Serum sickness-like drug reaction: two cases with a neutrophilic urticarial pattern

Neutrophilic Urticarial Dermatosis: A Window into Systemic Inflammation and Autoimmune Disorders

Neutrophilic urticarial dermatosis (NUD) is a distinctive dermatological manifestation that is commonly associated with systemic autoinflammatory and autoimmune diseases. This review comprehensively explores NUD in the context of five major conditions: Schnitzler syndrome, Still's disease, cryopyrin-associated periodic syndrome, systemic lupus erythematosus, and VEXAS syndrome. For each condition, a detailed discussion of the underlying mechanisms, clinical presentations, diagnostic criteria, and treatment strategies is provided. In addition, cases exhibiting features similar to NUD are emphasized, with a comprehensive examination of the pathological characteristics, particularly focusing on neutrophilic epitheliotropism. This review underscores the significance of identifying NUD as a potential indicator of systemic autoimmune disorders and discusses the role of skin biopsy and laboratory tests in diagnosing the underlying etiology. Finally, a diagnostic framework for NUD is proposed, highlighting the importance of a multidisciplinary assessment to ascertain the underlying systemic condition responsible for the dermatological manifestations. The objective of this review is to enhance the comprehension of NUD, thereby facilitating early diagnosis and the implementation of targeted strategies for affected patients.

Serum Sickness-Like Reactions Clinical Characteristics and Management: A Systematic Review

BACKGROUND

Serum sickness-like reaction (SSLR) is an adverse reaction mainly to drugs, infectious agents, or vaccines, characterized by the presence of rash, arthralgia, or arthritis and occasionally fever.

OBJECTIVE

This systematic review aimed to analyze the clinical characteristics, implicated agents, symptomatology, and management of SSLR.

METHODS

We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Case reports and case series were included owing to the paucity of data in the literature on SSLR. We performed a comprehensive search of Embase and MEDLINE. Data extracted included age, comorbidities, medication exposure, time to reaction, symptoms, diagnostic criteria, and treatment modalities. Descriptive statistics were employed to summarize the data. We used χ2 test was used to compare categorical variables between adults and children.

RESULTS

A total of 44 studies involving 468 patients were included. Antibiotics were more associated with SSLR in children than in adults (P < .01). β-Lactam antibiotics, particularly amoxicillin (72.1%), were the leading implicated agents. Dermatologic manifestations, primarily maculopapular rashes, were present in 100.0% of cases whereas joint symptoms occurred in 78.7%. Corticosteroids were effective in resolving symptoms in most cases.

CONCLUSIONS

Serum sickness-like reaction presents diagnostic challenges owing to overlapping symptoms with other drug reactions. β-Lactams are the most common implicated agents, particularly in pediatric populations. Systemic corticosteroids may provide relief, but standardized guidelines for diagnosis and management are needed. Further research is essential to clarify the pathophysiology and optimize treatment strategies for SSLR.

Delayed allergic reaction from bupropion in a 27-year-old male with MDD: A case report and literature review

Introduction

Bupropion is an antidepressant approved for the treatment of major depressive disorder (MDD), seasonal affective disorder, and smoking cessation. Nausea, headache, tremor, and insomnia are well-known adverse effects of this medication. Less well-recognized adverse effects include delayed allergic reactions, which, in some cases, can appear 2 or more weeks after bupropion initiation.

Case Report

A 27-year-old male with recurrent MDD was referred for medication treatment at an outpatient mental health clinic and prescribed bupropion XL. On day 28 of treatment, he reported significant improvement in depressive symptoms and the development of itchiness and urticaria on his extremities and back. Bupropion was tapered over the course of 7 days, and he was given cetirizine 10 mg daily. He was transitioned to venlafaxine treatment and experienced complete resolution of hives and pruritus.

Discussion

Despite published reports on bupropion causing delayed hypersensitivity reactions, there remains limited clinical recognition of this side effect, and the risk of underrecognition may be greater when the onset of the reaction is more than 2 weeks after bupropion initiation.

Conclusion

Bupropion can cause delayed hypersensitivity reactions, including delayed pruritis and urticaria. The risk may be highest in males aged 17 to 40 years and those with a history of allergic reactions.

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.

Case Report of Serum Sickness-like Reaction following the First Dose of the Chimpanzee Adenovirus-Vectored AstraZeneca COVID-19 Vaccine, ChAdOx1

Serum sickness-like reaction from serum sickness is critical. Serum sickness-like reaction has comparable symptoms to serum sickness, but their underlying pathophysiology is distinct. This delayed hypersensitivity response was first characterized as a drug-induced reaction and is uncommon in adults; it is more common in children. COVID-19 vaccinations are now being routinely given in the COVID-19 period, and adverse reactions to immunization have been recorded. We present a case of COVID-19 vaccination-induced serum sickness-like reaction which developed after receiving the first dose of AstraZeneca COVID-19 vaccine.

Bupropion in dermatology: A brief update

There is currently an interest in evaluating the role that antidepressants may play in the treatment of primary cutaneous disorders. It has been proposed that antidepressants could have anti-inflammatory effects, but the clinical relevance of this effect has not been adequately established. In the case of bupropion, evidence for its specific use in dermatologic conditions currently come only from a pilot study and a case report. While this level of evidence is unlikely to be sufficient to guide clinical practice, the authors of this brief update hope to sort the available information to serve as a guide and provide a structure for future research.

Cutaneous drug eruptions including serum sickness-like reaction, symmetrical drug-related intertriginous and flexural exanthema, and drug-induced lupus

Cutaneous manifestations of drug reactions are common yet vary widely in their appearance and degree of internal organ involvement. Serum sickness--like reactions, symmetrical drug-related intertriginous and flexural exanthem, granulomatous drug eruption, pseudolymphoma, and drug-induced lupus are medication-induced conditions with dermatologic presentations. Many of the conditions discussed are relatively rare but nonetheless demand our attention and understanding. Some of the conditions presented may be more likely encountered in the hospital setting, as is the case with serum sickness-like reactions and drug-induced lupus, whereas others may present to outpatient clinic for diagnosis. Given the similarities in clinical history of patients presenting with these conditions, an understanding of the clinical presentation, pathophysiology, culprit medications, histologic appearance, and serologic characteristics is warranted to correctly diagnose and manage these uncommon adverse reactions. We also discuss how to differentiate some of these conditions from more serious mimickers, as in the case of pseudolymphoma drug reaction mimicking a true lymphoma and drug-induced lupus mimicking acute systemic lupus erythematosus.

Clinical Phenotypes of Severe Cutaneous Drug Hypersensitivity Reactions

Drug hypersensitivity reactions are clinically heterogenous ranging from mild to severe. Most drug hypersensitivity reactions are accompanied by cutaneous manifestations. Fever, mucous membrane involvement, large blisters, facial oedema, pustulosis and visceral involvement are clinical features that lead to suspicion of severe adverse drug reactions. Severe cutaneous adverse drug reactions (SCARs) include Stevens-Johnson syndrome, toxic epidermal necrolysis, drug rash eosinophilia and systemic symptoms, acute generalized exanthematous pustulosis. Serum sickness like reactions, drug induced vasculitis and generalized bullous fixed drug eruptions are less severe clinical entities. SCARs are uncommon but associated with significant morbidity and mortality. Physician should be aware of specific red flags and danger signs to immediately identify these reactions. Immediate drug withdrawal is mandatory. Early diagnosis and appropriate treatment significantly affect the prognosis of the disease. The purpose of our review is to discuss clinical phenotypes of severe cutaneous drug hypersensitivity reactions.

Neutrophilic urticarial dermatosis: A review

Neutrophilic urticarial dermatosis (NUD) is a rare form of dermatosis. In clinical terms, it consists of a chronic or recurrent eruption comprising slightly elevated, pink to reddish plaques or macules. The elementary lesion lasts 24 to 48hours and resolves without leaving any residual pigmentation. Extra-cutaneous signs are common, particularly fever or arthralgia. At histopathology, the dermis contains dense neutrophilic interstitial infiltrate with leukocytoclasis, but without fibrinoid necrosis of vessel walls. NUD often occurs in a setting of underlying systemic disease. The most commonly associated diseases are adult-onset Still's disease, Schnitzler syndrome, lupus erythematosus and cryopyrin-associated periodic syndromes. Treatment of NUD depends on the clinical context. Dapsone and colchicine are often effective.