Erythema multiforme due to griseofulvin

[Severe cutaneous drug reactions to misused griseofulvin: 2 cases]

BACKGROUND

Griseofulvin is an antifungal drug known to cause drug rash. However, it is widely prescribed outside its classic indications. Herein, we describe 2 cases in which griseofulvin was prescribed for off-label indications.

PATIENTS AND METHODS

Case No. 1. A 51-year-old woman was referred to the department of internal medicine for management of Stevens-Johnson Syndrome (SJS). The symptoms appeared 17 days after she had taken griseofulvin for inguinal intertrigo. Case No. 2. A 19-year-old female patient consulted for toxic epidermal necrolysis (TEN) affecting 30% of her body surface, with a positive Nikolsky sign and severe mucosal lesions. These symptoms appeared 9 days after she began taking griseofulvin, which had initially been prescribed for her husband for mycosis.

DISCUSSION

Toxic epidermal necrolysis, a condition chiefly of drug-related origin, is a severe mucocutaneous syndrome characterized by massive keratinocytic apoptosis. Although there are few scientific publications referring to griseofulvin-induced drug eruption, they deserve to be mentioned since this drug is widely used for purposes other than the approved indications and can cause life-threatening reactions.

CONCLUSION

We report two cases of toxic epidermal necrolysis related to the misuse of griseofulvin. It is important to bear in mind the precautions for use of oral antifungal drugs, which are strictly reserved for use against resistant or diffuse forms of mucocutaneous fungal infections.

Drug-mediated rash: erythema multiforme versus Stevens-Johnson syndrome

A 92-year-old woman presented with an acute onset generalised maculopapular rash with associated mucosal involvement, on a background of recent start of griseofulvin. The rash progressed rapidly over 2 days to involve most of her body, however, mucosal involvement was limited to her oral mucosa. Characteristic target lesions appeared at 72 h, and a diagnosis of erythema multiforme secondary to griseofulvin was made after further investigation and skin biopsy. The patient was monitored closely for progression of the rash and other indicators of more severe dermatological conditions such as Stevens-Johnson syndrome. She was managed symptomatically, with resolution of the rash in 4 weeks and full recovery to her premorbid level of functioning. This case details the diagnostic and management approach to erythema multiforme, a condition that warrants thorough consideration for the differential of Stevens-Johnson syndrome.

Griseofulvin and its uses

Griseofulvin has been used in the treatment of dermatophyte infections for the past 30 years. The use of the drug in treating other medical conditions is reviewed.

Serum Sickness–Like Reaction Associated with Griseofulvin

OBJECTIVE

To describe a serum sickness—like reaction associated with griseofulvin in a child being treated for tinea capitis.

CASE SUMMARY

A previously healthy 5-year-old boy presented with tactile fever, rash on his legs and back, swelling of his toes and fingers, and leg pain. He was being treated at the time with griseofulvin for tinea capitis. Laboratory evaluation including immunologic workup revealed no abnormalities. Replacement of griseofulvin with itraconazole, along with an antihistamine and a nonsteroidal antiinflammatory drug, led to complete resolution of the patient's symptoms. An objective causality assessment revealed that the adverse reaction was probable.

DISCUSSION

Serum sickness—like reactions may occur 7–21 days following exposure to an offending agent. Clinical manifestations are similar to those of serum sickness, with fever, malaise, and cutaneous eruption. However, on laboratory workup, complement levels are normal. Management of serum sickness—like reaction includes replacing the offending agent and providing symptomatic relief.

CONCLUSIONS

Clinicians should be aware of the possibility of serum sickness—like reaction associated with griseofulvin therapy and consider the possibility when choosing between griseofulvin and newer, more expensive drugs.

Unusual Microsporum canis infections in adult HIV patients

Tinea capitis in men, even if infected with HIV, is infrequent. Microsporum species nail infections are extremely rare. In most cases Microsporum canis infection is usually easy to treat with antifungal agents. We describe two HIV-infected men with an unusual M. canis infection. Both patients had tinea capitis, presenting as alopecia in one and scaling of the scalp in the other. One patient also had tinea unguium caused by M. canis. Ketoconazole was ineffective in both patients; terbinafine was tried in one patient without benefit; itraconazole was effective in both, but treatment took many months and only one patient was cured.