Quinidine-induced lupus erythematosus

Cutaneous Lupus Erythematosus: Review and Considerations for Older Populations

Though more common earlier in life, increasing attention is being focused on the development of cutaneous lupus erythematosus (CLE) in patients with advancing age. Studies show that CLE is more common in older populations than previously thought, and all CLE subtypes are possible in this group. Just like patients in the third or fourth decade of life, CLE may appear alongside or independent of systemic lupus erythematosus. Older populations manifesting CLE for the first time seem to have a lower risk of progression to systemic disease than younger peers, and are more commonly White. CLE must be carefully distinguished from other skin conditions that have a predilection for presentation in older populations, including rosacea, lichen planus, and other autoimmune conditions such as dermatomyositis or pemphigus/pemphigoid. It is thought that most CLE in older populations is drug-induced, with drug-induced subacute cutaneous lupus erythematosus being the most common subtype. Management of CLE in older patients focuses on eliminating unnecessary medications known to induce CLE, and otherwise treatment proceeds similarly to that in younger patients, with a few special considerations.

Diagnosis and classification of drug-induced autoimmunity (DIA)

Since sulfadiazine associated lupus-like symptoms were first described in 1945, certain drugs have been reported to interfere with the immune system and induce a series of autoimmune diseases (named drug-induced autoimmunity, DIA), exemplified by systemic lupus erythematosus (SLE). Among the drugs, procainamide and hydralazine are considered to be associated with the highest risk for developing lupus, while quinidine has a moderate risk, and all other drugs have low or very low risk. More recently, drug-induced lupus has been associated with the use of newer biological modulators, such as tumor necrosis factor (TNF)-alpha inhibitors and cytokines. In addition to lupus, other major autoimmune diseases, including vasculitis and arthritis, have also been associated with drugs. Because resolution of symptoms generally occurs after cessation of the offending drugs, early diagnosis is crucial for treatment strategy and improvement of prognosis. Unfortunately, it is difficult to establish standardized criteria for DIA diagnosis. Diagnosis of DIA requires identification of a temporal relationship between drug administration and the onset of symptoms, but the relative risk with respect to dose and duration for each drug has rarely been determined. DIA is affected by multiple genetic and environmental factors, leading to difficulties in establishing a list of global clinical features that are characteristic of most or all DIA patients. Moreover, the distinction between authentic DIA and unmasking of a latent autoimmune disease also poses challenges. In this review, we summarize the highly variable clinical features and laboratory findings of DIA, with an emphasis on the diagnostic criteria.

Drug-induced pleural disease

Drug-induced pleural disease in the form of pleural fibrosis or pleural effusions is a common but frequently overlooked toxic or allergic manifestation of usage of a particular class of drugs. A detailed history of drug intake will often unveil the cause for the pleural pathology. Discontinuation of the drug with or without the addition of steroid therapy may be helpful.

Drug-induced lupus

Drug-induced lupus is a syndrome resembling mild systemic lupus erythematosus which can complicate treatment with certain apparently unrelated therapies. The most common individual agents are procainamide and hydralazine. Drugs less frequently associated with the disease are chlorpromazine, isoniazid, methyldopa, penicillamine, quinidine and sulfasalazine. Whole drug groups have also been implicated, such as the anticonvulsants, beta-blockers, sulfonamides and some of the newer 'biological' agents. The syndrome is characterised by arthralgia, myalgia, pleurisy, rashes and fever in association with antinuclear antibodies in the serum. More serious features of idiopathic lupus such as nephritis and cerebral disease are rare in drug-induced disease. The pathogenesis is unknown but in some cases is thought to be due to interactions between the drug and DNA or histones, rendering them immunogenic. For the biological agents, including interferons and antibodies to tumour necrosis factor-alpha, it has been suggested that it is due to disruption of the cytokine network. Although extremely rare, recognition of drug-induced lupus is important because it reverts within a few weeks of stopping the drug. It is possible that understanding its pathogenesis may shed light on its more serious relative, systemic lupus erythematosus.

Quinidine-induced rheumatic syndromes

Quinidine is a commonly used antiarrhythmic agent that is rarely associated with rheumatologic toxicity. However, quinidine-induced lupus, antinuclear antibody negative lupus-like syndrome, polymyalgia rheumatica-like illness, muscle weakness, and isolated creatine phosphokinase elevation have all been reported. We present one case of quinidine drug-induced lupus and another of a quinidine-induced polymyalgia rheumatica-like illness, and review the English literature for rheumatologic toxicity due to quinidine. Prompt recognition of quinidine associated rheumatologic toxicity is important because discontinuation of the medication leads to rapid resolution of clinical symptoms.

Thiazide diuretics induce cutaneous lupus-like adverse reaction

One of the side effects reported in patients taking thiazide diuretics is photosensitivity. We report two patients who developed lupus-like skin lesions while taking thiazide diuretics. One patient developed erythematous scaling papules, patches and plaques on the upper extremities and trunk resembling subacute cutaneous lupus erythematosus. Histopathology of a skin biopsy from the trunk showed basal cell layer liquefaction and lichenoid interface changes suggestive of lupus erythematosus. The skin lesions resolved completely within two months of discontinuing thiazide therapy. The second patient developed multiple flesh colored urticarial plaques on the trunk one year after beginning thiazide therapy. Slight lichenoid interface changes were noted on a skin biopsy, along with dense mucin deposition in the papillary and deep dermis, suggestive of tumid lupus erythematosus. The skin lesions persisted despite discontinuing thiazide therapy, necessitating systemic corticosteroid treatment. Both patients had circulating anti-SSA/Ro autoantibodies and antinuclear antibodies. These two patients illustrate that thiazide diuretics may induce a cutaneous lupus erythematosus-like adverse reaction and production of anti-SSA/Ro autoantibodies as demonstrated by immunodiffusion, immunoblot and immunoprecipitation testing.

Autoantibodies associated with lupus induced by diverse drugs target a similar epitope in the (H2A-H2B)-DNA complex

IgG reactivity with the (H2A-H2B)-DNA complex, a subunit of the nucleosome, has been detected in many patients with lupus induced by procainamide and quinidine, but the similarity among the epitopes targeted by these antibodies in this heterogeneous patient group as well as the prevalence of this specificity in lupus induced by other drugs is unknown. Studies with histone-DNA complexes formed by sequential addition on a solid phase demonstrated that complexes containing single histones had negligible antigenicity, indicating that DNA stabilizes a protein epitope in the H2A-H2B dimer or that the complete epitope is generated by a surface feature involving H2A-H2B and DNA. F(ab')2 isolated from a patient with procainamide-induced lupus blocked greater than 90% of the anti-[(H2A-H2B)-DNA] reactivity in six of six sera from patients with lupus induced by procainamide, four of four quinidine-induced patients and in sera from patients with lupus induced by acebutolol, penicillamine, and isoniazid, but not methyldopa or auto-antibodies to the component macromolecules. Fab fragments purified from the IgG of two quinidine-induced lupus patients and patients with isoniazid- and procainamide-induced lupus retained 39% +/- 8% of their original IgG reactivity compared to 34 +/- 28% of the original anti-tetanus toxoid activity of Fab fragments in two of the same sera and two normal sera. These results indicate that anti-[(H2A-H2B)-DNA] does not require divalent antigen-antibody complexes for stability, and that the complete epitope is created by the monomeric, trimolecular histone-DNA complex. We conclude that despite their pharmacologic and chemical heterogeneity, many lupus-inducing drugs elicit near identical autoantibodies.

D-penicillamine-induced lupus erythematosus

We describe a patient who presented with polyarthritis, pleurisy, rash, and a positive antinuclear antibody result after 5 years of D-penicillamine therapy. D-penicillamine-induced antinuclear antibodies were mainly high-titer IgG directed against the (H2A-H2B)-DNA complex. Weak IgM activity with H1 and H2B was also observed. Withdrawal of D-penicillamine therapy resulted in improvement in clinical symptoms and gradual resolution of serologic abnormalities.

Acute lymphadenopathy complicating quinidine therapy

A patient is described with quinidine-induced acute lymphadenopathy syndrome proven by rechallenge of the drug. Serum markers for systemic lupus were negative.

Drug-induced rheumatic syndromes. Diagnosis, clinical features and management

In order to avoid inappropriate therapy and prolonged morbidity, it is important to recognise when a patient's rheumatic complaints are due to drugs. However, this is often difficult because of the large number of drugs that have been implicated and the diversity of clinical presentations. Arthropathy may be seen with several different syndromes, including drug-induced lupus erythematosus (DILE), serum sickness and gout. The most widely reported of these is DILE, which usually develops after some months or even years of drug therapy. While many authors do not specifically require their presence for the diagnosis of DILE, antinuclear antibodies have been detected in the great majority of reported patients with DILE, whatever the causative drug. In contrast, patients who develop arthropathy soon after commencing a drug rarely have antinuclear antibodies and appear to be distinct from patients with DILE. Apart from arthropathy, a number of other syndromes that appear to have an immunological basis may be induced by drugs. Cutaneous vasculitis is not uncommon and drugs are frequently considered to be the aetiological factor. Whether drugs may cause larger vessel systemic vasculitis is less certain. Rarely, polymyositis and scleroderma-like syndromes have been associated with drug therapy. Corticosteroid-induced osteoporosis is a complication of all the corticosteroid preparations that are widely used at present. However, the development of deflazacort, a so-called 'bone-sparing' steroid, has raised the possibility that the effect of corticosteroids on bone may be separable, at least in part, from the other actions of these drugs. Data have been conflicting with regard to whether there is a 'safe' dose of corticosteroid. Similarly, it is unclear whether prophylactic therapy with agents such as calcium, fluoride and vitamin D is beneficial. Nonetheless, recent findings suggest that approaches will be developed to minimise the risk of osteoporosis in patients who require corticosteroids. There are a number of other ways in which drugs may affect bones. Osteomalacia is a well-known but uncommon complication of treatment with anticonvulsants and occasionally other drugs. The mechanism probably relates to the induction of hepatic enzymes and the consequent increased metabolism of vitamin D in patients with borderline levels initially. Osteosclerosis may also result from drug therapy; usually with fluoride or retinol (vitamin A) and its analogues. With continued research, the true spectrum of drug-induced rheumatic syndromes should become more clearly defined.(ABSTRACT TRUNCATED AT 400 WORDS)

Methyldopa-induced systemic lupus erythematosus

Thirteen months after starting methyldopa therapy, a 55-year-old white male patient presented with a syndrome of hemolytic anemia, arthritis, photosensitivity, and a positive antinuclear antibody test result. Methyldopa-induced antinuclear antibodies were mainly IgG, directed against class H1 histones. Antibodies to native DNA and nonhistone proteins were not detected. Upon withdrawal of methyldopa therapy, and with a short course of prednisone and danazol therapy, the patient's symptoms and hemolytic anemia resolved. His clinical symptoms and serologic abnormalities returned to normal and remained negative after 2 years of followup.

Chronic ventricular arrhythmias: which drug for which patient?

Many agents, including a number of drugs recently approved by the Food and Drug Administration, are now available for the treatment of chronic ventricular arrhythmias. The so-called first-generation agents--quinidine, procainamide and disopyramide--have been used in large numbers of patients for many years, and the safety and efficacy profiles of these drugs are well established. The "second-generation" antiarrhythmic agents recently approved by the Food and Drug Administration offer promising new alternatives; however, their safety and efficacy profiles have yet to be confirmed for broad populations over extended periods of time. Although it is recognized that the choice of agent for treatment of a particular patient is a "therapeutic trial," with an unpredictable outcome of efficacy and adverse effects, certain "descriptors," such as patient age or co-existing medical conditions, are often helpful in determining which agent is most likely to be clinically effective, and which agents are most likely to produce adverse effects. When other medical conditions such as hepatic or renal failure are present, the appropriate choice of drug and dosage is required for optimal management of the arrhythmia and for prevention of overdosage, exacerbation of other medical problems and deleterious interactions. Combination therapy with multiple antiarrhythmic agents is often quite effective for increasing arrhythmia control without increasing adverse effects. However dosage modifications are often necessary when an antiarrhythmic drug is given in conjunction with another such agent, or with agents that also have electrophysiologic activity or modify metabolic or elimination functions. The following report is one clinician's approach for optimizing efficacy and minimizing toxicity while using the difficult class of drugs called antiarrhythmic agents. It will encourage the use of certain drugs before others, based on considerations of efficacy, safety, ease of administration, follow-up, and other factors.

Emergency treatment of tachyarrhythmias

The diagnosis, clinical aspects, and emergency treatment of the most common cardiac arrhythmias, including atrial flutter and fibrillation, paroxysmal supraventricular tachycardia, the Wolff-Parkinson-White syndrome, ventricular tachycardia, and torsades de pointes, are discussed. The use of the antiarrhythmic drugs most frequently utilized in clinical practice is described.

Quinidine induced lupus syndrome

Five patients with a lupus-like syndrome secondary to quinidine are described. Eleven other cases have previously been reported. The quinidine induced lupus syndrome is similar to that seen with procainamide and hydralazine treatment but occurs less frequently. The lower incidence may reflect a difference in the metabolism of quinidine. Quinidine should be considered as potentially responsible when multisystem disease appears in patients receiving this drug.