Stevens-Johnsons syndrome or drug-induced lupus - a clinical dilemma: A case report and review of the literature

An Unusual Presentation of Cutaneous Bullous Lupus

Drug-induced lupus erythematosus (DILE) is an autoimmune reaction that results in symptoms of polyarthralgia, fever, and cutaneous lesions and other manifestations. Several drugs have been documented to cause this disease, including procainamide, isoniazid, methyldopa, penicillamine, and hydralazine. Systemic lupus erythematosus (SLE) manifestations often occur after the patient has been taking the drug without complications for months to years. Hydralazine, an oral antihypertensive drug, is a well-known cause of DILE; however, clinical presentation is generally limited to classic SLE symptoms such as malar or discoid rash and polyarthralgia. In this case, we will discuss a 75-year-old female patient with actively bleeding oral, nasal, and conjunctival ulcers of unknown origin, eventually found to have bullous lupus erythematosus while on hydralazine for several years. Bullous lupus erythematosus is a rare cutaneous manifestation of SLE that presents with blister-type lesions in patients with a history of SLE. Histologically, bullous lupus erythematosus is characterized by marked epidermal and dermal inflammation, and an inflammatory infiltrate that consists primarily of neutrophils at the base of the bullae. Although hydralazine has been implicated in DILE, it is very rarely noted to have a bullous lupus erythematosus presentation. Given the acuity of patient's presentation and resolution with cessation of hydralazine, it was concluded that hydralazine was the main contributing factor for this patient's multiple hemorrhagic bullous lupus erythematosus lesions.

Toxic Epidermal Necrolysis after COVID-19 mRNA-1237 Vaccination

This letter illustrates a case of toxic epidermal necrolysis (TEN) after COVID-19 mRNA-1273 vaccination, which corresponds with the existing published data and contributes detailed knowledge of TEN reaction after vaccination. Interestingly, the reaction started at the site of vaccination and the patient went on to tolerate a major excipient of the vaccine suggesting the reaction may be associated with the mRNA itself or is triggered by the immunostimulatory action of the vaccine.

İlaç alerjisi olan hastalarda otoantikor sıklığı

Giriş: Bu çalışma, ilaç alerjisi olan hastalarda otoantikor sıklığını incelemeyi amaçlamaktadır. İlaç alerjisi üzerine gözlemsel araştırmalar, otoimmünite patofizyolojisi hakkında yeni hipotezlerin oluşturulmasına katkıda bulunabilir.Yöntem: Eğitim ve Araştırma Hastanesi veri tabanına 31 Aralık 2018 sonuna kadar kayıt olan ve ilaç alerjisi tanısı konan hastaların verileri geriye dönük olarak değerlendirildi. Genel olarak, ICD 10'a göre “ilaçlara alerji durumu” tanısı konan ve en az bir otoantikor sonucu olan 617 adet yetişkin hasta çalışmaya dahil edildi.Bulgular: Araştırmada en az bir otoantikora sahip olma sıklığı % 0 ile % 92,1 arasında değişti. En sık saptanan otoantikor romatoid faktör (RF) idi (n = 241; % 92,1). İkinci en sık rastlanan oto antikorun anti-doku transglütaminaz IgA (Anti-tTG-IgA) (n = 22; % 68,2) olduğu görüldü. Anti-tiroglobulin (Anti-TG), anti-tiroid peroksidaz (anti-TPO) ve anti-çift sarmallı DNA (Anti-dsDNA) sıklıkları sırasıyla % 65,2 (n = 155), % 59,7 (n = 159) ve % 43,6 (n = 55) olarak saptandı.Sonuç: Birçok ilaç, otoimmün hastalıkları için ilerleme olmaksızın otoantikor gelişimini tetikleyebilir. İlaçlara alerjisi olan hastalarda otoantikorlardan şüphelenilmesi gereklidir. İlaç alerjisi üzerine yapılan gözlemsel araştırmalar, otoimmünitenin patofizyolojisi hakkında yeni hipotezlerin oluşturulmasına katkı sağlayacaktır. Bu alanda yapılacak çok sayıda çalışma, riskli ilaçların yaygın kullanımını daha objektif bir şekilde tartışmamızı sağlayabilir. Çalışmamızın ilaç reaksiyonu ile otoimmün hastalıklar arasındaki ilişkiye ışık tutacağını düşünüyoruz.Anahtar kelimeler: Otoantikorlar, otoimmünite, ilaç alerjisi, ilaç aşırı duyarlılığı

A Life-Threatening Case of Torsemide-Induced Toxic Epidermal Necrolysis Associated With the Treatment of Anasarca

Toxic Epidermal Necrolysis (TEN), along with Stevens-Johnson Syndrome (SJS), are rare, life-threatening delayed type IV hypersensitivity mucocutaneous skin disorders that can often be precipitated by medications. The most common culprits are sulfonamide antibiotics and various antiseizure medications. We report a case of a 41-year-old Black female that initially presented with SJS, which then rapidly progressed to TEN, confirmed by hematoxylin and eosin stain skin biopsies. Approximately 80% of her body surface area had necrosis and epidermal detachment lesions. It was concluded that TEN was caused by the use of torsemide for treatment of her underlying diffuse anasarca attributable to alcoholic cirrhosis. During her one-month hospital stay, a multi-disciplinary team consisting of dermatology, gynecology, rheumatology, nephrology, and infectious disease evaluated and treated the patient. Interventions included various supportive care measures as well as intravenous steroids, cyclosporine, plasma exchange, and intravenous immunoglobulin. Given that the mortality rate for TEN is over 30%, and this patient had end-stage cirrhosis, her prognosis was extremely poor. Even though her TEN eventually healed slowly, the patient experienced complications. This case demonstrates the importance of cautiously using sulfonamide medications in patients with known hypersensitivity to sulfa drugs.