Clinical evaluation and management of drug hypersensitivity

Erythema multiform-like lesions in a patient infected with SARS-CoV-2: a case report

Background: SARS-CoV-2, is followed by several manifestations, such as fever, cough, respiratory distress syndrome and mucocutaneous lesions such as papules, urticaria, vasculitic purpura and erythema multiform. Case: A 22-year old woman was diagnosed with COVID-19. Considering the skin and oral lesions, erythema multiform was suggested as the most likely diagnosis. Oral valaciclovir was administered. Discussion: Erythema multiforme were reported in some patients with COVID-19. Its pathophysiology is not yet completely understood, but it seems there is a lymphocyte-mediated hypersensitivity reaction to SARS-CoV-2 antigens presenting in the skin. Conclusion: Mucocutaneous and oral lesions might be the first manifestations of COVID-19. Therefore, during the pandemic, it is prudent to consider this virus as a differential diagnosis once we encounter oral ulceration.

We reported a 22-year old woman admitted to the hospital complaining of fever, abdominal pain, nausea and occasional vomiting that started about a week prior. According to the CT scan and real-time reverse transcription polymerase chain reaction (rRT-PCR), the patient was diagnosed with COVID-19. Oral examination by an oral medicine specialist revealed extensive ulcers in the mouth and crusts on the lips and she was diagnosed with erythema multiform. Oral valaciclovir was prescribed for 5 days and oral lesions relatively disappeared after 6 days. The pathophysiology of lesions is not yet completely understood, but it seems there is a hypersensitivity reaction to SARS-CoV-2 antigens presenting in the skin. SARS-CoV-2 could travel to other tissues such as skin, and make alterations to the cutaneous immune system, resulting in various manifestations on the skin.

Stevens Johnson Syndrome – “Steven Who? And Why I Should Care About His Johnson?”

Diagnosing rashes in the emergency department can be challenging. If the rash is extensive and targetoid, include Stevens-Johnson Syndrome (SJS) on your differential and be sure to obtain a thorough history to identify possible offending agents. Additionally, prioritize supportive care and obtaining a dermatology/burn consult to coordinate appropriate care.

An unexpected rash with gastroenteritis: erythema multiforme associated with campylobacter infection

We present the first documented case of erythema multiforme following campylobacter gastroenteritis.

Management of Psychotropic Drug-Induced DRESS Syndrome: A Systematic Review

Drug rash with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous eruption that has been linked to several common drugs and drug categories, including antiepileptics, allopurinol, sulfonamides, and various antibiotics; however, because of a number of recent case reports linking psychotropic medications to this condition, DRESS is increasingly recognized among psychiatrists. We systematically reviewed all psychotropic drugs linked to DRESS syndrome, and this article summarizes the clinical management relevant to psychiatric professionals. A comprehensive search was performed using Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus, and Litt's Drug Eruption and Reaction Database for articles published in English during the past 20 years (1996-2015) using the search terms (1) psychotropic drugs OR serotonin uptake inhibitors AND DRESS or (2) psychotropic drugs AND drug reaction (or rash) eosinophilia systemic syndrome, and all article abstracts were screened for inclusion and exclusion criteria by 3 reviewers. Two independent reviewers examined the full text of 163 articles, of which 96 (25 original articles, 12 review articles, 55 case reports, and 4 letters to the editor) were included in the systematic review. We identified 1072 cases of psychotropic drug-induced DRESS, with carbamazepine, lamotrigine, phenytoin, valproate, and phenobarbital being the most implicated drugs. Based on our review of the literature, we outline management principles that include prompt withdrawal of the causative drug, hospitalization, corticosteroid therapy, and novel treatments, including intravenous immunoglobulin, cyclophosphamide, and cyclosporine, for corticosteroid-resistant DRESS. Finally, we outline strategies for treating comorbid psychiatric illness after a DRESS reaction to the psychotropic medication.

Immediate and non-immediate allergic reactions to amoxicillin present a diagnostic dilemma: a case series

Background

Allergic reactions to amoxicillin are very common occurrences in the pediatric age group; however, onset of symptoms can present a diagnostic dilemma.

Case presentation

We present a case series that describes three children (8-year-old white girl, 2-year-old white boy and 14-month-old Chinese boy) who presented with varied onset of allergic reactions to amoxicillin, specifically immediate (within the first hour after exposure) and non-immediate onset. One child developed immediate onset allergy to oral challenge with amoxicillin although his clinical history was evident for non-immediate onset allergy to amoxicillin. He was the only case that had a positive skin test to penicillin. Two other children presented with reactions toward the end of their treatment course of amoxicillin, yet one patient developed immediate onset allergy while the other patient developed non-immediate onset allergy after challenge.

Conclusions

This case series demonstrates diagnostic challenges facing physicians assessing allergic reactions to amoxicillin. As onset of reactions can dictate severity and pathogenic type of allergy, a thorough clinical history and subsequent appropriate diagnostic testing including medication challenge can help establish the diagnosis.

Dapsone hypersensitivity syndrome-related lung injury without eosinophilia in the bronchoalveolar lavage fluid

A 73-year-old man was admitted in respiratory failure that had subacutely progressed after five weeks of dapsone treatment for a skin rash. He also presented with fever, systemic erythroderma and liver dysfunction. Chest computed tomography showed diffuse reticular shadows with ground-glass opacity and bilateral mediastinal lymphadenopathy. Lymphocytes, but not eosinophils, were increased in the bronchoalveolar lavage fluid. Moreover, reactivation of human herpes virus-6 was confirmed on a paired serum test. Finally, we diagnosed the patient with dapsone hypersensitivity syndrome (DHS), a rare adverse event of this drug. Lung injury unaccompanied by eosinophilia in the bronchoalveolar lavage fluid is even more rare as a DHS-related lung manifestation.

Drug induced erythema multiforme: two case series with review of literature

Erythema Multiforme, (EM) an uncommon, acute inflammatory reactive mucocutaneous disorder and primary allergies confined to the oral mucosa. However the subsequent attacks can produce more severe forms of EM involving the skin. Manifestations of EM are varied and present a diagnostic dilemma because infections (particularly herpes simplex and mycoplasma pneumoniae) and drugs seem to predispose towards development of EM. We report two cases of EM in which drugs (Dioclofenac sodium & Amoxycilline) seems to be precipitating factor. In addition, the article reviews various aspects of EM as relevant to dental practice and highlight the associated potential etiologic agents, pathogenic mechanisms and therapies.

Drug induced erythema multiforme: two case series with review of literature

Erythema Multiforme, (EM) an uncommon, acute inflammatory reactive mucocutaneous disorder and primary allergies confined to the oral mucosa. However the subsequent attacks can produce more severe forms of EM involving the skin. Manifestations of EM are varied and present a diagnostic dilemma because infections (particularly herpes simplex and mycoplasma pneumoniae) and drugs seem to predispose towards development of EM. We report two cases of EM in which drugs (Dioclofenac sodium & Amoxycilline) seems to be precipitating factor. In addition, the article reviews various aspects of EM as relevant to dental practice and highlight the associated potential etiologic agents, pathogenic mechanisms and therapies.

Effect of the amino chain length and the transformation into citric acid salts of aryl-diphenyl-butenes and ferrocenyl-diphenyl-butenes bearing two dimethylaminoalkyl chains on their antimicrobial activities

In a previous work we have demonstrated the antimicrobial activity of ferrocenyl or phenyl derivatives of diphenyl butene series. This finding has opened a new area of applications of organometallic compounds.

In order to improve these activities, we have synthesized new organic and organometallic diaryl butene compounds with different lengths of their amino chains. These new compounds, and also their ammonium salts, were tested against man pathogenic microorganisms Escherichia coli (ATCC 10536), Pseudomonas aeruginosa (ATCC 15442), Staphylococcus aureus (ATCC 6538) and Enterococcus hirae (ATCC 10541).

It emerged from the tests that the Gram+ bacteria are more sensitive to the compounds than Gram-, and the compounds with 3 carbon amino chains have a better antimicrobial activity than the one having a chain of 2 or 4 carbons.

The transformation of compounds to citrate salts was accompanied by a significant regression of antibacterial activity against Pseudomonas aeruginosa, for both organic and ferrocenic molecules. This resistance problem has been solved using hydrochlorides salts rather than citrates one.

Best practices in multiple sclerosis: infusion reactions versus hypersensitivity associated with biologic therapies

Infusion nurses are uniquely positioned to play a vital role in the early identification and management of infusion and hypersensitivity reactions during the administration of biologic therapies. This article reviews the current evidence regarding reactions related to the administration of monoclonal antibodies, namely, natalizumab, a humanized monoclonal antibody against the cellular adhesion molecule alpha4-integrin, in patients with multiple sclerosis. In addition to differentiating between infusion and hypersensitivity reactions, the article presents general guidelines for the management of these reactions and provides case studies to better illustrate the use of appropriate interventions.

Erythema multiforme associated with gemfibrozil monotherapy

BACKGROUND

A case of erythema multiforme associated with gemfibrozil monotherapy.

METHODS AND RESULTS

A 46-year-old man with hyperlipidemia was treated with 600 mg gemfibrozil twice a day. On the fifth day of treatment, skin lesions consistent with erythema multiforme appeared. With the discontinuation of the treatment and start of a topical steroid treatment, the lesions recovered after 4 weeks. After 6 months, when gemfibrozil therapy was restarted, lesions reappeared on the fourth day of therapy. Lesions recovered again following the previous treatment strategies after 4 weeks. An objective casualty assessment suggests that erythema multiforme was probably related to gemfibrozil monotherapy.

CONCLUSION

Patients starting gemfibrozil therapy should be warned about the occurrence of erythema multiforme in addition to previous reported and established side effects.

Recurrent erythema multiforme after alcohol ingestion in a patient receiving ciprofloxacin: a case report

The incidence of cutaneous adverse reactions to quinolones is low; moreover their development in patients with concomitant alcohol consumption is a phenomenon that has been scarcely reported. We present a case of 46-year-old male who developed erythema multiforme after ingestion of alcohol, while being treated with ciprofloxacin. The lesion was self-limiting and abstinence from alcohol permitted the completion of the course of therapy without any other adverse reaction.

The Dapsone hypersensitivity syndrome revisited: a potentially fatal multisystem disorder with prominent hepatopulmonary manifestations

4,4'-Diaminodiphenylsulphone (Dapsone) is widely used for a variety of infectious, immune and hypersensitivity disorders, with indications ranging from Hansen's disease, inflammatory disease and insect bites, all of which may be seen as manifestations in certain occupational diseases. However, the use of dapsone may be associated with a plethora of adverse effects, some of which may involve the pulmonary parenchyma. Methemoglobinemia with resultant cyanosis, bone marrow aplasia and/or hemolytic anemia, peripheral neuropathy and the potentially fatal dapsone hypersensitivity syndrome (DHS), the focus of this review, may all occur individually or in combination. DHS typically presents with a triad of fever, skin eruption, and internal organ (lung, liver, neurological and other systems) involvement, occurring several weeks to as late as 6 months after the initial administration of the drug. In this sense, it may resemble a DRESS syndrome (Drug Rash with Eosinophilia and Systemic Symptoms). DHS must be promptly identified, as untreated, the disorder could be fatal. Moreover, the pulmonary/systemic manifestations may be mistaken for other disorders. Eosinophilic infiltrates, pneumonitis, pleural effusions and interstitial lung disease may be seen. This syndrome is best approached with the immediate discontinuation of the offending drug and prompt administration of oral or intravenous glucocorticoids. An immunological-inflammatory basis of the syndrome can be envisaged, based on the pathological picture and excellent response to antiinflammatory therapy. Since dapsone is used for various indications, physicians from all specialties may encounter DHS and need to familiarize themselves with the salient features about the syndrome and its management.

Immediate-type allergy to drugs and related compounds: evaluation and management

Adverse drug reactions (ADR) constitute a major health issue in outpatient and inpatient clinical settings. An allergic drug reaction is an immunologically mediated adverse drug reaction that exhibits specificity and recurrence on re-exposure to the offending and/or cross-reactive compound(s). Diagnosis of drug allergy is difficult, as a broad spectrum of different drugs can elicit various immune-mediated diseases with distinct (sometimes unclear) pathomechanism, the exact structure (epitope) that causes the reaction is frequently unknown, the presence of an in vitro or in vivo test results might not be predictive of a clinical situation, and the gold standard or reference test for diagnosis, the drug challenge, is a complicated and sometimes dangerous endeavour. Nevertheless, during the past few years serious attempts have been made to standardise and validate in vitro and in vivo techniques for the diagnosis of drug allergy. New techniques, e.g. flow-assisted analysis of in vitro basophil activation, are replacing older ones like histamine release for immediate-type hypersensitivity reactions. However, additional comprehensive studies are required to further validate the technique and allow its entrance in mainstream diagnostic use, particularly for non-IgE-mediated hypersensitivity. This review attempts to summarize the major causes of immediate hypersensitivity reactions to drugs and related compounds. Special attention is paid to the diagnostic and therapeutic management of this common iatrogenic complication.

Review article: Acute serious and fatal reactions to contrast media: our current understanding

Serious or fatal reactions to a contrast medium (CM) are unpredictable but fortunately rare. History of serious reaction to CM, bronchial asthma or multiple allergies increases the incidence of serious reactions by a factor of 5. Serious or fatal reaction to CM could be due to direct effect on basophils and mast cells or IgE mediated (type 1 hypersensitivity reaction). Activation of the kinin system leading to the formation of bradykinin could also be involved. Complement activation is unlikely to be a primary factor in initiating a serious reaction to CM. Avoiding CM administration in patients at high risk of serious reaction is advisable, but if the administration is deemed essential all precautions should be implemented and measures to treat serious reactions should be readily available. Oxygen supplementation, intravenous administration of physiological fluids and intramuscular injection of 0.5 ml adrenalin (1:1000) should be considered in the first line management of acute anaphylaxis. The ability to assess and treat serious CM reaction effectively is an essential skill that the radiologist should have and maintain.

New Antifungal as a Potential Cause of Severe Thrombocytopenia: Pancreatitis Due to ACE Inhibitor: Recurrent Hepatitis Due to Cetirizine: Long-Term Cardiovascular Risks Associated with Protease Inhibitors: Pure Red Cell Aplasia and Epoetin Therapy: Pure Red Cell Aplasia Redux: Interferon Therapy: Excellent Drug Reaction Reviews

The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), to discuss methods of prevention, and to promote reporting of ADRs to the FDA's medWatch program (800-FDA-1088). If you have reported an interesting preventable ADR to medWatch, please consider sharing the account with our readers.

In 2004, ISMP is celebrating the 10th anniversary of its incorporation as a nonprofit organization. The Institute represents more than 20 years of experience in helping health care practitioners keep patients safe and continues to lead efforts to improve the medication use process.