Bullous erythema multiforme following herpes zoster and varicella-zoster virus infection

Erythema multiforme caused by varicella-zoster virus: A case report

Erythema multiforme is a widespread hypersensitivity reaction, its pathogenesis is related to a variety of factors, including drugs and viral and bacterial infections. It is true that erythema multiforme is often caused by viruses while current studies suggest that it is mostly associated with herpes simplex virus infection, rarely associated with varicella-zoster virus infection. Here, we report a 50-year-old man admitted to our hospital because of rashes on the left rib with pain for 9 days and on limbs and hands for 2 days. Laboratory data showed that varicella-zoster virus (VZV-DNA) test was negative in blood by qualitative polymerase chain reaction. Herpes zoster virus IgM (VZV-IgM) enzyme linked immune sorbent assay was negative, and herpes zoster virus IgG (VZV-IgG) enzyme linked immune sorbent assay was positive. Herpes zoster and erythema multiforme was diagnosed. After treatment with antiviral, antiallergic, and topical drugs, the rashes was significantly improved. Our case report contributes to the pathogenesis of erythema multiforme.

Bullous Pemphigoid with Atypical Skin Lesions and Acute Interstitial Nephritis: A Case Report and Focused Literature Review

Patient: Male, 76

Final Diagnosis: Drug induced bullous pemphigoid

Symptoms: Skin rash

Medication: Cephalexin

Clinical Procedure: Skin biopsy

Specialty: General and Internal Medicine

From HSV infection to erythema multiforme through autoimmune crossreactivity

Scientific and clinical data indicate that human herpes simplex virus 1 (HSV1) and, at a lesser extent, human herpes simplex virus 2 (HSV2) are factor(s) implicated in the development of erythema multiforme (EM). With a focus on oral EM, the present structured review of proteomic and epitope databases searched for the molecular basis that might link HSV1 and HSV2 infections to EM. It was found that a high number of peptides are shared between the two HSVs and human proteins related to the oral mucosa. Moreover, a great number of the shared peptides are also present in epitopes that have been experimentally validated as immunopositive in the human host. The results suggest the involvement of HSV infections in the induction of oral EM via a mechanism of autoimmune cross-reactivity and, in particular, highlight a potential major role for 180kDa bullous pemphigoid antigen and HSV1 infection in the genesis of crossreactions potentially conducive to EM.

Variations in herpes zoster manifestation

Herpes zoster (HZ) is a neurocutaneous disorder due to endogenous reactivation of the varicella-zoster virus (VZV). The typical clinical manifestation is an acute segmental eruption of herpetiform umbilicated vesicles associated with malaise, pain, dysaesthesia, allodynia and probably fever. This review focuses on other possible clinical manifestations of the disease to sensitize physicians not to overlook HZ since only an early antiviral treatment can reduce the risk of post-zosteric neuralgia.

Primary Varicella Infection Associated with Stevens-Johnson Syndrome in a Turkish Child

Stevens-Johnson syndrome (SJS) is defined as a severe erythema-multiforme-like eruption of the skin and lesions of the oral, genital and anal mucosa and hemorrhagic crusting on the lips; it is associated with fever, headache, and arthralgia. The disease is a part of a continuum of immunologically mediated mucocutaneous diseases at various grades of severity. SJS is often induced by drugs, but the pathophysiologic mechanism is completely unknown. Patients and their first degree-relatives may have genetic defects in their metabolic pathways that lead to the accumulation of toxic metabolites. However, viral infections are known triggers of this skin disorder. Varicella zoster virus has been only very rarely reported as an etiological agent in SJS, despite its high incidence as a pathogen in childhood. In this study, we report a case of primary varicella infection associated with SJS because of its rare presentation. To the best of our knowledge, our case is the youngest child in the literature.

Signal detection for Thai traditional medicine: examination of national pharmacovigilance data using reporting odds ratio and reported population attributable risk

Herbal containing medicine consumption has increased while the awareness of adverse drug reaction (ADR) was less than conventional medicine. Early detection of unexpected numbers of ADRs from herbal medicines' reports which are abnormal from the whole database needs quantification. Disproportionality analysis has been performed for signal detection by using reporting odds ratio (ROR) as measurement. The impact of having medicine as exposures in each ADR should be measured by using reported population attributable risks (RPAR). This study aimed to quantify the contribution of Thai traditional medicine (TTM) to ADR reports and to assess the association between TTMs and serious adverse drug reactions. Data were retrieved from the adverse drug reaction surveillance database, Thai-Food and Drug Administration from 2002 to 2013. Crude and adjusted RORs for each drug-ADR pair and RPARs were computed. TTM contributed only 0.001% of all serious ADRs reported. Out of 4208 TTM-ADR pairs were examined, three had the statistically significant RORs, namely Andrographis paniculata and anaphylactic shock (ROR 2.32, 95% CI 1.03, 5.21); green traditional medicine and Stevens-Johnson syndrome (ROR 13.04, 95% CI 5.4-31.51) and Derris scandens Benth and angioedema (ROR 2.71, 95% CI 1.05-6.95). Their RPARs ranged from 0.05% to 0.16%. We conclude that TTMs need more intensive surveillance.

Amlodipine-induced toxic epidermal necrolysis

The objective of this study is to report a case of amlodipine-induced dermatotoxicity following treatment for diabetic nephropathy. Although other members of the dihydropyridine calcium channel blockers have been reported to cause dermatotoxic reactions, this is the first report attributing this effect to amlodipine. A 71-year-old diabetic and hypertensive woman had been noted to have worsened renal dysfunction and hyperkalemia attributed to enalapril, thus a trial of amlodipine was begun. On day 12 of amlodipine therapy, the patient developed a pruritic maculopapular rash on her hands for which she sought medical attention. On day 16, she presented again to the emergency department now with hives and small blisters involving the trunk and arms with ∼25% TBSA involvement warranting transfer to a regional burn treatment center. The rash progressed after admission to 48.5% TBSA and included conjunctival sloughing. The patient's hospital course was uneventful, and she was discharged after 8 days. Drug-induced dermatotoxicity presenting as toxic epidermal necrolysis is often caused by antibiotics and antiepileptic medications; however, calcium channel blockers are an uncommon cause. The Naranjo assessment yielded a score of 5, and the SCORTEN was 4 with a predicted mortality of 58%. This report represents the first published case of amlodipine-induced toxic epidermal necrolysis.

Erythema multiforme due to Mycoplasma pneumoniae infection in two children

Mycoplasma pneumoniae is an important and highly relevant cause of bullous erythema multiforme, isolated mucositis, and Stevens-Johnson syndrome in children. In this article, we present two children with respiratory Mycoplasma pneumoniae infection and associated cutaneous findings within the spectrum of erythema multiforme. We review the literature associating these three entities with Mycoplasma pneumoniae infection and discuss controversies regarding the classification of erythema multiforme, as well as update reported infectious causes of the bullous form. Many understand the erythema multiforme spectrum to include bullous erythema multiforme, mucositis, and Stevens-Johnson syndrome in the order of increasing severity. We feel that this relationship should be reconsidered to help better understand the prognosis and outcomes. It is our opinion that bullous erythema multiforme is a separate, yet related condition that can occur in the context of Mycoplasma pneumoniae infection. With many similarities to mucositis and Stevens-Johnson syndrome, bullous erythema multiforme can be considered part of a spectrum of disease that includes Stevens-Johnson syndrome. Unlike mucositis and Stevens-Johnson syndrome, bullous erythema multiforme caused by Mycoplasma pneumoniae infection has low morbidity for the child. Mycoplasma pneumoniae-associated mucositis and Stevens-Johnson syndrome seem to occur along a spectrum with separate prognosis and potential pathogenesis compared with bullous erythema multiforme. Making the distinction between these conditions is valuable for predicting the child's prognosis. Patients who develop symptoms consistent with these conditions should be appropriately evaluated for Mycoplasma pneumoniae infection and closely monitored.

[Stevens-Johnson syndrome due to prednisone in a patient with systemic lupus erythematosus]

Stevens-Johnson syndrome is a systemic, mucocutaneous disease, frequently related to drugs. We present the case of a 35-year old patient with a diagnosis of systemic lupus erythematous treated with prednisone who developed a Stevens-Johnson syndrome and was treated with methylprednisolone.

Bullous herpes zoster in a child with leukemia: case report and review of the literature

Blistering disorders in childhood are usually difficult to diagnose and pose complicated management dilemmas. The incidence of herpes zoster in children with malignancy and immunodeficiency is greatly increased compared to normal children of comparable age. Although herpes zoster is known to occur in children with malignancy, the bullous form of herpes zoster is rare; to the authors' knowledge, there was no previous report of this phenomenon in children in general and in children with cancer in particular. The authors describe a 3.5-year-old girl who was diagnosed with acute lymphoblastic leukemia; 7 months after presentation, during chemotherapy treatment, she developed the bullous form of herpes zoster on her right hand. The authors describe the method of diagnosis and provide a review of the literature concerning this rare phenomenon. Recognizing this entity and differentiating it from other bullomatous conditions enable the application of appropriate treatment, without unnecessary delay.

Levofloxacin-induced toxic epidermal necrolysis in an elderly patient

Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN) are mild-to-life-threatening adverse reactions that have been described after exposure to fluoroquinolones. No published reports, however, exist of exfoliative disease after treatment with levofloxacin. A 78-year-old woman with many medical problems, including chronic obstructive pulmonary disease, was treated with parenteral levofloxacin for community-acquired pneumonia. She was discharged with oral levofloxacin to complete an additional 3 days of treatment as an outpatient. Two days after completing this regimen, the patient developed a rash with blistering. The rash progressed to TEN in 7 days, and she was transferred to a burn treatment center. She was treated with fluid resuscitation, wound dressing, and antibiotics. Her condition improved, and she was discharged after 22 days. To our knowledge, this case is the first published report of levofloxacin-induced TEN.