Acute febrile toxic reaction in patients with refractory rheumatoid arthritis who are receiving combined therapy with methotrexate and azathioprine

Azathioprine hypersensitivity syndrome: report of two cases with cutaneous manifestations

Azathioprine is an immunosuppressant drug used in many dermatological and nondermatological pathologies. Azathioprine hypersensitivity syndrome (AHS) is a rare idiosyncratic reaction that is not related to dose or thiopurine methyltransferase activity. Up to half of cases of AHS can present with variable cutaneous manifestations besides fever, malaise and other systemic symptoms. It is important to be aware of AHS, as continuance or reintroduction of the drug can led to multiorgan failure and cardiovascular collapse.

The cutaneous and systemic manifestations of azathioprine hypersensitivity syndrome

BACKGROUND

Azathioprine (AZA) hypersensitivity syndrome is a rare side effect that typically occurs early in the initiation of therapy and may include a cutaneous eruption. It is often under-recognized because it mimics infection or disease exacerbation. Until recently, the cutaneous findings associated with AZA hypersensitivity have been reported using nonspecific, descriptive terms without a supportive diagnostic biopsy.

OBJECTIVE

To characterize the cutaneous and histologic findings associated with AZA hypersensitivity syndrome.

METHODS

We conducted a retrospective analysis of two cases of AZA hypersensitivity syndrome and describe the cutaneous manifestations and histological findings of each case. A review of the English literature for cases of AZA hypersensitivity or allergic or adverse reactions associated with AZA was performed.

RESULTS

Sixty-seven cases of AZA hypersensitivity were reviewed; 49% (33/67) had cutaneous manifestations. Of those cases presenting with cutaneous findings, 76% (25/33) had biopsy results or clinical features consistent with a neutrophilic dermatosis, whereas the other 24% (8/33) were reported as a nonspecific cutaneous eruption.

LIMITATIONS

Only case reports in which the skin findings could be classified were reviewed.

CONCLUSIONS

The predominant cutaneous reaction reported in the literature and observed in the present case series is a neutrophilic dermatosis. Hypersensitivity to AZA can manifest along a wide clinical spectrum from local neutrophilic disease to a systemic syndrome. Skin findings may be an important early clue to the diagnosis of AZA hypersensitivity and aid in prompt recognition and treatment of this potentially life-threatening adverse drug effect.

Drug allergy: an updated practice parameter

Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient

The Use of Systemic Immune Moderators in Dermatology: An Update

In addition to corticosteroids, dermatologists have access to an array of immunomodulatory therapies. Azathioprine, cyclophosphamide, methotrexate, cyclosporine, and mycophenolate mofetil are the systemic immunosuppressive agents most commonly used by dermatologists. In addition, new developments in biotechnology have spurred the development of immunobiologic agents that are able to target the immunologic process of many inflammatory disorders at specific points along the inflammatory cascade. Alefacept, efalizumab, etanercept, and infliximab are the immunobiologic agents that are currently the most well known and most commonly used by dermatologists. This article reviews the pharmacology, mechanism of action, side effects, and clinical applications of these therapies.

Traditional therapies: glucocorticoids, azathioprine, methotrexate, hydroxyurea

The 'old favourites' used for treatment of inflammatory diseases, and hence, the original immunomodulators, include the glucocorticoids, azathioprine, methotrexate and hydroxyurea. Glucocorticoids are still one of the most effective anti-inflammatory agents because they work on several different intracellular processes and hence, block many components that contribute to inflammatory and immune responses. They bind to intracellular glucocorticoid receptors which transport them into the nucleus. Here the receptor/steroid complex may bind to many genes that interact with transcription factors including NFkappaB and AP-1, to inhibit their activation, thereby preventing activation of many genes encoding immune effector and pro-inflammatory cytokines. Also, protein kinases involved in intracellular signalling, are directly activated resulting in phosphorylation of various targets of which Annexin (AXA)-1 is critical in inhibiting biosynthesis of both purines and DNA. This results in reduced proliferation of B and T lymphocytes, reduced immune effector mechanisms and reduced recruitment of mononuclear cells including monocytes into sites of immune inflammation. Methotrexate also blocks DNA synthesis and hence cellular proliferation but also induces release of adenosine. This inhibits chemotaxis of polymorph neutrophils and release of critical cytokines such as TNF-alpha and Interleukins 6 and 8. Hydroxyurea also inhibits DNA synthesis with inhibitory effects on proliferation of lymphocytes and possibly kerationcytes. Even though many new agents with much greater selectivity are coming through into clinical use, this group of old agents still have an absolutely central position in the therapeutic armamentarium. Their value lies in the fact that they are not 'clean' drugs with narrow effects but they inhibit a wide range of mechanisms involved in immune and inflammatory processes.

Combination therapy with disease modifying anti-rheumatic drugs in rheumatoid arthritis

There is increasing interest in using combinations of two or more disease modifying anti-rheumatic drugs to treat rheumatoid arthritis. The use of such combinations is increasing in routine clinical practice. We have identified 18 well-conducted, randomised controlled trials of the use of combinations of disease modifying drugs, and a number of open studies that provide helpful supportive information. The 18 trials involved 2221 patients. Two trials reported strongly positive results, six reported moderately positive results and ten gave largely negative results. The combination of methotrexate, sulfasalazine and hydroxychloroquine appears to be effective with an acceptable level of adverse effects. There is also evidence that the combination of methotrexate and cyclosporin is advantageous. With both combinations, there appears to be further advantages from using corticosteroids in addition to the combination, although the evidence for this is incomplete. The use of other combinations is of less value, and in particular combinations involving parenteral gold, penicillamine and azathioprine are best avoided. Finally, there is growing evidence from randomised trials that the combination of anti-tumour necrosis factor (TNF) therapy with methotrexate is effective and well tolerated. We have identified four randomised controlled trials of the use of combinations of anti-TNF with methotrexate that all reported results favouring this combination. There is insufficient evidence to support the use of other combinations involving immunotherapies at the present time.

Cutaneous Reactions to Chemotherapeutic Agents

The task of evaluating a cutaneous eruption in the patient receiving chemotherapy can be quite formidable. Most of the time, these patients are receiving a multitude of agents and have profound immunosuppression. These factors may alter the more common manifestations of cutaneous eruptions. This article presents some of the more common cutaneous eruptions that may occur in an oncology patient receiving chemotherapy. It is hoped we may recognize clinical patterns seen with chemotherapeutic agents in the immunosuppressed population and, by recognizing these cutaneous eruptions, we may avoid the pitfalls of discontinuing medicines that may certainly be needed or altering the treatment course in a patient.

Immunosuppressive and cytotoxic drugs in the treatment of rheumatic skin disorders

Cytotoxic and immunosuppressive drugs are regularly used to treat proliferative, immunologically mediated inflammatory disorders and some neoplastic diseases of the skin. Methotrexate, azathioprine, mycophenolate mofetil, cyclosporin cyclophosphamide, chlorambucil, and other related drugs have potential benefits in the treatment of severe and/or recalcitrant rheumatic skin diseases. The therapeutic window for these agents is narrow. The major uses of these drugs are for life-threatening cutaneous disorders or as steroid-sparing agents.

Other novel immunosuppressants

The use of immunosuppressive agents in dermatology has increased widely. The role of these medications has become increasingly important for the treatment of dermatologic disorders in an inpatient setting, where there is frequently a requirement for highly potent, fast-acting, effective agents. This article presents an overview of the general application, mechanisms of action, metabolism, and adverse effects commonly associated with systemic immunosuppressive agents used in dermatology.

Management of therapy-resistant rheumatoid arthritis

During the last two decades, newly introduced therapeutic strategies have resulted in satisfactory modification of the disease course in the majority of the patients with rheumatoid arthritis (RA). Nevertheless, a definite number of RA patients remain therapy-resistant, and for this group more aggressive treatment may be required for preventing permanent disability and progressive joint damage necessitating surgical procedures. Therefore, management of therapy-resistant RA is one of the major challenges in modern rheumatology. RA patients who have not responded to conventional disease-modifying antirheumatic drug (DMARD) therapy are defined as refractory RA patients. However, a uniform description or definition for 'refractory' RA does not appear to be available. In this article we will deal with, and discuss, the term 'refractory RA' based on a MEDLINE database search using this term, currently available therapeutic options, data on therapy-resistant RA patients from an inception cohort of RA patients attending the Nijmegen University Hospital, management of extra-articular manifestations and future management strategies.

Cutaneous vasculitis in children and adults. Associated diseases and etiologic factors in 303 patients

Cutaneous vasculitis (CV), a condition characterized by palpable purpura and nonspecific histopathologic findings, presents a diagnostic and therapeutic challenge because it may be a primary disorder or it may be a cutaneous manifestation of another entity, such as systemic necrotizing vasculitis, connective tissue disease, systemic bacterial infection, or malignancy. We studied 303 unselected patients (172 adults and 131 children) with CV to assess the disease associations and etiologic factors, to identify the frequency of primary and secondary CV in different age-groups, and to characterize features that help to distinguish between primary and secondary CV. Of the 131 children, 130 had primary CV: Henoch-Schönlein purpura (HSP) in 116 and hypersensitivity vasculitis (HV) in 14. In contrast, of the 172 adults, only 120 had primary CV: HSP in 39, HV in 70, and essential mixed cryoglobulinemia in 11. CV was a manifestation of systemic necrotizing vasculitis in 23 adults (polyarteritis nodosa in 17, Wegener granulomatosis in 4, and Churg-Strauss syndrome in 2). CV was secondary to other processes in 29 adults: in 20 patients CV was associated with connective tissue disease or another autoimmune or rheumatic disease, in 5 patients CV was a manifestation of severe bacterial infection, especially bacterial endocarditis (4 cases), and in the other 4 patients CV was the presenting symptom of an underlying malignancy. The patients for whom CV was a manifestation of systemic necrotizing vasculitis or secondary to a connective tissue disease, severe bacterial infection, or malignancy had clinical and laboratory data suggestive of the associated disorder. The clinical picture and outcome of primary CV in both children and adults were benign. By contrast, the prognosis of patients with CV in the context of systemic necrotizing vasculitis or secondary to other entities depended on the primary process. Given the different disease association in children and adults, we propose a simple diagnostic workup in children with CV. By contrast the diagnostic approach in adults with CV should be more cautious and the workup more extensive. The early differentiation between primary CV, secondary CV, and CV presenting as a symptom of systemic necrotizing vasculitis, especially in adults, is of paramount importance for an adequate diagnosis and appropriate treatment.

Immunosuppressive agents in dermatology. An update

Azathioprine, cyclophosphamide, methotrexate, and cyclosporine are the immunosuppressive agents most commonly used by dermatologists. Azathioprine has a relatively good safety profile and is therefore often preferred for the treatment of chronic eczematous dermatitides and bullous disorders. Awareness of the role of genetic polymorphisms in its metabolism can increase the efficacy and safety of this drug. Cyclophosphamide is an antimetabolite that has a more rapid onset of immunosuppressive effect than azathioprine, but has significant short-term and long-term toxicity. It is of use in fulminant, life-threatening cutaneous disease. Methotrexate is an antimetabolite that has significant anti-inflammatory activity. Despite its hepatotoxicity, its role in inflammatory dermatoses is broadening. Likewise, the role of cyclosporine is being expanded. This drug has potent T-cell inhibitory effects secondary to interference with intracellular signal transduction. Given the evidence for cumulative renal toxicity, it currently has a role in the short-term treatment of refractory psoriasis and atopic dermatitis, as well as in select inflammatory dermatoses. Familiarity with disease-specific clinical efficacy, side-effect profile, and dosage allows the successful and judicious use of these drugs in dermatologic disorders.

Treatment of refractory myositis: a randomized crossover study of two new cytotoxic regimens

OBJECTIVE

To assess the clinical usefulness of 2 novel therapies for treatment-resistant myositis.

METHODS

Thirty patients with refractory myositis, of whom 25 had an inadequate or no response to previous cytotoxic therapy, were randomized to begin either a combination of weekly oral methotrexate and daily azathioprine (MTX/AZA) or intravenous methotrexate with leucovorin rescue (I.V. MTX) every 2 weeks for 6 months. Crossover to the alternate therapy occurred according to defined rules; evaluations of muscle strength and functional abilities were performed at the beginning, and after 3 and 6 months, of each treatment.

RESULTS

Of the 15 patients initially randomized to oral MTX/AZA, 8 improved with oral therapy and 1 improved with I.V. MTX during the crossover period. Of the 15 patients initially randomized to I.V. MTX therapy, 3 improved with the I.V. therapy and 4 with the oral combination during the crossover period. Although the study lacked the power to directly compare both treatments, intention-to-treat analysis showed a trend in favor of those patients who first received oral combination therapy (P = 0.025). There were 0.09 adverse events per patient-month with oral combination therapy and 0.16 per patient-month with I.V. therapy (P = 0.09).

CONCLUSION

Combination oral MTX/AZA may benefit patients with treatment-resistant myositis, including those who previously had inadequate responses to either MTX or AZA alone. I.V. MTX with leucovorin rescue may also benefit some patients with refractory myositis.

Side effects of immunosuppressant therapies used in neurology

This article provides an overview of the clinically relevant complications of the main immunosuppressants currently used in the treatment of neurologic disorders with suspected or established immune etiology. The most serious complications are discussed in detail, including pathophysiology and preventative measures. An intimate knowledge of these complications proves helpful in the day to day practice of the neurologist supervising immunotherapy.

Henoch-Schönlein purpura in adulthood and childhood: two different expressions of the same syndrome

OBJECTIVE

To assess the possible differences between children (< or = 20 years) and adults (> 20 years) with Henoch-Schönlein purpura (HSP).

METHODS

A retrospective study of an unselected population of patients with HSP who presented to our teaching hospital between 1975 and 1994. Patients were classified as having HSP according to the criteria proposed by Michel et al.

RESULTS

Following the above-mentioned criteria, 162 white patients (113 male and 49 female) were classified as having HSP; 46 of the patients were adults (mean +/- SD age 53.2 +/- 16.9 years) and 116 were children (6.9 +/- 3.1 years). We were unable to identify any precipitating event in 72% of the adults and 66% of the children. The frequency of previous drug treatment, primarily antibiotics or analgesics, was similar in both groups, whereas previous upper respiratory tract infection was more frequent among the children (P < 0.02). At symptom onset, cutaneous lesions were the main clinical manifestation in both groups. However, adults had a lower frequency of abdominal pain (P < 0.008) and fever (P < 0.01), and a higher frequency of joint symptoms (P < 0.001). During the clinical course, adults had more frequent (P < 0.001) and severe renal involvement. An increased erythrocyte sedimentation rate was also more frequent in the adults (P < 0.001). Adults required more aggressive therapy, consisting of steroids (P < 0.002) and/or cytotoxic agents (P < 0.001). The outcome was relatively good in both age groups, with complete recovery in 107 children (93.9%) and in 33 adults (89.2%) after a mean +/- SD followup of 19.4 +/- 27.7 (median 12) and 21.8 +/- 33.5 (median 15) months, respectively.

CONCLUSION

In adulthood, HSP, as defined by the criteria proposed by Michel et al, represents a more severe clinical syndrome, with a higher frequency of renal involvement. However, the final outcome of HSP is equally good in patients of both age groups.

Clinical features and outcome of 95 patients with hypersensitivity vasculitis

PURPOSE

To evaluate the clinical features and outcome of patients with isolated hypersensitivity vasculitis (HV).

PATIENTS AND METHODS

Retrospective study of patients with cutaneous vasculitis followed up at a University Hospital from 1975 to 1994. Patients with vasculitis secondary to collagen vascular diseases, neoplasia, or major infections were excluded. Patients were classified as HV according to the differential criteria proposed by Michel et al (J Rheumatol. 1992;19:721-728).

RESULTS

Ninety-five patients were classified as HV. The mean age was 42.7 +/- 21.7 years, with similar disease frequency in both sexes. In 43 patients, the precipitating event was drug therapy, either alone or as a treatment for a coexistent infection, usually an upper respiratory tract infection. The most frequent clinical manifestation was palpable purpura followed by joint symptoms. Systemic involvement was infrequent: 7 patients had nephropathy, manifested almost exclusively by microhematuria, and 5 patients had gastrointestinal symptoms. In 54 subjects the vasculitis did not require treatment; 26 patients were treated with NSAIDs, and 14 required corticosteroids (associated to immunosuppressive agents in 2 of them). After a mean follow-up of 15.5 +/- 28.9 months (median 6), only 2 patients had slight renal impairment, whereas the remaining had a complete recovery.

CONCLUSION

Hypersensitivity vasculitis is usually a benign syndrome, often secondary to drugs or infections, or both. Its main clinical manifestations are skin and joint symptoms. The systemic involvement is scarce and its prognosis is excellent.