Thiazide Diuretics Induce Cutaneous Lupus-Like Adverse Reaction

Abstract

One of the side effects reported in patients taking thiazide diuretics is photosensitivity. We report two patients who developed lupus-like skin lesions while taking thiazide diuretics. One patient developed erythematous scaling papules, patches and plaques on the upper extremities and trunk resembling subacute cutaneous lupus erythematosus. Histopathology of a skin biopsy from the trunk showed basal cell layer liquefaction and lichenoid interface changes suggestive of lupus erythematosus. The skin lesions resolved completely within two months of discontinuing thiazide therapy. The second patient developed multiple flesh colored urticarial plaques on the trunk one year after beginning thiazide therapy. Slight lichenoid interface changes were noted on a skin biopsy, along with dense mucin deposition in the papillary and deep dermis, suggestive of tumid lupus erythematosus. The skin lesions persisted despite discontinuing thiazide therapy, necessitating systemic corticosteroid treatment. Both patients had circulating anti-SSA/Ro autoantibodies and antinuclear antibodies. These two patients illustrate that thiazide diuretics may induce a cutaneous lupus erythematos us-like adverse reaction and production of anti-SSA/Ro autoantibodies as demonstrated by immunodiffusion, immunoblot and immunoprecipitation testing.     

Acute febrile neutrophilic dermatosis: Sweet's syndrome.

A case of acute febrile neutrophilic dermatosis (Sweet's syndrome) is described in a patient with chronic myelogenous leukemia, with a review of all published reports in the English literature. The disease is characterized by an acute febrile illness with painful plaques involving the extremities, face, and neck, and responds dramatically to corticosteroids with occasional recurrences. Histologically, the skin biopsy shows a dense dermal infiltrate of polymorphonuclear leukocytes without evidence of vasculitis.     

Erythema multiforme major due to occupational exposure to the herbicides alachlor and butachlor

Alachlor and butachlor are commonly used chloroacetanilide herbicides. They are cytotoxic, but there have been rare reported cases of alachlor or butachlor induced erythema multiforme major. We report the case of a 38‐year‐old farmer with erythema multiforme major due to the occupational exposure to alachlor/butachlor. The patient presented to the ED because of itching. Confluent erythematous to violaceous maculopatches with bullae and erosions were seen on the trunk, both upper extremities and both lower extremities. He had no relevant past or family history of a similar skin disease. He had used alachlor/butachlor for 3 days before he developed the itch. We performed a skin incisional biopsy and found diffuse hydropic degeneration with many necrotic keratinocytes in the epidermis and mild to moderate superficial perivascular lymphocytic infiltrate admixed with neutrophils and eosinophils in the upper dermis. These results confirmed the diagnosis of erythema multiforme major. The patient was admitted and received systemic and topical steroids. After 18 days, most lesions had healed, and he was discharged.     

骨髓增生异常综合征并发急性发热性嗜中性皮病一例

骨髓增生异常综合征（MDS）是一种异质性克隆性造血干细胞疾病,少部分MDS患者可并发急性发热性嗜中性皮病（SWEET综合征,SS）,其皮肤改变主要为不对称性疼痛性红色丘疹、结节和斑决,后期可进展为脓疱,同时伴发热、白细胞升高及ESR增快,皮肤病理活组织检查（活检）以弥漫分布于真皮浅层的成熟中性粒细胞浸润为特征,糖皮质激素治疗有效而抗感染治疗无效,合并SS的MDS容易进展为急性髓系白血病,预后不佳。该文报道1例接受皮下输液港植入化学治疗后继发SS的MDS患者,患者化学治疗过程顺利,但其皮下输液港植入部位发生胸壁皮肤感染,伴有持续高热,胸壁皮肤切口部位上方有疼痛性红色丘疹,经抗感染治疗无效,皮肤活检结果示真皮浅层中性粒细胞浸润,诊断为MDS并发SS,予糖皮质激素治疗后体温降至正常,皮损愈合,随访示MDS处于完全缓解状态。因此,临床上对于存在发热、痛性红色丘疹且抗感染治疗无效的MDS患者需警惕SS的可能,应及早完善皮肤活检以便早诊断、早治疗。     

Neutrophilic dermatoses and myeloproliferative disease: report of two cases

The term "neutrophilic dermatosis" has been suggested for a spectrum of skin lesions that have been noted in some patients with myeloproliferative diseases. These cutaneous conditions vary from plaques typical of Sweet's syndrome to bullous and pyodermatous lesions. We describe two patients with neutrophilic dermatoses and myeloproliferative disorders. Distinctive features included concurrent bullous pyodermatous lesions and characteristic lesions of Sweet's syndrome in one patient and overwhelming sterile pulmonary infiltration in the other patient. These disorders may be difficult to distinguish from acute infectious processes, and they may have systemic components, including pneumonitis. Possible therapeutic alternatives to systemic corticosteroid therapy are suggested.     

Tracheobronchial Pulmonary Disease Associated With Pyoderma Gangrenosum

We report a tracheobronchial pulmonary manifestation caused by pyoderma gangrenosum, a neutrophilic dermatosis of unknown etiology. A 54-year-old man presented with pulmonary infiltrates followed by multiple painful cutaneous pustules on the scrotum. Skin biopsy showed pronounced neutrophilic infiltration without microorganism or granuloma, consistent with pyoderma gangrenosum. Bronchoscopy revealed multiple scattered polypoid nodules with a yellowish irregular surface from the trachea to bilateral bronchi; the appearance closely mimicked that of a skin lesion. Endobronchial biopsy demonstrated inflamed granulation and necrosis with infiltration by numerous neutrophils without vasculitis or granulomas, interpreted as pyoderma gangrenosum of the bronchi. Although the etiology of pyoderma gangrenosum is poorly understood, this case suggests that a common pathogenesis may account for the simultaneous cutaneous and airway inflammation.Pyoderma gangrenosum is an uncommon inflammatory cutaneous disease characterized by sterile neutrophilic dermatosis of unknown etiology.^1,2 The disease has been reported in association with various systemic disorders, including inflammatory bowel disease, rheumatoid arthritis, and hematologic disease.^1,2 Pulmonary involvement in pyoderma gangrenosum has also been reported,^3-6 but few reports have described endobronchial lesions of pyoderma gangrenosum.⁶ In the current report, we demonstrate tracheobronchial pulmonary manifestation of pyoderma gangrenosum, the bronchoscopic appearance of which closely mimicked that of a skin lesion.     

Neutrophilic dermatoses in a seronegative rheumatoid arthritis patient: A case report

Rheumatoid arthritis (RA) is a chronic inflammatory disease, characterized by symmetric and destructive polyarthritis with a broad‐spectrum clinical manifestation of various organs. RND is an unusual distinctive manifestation of RA and typically develops in severe RA. This report aims to present an unusual and a rare neutrophilic skin condition, in a seronegative RA Sudanese patient. A 51‐year‐old woman was diagnosed with RA three years ago and a history of bilateral polyarthritis, presented with a skin rash involving her extremities and abdomen. Clinical examination of her skin revealed the presence of maculopapular lesions affecting the extensor surfaces of the lower extremities and the lower part of the abdomen with hyperpigmentation. Hand X‐ray demonstrated periarticular osteopenia, and laboratory and immunological studies that include C‐reactive protein, erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), anticitrullinated peptide antibodies (ACPAs), and antinuclear factor in addition to skin biopsy were all suggested a diagnosis of neutrophilic dermatosis. The patient received steroids for the skin lesion still no significant improvement was seen, and then, cyclosporin 100 mg was administrated twice/ day with close monitoring, and two weeks later marked improvement was shown.     

Acute febrile neurophilic dermatosis (Sweet's syndrome)--report of two cases (author's transl)

Acute, febrile, neutrophilic dermatosis (Sweeet's syndrome) is an uncommon, distinct disease of unknown origin. It is characterized by typical skin lesions and systemic symptoms such as fever and leucocytosis. Ultrastructural data suggest a primary vascular process as the initial pathogenic mechanism. In this paper two patients are described and the clinical variability, incidence and pathogenesis of this syndrome are discussed.     

A case of linear immunoglobulin A bullous dermatosis in a patient exposed to sun and an analgesic

Background: Medications are the most common triggers of linear immunoglobulin A bullous dermatosis (LABD). LABD induced by ultraviolet (UV) radiation has rarely been described. This article reports a case of LABD in a patient exposed simultaneously to an analgesic and UV radiation.Case summary: A 45-year-old woman developed LABD lesions on sun-exposed skin after 3 days of sunbathing and consumption of a medication for headache containing propyphenazone, butalbital, and caffeine. The lesions spread to unexposed skin and, by day 5, the patient had vesicles and bullae on the palms and soles, face, trunk, and extremities. LABD was diagnosed with direct and indirect immunofluorescence microscopy and Western blot analysis. Treatment was successful with prednisone, started at a dosage of 1 mg/kg/d, for 5 months. Lesions located on sunexposed areas, the absence of relapse for 5 years despite continuing sun exposure against medical advice, and subsequent avoidance of the suspected medication suggest that the bullous flare may have been due to the concomitant action of 2 triggers. That the analgesic had a role in this cutaneous manifestation is possible according to the Naranjo algorithm for adverse drug reactions.Conclusions: A case of LABD possibly associated with sun exposure and an analgesic is described. Treatment with prednisone successfully resolved the lesions in this patient.     

Skin ulcers as a complication of short-term use of phenazopyridine in an old man: A case report

IntroductionPhenazopyridine is an azo dye, which exerts local anesthetic or analgesic action on urinary tract mucosa through an unknown mechanism. Besides its common complications including orange discoloration of the urine and gastrointestinal problems, it may have rare side effects like hemolytic anaemia, methemoglobinemia, renal failure, and skin changes. We reported a paraplegic man with skin ulcers on scretom and right foot after about 3 days of phenazopyridine useCase reportA 62-year-old man presented with flesh shaped deep ulcers in lower parts of the body. He declared that at first a bluish discoloration was developed in the lower extremities and scrotum skin after use of eight phenazopyridine tablets (200 mg) and then these lesions turned to blisters and ulcers and they were prurient. The patient underwent sonography and CT-angiography; however, no pathologic findings were found. He just received losartan for many years as past drug history. According to the history, a delayed drug hypersensitivity reaction was suspected and the patient wounds healed after using special type of dressings and antibiotic therapy regarding positive wound cultures.ConclusionPhenazopyridine severe skin changes are hardly reported. We described a case who experienced severe skin reactions and ulcers following phenazopyridine use not related to other complications including renal dysfunction, methemoglobinemia, and hemolytic anemia.     

Chemerin expression marks early psoriatic skin lesions and correlates with plasmacytoid dendritic cell recruitment

Psoriasis is a type I interferon-driven T cell–mediated disease characterized by the recruitment of plasmacytoid dendritic cells (pDC) into the skin. The molecules involved in pDC accumulation in psoriasis lesions are unknown. Chemerin is the only inflammatory chemotactic factor that is directly active on human blood pDC in vitro. The aim of this study was to evaluate the role of the chemerin/ChemR23 axis in the recruitment of pDC in psoriasis skin. Prepsoriatic skin adjacent to active lesions and early lesions were characterized by a strong expression of chemerin in the dermis and by the presence of CD15⁺ neutrophils and CD123⁺/BDCA-2⁺/ChemR23⁺ pDC. Conversely, skin from chronic plaques showed low chemerin expression, segregation of neutrophils to epidermal microabscesses, and few pDC in the dermis. Chemerin expression was localized mainly in fibroblasts, mast cells, and endothelial cells. Fibroblasts cultured from skin of psoriatic lesions expressed higher levels of chemerin messenger RNA and protein than fibroblasts from uninvolved psoriatic skin or healthy donors and promoted pDC migration in vitro in a chemerin-dependent manner. Therefore, chemerin expression specifically marks the early phases of evolving skin psoriatic lesions and is temporally strictly associated with pDC. These results support a role for the chemerin/ChemR23 axis in the early phases of psoriasis development.     

Kawasaki disease in a 4-year-old boy

A 4-year-old boy experienced sudden fever, followed by a rash on the trunk and extremities and erythema of the pharynx. Five days later, the fever remained and erythema appeared on the oropharynx, tongue, and lips. The skin of the palms and soles became erythematous and indurated, and both conjunctivae became injected. Desquamation of the skin occurred on both thumbs and one finger, and an anterior cervical lymph node was found to be enlarged. The patient was diagnosed as having Kawasaki disease, and treatment with aspirin was started. The desquamation progressed to involve the entire surface of the palms and soles, and then symptoms resolved. Twenty years after recognition of Kawasaki disease, this enigmatic illness continues to defy attempts to understand its etiology and pathogenesis. Most experts agree that the cause is either an environmental toxin or an infectious agent, but other possible causative agents may need to be proposed and investigated.     

Diagnosis of upper gastrointestinal perforation complicated with fistula formation and subphrenic abscess by contrast-enhanced ultrasound: A case report

BACKGROUNDGastrointestinal perforation complicated by subphrenic abscess is a surgical emergency. Its diagnosis relies mainly on X-ray or computed tomography (CT), while the value of ultrasound, especially contrast-enhanced ultrasound (CEUS), has been underestimated.CASE SUMMARYA 37-year-old man presented with fever and edema of the lower extremities for 10 d. He had a history of laparoscopic repair of gastroduodenal perforation 6 mo prior. His first-time intravenous CEUS indicated a diagnosis of subphrenic abscess. He received antibiotic therapy and ultrasound-guided percutaneous drainage of the abscess. However, second-time intravenous CEUS revealed an unsatisfactory therapeutic effect. Intracavitary CEUS was proposed, and this examination detected communication between the abscess and the stomach. Upper gastrointestinal perforation complicated by fistula formation and subphrenic abscess was diagnosed with the help of CEUS. Abdominal CT and esophagogastroduodenoscopy confirmed the diagnosis. The patient recovered after the perforation was repaired by surgery.CONCLUSIONIntravenous and intracavitary CEUS provides helpful information for the diagnosis of upper gastrointestinal perforation complicated by fistula formation and subphrenic abscess.     

Autoimmune bullous dermatoses: a review

Bullous dermatoses can be debilitating and possibly fatal. A selection of autoimmune blistering diseases, including pemphigus vulgaris, paraneoplastic pemphigus, bullous pemphigoid, cicatricial pemphigoid, dermatitis herpetiformis and linear IgA dermatosis are reviewed. Pemphigus vulgaris usually starts in the oral mucosa followed by blistering of the skin, which is often painful. Paraneoplastic pemphigus is associated with neoplasms, most commonly of lymphoid tissue, but also Waldenstr?m's macroglobulinemia, sarcomas, thymomas and Castleman's disease. Bullous pemphigoid is characterized by large, tense bullae, but may begin as an urticarial eruption. Cicatricial (scarring) pemphigoid presents with severe, erosive lesions of the mucous membranes with skin involvement in one third of patients focused around the head and upper trunk. Dermatitis herpetiformis is intensely pruritic and chronic, characterized by papulovesicles and urticarial wheals on the extensor surfaces in a grouped or herpetiform, symmetric distribution. Linear IgA dermatosis is clinically similar to dermatitis herpetiformis, but it is not associated with gluten-sensitive enteropathy as is dermatitis herpetiformis.     

Sweet's syndrome associated with norfloxacin in a prostate cancer patient

Sir, Acute febrile neutrophilic dermatosis, also termed Sweet's syndrome(SS), is an uncommon disease first described by Robert Sweetin 1964.¹ It is a hypersensitivity reaction in response to systemicfactors, which may include malignant disease, infection, ordrug exposure. Patients with malignancy often take several medications,and if SS develops, it can be difficult to tell whether it isdrug-related or a paraneoplastic syndrome. Norfloxacin is an antibiotic from the family of     

Association of sagittal spinal alignment in the sitting position with the trunk and lower extremity muscle masses in children and adults with cerebral palsy: A pilot study

BackgroundWe examined the association of sagittal spinal alignment in the sitting position with the trunk and lower extremity muscle masses in children and adults with cerebral palsy (CP). We also compared muscle masses between children and adults with CP who could and could not sit without the support of their upper extremities.MethodsThe subjects were 34 children and adults with CP. Sagittal spinal alignment in the sitting position, such as thoracic kyphosis, lumbar lordosis, and sacral anterior inclination angles were measured using a Spinal Mouse. The thicknesses of the trunk and lower extremity muscles were measured using an ultrasound imaging device. Furthermore, the subjects were classified into the sitting-possible group (n = 18), who could sit without the support of the upper extremities, or a sitting-impossible group (n = 16), who could not sit without the support of the upper extremities.FindingsStepwise regression analysis revealed that the lumbar multifidus muscle thickness and body weight were significant and independent factors of the lumbar lordosis angle in the sitting position. The thicknesses of the thoracic erector spinae, gluteus maximus and minimus, long head of the biceps femoris, semitendinosus, and rectus femoris muscles were significantly lower in the sitting-impossible group than those in the sitting-possible group.InterpretationDecreased lumbar lordosis angle in the sitting position was associated with decreased lumbar multifidus muscle mass in children and adults with CP. Furthermore, not only trunk extensor but also hip joint muscles may contribute to sitting without upper extremity support.     

Acute febrile neutrophilic dermatosis

Acute febrile neutrophilic dermatosis, or Sweet's syndrome, usually occurs in middle-aged women with a preceding upper respiratory tract infection. In about 20 percent of reported cases, the syndrome is associated with an underlying malignancy, most frequently acute myelogenous leukemia. A dense infiltrate of mature neutrophils is seen in the middle and upper portions of the dermis. Corticosteroid therapy produces rapid improvement of all manifestations of the syndrome.     

Cytapheresis for pyoderma gangrenosum associated with inflammatory bowel disease: A review of current status

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis clinically characterized by the presence of painful skin ulcerations with erythematous. As it is frequently associated with inflammatory bowel diseases, including ulcerative colitis, gastroenterologists should be familiar with the disease including therapeutic options. Therefore, we have conducted a review focusing on the cytapheresis for PG in cases of inflammatory bowel diseases. A literature search was conducted to extract studies published in the last 20 years, with information on demographics, clinical symptoms, treatment, and the clinical course from a total of 22 cases reported and our recent case. In most patients, cytapheresis was associated with improvement or resolution of PG after failure of conventional therapeutic options such as corticosteroids, antibiotics, immunosuppressive agents and immunoglobulin. Based on the information summarized, cytapheresis is helpful in the majority of patients with PG refractory to medical treatment associated with inflammatory bowel diseases and could be further studied in a multicenter, randomized trial.