History

A 36-year-old male presented with fatigue, pallor, and swollen gums. He had a history of epilepsy and had been on unknown (details not available) drug for the past five years. The patient reported adherence to his medication regimen but had noticed worsening gum swelling over the last six months and a progressive decline in energy levels.

Clinical Examination

Vital Signs

• Blood Pressure (BP): 120/80 mmHg, within normal limits.
• Respiratory Rate (RR): 16 breaths per minute, normal.
• Heart Rate (HR): 90 beats per minute, slightly elevated, which can be associated with anemia.
• Temperature: 98.6°F (37°C), normal.

General Examination

• Pallor: The patient’s skin and conjunctiva appeared pale, indicating possible anemia.

Oral Examination

• Gum Hypertrophy: The patient’s gums were significantly swollen and tender. Hyperplastic tissue covered a substantial portion of the teeth, and the gums bled easily upon probing.
• Gingival Color and Texture: The gums were erythematous and firm, suggesting chronic inflammation and fibrotic changes.

Systemic Examination

• Cardiovascular Examination: Mild tachycardia was noted, which can be associated with anemia.
• Respiratory Examination: Breath sounds were normal, and no signs of respiratory distress were observed.
• Abdominal Examination: No hepatosplenomegaly or other abdominal abnormalities were detected.

Diagnostic Workup

Blood Tests

• Complete Blood Count (CBC): Revealed hemoglobin levels of 8 g/dL, mean corpuscular volume (MCV) of 75 fL, and a low reticulocyte count, consistent with microcytic anemia.
• Serum Ferritin: Levels were decreased, indicating iron deficiency anemia.
• Peripheral Blood Smear: Showed hypochromic and microcytic red blood cells.

Oral Examination

A thorough oral examination confirmed significant gum hypertrophy, with hyperplastic tissue covering a substantial portion of the teeth.

Medication Review

Reviewing the patient’s medication history confirmed long-term phenytoin use, a known risk factor for both anemia and gum hypertrophy.

Overview:

Phenytoin, a commonly prescribed anticonvulsant, can lead to significant side effects. Among these, anemia and gum hypertrophy stand out due to their impact on a patient’s quality of life.

Pathophysiology

Phenytoin-Induced Anemia

Phenytoin can cause anemia through several mechanisms:

1. Bone Marrow Suppression: Phenytoin may inhibit bone marrow activity, reducing red blood cell production.
2. Folate Deficiency: The drug interferes with folate metabolism, leading to megaloblastic anemia.
3. Drug-Induced Hemolysis: In rare cases, phenytoin can cause hemolytic anemia by triggering an autoimmune response.

Phenytoin-Induced Gum Hypertrophy

Gum hypertrophy, or gingival overgrowth, occurs in response to phenytoin due to:

1. Fibroblast Stimulation: Phenytoin stimulates gingival fibroblasts, leading to excessive collagen production.
2. Inflammatory Response: Chronic inflammation from plaque exacerbates the hypertrophic response.
3. Genetic Predisposition: Some individuals have a genetic susceptibility to drug-induced gingival overgrowth.

Management Strategies

Treating Anemia

1. Medication Adjustment: Switching from phenytoin to an alternative anticonvulsant can help mitigate anemia. Medications like levetiracetam or lamotrigine may be considered.
2. Supplementation: Iron and folate supplements can correct deficiencies. Vitamin B12 supplementation may also be necessary in some cases.
3. Dietary Modifications: Encouraging a diet rich in iron, folate, and vitamin B12 can support recovery.
4. Monitoring: Regular CBC and iron studies are essential to track improvement and adjust treatment accordingly.

Addressing Gum Hypertrophy

1. Oral Hygiene: Emphasizing rigorous oral hygiene practices can reduce inflammation and plaque accumulation, thereby mitigating hypertrophy.
2. Dental Interventions: Professional cleaning and possible surgical interventions, such as gingivectomy, can remove excess tissue.
3. Medication Review: As with anemia, transitioning to a different anticonvulsant can reduce gum hypertrophy.
4. Patient Education: Educating patients about the importance of oral hygiene and regular dental visits is crucial for managing this condition.

Conclusion

Phenytoin, while effective for epilepsy management, can lead to significant adverse effects such as anemia and gum hypertrophy. Thorough history taking, clinical examination, and appropriate diagnostic workups are vital for identifying these conditions.