Bullous pemphigoid induced by cephalexin

Drug associated bullous pemphigoid: what's new?

Bullous pemphigoid (BP) is considered to be one of the most common autoimmune diseases affecting the skin. Drug associated BP (DABP) is a subset of BP that is caused by the ingestion of specific types of medications. Until this point more than 80 medications have been associated with this condition that only recently has started to be better described. DABP has a better clinical course and prognosis compared to that of idiopathic BP, especially when the suspected inciting medication is discontinued in a timely manner. Therefore, it is very important to obtain detailed medical histories from BP patients especially if they are receiving multiple medications and also to be vigilant for subtle, but important, indications in histopathological, ELISA and immunofluorescence findings as well as in the clinical manifestations of the disorder.

Bullous Pemphigoid Induced by Cefixime: A Rare Side Effect

Bullous pemphigoid (BP) is the most prevalent autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and manifests with pruritus and localized or, most commonly, generalized bullous lesions. Numerous studies have established the association between BP and oral antidiabetic agents, particularly dipeptidyl peptidase 4 (DPP4) inhibitors, diuretics, and certain antibiotics, notably levofloxacin and cephalexin. In this report, we present a case of an 85-year-old female who presented with diffuse vesicles and bullae on her trunk and extremities five days after completing a four-week course of cefixime for pyelonephritis. Clinical examination and histopathological analysis confirmed the diagnosis of BP. The patient responded well to topical and systemic corticosteroids. This article presents the first documented case of BP induced by cefixime and underscores the importance of considering medication-induced BP in elderly patients presenting with blistering eruptions.

The role of eosinophils in the differential diagnosis of inflammatory skin diseases

Eosinophils are known to be present in inflammatory skin diseases, but their diagnostic utility is not well established. Upon review of the published status of lesional eosinophils, several categories were identified. 1) Lesional eosinophils highly characteristic such that, in their absence, the pathologist may question the diagnosis. These include arthropod bite reactions and scabies, urticarial dermatitis, and other eosinophilic dermatoses. 2) Lesional eosinophils rare or absent, such that, in their presence, the pathologist may question the diagnosis. These include pityriasis lichenoides, graft versus host disease, and connective tissue disorders. 3) Lesional eosinophils variable and, while in some cases expected, are not required for diagnosis. These include drug reactions, atopic dermatitis and allergic contact dermatitis. 4) Lesional eosinophils variable and not expected but may be seen to a limited extent. These include lichen planus and psoriasis.

Association Between Medication Use and Bullous Pemphigoid: A Systematic Review and Meta-analysis

Importance

The association between the use of medications and the development of bullous pemphigoid (BP) is unclear.

Objective

To assess the associations between previous exposure to certain medications and BP.

Data Sources

For this systematic review and meta-analysis, PubMed, the Cochrane Central Register of Controlled Trials, and Embase were searched for relevant studies from inception to February 20, 2020.

Study Selection

Case-control or cohort studies and randomized clinical trials that examined the odds or risk of BP in patients with previous medication use were included. No geographic or language limitations were imposed.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guideline was followed. The Newcastle-Ottawa Scale was used to evaluate the risk of bias of included observational studies; Cochrane Collaboration's tool was used for randomized clinical trials. Aggregate data were used to conduct a random-effects model meta-analysis if the included studies were sufficiently homogenous. Subgroup analyses were performed for use of various medications of the same category.

Main Outcomes and Measures

Odds ratio (OR), hazard ratio, and risk ratio of bullous pemphigoid in association with medication use.

Results

This meta-analysis included 13 case-control studies, 1 cohort study, and 1 randomized clinical trial with a total of 285 884 participants. The meta-analysis of case-control studies showed a significant association of BP with previous use of aldosterone antagonists (pooled OR, 1.75; 95% CI, 1.28-2.40), dipeptidyl peptidase 4 inhibitors (pooled OR, 1.92; 95% CI, 1.55-2.38), anticholinergics (pooled OR, 3.12; 95% CI, 1.54-6.33), and dopaminergic medications (pooled OR, 2.03; 95% CI, 1.34-3.05). One cohort study found an increased risk of BP among patients receiving dipeptidyl peptidase 4 inhibitors (hazard ratio, 2.38; 95% CI, 1.16-4.88; P = .02). One trial found a higher occurrence of BP in patients with diabetes receiving linagliptin (0.2% in diabetes group vs 0% in the placebo group).

Conclusions and Relevance

The findings of this systematic review and meta-analysis suggest that aldosterone antagonists, dipeptidyl peptidase 4 inhibitors, anticholinergics, and dopaminergic medications are associated with BP. These medications should be judiciously prescribed, particularly in high-risk patients who are elderly and have disabling neurologic disorders.

Neutrophil-predominant bullous pemphigoid induced by checkpoint inhibitors: A case series

Checkpoint inhibitors have been revolutionary in the treatment of metastatic melanoma, non-small-cell lung cancer, and renal cell carcinoma. By restricting negative feedback of T-cells, checkpoint inhibitors allow the immune system to identify and destroy malignant cells. This enhanced immune response is efficacious in the treatment of the aforementioned malignancies; however, it may lead to immune-related adverse events. Bullous pemphigoid (BP) is a well-documented cutaneous adverse reaction of checkpoint inhibitors, with a majority of cases reporting an eosinophil-predominant or mixed inflammatory infiltrate. We report two cases of neutrophil-predominant BP presenting in patients on checkpoint inhibitors.

Drug-induced skin reactions: a pathologist viewpoint

Cutaneous drug reactions are common adverse effects that occur in about 2-3% of the hospitalized patients. They have both immunologic and non-immunologic underlying mechanisms. These reactions are clinically and histologically similar to dermatoses. Their significant clinical indicators include: history of drug intake, atypical clinical features and improvement after cessation of the offending drugs. Their diagnostic histological clues include the presence of mixed histological patterns, apoptotic keratinocytes, eosinophils (dermis and epidermis), papillary dermal edema and extravasations of erythrocytes. However, no single clinical or histological feature is specific of drug eruptions. This work attempts to classify the histomorphologic reactions to various drugs in defined categories for assistance in morphologic diagnosis.

Bullous pemphigoid: etiology, pathogenesis, and inducing factors: facts and controversies

The term pemphigoids includes a group of autoimmune bullous diseases characterized by subepidermal blistering. Bullous pemphigoid (BP) is not only the most common disorder within the pemphigoid group, but also represents the most frequent autoimmune blistering disease in general. The onset and course of BP depend on a variable interaction between predisposing and inducing factors. HLA genes are the most significant genetic predisposition factor to autoimmunity mechanisms. Many studies show an association between HLA-DQβ1*0301 and distinct clinical pemphigoid variants. Imbalance between autoreactive T helper (Th) and T regulatory cells, toll-like receptor activation, and Th17/IL-17 pathway are the three possible autoimmunity triggers underlying BP. The pathomechanism of BP hinges on an autoantibody response toward structural components of the hemidesmosome (BP180 and BP230). The binding of autoantibodies leads to complement activation, recruitment of inflammatory cells, and release of proteolytic enzymes. The inflammatory cascade also may be directly triggered by activation of Th17 cells with no intervention of autoantibodies. The intervention of inducing factors in BP can be identified in no more than 15% of patients. Facilitating factors in genetically predisposed individuals are various (drug intake, physical agents, and viral infections). Drugs may act as triggers by either modifying the immune response or altering the antigenic properties of the epidermal basement membrane. Cases of induction of BP by physical agents (eg, radiation therapy, ultraviolet radiation, thermal or electrical burns, surgical procedures, transplants) are rare, but well-documented events. A contributing role in inducing BP has been suggested for infections, in particular human herpes virus (HHV) infections (cytomegalovirus, Epstein-Barr virus, and HHV-6), but also hepatitis B and C viruses, Helicobacter pylori, and Toxoplasma gondii. Unlike pemphigus, no dietary triggers have been suspected of being involved in the induction of BP. In all patients who have a diagnosis of BP, an environmental agent as a potential cause should always be considered, because the prompt discontinuation of it might result in rapid improvement or even cure of the disease.

Medication history of a series of patients with bullous pemphigoid from northern Greece - observations and discussion

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune bullous disease that mainly affects elderly patients. In this retrospective study, in a series of patients with BP, data on systemic medications were collected in order to investigate a possible association with active BP.

METHODS

Thirty-four patients with BP were studied in two groups. Group A contained patients who were receiving systemic medications and group B contained patients receiving no medications. All sera were examined by immunoassay for the possible existence of anti-BP180NC16a and anti-BP230, prior to the initiation of steroid treatment.

RESULTS

Patients were of a similar age in both groups (P = 0.07). Anti-BP180NC16a autoantibodies were detected in 80% of patients in group A and in 14% of patients in group B. Anti-BP230 autoantibodies were detected in 25% of patients in group A and in 50% of patients in group B. Levels of circulating anti-BP180NC16a autoantibodies were statistically significantly higher in group A than in group B (P = 0.04).

CONCLUSIONS

Patients who were receiving systemic medications seemed to be more susceptible to the development of BP. Should we consider drug exposure as one of the reasons for the increased prevalence of BP in the elderly? It is important to be more vigilant with this category of patients in order to provide an early diagnosis of the disease.

A rare cause of acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (AUGB) remains a common indication for admissions and is associated with significant morbidity and mortality. Peptic ulcer diseases and varices are the commonest lesions identified during endoscopy. However, endoscopists need to be aware of the rare causes of AUGB, as missing such lesions can potentially be fatal. Rare causes can be missed if they are not looked for systematically during endoscopy. We report a case of AUGB secondary to bullous pemphigoid involving the esophagus in an elderly gentleman presenting with significant blood loss from hematemesis. A review of the English literatures on bullous pemphigoid involvements of the esophagus was carried out and the underlying pathogenesis and management are discussed.