Arthritis, uveitis, and Stevens-Johnson syndrome induced by trimethoprim

VKH-like uveitis during donafenib therapy for hepatocellular carcinoma: a case report and review of the literature

Background

The incidence of uveitis has risen with the use of targeted therapies, particularly prevalent in the administration of immune checkpoint inhibitors and MAP-kinase pathway inhibitors. We report the first case of VKH-like uveitis linked to Donafenib employed for the primary hepatocellular carcinoma, highlighting the necessity of ophthalmological follow-up in patients undergoing treatment with Donafenib.

Case presentation

A 55-year-old man developed VKH-like symptoms, including sporadic white patches, tinnitus, headache, and mild bilateral vision reduction, after 18 months of treatment with Donafenib and Sintilimab for hepatocellular carcinoma. Based on ophthalmological examinations that fundus fluorescein angiography images demonstrating multiple focal areas of pinpoint hyperfluorescence, along with pooling indicative of neurosensory detachment and disc leakage in both eyes, choroid thickening in swept-source optical coherence tomography, and "sunset-glow" fundus appearance, a tentative diagnosis of VKH-like uveitis was made. Initially, his best-corrected visual acuity (BCVA) was 20/200 in the right eye and 20/80 in the left eye. Upon discontinuing Donafenib and starting a 3-month course of oral glucocorticoids, his BCVA improved to 20/30 in the right eye and 20/40 in the left eye.

Conclusion

Targeted drugs have been commonly used for cancer treatment in recent years, but challenges of ocular side effects emerged gradually. To optimize patient outcomes, regular ophthalmological follow-ups are essential for those undergoing treatment with targeted therapies like Donafenib.

Drug-induced uveitis: A review

Uveitis maybe induced by the use of various medications known as drug-induced uveitis (DIU), though rare it is an important cause of uveitis which one needs to be aware of. The drugs may be administered through any route including systemic, topical, and intravitreal. Ocular inflammation can be in the form of anterior, intermediate, posterior or pan uveitis, and rarely may present as episcleritis and scleritis. Identification of drug as the offending agent of uveitis is important as many a times stopping the drug may help recover the uveitis or the concomitant use of corticosteroids. An extensive literature review was done using the Pubmed. An overview of DIU is provided as it is important for us to be aware of this clinical entity.

A Case of Toxic Epidermal Necrolysis Caused by the Use of Trimethoprim Alone

Toxic epidermal necrolysis (TEN) is a rare, acute, severe mucocutaneous reaction commonly presenting following medication use. Thorough history taking and clinical examination are key to early diagnosis and management; skin biopsy provides diagnostic confirmation. We present a 54-year-old man who developed a widespread erythematous rash soon after the use of trimethoprim for an episode of acute prostatitis. An initial diagnosis of Stevens-Johnson syndrome evolved into toxic epidermal necrolysis following the rapid progression of his condition to a severe, blistering, and desquamating rash affecting more than 60% of his body surface area and mucosa. Through careful management with best supportive care and clinical judgement regarding the role of pharmacological intervention, he made a steady recovery supported by the wider multidisciplinary team. This is one of the very few reports in the literature implicating trimethoprim alone as an etiological agent in a severe case of TEN.

Drug-induced uveitis

INTRODUCTION

Drug-induced uveitis is a well described but often overlooked and/or misdiagnosed adverse reaction to medication. There are an increasing number of medications that have been related to the onset of intraocular inflammation. Identification of these inciting agents may decisively help the diagnostic algorithm involving new cases of uveitis.

AREAS COVERED

This review intends to be an updated comprehensive, practical guide for practitioners regarding the main drugs that have been associated with uveitis. A classification proposed by Naranjo et al. in 1981 for establishing potential causality is applied examining possible mechanisms of action. A guide for clinicians about the rationale of these observations when dealing with patients with uveitis is provided.

EXPERT OPINION

Several agents with different routes of administration (systemic, topical and/or intraocular) may cause intraocular inflammation. The mechanism behind ocular inflammation is frequently unknown. Clinicians should be aware of the potential drug effect to optimize diagnosis and management of such patients.

Drug-induced uveitis

A number of medications have been associated with uveitis. This review highlights both well-established and recently reported systemic, topical, intraocular, and vaccine-associated causes of drug-induced uveitis, and assigns a quantitative score to each medication based upon criteria originally described by Naranjo and associates.