The United States Medical Licensing Examination (USMLE) is administered by the National Board of Medical Examiners (NBME) and is required for physicians who possess an M.D. in order to practice medicine in the United States. This stressful examination requires weeks of studying, and many doctors go online to find practice questions and discuss hypothetical cases with others in the same boat. The official USMLE website features tough practice questions that help prepare future practicing physicians for just about anything.

Dilantin, an anti-seizure medication, has been linked to Stevens Johnson Syndrome (SJS), which is a severe and sometimes deadly skin reaction. SJS itself is still a relatively rare reaction, but so many patients have been injured or killed by Dilantin SJS side effects that an SJS class action lawsuit has been formed. Unfortunately, many victims are incorrectly diagnosed when they begin presenting symptoms, with medical staff and doctors dismissing the cases as “just a rash.” However, a few hours can take SJS into skin death territory which is challenging to survive. There are even cases of children as young as 2 dying overnight after an incorrect diagnosis.

The silver lining is that the USMLE is including Dilantin SJS hypothetical situations to help prepare doctors for what’s becoming an increasingly more common issue.

In one hypothetical situation, a USMLE moderator says, “A 45-year-old woman presents to your office after developing a pruritic rash and a fever. She first noticed it on her wrists two weeks ago but states that it has now spread to her feet as well. Her past medical history is significant for a seizure disorder following the removal of a meningioma. She has been treated with Dilantin. Physical examination is significant for icteric sclera. There are polygonal, flat-topped, violaceous papules limited to her wrists and her ankles. A white, reticulated, lacy lesion is also evident on examination of her buccal mucosa. Her liver is enlarged and is nontender to palpation. Laboratory analysis reveals: PT 11 seconds, albumin 3.6 g/dL, alkaline phosphatase 160 U/L, AST 700 U/L, ALT 960 U/L, ANA 1:160. Anti-hepatitis C virus (second generation) is negative; anti-hepatitis-B surface antibody (HBs) is positive; and anti-hepatitis-B core antibody (Hbc)is negative. She has an erythrocyte sedimentation rate of 20 mm/h and a cholesterol of 160 mg/dL. Anti-smooth muscle antibody test is negative, and an ultrasound of the abdomen is normal. What would you do next?”

The options include starting prednisone, initiate interferon-ï¡-2b therapy, administer N-acetylcysteine, stop Dilantin, or start methotrexate. The good news is that many of these doctors en route to being able to practice took note of the Dilantin option.

One replied, “So let’s think, meningioma mets, shouldn’t give rash…Dilantin toxic definitely hits liver … rash I’m not so sure about. But w/ NL ESR I want to rule out any inflammatory diseases (most answer choices are toxic to inflammatory disease). So … stop Dilantin?” This doctor seemed uncertain of his response, and wasn’t aware of that Dilantin caused SJS.

At the core of the Dilantin class action lawsuits are a number of similar SJS claims, and all detail a rash as the first sign. Another doctor replied simply, “Drug induced lichen planus, stop Dilantin,” which would have ensured the hypothetical patient got the right diagnosis immediately.

However, another replied, “Stop Dilantin, I think that’s the answer. But why…?,” which perhaps means the hypothetical patient wouldn’t have received the right treatment in this situation, although stopping Dilantin may help the body heal from SJS quicker.

Another respondent says, “Dilantin is phenytoin. If you stop the Dilantin, the symptoms should stop. She was taking the Dilantin as an anti-seizure medication. It’s a long shot but I do know that the steps are all about those rare cases.”

There were a number of doctors in the forum who weren’t sure about Dilantin and SJS, or who tried other explanations.