Captopril-induced pemphigus vegetans with Charcot-Leyden crystals

Oral Adverse Drug Reactions to Cardiovascular Drugs

A great many cardiovascular drugs (CVDs) have the potential to induce adverse reactions in the mouth. The prevalence of such reactions is not known, however, since many are asymptomatic and therefore are believed to go unreported. As more drugs are marketed and the population includes an increasing number of elderly, the number of drug prescriptions is also expected to increase. Accordingly, it can be predicted that the occurrence of adverse drug reactions (ADRs), including the oral ones (ODRs), will continue to increase. ODRs affect the oral mucous membrane, saliva production, and taste. The pathogenesis of these reactions, especially the mucosal ones, is largely unknown and appears to involve complex interactions among the drug in question, other medications, the patient’s underlying disease, genetics, and life-style factors. Along this line, there is a growing interest in the association between pharmacogenetic polymorphism and ADRs. Research focusing on polymorphism of the cytochrome P450 system (CYPs) has become increasingly important and has highlighted the intra- and inter-individual responses to drug exposure. This system has recently been suggested to be an underlying candidate regarding the pathogenesis of ADRs in the oral mucous membrane. This review focuses on those CVDs reported to induce ODRs. In addition, it will provide data on specific drugs or drug classes, and outline and discuss recent research on possible mechanisms linking ADRs to drug metabolism patterns. Abbreviations used will be as follows: ACEI, ACE inhibitor; ADR, adverse drug reaction; ANA, antinuclear antigen; ARB, angiotensin II receptor blocker; BAB, beta-adrenergic blocker; CCB, calcium-channel blocker; CDR, cutaneous drug reaction; CVD, cardiovascular drug; CYP, cytochrome P450 enzyme; EM, erythema multiforme; FDE, fixed drug eruption; I, inhibitor of CYP isoform activity; HMG-CoA, hydroxymethyl-glutaryl coenzyme A; NAT, N-acetyltransferase; ODR, oral drug reaction; RDM, reactive drug metabolite; S, substrate for CYP isoform; SJS, Stevens-Johnson syndrome; SLE, systemic lupus erythematosus; and TEN, toxic epidermal necrolysis.

Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and the risk of developing rheumatoid arthritis in antihypertensive drug users

PURPOSE

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are effective in the treatment of cardiovascular disease. Next to effects on hypertension and cardiac function, these drugs have anti-inflammatory and immunomodulating properties which may either facilitate or protect against the development of autoimmunity, potentially resulting in autoimmune diseases. Therefore, we determined in the current study the association between ACE inhibitor and ARB use and incident rheumatoid arthritis (RA).

METHODS

A matched case-control study was conducted among patients treated with antihypertensive drugs using the Netherlands Information Network of General Practice (LINH) database in 2001-2006. Cases were patients with a first-time diagnosis of RA. Each case was matched to five controls for age, sex, and index date, which was selected 1 year before the first diagnosis of RA. ACE inhibitor and ARB exposure was considered to be any prescription issued in the period before index date. Logistic regression analysis was used to estimate odds ratios (ORs) and their 95% confidence intervals (CI).

RESULTS

Our study included 211 cases and 667 matched controls. After controlling for potential confounders, ever use of ACE inhibitors or ARBs was not associated with incident RA (adjusted ORs [95%CI], 0.99 [0.55-1.79] and 1.02 [0.67-1.56], respectively). The adjusted ORs (95%CI) for current and past use of ACE inhibitors were 1.18 (0.75-1.85) and 0.61 (0.28-1.35). For current and past use of ARBs, these adjusted ORs (95%CI) were 1.40 (0.80-2.45) and 0.29 (0.05-1.67), respectively. No duration and dose-effect relationship was observed.

CONCLUSIONS

ACE inhibitor or ARB use is not associated with incident RA.

The neumann type of pemphigus vegetans treated with combination of dapsone and steroid

Pemphigus vegetans is a rare variant of pemphigus vulgaris and is characterized by vegetating lesions in the inguinal folds and mouth and by the presence of autoantibodies against desmoglein 3. Two clinical subtypes of pemphigus vegetans exist, which are initially characterized by flaccid bullae and erosions (the Neumann subtype) or pustules (the Hallopeau subtype). Both subtypes subsequently develop into hyperpigmented vegetative plaques with pustules and hypertrophic granulation tissue at the periphery of the lesions. Oral administration of corticosteroids alone does not always induce disease remission in patients with pemphigus vegetans. We report here on a 63-year-old woman with pemphigs vegetans. She had a 2-year history of vegetating, papillomatous plaques on the inguinal folds and erosions of the oral mucosa. The enzyme-linked immunosorbent assay was positive for anti-desmoglein 3, but it was negative for anti-desmoglein 1. She was initially treated with systemic steroid, but no improvement was observed. The patient was then successfully treated with a combination of systemic steroid and dapsone with a good clinical response.

Indapamide-induced pemphigus foliaceus

A variety of drugs have been implicated to induce or trigger pemphigus. A case of pemphigus foliaceus that was probably caused by indapamide, in whom the diagnosis was based on clinical, histologic and direct immunofluorescence testing, is reported here. To the best of the authors' knowledge, this is the first reported patient with indapamide-induced pemphigus.

Pemphigus vegetans of the oral cavity

BACKGROUND

Pemphigus vegetans, a variant of pemphigus vulgaris, constitutes a rare form of all pemphigus cases, and oral involvement is common. Two clinical subtypes of pemphigus vegetans exist, characterized initially by flaccid bullae and erosions (Neumann) or pustules (Hallopeau). Both subtypes subsequently develop into hyperpigmented vegetative plaques with pustules and hypertrophic granulation tissue at the periphery.

METHODS

We report three cases of pemphigus vegetans with oral manifestations exclusively. Two patients were male aged 30 and 45 years old, respectively, while one was a 51-year-old female.

CONCLUSION

Oral lesions in all cases consisted of erosions and whitish, vegetating plaques. The histopathological characteristics were in all cases identical. The spinous cell layer was characterized by intense acanthosis and by the presence of vesicles between the spinous and basal cell layers. Inside the vesicles exudative elements were observed consisting mainly of eosinophils. In the upper lamina propria severe inflammatory reaction was observed. Streptavidin-biotin immunoperoxidase technique showed in all cases intercellular epithelial deposition of IgG and C3.

Pemphigus vegetans occurring in a split-thickness skin graft

BACKGROUND

Pemphigus vegetans, a variant of pemphigus vulgaris, most commonly occurs in the flexural area.

OBJECTIVE

To describe an unusual case of pemphigus vegetans occurring in a skin graft recipient site and to discuss the possible etiology.

METHODS

We present a 41-year-old man who developed vegetating plaques from the graft recipient site of his left leg for 8 months.

RESULTS

Based on the histopathologic findings of a skin biopsy, this case was diagnosed as pemphigus vegetans. The patient's condition was successfully treated with systemic corticosteroids and acitretin.

CONCLUSION

Our case is unique in its presentation of pemphigus vegetans shortly after a split-thickness skin graft. Physicians should be aware of this entity while differentiating cutaneous lesions arising from a skin graft.

[Inguinal pseudotumor: relapse of a pemphigus after 15 years' remission]

INTRODUCTION

Pemphigus vegetans (PV) is a rare type of pemphigus vulgaris. We report a patient with pemphigus vulgaris relapsing as an isolated vegetative tumour.

CASE REPORT

A 59-year-old man was seen in February 2001 for a tumour on the right groin. He had received systemic corticosteroids and cyclophosphamide for pemphigus vulgaris from 1974 to 1985, and he had been in complete remission since 1985. At the time of evaluation, a 10 x 5 x 5 cm, smooth vegetative tumour was seen on the right groin. Biopsies showed spongiosis, acanthosis and some acantholysis. Direct immunofluorescence showed strong deposition of immunoglobulin G within the intercellular substance of the epidermis. Indirect immunofluorescence revealed anti-intercellular antibodies at a titer of 1/800. Immunoblot analysis showed reactivity with the 130 kD pemphigus vulgaris antigen. PVg was diagnosed. Local corticosteroid treatment was initiated. The patient was disease-free at follow-up three years later.

DISCUSSION

Localised forms of pemphigus are very rare. Twenty four other cases have been reported among them just one case of localised PV. Our case report is very unusual because of the variability of the expression of the disease, the high antibody level, the absence of trigger factors, and the efficacy of the local corticosteroid treatment.

Mechanisms in cutaneous drug hypersensitivity reactions

Up to 3% of all hospital admissions are due to adverse drug reactions (ADRs), and between 10% and 20% of hospital inpatients develop ADRs. Individual susceptibility to becoming 'sensitized' or allergic to a drug is thought to result from altered metabolic handling of the drug. Reactive intermediate compounds form haptens, bind to proteins and induce immune responses. Depending on whether the immune system generates antibodies or sensitized T cells, different clinical patterns of hypersensitivity may result. At present, both in vivo or in vitro tests to identify the culprit drug or to confirm the presence of hypersensitivity are not widely used because they are either not generally robust or not readily accessible. In vitro tests require the true immunogen/antigen to detect antibodies or sensitized T cells. As the metabolic basis underlying susceptibility to adverse drug reactions is elucidated, the resolution of immunological mechanisms and development of reliable tests will ensue. This will also become of great value for prediction of individuals at risk of becoming sensitized by a particular drug.

Adverse dermatologic effects of cardiovascular drug therapy: part II

Cardiovascular disease is common, affecting an increasing number of persons as the population ages. To combat this growing health problem, physicians use a multitude of medications in the treatment of their patients. Although pharmacologic therapy greatly enhances quality of life for a majority of patients, there is always the potential for an unfavorable reaction. For example, cardiovascular drugs can induce a vast array of adverse dermatologic responses. This article reviews the various cutaneous reaction patterns that can occur as a result of treatment with class III, IV, and other antiarrhythmic agents, ACE inhibitors, Angiotensin II receptor blockers, and diuretics.

Drug-related pemphigus and angiotensin converting enzyme inhibitors

A 105-year-old woman developed pemphigus foliaceus. She had been on fosinopril, an angiotensin-converting enzyme inhibitor (ACE inhibitor) for 4 years. Anti-intercellular cement substance antibodies were positive with titre > 160. She died during admission of an unrelated illness. A 57-year-old man developed pemphigus vulgaris after 11 months treatment with quinapril. At 14 months after developing pemphigus, this man continues on prednisone and azathioprine. We speculate that these are cases of ACE-inhibitor-related pemphigus and we review ACE-inhibitor-related pemphigus.

The ultrastructural findings of Charcot-Leyden crystals in stroma of mastocytoma

Charcot-Leyden crystals (CLCs) have been found in many conditions associated with eosinophilia, but their occurrence in skin diseases is very rare. We report ultrastructural observations on the presence of CLCs in the cutaneous lesions of two cases of mastocytoma. Electron microscopy documented CLCs located in phagosomes of morphologically activated macrophages as well as free CLCs in the stromal tissue, close association between CLCs formation and damaged and lysed eosinophils was present. These findings provided evidence that the formation of CLCs in mastocytoma implicated the individual and interrelated biology of mast cells, eosinophils and macrophages. Phagosomes probably acted as the site of CLCs formation. The clinic and pathologic role of CLCs in mastocytoma deserves further investigation.

Angiotensin-converting enzyme inhibitor-induced pemphigus: three case reports and literature review

OBJECTIVE

To identify patients examined in the Mayo Clinic Department of Dermatology whose pemphigus was attributable to an angiotensin-converting enzyme inhibitor and to compare these cases with previously reported cases of drug-induced pemphigus.

RESULTS

A retrospective review of medical records revealed two cases of captopril-induced pemphigus and one of enalapril-induced pemphigus. Our patients had substantially increased circulating IgG autoantibodies to intercellular substance, as detected on monkey esophagus substrate.

CONCLUSION

Our findings contrast those of other reports of drug-induced pemphigus in which circulating autoantibodies are implied to be low or absent.

Captopril-induced lichenoid eruption

The case of a patient who developed remarkably extensive tumid nodules and plaques in a cobblestone pattern on the extensor aspects of the limbs is reported as a late presentation of captopril-induced lichenoid eruption. The severity and chronicity of our patient's symptoms and signs reflected delay in reaching the diagnosis.

Three cases of pemphigus vegetans: induction by enalapril--association with internal malignancy

BACKGROUND

Pemphigus vegetans, a rare form of pemphigus vulgaris, consists of vegetating plaques localized to flexural areas. Two types, the Neumann and the Hallopeau type, are recognized with their own characteristics.

METHODS

Three patients with pemphigus vegetans were examined, two with Hallopeau type and one with Neumann type. The microscopic and immunofluorescence findings were recorded.

RESULTS

Two remarkable features were present. In one case pemphigus vegetans was possibly induced by the use of enalapril. Only in three previous cases has enalapril been described in relation to pemphigus. A second case was associated with a malignant lung tumor, a phenomenon which could not be traced in the literature.

CONCLUSIONS

Two types of pemphigus vegetans must be distinguished. Induction of pemphigus (also vegetans) is an accepted side effect of captopril. The effect of enalapril on pemphigus is still in debate. To the best of our knowledge, this is the first time that a patient with pemphigus vegetans and a simultaneously occurring internal malignancy is described.