[Hepatic and renal toxicity to fluindione (Previscan)]

DRESS syndrome with thrombotic microangiopathy revealing a Noonan syndrome: Case report

RATIONALE

The life-threatening drug rash with eosinophilia and systemic symptoms (DRESS) syndrome occurs most commonly after exposure to drugs, clinical features mimic those found with other serious systemic disorders. It is rarely associated with thrombotic microangiopathy.

PATIENT CONCERNS

We describe the unique case of a 44-year-old man who simultaneously experienced DRESS syndrome with thrombotic microangiopathy (TMA) after a 5 days treatment with fluindione.

DIAGNOSES

Clinical evaluation leads to the discovery of an underlying lymphangiomatosis, due to a Noonan syndrome.

INTERVETIONS

The anticoagulant was withdrawn, and corticosteroids (1 mg/kg/day) and acenocoumarol were started.

OUTCOMES

Clinical improvement ensued. At follow-up the patient is well.

LESSONS

The association of DRESS with TMA is a rare condition; we believe that the presence of the underlying Noonan syndrome could have been the trigger. Moreover, we speculate about the potential interrelations between these entities.

[Agranulocytosis related to fluindione: A case report]

INTRODUCTION

While in most countries warfarin is the preferred anti-vitamin K, fluindione, a molecule with a prolonged half-life remains largely prescribed in France. Some of its side effects, including immuno-allergic complications, remain poorly understood.

CASE REPORT

A 77-year-old woman presented with a febrile severe neutropenia of immunoallergic mechanism with a favourable outcome associated with fluindione, introduced 25 days earlier for the treatment of atrial fibrillation.

CONCLUSION

This rare side effect is a reminder of the importance of biological monitoring in the first weeks following the introduction of fluindione and key diagnostic elements and therapeutic aspects of iatrogenic agranulocytosis.

Fluindione and drug reaction with eosinophilia and systemic symptoms: an unrecognised adverse effect?

PURPOSE

Fluindione is an oral vitamin K antagonist (indanedione derivative) exclusively marketed in France and Luxembourg, known to have immuno-allergic adverse effects such as hepatitis, fever or interstitial nephritis. A few cases of drug reaction with eosinophilia and systemic symptoms (DRESS) have been reported with fluindione. The aim of the present study was to investigate fluindione-induced DRESS cases reported in France and to describe their characteristics.

METHODS

We searched for potential cases of DRESS with fluindione reported in the French pharmacovigilance database since 2000.

RESULTS

Thirty-six cases of DRESS were included and concerned 17 women and 19 men. The mean age was 65 years (median: 68 years, range: 28-95 years). Kidneys and liver were the most frequent organs involved. Thirty-five cases were serious. In 5 cases, the effect was life-threatening. Most of the patients recovered. Fluindione was the only medicine suspected in 26 cases. Skin patch tests, performed in 10 cases, were positive with fluindione in 9 cases.

CONCLUSIONS

Fluindione is not known to be a frequent cause of DRESS. However, the number of reports found is probably underestimated. The seriousness of DRESS, as all immuno-allergic adverse effects, contraindicates fluindione reintroduction. Coumarinic derivatives are the alternatives in patients who need oral anticoagulant treatment.