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Severe adverse skin reactions to drugs in Finland, 1990–1997
St92
Posfers -Adverse
this association, further observations are needed to decide the clinical relevance. I P24
2Finrlislr
Institute
Hospital; K. Alanko 2. ‘Kuopio University of Occupational Health, Helsinki, Finland
Dermatomyositis-like eruption following hydroxyurea therapy
L. Puig, V. Rocamora, A. Alomar. Hospital Sam Pau, Barcelona,
de la Santa
Creu
Papular palmoplantar hyperkeratosis in a patient with vitiligo, caused by chronic medical exposure to arsenic
Gertiiariy
Side effects to drugs, especially severe adverse reactions, are reported to the Adverse Drug Reaction Register of the National Agency for Medicines, Finland, by physicians of all specialities in Finland. Adverse skin reactions to drugs, based on the reports to the Register between January 1990 and September 1997, are examined. The total number of side effects reported was 4424. About one third, 1374, were skin reactions. The eruptions were of various types and severity. Ten cases of toxic epidermal necrolysis, i.e. Lyell’s syndrome, were reported as well as 27 cases of Stevens-Johnson syndrome. There were 19 cases of fixed drug eruption, but none of them were reported to be of the severe bullous type. Sulfonamides and trimethoprim continue to be the most common drugs responsible for toxic epidermal necrolysis and Stevens-Johnson syndrome in Finland. No frequently occurring new agents causing severe skin reactions were reported. I P25
IP26
R. Gerdsen’, K. Steen’. H.W. Seifert2. M. Uerlich’. P Mulkens’, M. Fartasch”, T. Bieber’. ‘Deparfmentof Dermatology, Universify of Bonn; ‘Practice for Dermatology, Borra; 3Departr,tet~r of Dertnarology, University of Erlarrgerr,
Severe adverse skin reactions to drugs in Finland, 1990-l 997
K. Kauppinen’.
drug reactions
i
Spain
A 57-year-old man who had been treated during the last 4 years with hydroxyurea 1 to 2 g/day for chronic myelogenous leukemia developed nail changes, xerosis, a leg ulcer and an erythemato-violaceous lichenoid eruption, with scaling and slight atrophy on the dorsa of the hands, of 4 months’ evolution. Histopathologic study of a skin biopsy specimen showed orthohyperkeratosis and vacuolar changes in the basal cell layer with colloid bodies in the papillar dermis. Due to the benign nature of the eruption and acceptable tolerance by the patient, a decision was made not to discontinue hydroxyurea treatment. A recent review about cutaneous side effects of hydroxyurea included leg ulcers, fixed drug eruption, diffuse hyperpigmentation, brown nail discoloration, photosensitization, oral ulceration, erosive erythematous eruption on the gland penis, stomatitis and cutaneous vasculitis. Dermatomyositis-like eruption, also referred to as hydroxyurea dermopathy, is a drug eruption with a distinctive clinicopathological pattern which has been recently reported, mainly by French-speaking authors. This peculiar and characteristic eruption usually follows a benign course and tends to resolve slowly following hydroxyurea discontinuation. Its pathomechanism is unknown. Hydroxyuma dennopathy is probably under-reported and deserves diagnostic consideration in patients under treatment with hydroxyurea.
Arsenic Hyperkeratosis, Bowen’s Disease and Basal cell carcinoma have been described in patients with a history of chronic occupational, medical, or environmental exposure to arsenic. We present a 38 year old patient from Pakistan with vitiligo, who developed multiple verrucous papules on palms and soles several years after receiving “herbal treatment” from a travelling indian doctor for a period of 12 months. Histopathological examination showed marked hyperkeratosis with intermittent columns of parakeratosis, acanthosis, a poorly developed granular layer and only minor nuclear atypicality with some dyskeratosis. These findings are consistent with the diagnosis of arsenic keratosis. Environmental exposure to arsenic by polluted water or pesticides has not been known to occur in Karachi, the patient’s hometown in Pakistan. Arsenic however is still used in a traditional form of indian medicine and is therefore likely to be the cause of the palmoplantar skin lesions in this case. Incidence of Vitiligo is increased in patients with a history of arsenic ingestion. Arsenic-therapy may therefore be an additional causative factor for the gradual worsening of the vitiligo in this case. I P27 Subacute lupus erythematosus
immunoglobulin
following
therapy
J. Chevrant-Breton, E. Gueret, H. Grimaud, I. Mourtada, F. Le Gall, V. de Burgraeve, R. Tardivel. CHU Pontchaillou Rerrrres, France
Complications of intra venous immunoglobulin (IVIG) therapy are relatively rare, but controversy exists about those observed in auto immune diseases and specially lupus erythematosus (LE) (1); we report on a case of an 80-year-old man who had in 1993 a peripheral neuropathy with isolated IgM monoclonal gammopathy; he was treated with IVIG (400 u/kg daily for 2 days monthly): since the second infusion he had developed, suddenly, a painful facial erythematosquamous eruption regressing in 10 days; it reappeared after each new infusion, extended to the arms and the back and became necrotic; treatment was stopped at the fifth month; subacute L.E. was diagnosed on the basis of clinical and histopathological aspects; Anti DNA and antihistone antibodies were negative but anti SSA antibodies were positive. No other LE systemic symptoms were found. Some cases of acute renal insufficiency in LE after IVIG therapy have been reported but we are not aware of induction of cutaneous LE in the literature: we found only one case of severe gangrenous vasculitis in an infantile systemic LE. (2) References [I] Heyneman Ca et al. Ann Pharmacother, 1997,31: 242-244. [2] Hashkes PJ et all. Clin Exp Rheumatol, 1996, 14: 673-675.
Posfers -Adverse
this association, further observations are needed to decide the clinical relevance. I P24
2Finrlislr
Institute
Hospital; K. Alanko 2. ‘Kuopio University of Occupational Health, Helsinki, Finland
Dermatomyositis-like eruption following hydroxyurea therapy
L. Puig, V. Rocamora, A. Alomar. Hospital Sam Pau, Barcelona,
de la Santa
Creu
Papular palmoplantar hyperkeratosis in a patient with vitiligo, caused by chronic medical exposure to arsenic
Gertiiariy
Side effects to drugs, especially severe adverse reactions, are reported to the Adverse Drug Reaction Register of the National Agency for Medicines, Finland, by physicians of all specialities in Finland. Adverse skin reactions to drugs, based on the reports to the Register between January 1990 and September 1997, are examined. The total number of side effects reported was 4424. About one third, 1374, were skin reactions. The eruptions were of various types and severity. Ten cases of toxic epidermal necrolysis, i.e. Lyell’s syndrome, were reported as well as 27 cases of Stevens-Johnson syndrome. There were 19 cases of fixed drug eruption, but none of them were reported to be of the severe bullous type. Sulfonamides and trimethoprim continue to be the most common drugs responsible for toxic epidermal necrolysis and Stevens-Johnson syndrome in Finland. No frequently occurring new agents causing severe skin reactions were reported. I P25
IP26
R. Gerdsen’, K. Steen’. H.W. Seifert2. M. Uerlich’. P Mulkens’, M. Fartasch”, T. Bieber’. ‘Deparfmentof Dermatology, Universify of Bonn; ‘Practice for Dermatology, Borra; 3Departr,tet~r of Dertnarology, University of Erlarrgerr,
Severe adverse skin reactions to drugs in Finland, 1990-l 997
K. Kauppinen’.
drug reactions
i
Spain
A 57-year-old man who had been treated during the last 4 years with hydroxyurea 1 to 2 g/day for chronic myelogenous leukemia developed nail changes, xerosis, a leg ulcer and an erythemato-violaceous lichenoid eruption, with scaling and slight atrophy on the dorsa of the hands, of 4 months’ evolution. Histopathologic study of a skin biopsy specimen showed orthohyperkeratosis and vacuolar changes in the basal cell layer with colloid bodies in the papillar dermis. Due to the benign nature of the eruption and acceptable tolerance by the patient, a decision was made not to discontinue hydroxyurea treatment. A recent review about cutaneous side effects of hydroxyurea included leg ulcers, fixed drug eruption, diffuse hyperpigmentation, brown nail discoloration, photosensitization, oral ulceration, erosive erythematous eruption on the gland penis, stomatitis and cutaneous vasculitis. Dermatomyositis-like eruption, also referred to as hydroxyurea dermopathy, is a drug eruption with a distinctive clinicopathological pattern which has been recently reported, mainly by French-speaking authors. This peculiar and characteristic eruption usually follows a benign course and tends to resolve slowly following hydroxyurea discontinuation. Its pathomechanism is unknown. Hydroxyuma dennopathy is probably under-reported and deserves diagnostic consideration in patients under treatment with hydroxyurea.
Arsenic Hyperkeratosis, Bowen’s Disease and Basal cell carcinoma have been described in patients with a history of chronic occupational, medical, or environmental exposure to arsenic. We present a 38 year old patient from Pakistan with vitiligo, who developed multiple verrucous papules on palms and soles several years after receiving “herbal treatment” from a travelling indian doctor for a period of 12 months. Histopathological examination showed marked hyperkeratosis with intermittent columns of parakeratosis, acanthosis, a poorly developed granular layer and only minor nuclear atypicality with some dyskeratosis. These findings are consistent with the diagnosis of arsenic keratosis. Environmental exposure to arsenic by polluted water or pesticides has not been known to occur in Karachi, the patient’s hometown in Pakistan. Arsenic however is still used in a traditional form of indian medicine and is therefore likely to be the cause of the palmoplantar skin lesions in this case. Incidence of Vitiligo is increased in patients with a history of arsenic ingestion. Arsenic-therapy may therefore be an additional causative factor for the gradual worsening of the vitiligo in this case. I P27 Subacute lupus erythematosus
immunoglobulin
following
therapy
J. Chevrant-Breton, E. Gueret, H. Grimaud, I. Mourtada, F. Le Gall, V. de Burgraeve, R. Tardivel. CHU Pontchaillou Rerrrres, France
Complications of intra venous immunoglobulin (IVIG) therapy are relatively rare, but controversy exists about those observed in auto immune diseases and specially lupus erythematosus (LE) (1); we report on a case of an 80-year-old man who had in 1993 a peripheral neuropathy with isolated IgM monoclonal gammopathy; he was treated with IVIG (400 u/kg daily for 2 days monthly): since the second infusion he had developed, suddenly, a painful facial erythematosquamous eruption regressing in 10 days; it reappeared after each new infusion, extended to the arms and the back and became necrotic; treatment was stopped at the fifth month; subacute L.E. was diagnosed on the basis of clinical and histopathological aspects; Anti DNA and antihistone antibodies were negative but anti SSA antibodies were positive. No other LE systemic symptoms were found. Some cases of acute renal insufficiency in LE after IVIG therapy have been reported but we are not aware of induction of cutaneous LE in the literature: we found only one case of severe gangrenous vasculitis in an infantile systemic LE. (2) References [I] Heyneman Ca et al. Ann Pharmacother, 1997,31: 242-244. [2] Hashkes PJ et all. Clin Exp Rheumatol, 1996, 14: 673-675.