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Vasculitis occurring after intravenous anistreplase
Journal of the American Academy of Dermatology
508 Correspondence Certainly, our patients were "amyopathic" in this sense because none had clinical evidence of a muscle disease. Therefore Pearson's designation "amyopathic dermatomyositis" seemed to be the most appropriate for referring to the disease of patients such as the ones we have described. Since the publication of our article, we have identified two additional patients who fulfill our criteria for amyopathic DM. Oneofthese two patients, a 42-year-old white woman, had ductal carcinoma of the breast approximately 21jz years after the onset of the classical cutaneous manifestations of DM including Gottron's papules at a time when she still had no clinical evidence of muscle involvement. When last seen, 5 months after lumpectomy and radiation therapy, there had been no improvement in her skin disease. We have recently learned about two other similar patients (T. T. Provost, MD, personal communication, August 1991). Thus a diagnosis of amyopathic DM does not appear to preclude the possibility of an associated malignancy. More amyopathic DM patients will have to be studied to determine whether the cutaneous manifestations of DM alone place a person at a significantly increased risk for development of an internal malignancy. We would also like to take this opportunity to correct an error that was made in our article. The abstract mistakenly states that six of six (100%) of the patients had Gottron'spapu!es; however, in Table III the correct figure of five of six (83%) is listed. Although all six patients did have erythematous to violaceous macules overlying their interphalangeal ~oints, only five also had a superimposed papular component to allow classification as classical Gottron's papules.
R. Euwer, MD, and R, D. Sontheimer, MD Department of Dermatology University of Texas Southwestern Medical Center 5323 Harry Hines Blvd. Dallas, TX 75235
7.
8. 9,
10.
atine kinase elevation: a poor prognostic sign. Am J Med 1986;80:329-32. Tymms KE, Webb J. Dermatopolymyositis and other connective tissue diseases: a review of 105 cases. J Rheumatol 1985;12:1140-8, Rockerbie NR, Woo TY, Callen JP, et al. Cutaneous changes of dermatomyositis precede muscle weakness. J AM ACAD DERMATOL 1989;20:629-32. Bradley WG, Tandan R.Inflammatorydiseases of muscle, In: KelleyWN, Harris ED Jr,RuddyS,etal,eds. Textbook of rheumatology. 3rd ed. Philadelphia: WB Saunders, 1989:1273. Pearson CM. Polymyositis and dermatomyositis. In: McCarty DJ, ed. Arthritis (and allied conditions). 9th ed. Philadelphia: Lea & Febiger, 1979:748.
Vasculitis occurring after intravenous .anistreplase To the Editor: We were interested to read the report by Patel et a1. (J AM ACAD DERMATOL 1991;24:652-3) describing a serum sickness-like illness and leukocytoclastic vasculitis after intravenous streptokinase. Similar clinical symptoms and signs may follow the administration of anistreplase (anisoylated plasminogen streptokinase activator complex [APSAC]). Anistreplase is a closely related thrombolytic compound that may be administered by an intravenous injection rather than a prolonged infusion. Preliminary results from the International Study on Infarct Survival-3 (Prof. P. Sleight, unpublished data) show a similar reduction in mortality rate compared with streptokinase. We have previously reported the case of a 54-year-old woman in whom a leukocytoclastic vasculitis developed 5days after intravenous administration of anistreplase.! An additional six cases of vasculitis from a total of 253 patients who received anistreplase have also been reported. 2 Palpable purpura was found most commonly on the legs 5 to 15 days after intravenous infusion of anistreplase. Five patients had associated symptoms of arthralgia or abdominal pain. Two cases revealed transient proteinuria and hematuria without evidence of renal impairment. All patients recovered spontaneously within 2 weeks. Nigel Burrows, MB, MRCP Robin Russell Jones, MA, FRCP Department ofDermatology Ealing Hospital Uxbridge Road Southall, Middlesex, UBI 3HW United Kingdom
REFERENCES 1. Bohan A, Peter JB, Bowman RL, et al. A computer-assisted analysis of 153 patients with polymyositis and dermatomyositis. Medicine 1977;56:255-86. 2. DeVere R, Bradley WG. Polymyositis: its presentation, morbidity and mortality. Brain 1975;98:637-66. 3. Braverman 1. Connective tissue (rheumatic) diseases. In; Cutaneous signs of systemic disease, 2nd ed. Philadelphia: WB Saunders, 1981:301. 4. Mills JA. Dermatomyositis. In; Fitzpatrick TB, Eisen AZ, Wolff K, et ai, eds. Dermatology in general medicine. 3rd ed. New York: McGraw-Hill, 1987:1835, 5. Winkelmann RK. The cutaneous diagnosis of dermatomyositis, lupus erythematosus, and scleroderma. N Y State J 1963 (November 1):3080-6. 6. Fudman EJ, Schnitzer TJ. Dermatomyositis without cre-
Moo
REFERENCES 1. Burrows N, Russell Jones R. Rash after treatment with anistreplase, Br Heart J 1990;64:289-90. 2. Bucknall C, Darley C, Flax J, et al. Vasculitis complicating treatment with intravenous anisoy1ated plasminogen streptokinase activator complex in acute myocardial infarction. Br Heart J 1988;59:9-11.
508 Correspondence Certainly, our patients were "amyopathic" in this sense because none had clinical evidence of a muscle disease. Therefore Pearson's designation "amyopathic dermatomyositis" seemed to be the most appropriate for referring to the disease of patients such as the ones we have described. Since the publication of our article, we have identified two additional patients who fulfill our criteria for amyopathic DM. Oneofthese two patients, a 42-year-old white woman, had ductal carcinoma of the breast approximately 21jz years after the onset of the classical cutaneous manifestations of DM including Gottron's papules at a time when she still had no clinical evidence of muscle involvement. When last seen, 5 months after lumpectomy and radiation therapy, there had been no improvement in her skin disease. We have recently learned about two other similar patients (T. T. Provost, MD, personal communication, August 1991). Thus a diagnosis of amyopathic DM does not appear to preclude the possibility of an associated malignancy. More amyopathic DM patients will have to be studied to determine whether the cutaneous manifestations of DM alone place a person at a significantly increased risk for development of an internal malignancy. We would also like to take this opportunity to correct an error that was made in our article. The abstract mistakenly states that six of six (100%) of the patients had Gottron'spapu!es; however, in Table III the correct figure of five of six (83%) is listed. Although all six patients did have erythematous to violaceous macules overlying their interphalangeal ~oints, only five also had a superimposed papular component to allow classification as classical Gottron's papules.
R. Euwer, MD, and R, D. Sontheimer, MD Department of Dermatology University of Texas Southwestern Medical Center 5323 Harry Hines Blvd. Dallas, TX 75235
7.
8. 9,
10.
atine kinase elevation: a poor prognostic sign. Am J Med 1986;80:329-32. Tymms KE, Webb J. Dermatopolymyositis and other connective tissue diseases: a review of 105 cases. J Rheumatol 1985;12:1140-8, Rockerbie NR, Woo TY, Callen JP, et al. Cutaneous changes of dermatomyositis precede muscle weakness. J AM ACAD DERMATOL 1989;20:629-32. Bradley WG, Tandan R.Inflammatorydiseases of muscle, In: KelleyWN, Harris ED Jr,RuddyS,etal,eds. Textbook of rheumatology. 3rd ed. Philadelphia: WB Saunders, 1989:1273. Pearson CM. Polymyositis and dermatomyositis. In: McCarty DJ, ed. Arthritis (and allied conditions). 9th ed. Philadelphia: Lea & Febiger, 1979:748.
Vasculitis occurring after intravenous .anistreplase To the Editor: We were interested to read the report by Patel et a1. (J AM ACAD DERMATOL 1991;24:652-3) describing a serum sickness-like illness and leukocytoclastic vasculitis after intravenous streptokinase. Similar clinical symptoms and signs may follow the administration of anistreplase (anisoylated plasminogen streptokinase activator complex [APSAC]). Anistreplase is a closely related thrombolytic compound that may be administered by an intravenous injection rather than a prolonged infusion. Preliminary results from the International Study on Infarct Survival-3 (Prof. P. Sleight, unpublished data) show a similar reduction in mortality rate compared with streptokinase. We have previously reported the case of a 54-year-old woman in whom a leukocytoclastic vasculitis developed 5days after intravenous administration of anistreplase.! An additional six cases of vasculitis from a total of 253 patients who received anistreplase have also been reported. 2 Palpable purpura was found most commonly on the legs 5 to 15 days after intravenous infusion of anistreplase. Five patients had associated symptoms of arthralgia or abdominal pain. Two cases revealed transient proteinuria and hematuria without evidence of renal impairment. All patients recovered spontaneously within 2 weeks. Nigel Burrows, MB, MRCP Robin Russell Jones, MA, FRCP Department ofDermatology Ealing Hospital Uxbridge Road Southall, Middlesex, UBI 3HW United Kingdom
REFERENCES 1. Bohan A, Peter JB, Bowman RL, et al. A computer-assisted analysis of 153 patients with polymyositis and dermatomyositis. Medicine 1977;56:255-86. 2. DeVere R, Bradley WG. Polymyositis: its presentation, morbidity and mortality. Brain 1975;98:637-66. 3. Braverman 1. Connective tissue (rheumatic) diseases. In; Cutaneous signs of systemic disease, 2nd ed. Philadelphia: WB Saunders, 1981:301. 4. Mills JA. Dermatomyositis. In; Fitzpatrick TB, Eisen AZ, Wolff K, et ai, eds. Dermatology in general medicine. 3rd ed. New York: McGraw-Hill, 1987:1835, 5. Winkelmann RK. The cutaneous diagnosis of dermatomyositis, lupus erythematosus, and scleroderma. N Y State J 1963 (November 1):3080-6. 6. Fudman EJ, Schnitzer TJ. Dermatomyositis without cre-
Moo
REFERENCES 1. Burrows N, Russell Jones R. Rash after treatment with anistreplase, Br Heart J 1990;64:289-90. 2. Bucknall C, Darley C, Flax J, et al. Vasculitis complicating treatment with intravenous anisoy1ated plasminogen streptokinase activator complex in acute myocardial infarction. Br Heart J 1988;59:9-11.