Linear IgA bullous dermatosis mimicking erythema multiforme in adult

Fixed drug eruptions, bullous drug eruptions, and lichenoid drug eruptions

Drug reactions are among the most common reasons for inpatient dermatology consultation. These reactions are important to identify because discontinuation of the offending agent may lead to disease remission. With the rising use of immunomodulatory and targeted therapeutics in cancer care and the increased incidence in associated reactions to these drugs, the need for accurate identification and treatment of such eruptions has led to the development of the "oncodermatology" subspecialty of dermatology. Immunobullous drug reactions are a dermatologic urgency, with patients often losing a significant proportion of their epithelial barrier; early diagnosis is critical in these cases to prevent complications and worsening disease. Lichenoid drug reactions have myriad causes and can take several months to occur, often leading to difficulties identifying the offending drug. Fixed drug eruptions can often mimic other systemic eruptions, such as immunobullous disease and Stevens-Johnson syndrome, and must be differentiated from them for effective therapy to be initiated. We review the clinical features, pathogenesis, and treatment of immunobullous, fixed, and lichenoid drug reactions with attention to key clinical features and differential diagnosis.

Cephalosporin-induced linear IgA dermatosis in a child: Case report and literature review

Linear IgA dermatosis (LAD) is a rare, subepidermal blistering disease with mucocutaneous involvement. It may be idiopathic or drug induced. We describe a 4-year-old girl who presented with a vesiculobullous eruption after she had been treated with cefixime for urinary tract infection. A diagnosis of drug-induced LAD was made based on clinical, histopathological, and immunofluorescence findings. Naranjo adverse drug reaction algorithm was used to assess imputability resulting with a "probable" association. In literature, cephalosporin antibiotics are rarely reported in association with LAD. To our knowledge, this is the first case of a cefixime-induced LAD among adults and children.

Shape and configuration of skin lesions: targetoid lesions

What is probably the first description of targetoid or iris lesions, as they appear in erythema multiforme (EM), can be found in Thomas Bateman's 1836 textbook "Practical Synopsis of Cutaneous Diseases According to the Arrangement of Dr. Willan." EM was initially described by Bateman and later by von Hebra as an acute self-limiting skin disease, symmetrically distributed on the extremities with typical concentric "targetoid" or "iris" lesions, and often recurrent. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) were added to this syndrome later. A newer classification has created two disease spectra: EM consisting of EM minor and EM major (or bullous EM), and SJS and TEN. EM minor and EM major are often recurrent, postinfectious (especially after herpes and mycoplasma) disorders with low morbidity and almost no mortality. SJS and TEN are usually severe drug-induced reactions with high morbidity and poor prognosis. The target lesions found in each form of the disease are described and defined. Although the term "target lesion" originated from the description of EM and despite its being the dominant lesion in this disease, it is not pathognomonic for EM, and these lesions can sometimes appear in other diseases. Short descriptions of these other diseases are presented.

Bull's-eye cutaneous infarct of zygomycosis: A bedside diagnosis confirmed by touch preparation

We report an immunocompromised woman with chronic lymphocytic leukemia who developed cutaneous zygomycosis at the site of an arterial line. The initial lesion resembled a bulls-eye. Bull's-eye lesions of zygomycosis have been reported twice before. Recognition of this sign may allow the dermatologist to make a rapid presumptive diagnosis and initiate treatment for this life-threatening infection.

Unusual clinical manifestation of linear IgA dermatosis: A report of two cases

Linear IgA dermatosis is a rare autoimmune bullous skin disease with subepidermal blister formation and linear IgA deposits along the basement membrane zone. We describe two female patients showing erythematous annular plaques with scaling at the margin, strictly localized to the palms in one patient, and also found on the soles and buttocks in the second patient. Histology showed numerous neutrophils in the dermis with an admixture of eosinophils, some subepidermal clefting, and occasional papillary microabscesses. Direct immunofluorescence and immunoelectron microscopy revealed in vivo IgA deposition along the basement membrane zone. One patient cleared after treatment with dapsone. The second patient did not respond to dapsone alone and various immunosuppressive treatment regimens. Considerable improvement was achieved with intravenous immunoglobulin therapy combined with corticosteroid and dapsone.

Drug-induced linear IgA bullous disease following antibiotics

A 69-year-old woman presented with pneumonia and subacute bacterial endocarditis. Nine days after intravenous vancomycin and ciprofloxacin were commenced, the patient developed a bullous mucocutaneous eruption. Clinical presentation and histopathology were consistent with drug-induced linear IgA bullous disease (LABD). The patient's lesions resolved with cessation of antibiotics. A review of the features of drug-induced LABD and the drugs that have been implicated are presented.

Linear IgA disease histopathologically and clinically masquerading as lichen planus

In each of 2 cases reported, the patient presented with features of erosive lichen planus or lichenoid drug eruptions and an incisional biopsy taken from the patient was diagnosed histologically as lichen planus. Subsequent recurrences or exacerbations were associated with vesiculobullous lesions. Simultaneous or subsequent direct immunofluorescence studies--from the same tissue sample in one case and from a similar site in the other case--demonstrated classic features of linear IgA disease. Both patients were originally treated for lichen planus with systemic and/or topical corticosteroids with limited success. One patient was treated with sulfapyridine with minimal improvement. Both patients were subsequently treated with dapsone and demonstrated significant clinical improvement. We propose that linear IgA disease may be more common than reported in the oral cavity, inasmuch as many cases of recalcitrant lichen planus, erosive lichen planus, and lichenoid drug eruptions, especially those with a vesiculobullous component, may in reality represent linear IgA disease. We recommend that direct immunofluorescence be done in any case in which bullous lichen planus is suspected.

Drug-induced linear IgA bullous dermatosis: report of six cases and review of the literature

BACKGROUND

Linear IgA bullous dermatosis (LABD) is an autoimmune subepidermal blistering disease that may be associated with drug exposure.

OBJECTIVE

Our purpose was to compare the clinical, pathologic, and immunofluorescence findings in drug-induced LABD with those in the idiopathic type.

METHODS

Six patients with an acute drug eruption were identified who had linear IgA deposition at the basement membrane zone (BMZ). Lesional tissue was examined by brightfield microscopy, and perilesional tissue was examined by direct immunofluorescence (DIF). The presence of circulating BMZ antibody was assayed by indirect immunofluorescence (IIF) on monkey esophagus (ME) and salt-split human skin (SS).

RESULTS

Histopathologic examination showed subepidermal bullae with varying numbers of inflammatory cells. DIF showed linear IgA at the BMZ; three of the patients also had weak deposition of C3 at the BMZ. Serum from five patients was studied by IIF. One patient had circulating IgA BMZ antibodies in a titer of 1:80 on ME, localized to the dermal side on SS. All patients were free of lesions within 5 weeks after discontinuation of the drug.

CONCLUSION

Drug-induced LABD is a self-limited eruption characterized by linear deposition of IgA without IgG at the BMZ. Most patients lack circulating antibodies. The distribution of lesions and the course of the disease differ from those of idiopathic LABD.

Antigen identification in drug-induced bullous pemphigoid

Immunobullous diseases usually develop spontaneously, but drug-induced bullous disease develops in a small subgroup of patients. We examined a patient in whom bullous pemphigoid developed after she received enalapril for treatment of hypertension. IgG antibody directed against a 230 kd antigen was identified. The eluted IgG autoantibody was shown to bind to the basement membrane zone on split skin. This study demonstrates that drug-induced bullous pemphigoid autoantibody in this patient was directed against the same antigen as the spontaneous bullous pemphigoid antigen.

Erythema annulare-like acantholytic dermatosis (EAAD): nonbullous pemphigus or a new entity?

This article describes a case of unusual annular erythema-like dermatosis, with histological features of pemphigus foliaceus (subcorneal acantholysis) and IgG antibodies in circulation and bound in vivo to the keratinocyte surface. The reactivity of the antibodies, restricted to human squamous epithelium, was unique, differing from that of all known forms of pemphigus. This also was confirmed by immunoprecipitation. The problem is that these circulating antibodies could be missed if not determined on human substrate. It is to be established whether such cases present a new type of pemphigus or a unknown dermatosis with an autoimmune response of a pemphigus type.