Thiazides: A cause of necrotising vasculitis?

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.

The Interface between Rheumatology and Dermatology

Although the division of medicine into specialties according to different systems is convenient, it is also artificial: the different systems interact and many diseases overlap both in their pathological features as well as their clinical expression. Many examples of such interactions are seen in the connective tissue disorders, where rheumatological and dermatological manifestations may be prominent features. In some of them the skin rash may be a diagnostic marker (e.g., systemic lupus erythematosus, dermatomyositis). Joint involvement can also be found in "primary" skin disorders such as psoriasis; certain infections can produce both skin and joint manifestations including a number of fairly common viral disorders as well as Lyme borelliosis and the acquired immune deficiency syndrome (A.I.D.S.) The skin may also be the major target of toxicity from a number of drugs, particularly those that are used in the management of rheumatic disorders.

Thiazide-induced kidney damage with circulating antibodies against myeloperoxidase and cardiolipin

A 79-year-old man developed a renal insufficiency while on thiazide. Extrarenal symptoms were absent. Screening for antibodies revealed high titre for anti-myeloperoxidase and anti-cardiolipin antibodies, but no other antibodies were present. After withdrawal of the drug the progression of renal insufficiency ceased. Four months later the both antibodies had disappeared. We conclude, that antibodies against granulocytes will become a valuable diagnostic tool in diagnosing drug-induced vasculitis.

Thiazide-induced photosensitivity: a study of 33 subjects

The clinical features, action spectrum and subsequent course, are described in 33 subjects with thiazide-induced photosensitivity. The reaction appeared to be phototoxic in nature. The wavelengths involved were those of the longer UVA and, not infrequently, also the shorter UVB waveband. In most instances withdrawal of the drug resulted in clearance of the clinical reaction and a return of the action spectrum to normal. In the few subjects in whom the photosensitivity persisted, either in the form of the clinical reaction or an abnormal action spectrum, or both, either a specific photodermatosis was present or another potentially photoactive drug was being taken. In no instance, was there evidence of the induction of long-term chronic photosensitivity (persistent light reaction) following the withdrawal of the thiazide drug.

Psychogenic purpura in adolescent patients

The occurrence of psychogenic purpura has been documented in adults. The authors present their experience with nine adolescent and young adult patients observed since 1981. The age of eight of these patients ranged from 13 to 18 years. One patient with cystic fibrosis was 23-years-old. All patients presented with painful inflammatory lesions followed by bruising. There was no evidence of an infectious process or a hematologic, immunologic, or renal abnormality. Integral to the diagnosis was the existence of an underlying emotional disorder. In all patients, bruising decreased after diagnosis was explained to the patient and family. Four patients required psychotherapy. Results of 2-year follow-up suggest that early intervention may produce a favorable outcome in this age group.

Acute interstitial nephritis associated with thiazide diuretics. Clinical and pathologic observations in three cases

Renal failure insidiously developed in three patients treated with a combination of hydrochlorothiazide and triamterene five to 10 weeks after commencing therapy. All had normal renal function prior to therapy and none had preexisting renal disease. Two of the patients had eosinophilia and two had a fever. One patient was oliguric. Renal biopsy demonstrated acute interstitial nephritis histologically. Direct immunofluorescence did not disclose evidence of either immune complex or antitubular basement membrane antibody deposition. Withdrawal of the drug led to remarkable improvement with renal function returning to normal in two patients and near normal in the third. The sequence of events and the histologic findings strongly suggest that the acute interstitial nephritis was due to a drug-induced hypersensitivity reaction. Although hydrochlorothiazide appears to be the drug responsible for the reaction, certain observations suggest a possible potentiating role for triamterene.

Drug related vasculitis. Clinicopathologic correlations in 30 patients

Drug related vasculitis has variously been described as necrotizing hypersensitivity or allergic angiitis or microscopic panarteritis nodosa. We reviewed tissue sections from 30 patients with validated drug hypersensitivity and vasculitis in order to precisely define this entity. No evidence of necrotizing vascular lesions or of fibrinoid associated with necrosis was found. The vascular lesions in all 30 patients involved small arteries, arterioles, capillaries, and venules. The inflammatory infiltrate consisted primarily of mononuclear cells and prominent numbers of eosinophils and was present in all three layers of the involved vessel walls. Clinically the patients developed either localized or systemic vasculitis, which could not be predicted on the basis of the associated drug. The findings of a skin rash, fever, or eosinophilia and the development of symptoms consistent with a hypersensitivity reaction while medication was being taken were all suggestive of the diagnosis of drug related vasculitis.

Vasculitis with alclofenac therapy

Three patients developed a vasculitis while taking alclofenac. Two recovered with corticosteroid therapy, and the third, who had continued to take the drug for a further week despite epistaxis, haemoptysis, haematuria, and cutaneous vasculitis, developed a more persistent vasculitis with histological evidence of progressive renal involvement.