Generalized Lichenoid Drug Eruption Associated with Imatinib Mesylate Therapy

Imatinib mesylate (IM), an anticancer drug, has been widely used to treat chronic myeloid leukemia (CML), gastrointestinal stromal tumors (GIST), and dermato-fibrosarcoma protuberans. Cutaneous reactions to IM have been reported to occur in varying number of patients in different case series. Non-lichenoid cutaneous reactions secondary to IM have been well-documented in the literature and are the commonest non-hematologic adverse reactions associated with its use. Lichenoid drug eruption (LDE) associated with IM therapy has rarely been reported in the literature. A case of a generalized LDE associated with IM therapy has been described here for its rarity and interesting clinical presentation. As the clinical usage of IM is increasing, one might expect an increasing number of similar patients in the future. It is thus important to realize the potential of IM to produce LDE and to differentiate this entity from idiopathic lichen planus. In the present article, the reports of IM-associated LDE, described in the PubMed and Medline database (in English language literature), have also been reviewed.     

Drug Eruptions: An 8-year Study Including 106 Inpatients at a Dermatology Clinic in Turkey

Background:

Few clinical studies are found in the literature about patients hospitalized with a diagnosis of cutaneous drug eruption.

Aims:

To determine the clinical types of drug eruptions and their causative agents in a hospital-based population.

Materials and Methods:

This retrospective study was performed in the Dermatology Department of Haseki General Hospital. Through 1751 patients hospitalized in this department between 2002 and 2009, inpatients diagnosed as drug eruption were evaluated according to WHO causality definitions. 106 patients composed of probable and possible cases of cutaneous drug eruptions were included in this study.

Results:

Seventy one females and 35 males were evolved. Mean age was 44.03±15.14. Duration between drug intake and onset of reaction varied from 5 minutes to 3 months. The most common clinical type was urticaria and/or angioedema in 48.1% of the patients, followed by maculopapular rash in 13.2%, and drug rash with eosinophilia and systemic symptoms in 8.5%. Drugs most frequently associated with cutaneous drug eruptions were antimicrobial agents in 40.5% of the patients, followed by antipyretic/anti-inflammatory analgesics in 31.1%, and antiepileptics in 11.3%.

Conclusion:

Urticaria and/or angioedema and maculopapular rash comprised majority of the drug eruptions. Rare reactions such as acute generalized exanthematous pustulosis, sweet syndrome, oral ulceration were also found. Antimicrobial agents and antipyretic/anti-inflammatory analgesics were the most commonly implicated drugs. Infrequently reported adverse reactions to myorelaxant agents, newer cephalosporins and fluoroquinolones were also detected. We suppose that studies on drug eruptions should continue, because the pattern of consumption of drugs is changing in every country at different periods and many new drugs are introduced on the market continuously.     

Fixed Drug Eruption Due to Influenza Vaccine

Two females, one 28 years old and the other 32 years old, developed dusky red macules with pain and a burning sensation within 24 hours of receiving influenza vaccine. One patient had blisters within the lesion. A clinical diagnosis of fixed drug eruption (FDE) due to influenza vaccine was made. Histopathology was consistent with the diagnosis of FDE. The lesions subsided within 2 weeks of topical corticosteroid treatment. The diagnosis was confirmed by topical provocation test with influenza vaccine. A Medline search revealed these cases to be the second report of this kind of reaction due to influenza vaccine.

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Deux femmes âgées respectivement de 28 et de 32 ans ont développé des macules rouges, accompagnées de douleurs et de brûlures, dans un intervalle de 24 heures suivant une vaccination antigrippale. Une des patientes a présenté des vésicules à lintérieur des lésions. Un diagnostic clinique a révélé un érythème pigmenté fixe dû au vaccin antigrippal. Lhistopathologie a confirmé le diagnostic. Les lésions ont disparu après deux semaines de traitement aux corticostéroïdes topiques. Le diagnostic a été confirmé par un test de provocation au vaccin antigrippal par voie topique. Une recherche dans la base de données Medline a révélé quil sagit du second rapport de cas de réactions au vaccin antigrippal.

     

Multiple Carboxylase Deficiency (Late Onset) Due to Deficiency of Biotinidase

Biotinidase is a ubiquitous mammalian cell enzyme occurring in liver, serum and kidney. It cleaves biotin from biocytin, which is a cofactor for biotin dependent enzymes, namely the human carboxylases. Biotinidase deficiency is associated with a wide spectrum of neurological, dermatological, immunological and ophthalmological abnormalities. This is a case of a 3-year-old boy presenting with delayed developmental milestones, tachypnea, progressively increasing ataxia, alopecia and dermatitis, all which dramatically responded to high doses of biotin.     

Acetaminophen-induced cellulitis-like fixed drug eruption

Acetaminophen is a widely used analgesic drug. Its adverse reactions are rare but severe. An 89-year-old man developed an indurated edematous and erythematous plaque on his left arm 1 day after acetaminophen ingestion. Cellulitis was suspected and antibiotictherapy was started but there was no improvement of the rash; there was a spectacular extension of the lesion with occurrence of flaccid vesicles and blisters in the affected sites. The diagnosis of generalized-bullous-fixed drug eruption induced by acetaminophen was considered especially with a reported history of a previous milder reaction occurring in the same site. Acetaminophen was withdrawn and the rash improved significantly. According to the Naranjo probability scale, the eruption experienced by the patient was probably due to acetaminophen. Clinicians should be aware of the ability of acetaminophen to induce fixed drug eruption that may clinically take several aspects and may be misdiagnosed.     

Livedo Reticularis Due to Pellagra in a Two Year Old Child

A two-year-old girl child was admitted with complaints of diarrhoea of one week duration in the paediatric ward. She was referred to the skin OPD for gradually progressive skin rashes on both lower limbs noticed since two days. Dermatological examination revealed finding of livedo reticularis. Dietary history revealed maize forming a significant portion of the child''s diet since the age of nine months. The child was treated with a course of Niacin in the form of Nicotinamide 50 mg twice a day for 4 weeks and the parents were advised not to give her maize in the diet. The skin lesions and diarrhoea regressed in duration of two weeks. This is probably the first time that a case of pellagra causing livedo is being reported, that too in a child.     

Biostatistics Series Module 4: Comparing Groups – Categorical Variables

Categorical variables are commonly represented as counts or frequencies. For analysis, such data are conveniently arranged in contingency tables. Conventionally, such tables are designated as r × c tables, with r denoting number of rows and c denoting number of columns. The Chi-square (χ²) probability distribution is particularly useful in analyzing categorical variables. A number of tests yield test statistics that fit, at least approximately, a χ² distribution and hence are referred to as χ² tests. Examples include Pearson''s χ² test (or simply the χ² test), McNemar''s χ² test, Mantel–Haenszel χ² test and others. The Pearson''s χ² test is the most commonly used test for assessing difference in distribution of a categorical variable between two or more independent groups. If the groups are ordered in some manner, the χ² test for trend should be used. The Fisher''s exact probability test is a test of the independence between two dichotomous categorical variables. It provides a better alternative to the χ² statistic to assess the difference between two independent proportions when numbers are small, but cannot be applied to a contingency table larger than a two-dimensional one. The McNemar''s χ² test assesses the difference between paired proportions. It is used when the frequencies in a 2 × 2 table represent paired samples or observations. The Cochran''s Q test is a generalization of the McNemar''s test that compares more than two related proportions. The P value from the χ² test or its counterparts does not indicate the strength of the difference or association between the categorical variables involved. This information can be obtained from the relative risk or the odds ratio statistic which is measures of dichotomous association obtained from 2 × 2 tables.     

Psoriasis Herpeticum due to Varicella Zoster Virus: A Kaposi's Varicelliform Eruption in Erythrodermic Psoriasis

Kaposi's varicelliform eruption (KVE) or eczema herpeticum is characterized by disseminated papulovesicular eruption caused by a number of viruses like Herpes simplex virus I and II, Coxsackie virus, and Vaccinia and Small pox viruses in patients with pre-existing skin disease. The occurrence of KVE with psoriasis has been reported recently as a new entity psoriasis herpeticum. The rare causation of psoriasis herpeticum due to Varicella zoster virus in a patient with underlying psoriasis is being reported for the first time.     

Toxic Epidermal Necrolysis Due to Concomitant Use of Lamotrigine and Valproic Acid

Anti-epileptic drugs can be associated with a wide spectrum of cutaneous adverse reactions ranging from simple maculopapular rashes to more severe and life threatening reactions like Stevens-Johnson syndrome and toxic epidermal necrolysis. These rashes are well documented with older antiepileptic drugs like phenytoin, phenobarbitone and carbamazapine. Lamotrigine is a newer, unrelated antiepileptic drug that causes skin rashes in 3-10% of new users. Higher starting dose or rapid escalation, concurrent treatment with valproic acid, and a previous history of a rash with other antiepileptic drugs are well recognized risk factors for lamotrigine related serious rashes. We report two patients with toxic epidermal necrolysis, resulting from concomitant use of lamotrigine and valproic acid. It is emphasized that clinicians adhere to the recommended dosage guidelines and adopt a slow dose titration when initiating treatment with lamotrigine.     

Pustular Drug Eruption Due to Bacampicilin Hydrochloride in a Patient with Psoriasis

We report a case of pustular drug eruption due to bacampicilin hydrochloride which developed in a patient with pustular psoriasis. The patient was a 45-year-old Japanese woman with psoriasis which started as pustular psoriasis twenty years previously. In 1994, she developed generalized erythema with pustules accompanied by high fever and liver injury. Clinical and histological findings of this pustular eruption were different from her previous episodes of pustular psoriasis. Erythemas and pustules disappeared and her abnormal transaminase returned to normal rapidly when she discontinued bacampicilin hydrochloride. Her positive reaction to a patch test and a lymphocyte stimulation test also suggested that our case had a pustular drug eruption rather than pustular psoriasis induced by a drug.     

Drug Eruption (Erythema Multiforme Type) Due to a Digestive Enzyme Drug

An 84-year-old Japanese male had pruritic indurated erythema on his upper limb and left lower abdomen, which had developed abruptly two months before visiting our hospital. Hematological examination showed eosinophilia, 550/mm³. Histopathological findings were suggestive of erythema multiforme in response to a drug. By means of patch tests and a p.o. challenge test, Aczym^®, a digestive enzyme drug, was shown to be the cause of his condition. Further study revealed that the specific ingredients involved were pancreatin and Taka-diastase. An eruption resulting from ingestion of a digestive enzyme drug has not previously been reported.     

ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS: AN UNUSUAL SIDE EFFECT OF MEROPENEM

A male patient was hospitalized as a case of pneumonia. He was diabetic, hypertensive and post Hepatitis “C” “H-C”. He reported skin eruption following administration of meropenem. Skin biopsy revealed acute generalized exanthematous pustulosis. To elucidate this side effect, we conducted a literature search - this is the second case induced by meropenem. The diagnosis was made after excluding all other possible causes. Dermatologists and clinicians must be aware of this an unusual side effect.     

Long-lasting Localized Pemphigus Vulgaris without Detectable Serum Autoantibodies Against Desmoglein 3 and Desmoglein 1

Pemphigus vulgaris (PV) is an autoimmune blistering disease elicited by anti-desmoglein (DsG) 3 antibody. Although skin lesions tend to be distributed over the entire body, in some patients, they are confined to a restricted area. We report two patients who presented with long-lasting localized PV without detectable anti-DsG antibodies after suffering antibody-positive systemic PV. Initial treatment with prednisolone (PSL) was successful in both patients, but a local relapse occurred on the cheek or lower lip after a reduction in the PSL dose. Biopsy of the localized lesions showed suprabasal acantholysis; no serum DsG antibodies were found. Local immunosuppression therapy was effective in both patients. Based on our findings, we suggest that localized PV without detectable antibodies can develop after systemic PV.