Amiodarone-induced vasculitis and a review of the cutaneous side-effects of amiodarone

Small-Vessel Vasculitis After ST-Segment Elevation Myocardial Infarction

We report a case of cutaneous small-vessel vasculitis in a patient treated with clopidogrel after an ST-segment elevation myocardial infarction and with amiodarone caused by persistent atrial fibrillation 6 weeks before. (Level of Difficulty: Intermediate.)

Amiodarone-induced cutaneous leukocytoclastic vasculitis: a case report and a review of the literature

Amiodarone can be used in a variety of arrhythmias. Given its widespread use, the probability of clinicians encountering its cutaneous adverse effects is high. A few cases of amiodarone-induced cutaneous vasculitis were reported in the literature, probably because it is underdiagnosed in clinical practice. Indeed, amiodarone-related cutaneous reactions may present a wide range of manifestations and are sometimes difficult to diagnose. Herein, we report a case with a sizeable necrotic ulcer on the left lower leg shortly after amiodarone exposure. A rigorous diagnostic study was performed before concluding the diagnosis of amiodarone-induced cutaneous vasculitis, which showed the histopathological features of leukocytoclastic vasculitis. The lesion was almost completely healed by the third month of discontinuation of amiodarone. We did a literature search and found seven cases which were reported as leukocytoclastic or lymphocytic vasculitis. We reviewed previous cases and presented our case in comparison to prior cases.

Recurrent blistering distal dactylitis due to Staphylococcus aureus in an immunocompetent elderly woman

An 86-year-old woman presented with marked blistering of her left index fingertip and ulceration of the left middle fingertip, with a 2-year history of recurrent blistering and ulceration of her fingers bilaterally. She denied any preceding finger trauma, although she reported frequent gardening. She denied systemic symptoms. Her medical history was significant for a 2-year history of atrial fibrillation on carvedilol, amiodarone and apixaban, and she was a lifetime non-smoker. On admission, she had elevated inflammatory markers but unremarkable autoantibodies. Radiograph of the hand revealed diffuse soft tissue fullness and subtle irregularities at the tuft of the index finger, but all other investigations were unremarkable. The lesion was incised and drained, revealing blood-tinged purulent fluid. Wound biopsy revealed spongiosis with neutrophils, consistent with a diagnosis of blistering distal dactylitis.

Anti-arrhythmic medications increase non-cardiac mortality - A meta-analysis of randomized control trials

Introduction

Anti-arrhythmic medications (AAMs) are known to increase cardiac mortality significantly due to their pro-arrhythmic effects. However, the effect of AAMs on non-cardiac mortality has not been evaluated.

Methods

Trials published in English language journals from 1990 to 2015 were thoroughly retrieved by searching websites such as PubMed, Medline, Cochrane Library, and Google Scholar. Randomized controlled trials reporting non-cardiac deaths as primary or secondary outcomes were used to compare AAMs to non-arrhythmic therapy (AV nodal blocking agents, implantable cardiovascular defibrillation (ICD), or placebo). Information regarding the sample size, treatment type, baseline characteristics, and outcomes was obtained by using a standardized protocol. The fixed effect model was used to perform meta-analysis, and results were expressed in terms of odds ratio (OR) with confidence interval (CI) of 95%, inter study heterogeneity was assessed using I². Intention to treat principle was applied to extract data.

Results

Total of 18,728 patients were enrolled in 15 trials; 9359 patients received AAMs and 9369 received non-arrhythmic therapy. AAMs were associated with an increased risk of non-cardiac mortality (OR=1.30, [95% CI: 1.12, 1.50], p=0.0005, I² index=24%) and all-cause mortality (OR=1.09, [95% CI: 1.01, 1.18], p=0.04, I²=54%) as compared to non-arrhythmic therapy. There was no difference in the cardiac mortality (OR=1.01, [95% CI: 0.92, 1.11], p=0.82, I²=53%) or arrhythmic mortality (OR=1.00, [95% CI: 0.89, 1.13], p=0.94, I²=64%) between the two groups.

Conclusion

AAMs are associated with an increased risk of non-cardiac and all-cause mortality. The effect of AAMs, especially amiodarone, on non-cardiac mortality requires further evaluation.

Amiodarone-Induced Cutaneous Leukocytoclastic Vasculitis after Cardiac Surgery

Objective:

To remind physicians and pharmacists of the potential of amiodarone to cause leukocytoclastic vasculitis (LCV) as a potentially serious acute adverse drug reaction, and that the cornerstone of treatment for LCV is identification and removal of the etiologic agent (usually a drug such as amiodarone).

Case Summary:

A 70-year-old white male who underwent aortic valve replacement developed cutaneous LCV (without serious systemic involvement) 2 days after treatment with amiodarone 800 mg/day was initiated. Amiodarone was discontinued and the rash almost completely resolved within 48 hours. Amiodarone 400 mg/day was restarted 13 days later and arthralgias and palpable purpuric lesions reappeared in the same distribution, but much more extensively, within 2 days. Amiodarone was discontinued and, once again, arthralgias and skin lesions resolved within 1 week.

Discussion:

Photosensitivity and the development of blue/grey skin pigmentation are the most commonly and classically recognized cutaneous adverse drug reactions (ADRs) of long-term use of amiodarone. LCV, the most common small-vessel necrotizing vasculitis as an acute ADR to amiodarone, is rare, but needs to be considered in day-to-day clinical practice. The Naranjo probability scale suggested a highly probable association between LCV and the use of amiodarone in our patient.

Conclusions:

To the best of our knowledge, this is the first case report of LCV occurring in a post–cardiac surgery setting with the use of amiodarone. Cardiothoracic surgeons, cardiologists, other treating physicians and pharmacists should be aware of this rare but potentially serious adverse event related to amiodarone.

Laser treatment of imipramine-induced hyperpigmentation

BACKGROUND

Blue or slate-gray hyperpigmentation is seen with a variety of medications, including imipramine. We describe a patient with significant imipramine-induced pigmentation.

OBJECTIVE

The purpose of this study was to describe an effective laser treatment resulting in improvement of imipramine-induced hyperpigmentation, without discontinuing the medication.

METHODS

The patient underwent treatment with carbon dioxide, erbium, alexandrite, and ruby lasers to hyperpigmented areas. Tissue biopsy specimens taken before treatment, immediately after treatment with the alexandrite laser, and at clearing were analyzed by light microscopy.

RESULTS

The Q-switched alexandrite and ruby lasers resulted in clinical improvement in the patient's hyperpigmentation and a decrease in pigment granules on light microscopy.

CONCLUSION

Both the Q-switched alexandrite and ruby lasers are effective treatments for imipramine-induced hyperpigmentation. The improvement is progressive with successive sessions.

Photosensitizing drugs containing the benzophenone chromophore

The nonsteroidal anti-inflammatory agents ketoprofen, tiaprofenic acid, suprofen and tolmetin, together with the anti-hyperlipoproteinemic drug fenofibrate and the anti-arrhythmic amiodarone can be included in the group of benzophenone-derived photosensitizing drugs. They contain a diaryl ketone chromophore and mediate the development of phototoxic reactions. In some cases, photoallergic responses have been reported. These properties have been substantiated in clinical reports, as well as by means of in vivo and in vitro assays. Tolmetin is phototoxic in vitro, however there are no reports on photosensitization by this drug in humans. In general, photochemical and photobiological studies strongly suggest that photosensitization involves formal hydrogen abstraction (either in a single step or via electron transfer followed by proton transfer) by the benzophenone-like chromophore from the excited triplet state. In the case of amiodarone, the radicals generated by photodehalogenation from the triplet are responsible for the photosensitivity side-effects.