Drug rashes in glandular fever

Association between Antibiotic Exposure and the Risk of Rash in Children with Infectious Mononucleosis: a Multicenter, Retrospective Cohort Study

Present evidence suggests that the administration of antibiotics, particularly aminopenicillins, may increase the risk of rash in children with infectious mononucleosis (IM). This retrospective, multicenter cohort study of children with IM was conducted to explore the association between antibiotic exposure in IM children and the risk of rash. A robust error generalized linear regression was performed to address the potential cluster effect, as well as confounding factors such as age and sex. A total of 767 children (aged from 0 to 18 years) with IM from 14 hospitals in Guizhou Province were included in the final analysis. The regression analysis implied that exposure to antibiotics was associated with a significantly increased incidence of overall rash in IM children (adjusted odds ratio [AOR], 1.47; 95% confidence interval [CI], ~1.04 to 2.08; P = 0.029). Of 92 overall rash cases, 43 were probably related to antibiotic exposure: two cases (4.08%) in the amoxicillin-treated group and 41 (8.15%) in the group treated with other antibiotics. Regression analysis indicated that the risk of rash induced by amoxicillin in IM children was similar to that induced by other penicillins (AOR, 1.12; 95% CI, ~0.13 to 9.67), cephalosporins (AOR, 2.45; 95% CI, ~0.43 to 14.02), or macrolides (AOR, 0.91; 95% CI, ~0.15 to 5.43). Antibiotic exposure may be associated with an increased risk of overall rash in IM children, but amoxicillin was not found to be associated with any increased risk of rash during IM compared to other antibiotics. We suggest that clinicians be vigilant against the occurrence of rash in IM children receiving antibiotic therapy, rather than indiscriminately avoiding prescribing amoxicillin.

Increased risk of severe cutaneous adverse reactions when cladribine is used together with other medications with a propensity for skin reactions

Cladribine is a purine analog used in first-line treatment of hairy cell leukemia and in relapsed/refractory chronic lymphocytic anemia. Although cladribine is typically associated with mild, self-limited skin reactions, there is increasing evidence that cladribine may increase the risk of severe cutaneous adverse reactions (SCAR) when combined with drugs classically associated with SCAR (e.g. allopurinol) beyond what would be expected for either drug alone, possibly due to cladribine-induced lymphopenia. We analyzed all SCAR cases reported for cladribine in Janssen's Global Safety Database and found that 26/35 (74.3%) reported concomitant drugs known to be associated with SCAR, most commonly sulfamethoxazole/trimethoprim (SMX/TMP) and allopurinol. In addition, a review of the WHO VigiBase showed that several drugs, including penicillins, SMX/TMP, and allopurinol had a statistically significant contribution to cladribine-associated SCAR. These results lend further support that cladribine may increase the propensity of these drugs to cause SCARs.

Antibiotic-Induced Rash in Patients With Infectious Mononucleosis

Objective: To provide an extensive review of case reports, epidemiological data, and the underlying mechanism of antibiotic-induced skin rash in patients with concurrent infectious mononucleosis (IM). Data Sources: A MEDLINE literature search inclusive of the dates 1946 to June 2016 was performed using the search terms anti-bacterial agents and infectious mononucleosis. EMBASE (1980 to June 2016) was searched using the terms mononucleosis and antibiotic agent and drug eruption. References of all relevant articles were reviewed for additional citations and information. Study Selection and Data Extraction: We selected English-language, primary literature, review articles, and mechanistic articles that addressed antibiotic-induced skin rash in patients with concurrent IM. We assessed all case reports available for causality utilizing a modified Naranjo nomogram specifically designed for this subject. We assembled the available epidemiological data into tables to identify trends in incidence rates over the years. Data Synthesis: We identified 17 case reports of antibiotic-associated rash in patients with IM. The median Naranjo score was 6 (range = 1 to 8). The top 3 reported drugs were ampicillin, azithromycin, and amoxicillin. Incidence of this adverse effect was higher in the 1960s (55.6%, 45%, and 33%) than in 2013 (33% and 15%). The mechanism most commonly proposed is a transient virus-mediated immune alteration that sets the stage for loss of antigenic tolerance and the development of a reversible, delayed-type hypersensitivity reaction to the antibiotic. Conclusion: A reassessment of the long-held belief of the high incidence (80%-100%) of antibiotic-induced skin rash in patients with IM seems prudent. Additional studies will be necessary to clarify this issue.

Baboon syndrome: an unusual complication arising from antibiotic treatment of tonsillitis and review of the literature

A 40-year-old man presented with sore throat and fevers associated with bilaterally enlarged and inflamed tonsils. A clinical diagnosis of tonsillitis was made and the patient received intravenous benzylpenicillin. Over subsequent days, the patient developed a macular rash over both groins, buttocks and axillae, with necrotic patches in the groins. An assumptive diagnosis of necrotising fasciitis was made. The patient underwent urgent groin biopsy and was started on broad spectrum antibiotics. No organisms were seen on Gram stain. Following a multidisciplinary discussion, the patient was diagnosed with baboon syndrome (symmetrical drug-related intertriginous and flexural exanthema). He was treated with oral steroid along with topical agents. Baboon syndrome can develop following penicillin administration. Given the widespread use of penicillin antibiotics to treat tonsillitis and many other conditions, it is important that medical staff recognise the side effects of these medications.

Incidence of rash after amoxicillin treatment in children with infectious mononucleosis

BACKGROUND

"Ampicillin rash," a phenomenon unique to patients with Epstein-Barr virus acute infectious mononucleosis (AIM) treated with ampicillin, was first reported in the 1960s. The incidence was estimated as being between 80% and 100%, and the figures have not been reviewed since those first accounts. We sought to establish the current incidence of rash associated with antibiotic treatment among children with AIM.

METHODS

A retrospective study of all hospitalized children diagnosed as having AIM based upon positive Epstein-Barr virus serology in 2 pediatric tertiary medical centers in Israel.

RESULTS

Of the 238 children who met the study entry criteria during the study period, 173 were treated with antibiotics. Fifty-seven (32.9%) of the subjects treated with antibiotics had a rash during their illness compared with 15 (23.1%) in untreated patients (P = .156; not significant). Amoxicillin was associated with the highest incidence of antibiotic-induced rash occurrence (29.5%, 95% confidence interval: 18.52-42.57), but significantly lower than the 90% rate reported for ampicillin in past studies. Age, gender, ethnicity, and atopic or allergic history were not associated with the development of rash after antibiotic exposure. Among the laboratory data, only increased white blood cell counts were more prevalent among subjects who did not develop an antibiotic-induced rash.

CONCLUSIONS

The incidence of rash in pediatric patients with AIM after treatment with the current oral aminopenicillin (amoxicillin) is much lower than originally reported.

Amoxicillin-induced exanthema in young adults with infectious mononucleosis: demonstration of drug-specific lymphocyte reactivity

BACKGROUND

Teenagers and young adults frequently develop maculopapular exanthema following amoxicillin intake within infectious mononucleosis. The underlying pathomechanisms are still largely unknown.

OBJECTIVES

To investigate whether amoxicillin-induced exanthema in florid infectious mononucleosis is a disease-associated phenomenon or results from specific sensitization to the drug.

METHODS

Four patients with amoxicillin-induced exanthema within infectious mononucleosis were analysed in vivo by prick, intradermal and patch tests and in vitro by means of the lymphocyte transformation test (LTT) employing amoxicillin, ampicillin, benzylpenicillin and phenoxymethylpenicillin.

RESULTS

Drug-specific sensitization to amoxicillin in the LTT was observed in three patients, two of whom showed a side-chain-specific sensitization to amoxicillin and ampicillin. The in vitro results were confirmed in vivo by skin tests.

CONCLUSIONS

These data suggest that real sensitization to amoxicillin and ampicillin may occur within infectious mononucleosis and may be detected in vivo and in vitro by means of skin tests and the LTT.

Potentiation of ampicillin skin reactions by allopurinol or hyperuricemia

Of 4434 hospitalized medical patients who received ampicillin in the absence of allopurinol, 251 (5.9 per cent) developed a rash within 21 days of exposure. Of 252 patients who received ampicillin and allopurinol together, 35 (13.9 percent) developed a rash. The present data confirm the previously reported increase in rash frequency in patients who receive both ampicillin and allopurinol.

Temporary skin reactions to penicillins during the acute stage of infectious mononucleosis

During the acute stage of infectious mononucleosis (IM), 16 out of 19 patients have reacted to skin tests with ampicillin and/or benzylpenicillin or their derivatives. Two thirds reacted to ampicillin and less than half (10/19) to benzylpenicillin, or their derivatives. No reaction was observed with cloxacillin. The lack of reactivity in 3 of 7 patients and the circumstance that the frequency of reactions with the penicilloylated Escherichia coli proteins makes it likely that the greater reactivity to penicillins and in particular to ampicillin in IM is not due mainly to protein impurities, but chiefly to the antibiotic molecule as such. There was no definite relationship between reactivity and clinical involvement. After the acute stage, disappearance of skin reactivity was noted. Intracutaneous testing with penicillins may be used to monitor the increased cutaneous reactivity during acute IM, and it may be helpful when the acute stage is over to determine when a patient may use these antibiotics without side reactions.

Ampicillin hypersensitivity in lymphatic leukaemia

Skin rashes developed during ampicillin therapy in 10 of 12 patients with lymphatic leukaemia. This apparent susceptibility to ampicillin is similar to that previously described in patients with infectious mononucleosis. It is postulated that patients with lymphatic leukaemia and infectious mononucleosis have an alteration in immune response due to abnormal lymphocytic function. It is suggested that, in these patients with bacterial infection, initial antibiotic treatment should not include ampicillin.