Drug-induced vasculitides

Drug-induced cutaneous vasculitis and anticoagulant-related cutaneous adverse reactions: insights in pathogenesis, clinical presentation, and treatment

Drug-induced vasculitis and anticoagulant-related skin reactions are commonly encountered in the inpatient and outpatient settings. The spectrum of clinical presentation is broad and ranges from focal, skin-limited disease, to more extensive cutaneous and soft tissue necrosis, to potentially fatal systemic involvement. The prompt recognition of these adverse events can have a significant impact on patient morbidity and mortality. We highlight the key features of the clinical presentation with an emphasis on primary lesion morphology, distribution, and epidemiology of purpuric drug reactions. The proposed pathophysiology, histologic findings, and therapeutic interventions of these potentially life-threatening diseases are discussed.

Letrozole-induced necrotising leukocytoclastic small vessel vasculitis: First report of a case in the UK

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Letrozole is a commonly used drug in breast cancer treatment.

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Letrozole induced cutaneous leukocytoclastic small vessel vasculitis: first UK case.

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There was extensive superficial skin necrosis; needed local and systemic steroids.

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Interestingly, the cancer shrank without treatment during the 3-4 month episode.

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Breast teams should be aware of this rare side effect.

Introduction

Letrozole, an aromatase inhibitor, is a commonly used neo-adjuvant drug to treat hormone-sensitive breast cancer. There have been a few cases of aromatase inhibitor induced vasculitis but the first case of letrozole-induced vasculitis was reported from Switzerland in 2014 (Digklia et al.) [1].

Presentation of case

We report the case of a 72-year-old woman with a small breast cancer. She was started on pre-operative letrozole (2.5 mg/d) whilst awaiting surgery. Ten days later she presented with burning pain and purpuric skin lesions which progressed to extensive ischaemic superficial necrosis of the lower limb skin, resolving over 3–4 months after local and systemic steroids. Histologically, it showed leucocytoclasis with evidence of eosinophilia consistent with a diagnosis of cutaneous leukocytoclastic small vessel vasculitis.

Discussion

The initial clinical presentation was severe burning pain around the ankles and a spreading violaceous rash. Letrozole was stopped. Wide local excision (lumpectomy) and sentinel node biopsy were postponed because of the accompanying pneumonitis and gastrointestinal upset, and were carried out 3.5 months later. Fortunately, the tumour size did not increase, but appeared to reduce, and axillary lymph nodes remained negative, i.e., this patient’s cancer outcome does not seem to have been jeopardized.

Conclusion

Leukocytoclastic vasculitis is a hypersensitivity reaction that is usually self-resolving, though our case needed systemic steroid treatment. Letrozole is a commonly used drug in clinical practice and prescribers should be aware of this rare side effect, which in our case delayed treatment without any apparent harm and possibly reduced tumour size.

Scientific and Regulatory Policy Committee Points-to-consider Paper*

Drug-induced vascular injury (DIVI) is a recurrent challenge in the development of novel pharmaceutical agents. Although DIVI in laboratory animal species has been well characterized for vasoactive small molecules, there is little available information regarding DIVI associated with biotherapeutics such as peptides/proteins or antibodies. Because of the uncertainty about whether DIVI in preclinical studies is predictive of effects in humans and the lack of robust biomarkers of DIVI, preclinical DIVI findings can cause considerable delays in or even halt development of promising new drugs. This review discusses standard terminology, characteristics, and mechanisms of DIVI associated with biotherapeutics. Guidance and points to consider for the toxicologist and pathologist facing preclinical cases of biotherapeutic-related DIVI are outlined, and examples of regulatory feedback for each of the mechanistic types of DIVI are included to provide insight into risk assessment.

Adverse Cutaneous Reactions and Drugs: A Focus on Antimicrobials

Rashes are a common adverse event observed during antimicrobial therapy. Many rashes are mild to moderate in intensity, however some reactions can be the prelude to much more severe outcomes such as Stevens-Johnson Syndrome (SJS) or Toxic Epidermal Necolysis. Several risk or influencing factors are known such as female gender, age and concomitant viral infections, and these may apply to more than one drug class. The incidence of rashes and other cutaneous reactions vary, however rates of >3% are reported with the beta-lactams while serious reactions such as SJS are observed with trimethoprim-sulphamethoxazole. Newer fluoroquinolone agents are devoid of the moiety which caused phototoxic reactions, while rates of rash vary from < 1%-3% or higher if longer courses of therapy are given. Serious systemic events have not been reported with these agents unlike other older, well-accepted antimicrobials. Rashes, while occasionally itchy and sometimes transiently unsightly, have less of an impact on a patient's daily activities than diarrhea, nausea or other more profound adverse events. However, it is essential that any rash be carefully monitored for possible, but rare, serious systemic events ensuing.

Vancomycin-induced leukocytoclastic vasculitis

Vancomycin is well recognized as causing the nonallergic skin reaction known as red man syndrome; however, it is rarely suspected as causative in the setting of an immune-mediated skin reaction. We describe a 76-year-old Caucasian woman with a history of penicillin and sulfa allergies who was transferred to our medical center while receiving vancomycin for treatment of persistent methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. After admission, the patient's pacemaker was explanted; cultures from the pacemaker grew MSSA. Based on the culture data and her allergy to penicillin, vancomycin was continued. On day 4 of therapy, the patient developed a papular rash with small blisters on her distal upper extremities. Furosemide, which she was receiving intermittently to maintain fluid balance, was initially suspected as the likely cause. Furosemide was withheld; however, the rash worsened and spread to her neck and torso. Results of skin biopsy confirmed a severe leukocytoclastic, necrotizing small-cell vasculitis that met the criteria for a hypersensitivity vasculitis associated with drug therapy. Five days after discontinuation of vancomycin, the vasculitis was resolving and continued to resolve throughout the remainder of her hospitalization. Furosemide was readministered without worsening of the vasculitis. Use of the Naranjo adverse drug reaction probability scale indicated that the likelihood of vancomycin being the cause of the vasculitis was probable (score of 5). Clinicians should be aware of vancomycin as a potential cause of small-vessel vasculitis.

Drug eruptions and other adverse drug effects in aged skin

The elderly are at higher risk for suffering the annoying and hazardous skin reactions that are associated with drug therapy. If a serious reaction occurs, the aged are also at higher risk for major morbidity and mortality compared with younger individuals. Early consideration of a drug cause and prompt cessation of all potentially associated drugs may improve a patient's outcome. Thus, a prompt, careful, and accurate characterization of a drug-related reaction is important in optimizing patient care, along with close monitoring for associated internal toxicities and other medical complications of severe cutaneous reactions.

Cutaneous and systemic manifestations of drug-induced vasculitis

OBJECTIVE

To evaluate the literature for published cases of drug-induced vasculitis with cutaneous and/or systemic manifestations.

DATA SOURCES

The MEDLINE database was searched from 1965 to December 1999 for articles focusing on drugs and vasculitis, using various search terminologies (e.g., Churg-Strauss syndrome, Goodpasture's syndrome, Henoch-Schönlein purpura, various drugs suspected to induce vasculitis). Cases were included when they met the established criteria as described in the methodology.

DATA SYNTHESIS

Drugs found to be most frequently associated with vasculitis were propylthiouracil, hydralazine, colony-stimulating factors, allopurinol, cefaclor, minocycline, D-penicillamine, phenytoin, isotretinoin, and methotrexate. The interval between the first exposure and appearance of symptoms was reported to be extremely variable (hours to years). Vasculitis has occurred after drug dosage increases and after rechallenge with the suspected drug. In the majority of cases, vasculitis has resolved after discontinuing the drug. Patients with more severe, often life-threatening, manifestations have required treatment with corticosteroids, plasmapheresis, hemodialysis, or cyclophosphamide. Death was the result in 10% of all published cases, with a predominance in patients in whom multiple organ systems were involved.

CONCLUSIONS

Clinicians need to be suspect of drug-induced vasculitis to enable prompt diagnosis and treatment. This should improve patient outcomes based on the data referenced for this article.

Drug-induced vasculitis

DIV is a relatively common cause of inflammatory vasculitis. Drugs from almost every pharmacologic class have been implicated in causing vasculitis in sporadic cases. The level of certainty and quality of evidence for these associations between specific agents and vasculitis vary greatly. The clinical manifestations of DIV range from single organ involvement (most commonly, skin) to life-threatening multiorgan disease. The recently described subset of cases of DIV associated with positive tests for ANCA are an interesting subset of DIV. The diagnosis of DIV is usually one of exclusion. The treatment of DIV is dependent on the severity of disease activity but should always include withdrawal of the suspected drug. If no agent can be implicated, as many drugs as feasible should be discontinued. The necessity of prescribing glucocorticoids or immunosuppressive agents depends on the disease severity and other case-specific information. Increasing understanding of the pathophysiologic characteristics of all inflammatory vasculitides should lead to better diagnostic and therapeutic approaches to DIV.

Autoimmune diseases associated with drugs, chemicals and environmental factors

Autoimmune connective tissue diseases are complex multisystems and may be life threatening. Their aetiology is unknown but genetic, hormonal and environmental factors are important. In systemic lupus erythematosus (SLE), factors such as UV light and drugs, including oestrogen, may trigger the disease; silica exposure may also be important. Scleroderma is associated with silica exposure and drugs such as bleomycin and pentazocine may induce scleroderma-like diseases. Organic solvents such as vinyl chloride and epoxy resins may also be associated with scleroderma-like illnesses. The toxic oil syndrome and eosinophila-myalgia syndrome are best known examples of connective tissue diseases induced by chemical exposure. The systemic vasculitides and in particular cutaneous vasculitis may be induced by drugs and possibly environmental factors. A number of autoimmune connective tissue diseases may therefore be associated with exposure to drugs, chemicals and environmental factors and the risks associated with these should be minimised where possible.

Drug-induced severe skin reactions. Incidence, management and prevention

Severe skin adverse drug reactions can result in death, but the rate of such events is fortunately low. The incidences of Stevens-Johnson syndrome and toxic epidermal necrolysis range from 1.2 to 6 per million per year and 0.4 to 1.2 per million per year, respectively. Stevens-Johnson syndrome is fatal in about 5% and toxic epidermal necrolysis in 30% of cases. Drugs implicated in these diseases are the sulphonamides, anticonvulsants, allopurinol, pyrazolone derivatives, oxicams and chlormezanone. The principles of symptomatic treatment are the same as for burns, and patients with extensive skin detachment should be transferred to an intensive care unit or a burn centre. Hypersensitivity syndrome is characterised by mucocutaneous eruption and fever with frequent lymphadenopathy, hepatitis and eosinophilia. Drugs implicated are mainly anticonvulsants and sulphonamides. The mortality rate of such a reaction has been estimated to be about 8%. Corticosteroid therapy has been widely used in hypersensitivity syndrome, despite the lack of controlled studies. Drug-induced vasculitis and serum sickness may also be life-threatening when the kidney, liver, gastrointestinal tract or nervous system are involved. In angioedema, congestion may involve mucous membranes and therefore impair swallowing and ventilation. Drugs associated with angioedema include penicillins, radiographic contrast agents and ACE inhibitors. Severe forms of angioedema necessitate epinephrine (adrenaline) subcutaneous injection and possibly resuscitative efforts. Corticosteroids and/or antihistamines are used to block or reduce prolonged or late phase reactions. Prompt recognition and withdrawal of the suspected drug is essential in severe drug-induced skin reactions.

Chronic suppurative lung disease with associated vasculitis

We report a patient with chronic bronchiectasis who developed systemic vasculitis. The patient was initially treated with immunosuppression; however, the addition of antibiotic therapy improved control of her vasculitis and the need for immunosuppression was reduced. Chronic bronchial suppuration may have an aetiological role in the pathogenesis of this condition.