervous system (CNS) tumors
Hypoglycemia
Other intoxications

Arrhythmias

Although arrhythmias are uncommon in pediatric patients, they may occur in children with underlying cardiac disease and with very large overdoses. Other causes of arrhythmias should be assessed, including electrolyte abnormalities, hypoxia, and overdoses with other drugs known to cause arrhythmias (eg, phenytoin, digoxin, cocaine, tricyclic antidepressants).

Seizures

In patients taking long-term carbamazepine therapy for epilepsy, identifying the cause of the current seizure is important. A seizure could be due to subtherapeutic drug levels, breakthrough seizures with therapeutic drug levels, or carbamazepine toxicity. Other causes that must also be considered include the following:

Other drug ingestion
Trauma
Hypoglycemia
Electrolyte disturbances
Brain tumors
CNS infection
New-onset epilepsy

Differential Diagnoses

Workup

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Author

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA Professor of Emergency Medicine and Clinical Pediatrics, Weill Cornell Medical College; Attending Physician, Departments of Emergency Medicine and Pediatrics, Lincoln Medical and Mental Health Center; Adjunct Professor of Emergency Medicine, Adjunct Professor of Pediatrics, St George's University School of Medicine, Grenada

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Academy of Urgent Care Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, Association of Clinical Research Professionals, Public Responsibility in Medicine and Research, Society for Academic Emergency Medicine, Society for Simulation in Healthcare

Disclosure: Nothing to disclose.

Coauthor(s)

Richard J Hamilton, MD, FAAEM, FACMT, FACEP Professor and Chair, Department of Emergency Medicine, Drexel University College of Medicine

Richard J Hamilton, MD, FAAEM, FACMT, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Joel R Gernsheimer, MD, FACEP Visiting Associate Professor, Department of Emergency Medicine, Attending Physician and Director of Geriatric Emergency Medicine, State University of New York Downstate Medical Center

Joel R Gernsheimer, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Geriatrics Society

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Chief Editor

Stephen L Thornton, MD Associate Clinical Professor, Department of Emergency Medicine (Medical Toxicology), University of Kansas Hospital; Medical Director, University of Kansas Hospital Poison Control Center; Staff Medical Toxicologist, Children’s Mercy Hospital

Stephen L Thornton, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Additional Contributors

David C Lee, MD Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.