Fatal reaction to dapsone during treatment of leprosy

Novel approaches in the treatment of Hansen's disease (Leprosy): a case series of multidrug therapy of monthly rifampin, moxifloxacin, and minocycline (RMM) in the United States

The World Health Organization (WHO) recommends multidrug therapy (MDT) for the treatment of paucibacillary and multibacillary forms of leprosy, also known as Hansen's disease (HD). MDT combinations of dapsone, rifampin, and clofazimine have reduced the prevalence of the disease but are not without adverse effects impacting regimen adherence. Hence, an urgent need exists to consider alternative MDT regimens with an improved safety profile that promotes treatment adherence. Herein, we described a case series of 10 patients with HD (nine patients with multibacillary leprosy and one with pure neural leprosy) treated with monthly rifampin, moxifloxacin, and minocycline (RMM). The United States National Hansen's Disease Program (NHDP) diagnosed and treated patients across US institutions. All patients received a regimen of 12-24 months of RMM. We reviewed the clinical outcomes, adherence, rate of completion, and adverse events of patients treated with monthly RMM from January 2019 to August 2022. Nine patients had multibacillary leprosy, with some having type-2 reactions. One patient had pure neural leprosy with a reversal reaction. In this case series, we identified that all patients completed the RMM regimen without treatment interruptions. None of the patients experienced any skin hyperpigmentation or any significant side effects. All patients tolerated the monthly RMM regimen with rapid improvement of skin lesions and without logistic hurdles. Based on previous clinical evidence and the results of this case series, the NHDP and other programs should consider the RMM regimen as first-line therapy.

Dapsone hypersensitivity syndrome in an adolescent during treatment during of leprosy

A 12 y old girl was admitted 24 days after start a WHO multidrug therapy scheme for multibacillary leprosy (dapsone, clofazimine and rifampicin) with intense jaundice, generalized lymphadenopathy, hepatoesplenomegaly, oral erosions, conjunctivitis, morbiliform rash and edema of face, ankles and hands. The main laboratory data on admission included: hemoglobin, 8.4 g/dL; WBC, 15,710 cells/mm³; platelet count, 100,000 cells/mm³; INR = 1.49; increased serum levels of aspartate and alanine aminotransferases, gamma-glutamyl transpeptidase, alkaline phosphatase, direct and indirect bilirubin. Following, the clinical conditions had deteriorated, developing exfoliative dermatitis, shock, generalized edema, acute renal and hepatic failure, pancytopenia, intestinal bleeding, pneumonia, urinary tract infection and bacteremia, needing adrenergic drugs, replacement of fluids and blood product components, and antibiotics. Ten days after admission she started to improve, and was discharged to home at day 39th, after start new supervised treatment for leprosy with clofazimine and rifampicin, without adverse effects. This presentation fulfils the criteria for the diagnosis of dapsone hypersensitivity syndrome (fever, generalized lymphadenopathy, exfoliative rash, anemia and liver involvement with mixed hepatocellular and cholestatic features). Physicians, mainly in geographical areas with high prevalence rates of leprosy, should be aware to this severe, and probably not so rare, hypersensitivity reaction to dapsone.

Dapsone induced cholangitis as a part of dapsone syndrome: a case report

BACKGROUND

Dapsone can rarely cause a hypersensitivity reaction called dapsone syndrome, consisting of fever, hepatitis, exfoliative dermatitis, lymphadenopathy and hemolytic anemia. Dapsone syndrome is a manifestation of the DRESS (drug rash with eosinophilia and systemic symptoms) syndrome which is a serious condition that has been reported in association with various drugs. Cholangitis in dapsone syndrome has not been reported so far in the world literature.

CASE PRESENTATION

We report a patient who presented with fever, exfoliative dermatitis, jaundice and anemia within three weeks of starting of dapsone therapy. These features are typical of dapsone syndrome, which is due to dapsone hypersensitivity and is potentially fatal. Unlike previous reports of hepatitic or cholestatic injury in dapsone syndrome we report here a case that had cholangitic liver injury. It responded to corticosteroids.

CONCLUSION

We conclude that cholangitis, though unusual, can also form a part of dapsone syndrome. Physicians should be aware of this unusual picture of potentially fatal dapsone syndrome.

Dapsone-induced sulfone syndrome

OBJECTIVE

To report a patient with dapsone-induced sulfone syndrome.

CASE SUMMARY

A 42-year-old HIV-infected African American man developed fever, lymphadenopathy, exfoliative dermatitis, hepatitis, and methemoglobinemia 4 weeks after starting dapsone. Complete resolution of symptoms and laboratory abnormalities occurred with cessation of dapsone therapy.

DISCUSSION

Sulfone syndrome is not a well-known sequela of dapsone therapy. It is not dose-related, usually occurs in doses of 50-300 mg/d, all cases occur within 2 months of starting dapsone, all patients have fever, and most patients will develop rash and evidence of hepatic injury. The temporal relationship between dapsone therapy and onset of clinical symptoms and objective data led us to believe that dapsone caused sulfone syndrome in our patient. An objective causality assessment revealed that the adverse drug event was probable.

CONCLUSIONS

Although sulfone syndrome appears to be relatively uncommon, healthcare practitioners must be aware of the potentially fatal syndrome associated with dapsone use.

Clinical presentation and outcome of brown recluse spider bite

STUDY OBJECTIVE

To examine the clinical presentation and outcome of patients treated in the ED or toxicology clinic for suspected brown recluse spider bites.

METHODS

We assembled a retrospective case of patients at a southeastern US university hospital. Our study group comprised 111 patients with suspected brown recluse spider bites treated during a 30-month period. Our main outcome measures were the need for skin grafting and the development of other complications.

RESULTS

The mean age of our subjects was 34 +/- 17 years. Thirteen patients (12%) brought the spider to the hospital, 22 (20%) saw a spider at the time of the bite, and an exclusively clinical diagnosis was made in the remaining 76 (68%). Most wounds (59%) involved the leg. At the time of presentation, 81% had central discoloration and 37% necrosis. Sixteen patients (14%) were systemically ill, and 6 (5%) were admitted to the hospital. Most (86%) were treated with antibiotics. Dapsone was infrequently used (9%) and had usually been prescribed before the patient's presentation to our ED. Only three patients (3%; 95% confidence interval, 1% to 8%) required grafting. Mild hemolytic anemia developed in one patient, and another had mild hemolysis and a mild coagulopathy; neither patient was taking dapsone. No deaths or serious complications occurred in our study group.

CONCLUSION

In our series, long-term outcome after brown recluse spider bite was good. Serious complications were rare, as was the need for skin grafting. Because the vast majority of bites heal with supportive care alone, aggressive medical therapy does not appear warranted.

Dapsone in rheumatoid arthritis

Dapsone, a synthetic sulfone with chemical similarities to sulfapyridine, has been used for a number of years to treat leprosy and dermatitis herpetiformis. Recently, a number of prospective, randomized, double-blind trials have shown their success in the management of rheumatoid arthritis, with dapsone being superior to placebo and comparable to chloroquine and hydroxychloroquine. Its mode of anti-inflammatory actions in rheumatoid arthritis is not clearly understood, but modulation of neutrophil activity or inhibition of neutrophil inflammatory product formation or release appear to play a role. The major limiting side effect is hemolytic anemia, which may be mitigated through careful patient selection, conservative drug dosing, close monitoring, and possibly, concurrent administration of antioxidants or cytochrome P450 inhibitors. Methemoglobinemia is another common finding among patients receiving dapsone therapy, but rarely does it result in prominent symptoms other than transient pallor. Less common adverse events to dapsone include the idiosyncratic reactions of leukopenia and agranulocytosis, cutaneous eruptions, peripheral neuropathy, psychosis, toxic hepatitis, cholestatic jaundice, nephrotic syndrome, renal papillary necrosis, severe hypoalbuminemia without proteinuria, an infectious mononucleosis-like syndrome, and minor neurological and gastrointestinal complaints. In this report, two patients with advanced rheumatoid arthritis, who were safely and effectively treated with dapsone after failure with other second-line agents, are described and the literature is reviewed. We suggest that dapsone is an effective second-line agent in the treatment of rheumatoid arthritis.

Dapsone-induced aplastic anemia in a woman with bullous systemic lupus erythematosus

Aplastic anemia developed in a black woman who was receiving dapsone therapy for bullous systemic lupus erythematosus. Aplastic anemia is an uncommon adverse hematologic effect in patients treated with dapsone, the pathogenesis of which remains unknown. To our knowledge, dapsone-induced aplastic anemia has been previously reported in only four patients; the characteristics of their cases are described herein. Conservative monitoring of hematologic variables may alert clinicians to the early stages of this rare drug reaction.

Monitoring for adverse effects from systemic drugs used in dermatology

Systemic drugs with an associated element of risk are essential in managing many important dermatoses. This review identifies eight major drugs or drug groups used in dermatology that require systematic monitoring for adverse effects. The complete monitoring process is emphasized, including significant patient involvement in reporting key signs or symptoms that allow early diagnosis of many of these adverse effects. The concepts of "risk-risk" assessment and "critical toxicities" are defined, emphasizing their important role in maximizing drug benefits and safety. Drug-related risk factors, disease-specific risk factors, and patient characteristics or habits that increase the risks from systemic drugs are identified. Basic principles of monitoring for adverse effects, specific clinical features of the most important adverse effects, along with detailed monitoring guidelines for methotrexate, retinoids, dapsone, corticosteroids, and cyclosporine are presented.

The role of leukocyte-generated reactive metabolites in the pathogenesis of idiosyncratic drug reactions

Evidence strongly suggests that many adverse drug reactions, including idiosyncratic drug reactions, involve reactive metabolites. Furthermore, certain functional groups, which are readily oxidized to reactive metabolites, are associated with a high incidence of adverse reactions. Most drugs can probably form reactive metabolites, but a simple comparison of covalent binding in vitro is unlikely to provide an accurate indication of the relative risk of a drug causing an idiosyncratic reaction because it does not provide an indication of how efficiently the metabolite is detoxified in vivo. In addition, the incidence and nature of adverse reactions associated with a given drug is probably determined in large measure by the location of reactive metabolite formation, as well as the chemical reactivity of the reactive metabolite. Such factors will determine which macromolecules the metabolites will bind to, and it is known that covalent binding to some proteins, such as those in the leukocyte membrane, is much more likely to lead to an immune-mediated reaction or other type of toxicity. Some reactive metabolites, such as acyl glucuronides, circulate freely and could lead to adverse reactions in almost any organ; however, most reactive metabolites have a short biological half-life, and although small amounts may escape the organ where they are formed, these metabolites are unlikely to reach sufficient concentrations to cause toxicity in other organs. Many idiosyncratic drug reactions involve leukocytes, especially agranulocytosis and drug-induced lupus. We and others have demonstrated that drugs can be metabolized by activated neutrophils and monocytes to reactive metabolites. The major reaction appears to be reaction with leukocyte-generated hypochlorous acid. Hypochlorous acid is quite reactive, and therefore it is likely that many other drugs will be found that are metabolized by activated leukocytes. Some neutrophil precursors contain myeloperoxidase and the NADPH oxidase system, and it is likely that these cells can also oxidize drugs. Therefore, although there is no direct evidence, it is reasonable to speculate that reactive metabolites generated by activated leukocytes, or neutrophil precursors in the bone marrow, could be responsible for drug-induced agranulocytosis and aplastic anemia. This could involve direct toxicity or an immune-mediated reaction. These mechanisms are not mutually exclusive, and it may be that both mechanisms contribute to the toxicity, even in the same patient. In the case of drug-induced lupus, a prevalent hypothesis for lupus involves modification of class II MHC antigens.(ABSTRACT TRUNCATED AT 400 WORDS)

Drug metabolism by leukocytes and its role in drug-induced lupus and other idiosyncratic drug reactions

This review presents a unifying hypothesis that provides a connection between several types of hypersensitivity reactions associated with several types of drugs and explains some of the therapeutic effects (antiinflammatory activity and antithyroid effects) of these same drugs. This hypothesis centers on the oxidation of these drugs to chemically reactive metabolites by peroxidases. The drugs of interest have functional groups that are easily oxidized. The major peroxidase involved in this hypothesis is MPO because of its critical location in leukocytes which play a key role in the function of the immune system. However, thyroid peroxidase can probably also oxidize many of the same drugs to reactive metabolites, and this may be responsible for the thyroid autoimmunity observed in connection with some hypersensitivity reactions. Peroxidases have also been described in the skin and in platelets, and their presence may be responsible for the high incidence of skin reactions in the hypersensitivity response and the occurrence of immune-mediated thrombocytopenia, respectively. Involvement of other peroxidases, such as prostaglandin peroxidase, may also be important for antiinflammatory effects of drugs. In addition, leukocytes contain prostaglandin synthetase, and the activation of leukocytes leads to the release of arachidonic acid and the production of prostaglandins. This process may also lead to the metabolism of drugs to reactive metabolites. In studies of the metabolism of procainamide and dapsone, aspirin and indomethacin did not inhibit the formation of the hydroxylamine by neutrophils and mononuclear leukocytes. This is evidence against the involvement of prostaglandin synthetase in these oxidation; however, preliminary studies with other drugs suggest that prostaglandin synthetase may contribute to the metabolism of some drugs by leukocytes. Furthermore, the metabolism of phenylbutazone, phenytoin, and tenoxicam, as well as our preliminary work with other drugs such as carbamazepine, suggests that the range of drugs that are metabolized to reactive metabolites by peroxidases may be broader than initially suspected. There are several other drugs that do not fit into the functional group classes covered in this review but have similar properties. A good example is alpha-methyldopa, which is associated with drug-induced lupus, immune-mediated hemolytic anemia, and other hypersensitivity reactions. Such drugs may also be metabolized to reactive metabolites by peroxidases. Another aspect of the hypothesis is that an infection, or other inflammatory condition, may be an important risk factor for a hypersensitivity reaction because such a stimulus leads to activation of leukocytes which can lead to formation of reactive metabolites from certain drugs.(ABSTRACT TRUNCATED AT 400 WORDS)

Idiosyncratic drug reactions: possible role of reactive metabolites generated by leukocytes

Idiosyncratic drug reactions represent a poorly understood problem with serious medical implications. Many idiosyncratic drug reactions appear to be hypersensitivity reactions that involve an immune mechanism. The initiating step appears to involve the formation of a chemically reactive metabolite which can act as a hapten. Although the major site of drug metabolism is the liver, we have found that leukocytes, which contain myeloperoxidase and can generate hydrogen peroxide when stimulated, can also generate reactive metabolites. This has obvious implications for such idiosyncratic reactions as agranulocytosis. Furthermore, because of the importance of monocytes in the processing of antigen and the presentation of antigen to T lymphocytes in the initiation of an immunological reaction, formation of reactive metabolites by monocytes may also have implications for other idiosyncratic reactions such as drug-induced lupus and generalized idiosyncratic reactions.

Case report: dapsone hypersensitivity syndrome associated with treatment of the bite of a brown recluse spider

Dapsone (4-4-diaminodiphenyl-sulfone) is a member of the sulfone group of antibiotics used in the treatment of leprosy and various dermatitidies and more recently employed in the management of local reactions to the bite of the brown recluse spider, Loxosceles reclusa. A dapsone hypersensitivity syndrome, consisting of fever, headache, nausea, vomiting, lymphadenopathy, hepatitis, hemolysis, leukopenia, and mononucleosis, has been described in patients treated with the drug for leprosy. A case report of the hypersensitivity syndrome occurring in a patient being treated with dapsone for a brown recluse spider bite is presented.