1
|
Longobardi SA, Alkowati H, Kang G, Slade C, Oyesanmi O. Ibuprofen-Induced Pancytopenia and Erythema Multiforme in an Elderly Female Patient. Cureus 2024; 16:e62785. [PMID: 39036150 PMCID: PMC11260218 DOI: 10.7759/cureus.62785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2024] [Indexed: 07/23/2024] Open
Abstract
Erythema multiforme (EM) is a delayed, cell-mediated cutaneous disease with varying clinical manifestations. It is most commonly associated with infections but can also be associated with medications, vaccines, and autoimmune diseases. Non-steroidal anti-inflammatory Drugs (NSAIDs) are commonly used analgesics that have rare associations with EM and pancytopenia. These adverse reactions to NSAIDs can obscure definitive diagnosis due to their rarity. We present a case where an elderly female patient taking 600mg of ibuprofen up to four times a day for shoulder bursitis developed EM and pancytopenia. In this case, a 75-year-old female with a medical history of atrial fibrillation, essential hypertension, non-insulin-dependent type 2 diabetes mellitus, and ischemic stroke with residual right-sided visual impairment presented to our Emergency Department in 2023 with neck swelling, skin rash, and ulceration of the oral cavity. She reported a generalized, targetoid body rash that occurred 15 days after she started taking ibuprofen regularly for left shoulder bursitis. No other medications were started before, after, or during this time period. CBC on admission was remarkable for a white blood cell count of 1.5x109/L, hemoglobin of 6.5 g/dL, and platelet count <10x109/L, consistent with pancytopenia. Ibuprofen was discontinued, and the patient was treated supportively with analgesia and packed red blood cell transfusions. Testing for HIV, antinuclear antibodies (ANA) panel, Hepatitis panel, and copper and zinc levels were negative. A biopsy of a targetoid lesion on the skin showed changes consistent with EM. Esophagogastroduodenoscopy revealed no actively bleeding lesions or ulcers in the stomach mucosa. The patient's blood counts eventually recovered with supportive treatment, and symptomatology improved. The patient was discharged six days after admission. Healthcare professionals should be aware of rare hematologic and immunologic side effects of NSAIDs, which may often be overlooked and misdiagnosed. More studies are needed to build on our wealth of knowledge regarding the etiology and management of EM, Steven Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN).
Collapse
Affiliation(s)
- Stefan A Longobardi
- Internal Medicine, Hospital Corporation of America (HCA) Florida Blake Hospital, Bradenton, USA
| | - Hamza Alkowati
- Internal Medicine, Hospital Corporation of America (HCA) Florida Blake Hospital, Bradenton, USA
| | - Grace Kang
- Internal Medicine, Hospital Corporation of America (HCA) Florida Blake Hospital, Bradenton, USA
| | - Cole Slade
- Internal Medicine, Hospital Corporation of America (HCA) Florida Blake Hospital, Bradenton, USA
| | - Olu Oyesanmi
- Internal Medicine, Hospital Corporation of America (HCA) Healthcare Oak Hill Hospital, Brooksville, USA
| |
Collapse
|
2
|
Murphy MJ, Gruenstein D, Wang A, Peterson D, Levitt J, King B, Damsky W. Treatment of Persistent Erythema Multiforme With Janus Kinase Inhibition and the Role of Interferon Gamma and Interleukin 15 in Its Pathogenesis. JAMA Dermatol 2021; 157:1477-1482. [PMID: 34757416 PMCID: PMC8581795 DOI: 10.1001/jamadermatol.2021.4084] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/06/2021] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Persistent erythema multiforme (PEM) is poorly understood and lacks effective therapies other than glucocorticoids. OBJECTIVE To report outcomes following treatment of PEM with Janus kinase (JAK) inhibition and to elucidate cytokine drivers of erythema multiforme (EM). DESIGN, SETTING, AND PARTICIPANTS This was a retrospective case series of 4 patients with PEM treated with tofacitinib and/or upadacitinib in 2015 to 2021 at the dermatology clinics of 2 major tertiary referral centers. Four consecutive patients with PEM refractory to multiple treatment approaches were treated. In 1 patient, skin biopsy specimens were obtained for RNA sequencing and proteomic analysis before and during treatment. Molecular findings were validated through RNA in situ hybridization analysis of cytokine expression in biopsy specimens from a total of 12 patients with EM (3 treated with tofacitinib in this study and 9 historic samples). INTERVENTIONS Treatment with tofacitinib, 5 to 10 mg, twice daily or upadacitinib, 15 mg, once daily. MAIN OUTCOMES AND MEASURES Change in PEM activity was assessed in all 4 patients treated with a JAK inhibitor. Median (range) follow-up was 20.5 months (10.0-36.0 mo). RESULTS The study population of 4 female patients had a mean (SD) age of 46.2 (13.7) years and a mean (SD) disease duration of 21.75 (11.30) years. Marked clinical improvement was noted in all 4 patients. In 1 patient with a robust improvement following treatment with tofacitinib, RNA sequencing identified interferon gamma (IFN-γ) and interleukin 15 (IL-15) as cytokines with activity both highly upregulated at baseline in lesional skin and subsequently suppressed following tofacitinib treatment. Measurement of IFNG- and IL15-positive cells in additional EM biopsy specimens of 12 patients showed significant upregulation of IFNG (8.72 cells per mm; 95% CI, 2.60-14.84) and IL15 (14.13 cells per mm; 95% CI, 0.14-28.11) compared with normal skin (P = .008 and P = .045, respectively). CONCLUSIONS AND RELEVANCE The results of this case series study suggest that JAK inhibition may be effective in treating PEM and that IFN-γ and IL-15 may be important cytokine mediators of the disease.
Collapse
Affiliation(s)
- Michael J. Murphy
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Diana Gruenstein
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alice Wang
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Danielle Peterson
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jacob Levitt
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brett King
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, Yale University, New Haven, Connecticut
| |
Collapse
|
3
|
Dominguez AR, Lopez SN. Novel Treatments for Chronic Erythema Multiforme Inform Translational Science and Disease Pathogenesis. JAMA Dermatol 2021; 157:1411-1413. [PMID: 34757395 DOI: 10.1001/jamadermatol.2021.4082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Arturo R Dominguez
- Departments of Dermatology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas
| | - Samantha N Lopez
- University of Texas Southwestern Medical School, The University of Texas Southwestern Medical Center, Dallas
| |
Collapse
|
4
|
Herpes Simplex Associated Erythema Multiforme: A Case Report and Review of the Literature. ACTA MEDICA BULGARICA 2021. [DOI: 10.2478/amb-2021-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Erythema multiforme (EM) is an acute immune-mediated disease with multifactor etiology, which presents with symmetric target-like lesions on the skin. Probably the most common etiological factor of EM is viral infections, particularly herpes simplex virus (HSV). Herpes-associated erythema multiforme (HAEM) is an acute exudative dermatosis, caused mostly by HSV-1 and much rarely by HSV-2. A 44-year-old female patient with herpes associated erythema multiforme was consulted with initial appearance of typical target lesions on the dorsal surface of both hands, after long history of labial herpes episodes. The diagnostic algorithm included routine laboratory tests, histological examination and serologic test for HSV-1 and 2. Our first choice of treatment was acyclovir 5 x 200 mg/24 h and dexamethasone 4 mg/24 h, however due to increased anxiety and tachycardia reported by patient the corticosteroid therapy was discontinued and promethazine was initiated. The patient responded well to the therapeutic regimen and at the follow-up visit was in clinical remission. In conclusion, the diagnosis of HAEM is mainly clinical, when the patient develops target lesions and coexisting HSV infection is detected.
Collapse
|
5
|
Soares A, Sokumbi O. Recent Updates in the Treatment of Erythema Multiforme. MEDICINA-LITHUANIA 2021; 57:medicina57090921. [PMID: 34577844 PMCID: PMC8467974 DOI: 10.3390/medicina57090921] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/23/2021] [Accepted: 08/27/2021] [Indexed: 02/07/2023]
Abstract
Erythema multiforme (EM) is an immune-mediated condition that classically presents with discrete targetoid lesions and can involve both mucosal and cutaneous sites. While EM is typically preceded by viral infections, most notably herpes simplex virus (HSV), and certain medications, a large portion of cases are due to an unidentifiable cause. EM can be confused with other more serious conditions like Stevens–Johnson syndrome (SJS); however, clinical research has provided significant evidence to classify EM and SJS as separate disorders. Treatment of EM is highly variable, depending on the etiology, the involvement of mucosal sites, and the chronicity (acute vs. recurring) of the disease. If the etiology or causal medication/infection is identified, then the medication is stopped and/or the infection is treated prior to initiating symptomatic treatment. Treatment for acute EM is focused on relieving symptoms with topical steroids or antihistamines. Treatment for recurrent EM is most successful when tailored to individual patients. First line treatment for recurrent EM includes both systemic and topical therapies. Systemic therapies include corticosteroid therapy and antiviral prophylaxis. Topical therapies include high-potency corticosteroids, and antiseptic or anesthetic solutions for mucosal involvement. Second-line therapies for patients who do not respond to antiviral medications include immunosuppressive agents, antibiotics, anthelmintics, and antimalarials
Collapse
Affiliation(s)
- Alexa Soares
- Mayo Clinic Alix School of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA;
| | - Olayemi Sokumbi
- Department of Dermatology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA
- Correspondence: ; Tel.: +1-904-953-6402
| |
Collapse
|
6
|
Dias de Oliveira NF, Miyamoto D, Maruta CW, Aoki V, Santi CG. Recurrent erythema multiforme: A therapeutic proposal for a chronic disease. J Dermatol 2021; 48:1569-1573. [PMID: 34223646 DOI: 10.1111/1346-8138.16046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/26/2021] [Accepted: 06/05/2021] [Indexed: 11/28/2022]
Abstract
Recurrent erythema multiforme is a chronic relapsing disease that represents a therapeutic challenge. Our objective was to retrospectively evaluate the clinical-epidemiological characteristics and therapeutic response of patients with recurrent erythema multiforme and suggest a therapeutic protocol. We included patients with recurrent erythema multiforme diagnosed between January 2000 and December 2019. Clinical symptoms and a positive serology for herpes simplex virus were the inclusion criteria to initiate acyclovir in monotherapy or a combined treatment with dapsone, thalidomide, or immunosuppressants in refractory cases. Thirty-five patients were included and 71.4% were female. The median disease onset age was 35.7 years and the mean follow-up was 7.58 years. The skin was the most affected site (91.4%). Herpes simplex virus immunoglobulin (Ig)G serology was positive in 91.1% of cases. Acyclovir treatment was used in 33 of 35 patients, and complete remission was achieved in 22 of 33 after the first therapeutic course; 16 of 22 relapsed and required a second acyclovir cycle. Combined treatment with dapsone was required in nine of 33 due to partial response to acyclovir; thalidomide was an adjuvant drug in four of 33 due to adverse effects to dapsone. After the first cycle of acyclovir with or without combined therapy, 19 of 33 patients relapsed and received 2-6 additional cycles. Our results suggest that recurrent erythema multiforme presents a good response to acyclovir in monotherapy or in combined therapy with dapsone or thalidomide in the majority of patients. We propose a long-term therapeutic protocol to enable disease remission.
Collapse
Affiliation(s)
| | - Denise Miyamoto
- Department of Dermatology, University of São Paulo Medical School, Sao Paulo, Brazil
| | | | - Valeria Aoki
- Department of Dermatology, University of São Paulo Medical School, Sao Paulo, Brazil
| | - Claudia Giuli Santi
- Department of Dermatology, University of São Paulo Medical School, Sao Paulo, Brazil
| |
Collapse
|
7
|
Du Y, Wang F, Liu T, Jin X, Zhao H, Chen Q, Zeng X. Recurrent oral erythema multiforme: a case series report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 129:e224-e229. [DOI: 10.1016/j.oooo.2019.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/16/2019] [Accepted: 11/19/2019] [Indexed: 12/29/2022]
|
8
|
Adverse Cutaneous Reactions of Common Biologic Medications for Rheumatic Diseases. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00129-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
9
|
Liu RF, Chen CB, Hui RC, Kuan YZ, Chung WH. The effect of levamisole in the treatment of recalcitrant recurrent erythema multiforme major: An observational study. J Dermatol Sci 2018; 92:38-44. [DOI: 10.1016/j.jdermsci.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/25/2018] [Accepted: 08/05/2018] [Indexed: 01/12/2023]
|
10
|
Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Current Perspectives on Erythema Multiforme. Clin Rev Allergy Immunol 2018; 54:177-184. [PMID: 29352387 DOI: 10.1007/s12016-017-8667-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Recognition and timely adequate treatment of erythema multiforme remain a major challenge. In this review, current diagnostic guidelines, potential pitfalls, and modern/novel treatment options are summarized with the aim to help clinicians with diagnostic and therapeutic decision-making. The diagnosis of erythema multiforme, that has an acute, self-limiting course, is based on its typical clinical picture of targetoid erythematous lesions with predominant acral localization as well as histological findings. Clinically, erythema multiforme can be differentiated into isolated cutaneous and combined mucocutaneous forms. Atypical erythema multiforme manifestations include lichenoid or granulomatous lesions as well as lesional infiltrates of T cell lymphoma and histiocytes. Herpes simplex virus infection being the most common cause, other infectious agents like-especially in children-Mycoplasma pneumoniae, hepatitis C virus, Coxsackie virus, and Epstein Barr virus may also trigger erythema multiforme. The second most frequently identified cause of erythema multiforme is drugs. In different studies, e.g., allopurinol, phenobarbital, phenytoin, valproic acid, antibacterial sulfonamides, penicillins, erythromycin, nitrofurantoin, tetracyclines, chlormezanone, acetylsalicylic acid, statins, as well as different TNF-α inhibitors such as adalimumab, infliximab, and etanercept were reported as possible implicated drugs. Recently, cases of erythema multiforme associated with vaccination, immunotherapy for melanoma, and even with topical drugs like imiquimod have been described. In patients with recurrent herpes simplex virus-associated erythema multiforme, the topical prophylactic treatment with acyclovir does not seem to prevent further episodes of erythema multiforme. In case of resistance to one virostatic drug, the switch to an alternative drug, and in patients non-responsive to virostatic agents, the use of dapsone as well as new treatment options, e.g., JAK-inhibitors or apremilast, might be considered.
Collapse
Affiliation(s)
- Marianne Lerch
- Allergy/Dermatology Unit, Department of Internal Medicine, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Carlo Mainetti
- Department of Dermatology, Bellinzona Regional Hospital, Bellinzona, Switzerland
| | | | - Thomas Harr
- Unité d'allergologie, Service d'immunologie et d'allergologie, Hôpitaux Universitaires de Genève HUG, Rue Micheli-du-Crest 24, CH-1211, Genève, Switzerland.
| |
Collapse
|
11
|
From HSV infection to erythema multiforme through autoimmune crossreactivity. Autoimmun Rev 2018; 17:576-581. [PMID: 29635075 DOI: 10.1016/j.autrev.2017.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/24/2017] [Indexed: 12/26/2022]
Abstract
Scientific and clinical data indicate that human herpes simplex virus 1 (HSV1) and, at a lesser extent, human herpes simplex virus 2 (HSV2) are factor(s) implicated in the development of erythema multiforme (EM). With a focus on oral EM, the present structured review of proteomic and epitope databases searched for the molecular basis that might link HSV1 and HSV2 infections to EM. It was found that a high number of peptides are shared between the two HSVs and human proteins related to the oral mucosa. Moreover, a great number of the shared peptides are also present in epitopes that have been experimentally validated as immunopositive in the human host. The results suggest the involvement of HSV infections in the induction of oral EM via a mechanism of autoimmune cross-reactivity and, in particular, highlight a potential major role for 180kDa bullous pemphigoid antigen and HSV1 infection in the genesis of crossreactions potentially conducive to EM.
Collapse
|