Hyperpigmentation, neutrophilic alveolitis, and erythema nodosum resulting from minocycline

Minocycline-induced hyperpigmentation in multibacillary leprosy

Minocycline has been used in the treatment of leprosy since the demonstration of its efficacy in inhibiting Mycobacterium leprae growth in 1987. Hyperpigmentation, a well-documented adverse effect, classically shows 3 clinical and histological patterns: type I consists of blue-black pigmentation in areas of current or previous inflammation, type II consists of blue-gray pigmentation of normal skin, often seen on the legs, and type III consists of diffuse muddy-brown pigmentation accentuated on sun-exposed sites. Whereas type I hyperpigmentation stains positively for hemosiderin and type III hyperpigmentation stains positively for melanin, type II hyperpigmentation stains positively for both. We describe 2 patients with leprosy on minocycline therapy who developed multiple patches of blue-gray pigmentation within preexisting leprosy lesions. Biopsies from both patients demonstrated deposition of brownish-black pigment granules within the cytoplasm of foamy histiocytes that was highlighted by both Perls and Fontana-Masson stains. Given the clinical and histological findings in our patients, it is as yet unclear whether this coexistent type I clinical pattern and type II histopathologic pattern of pigmentation is unique to multibacillary leprosy. These findings provide support for the existence of additional subtypes of minocycline-induced hyperpigmentation that do not adhere to the classic 3-type model described.

Erythema Nodosum

Erythema nodosum is the most frequent clinicopathologic variant of panniculitis. The process is a cutaneous reaction that may be associated with a wide variety of disorders, including infections, sarcoidosis, rheumatologic diseases, inflammatory bowel diseases, medications, autoimmune disorders, pregnancy, and malignancies. Erythema nodosum typically manifest by the sudden onset of symmetrical, tender, erythematous, warm nodules and raised plaques usually located on the lower limbs. Often the lesions are bilaterally distributed. At first, the nodules show a bright red color, but within a few days they become livid red or purplish and, finally, they exhibit a yellow or greenish appearance, taking on the look of a deep bruise. Ulceration is never seen, and the nodules heal without atrophy or scarring. Histopathologically, erythema nodosum is the stereotypical example of a mostly septal panniculitis with no vasculitis. The septa of subcutaneous fat are always thickened and variously infiltrated by inflammatory cells that extend to the periseptal areas of the fat lobules. The composition of the inflammatory infiltrate in the septa varies with age of the lesion. In early lesions edema, hemorrhage, and neutrophils are responsible for the septal thickening, whereas fibrosis, periseptal granulation tissue, lymphocytes, and multinucleated giant cells are the main findings in late stage lesions of erythema nodosum. A histopathologic hallmark of erythema nodosum is the presence of the so-called Miescher's radial granulomas, which consist of small, well-defined nodular aggregations of small histiocytes arranged radially around a central cleft of variable shape. Treatment of erythema nodosum should be directed to the underlying associated condition, if identified. Usually, nodules of erythema nodosum regress spontaneously within a few weeks, and bed rest is often sufficient treatment. Aspirin, nonsteroidal antiinflammatory drugs, such as oxyphenbutazone, indomethacin or naproxen, and potassium iodide may be helpful drugs to enhance analgesia and resolution. Systemic corticosteroids are rarely indicated in erythema nodosum and before these drugs are administered an underlying infection should be ruled out.

Safety of doxycycline and minocycline: a systematic review

OBJECTIVE

The goal of this review was to summarize the available literature covering the safety profiles of oral doxycycline and minocycline.

METHODS

Scientific literature published between 1966 and August 2003 was searched using the MEDLINE, EMBASE, and Biosis databases (search terms: minocycline or doxycycline, each paired with adverse reaction, adverse event, and side effect, and doxycycline or minocycline with the limits English language, human, and clinical trials). Safety information was collected from case reports and clinical trials. Adverse event (AE) rates in the United States were calculated by comparing data from the MedWatch AE reporting program used by the US Food and Drug Administration (FDA) with the number of new prescriptions dispensed for each drug from January 1998 to August 2003.

RESULTS

Between 1966 and 2003, a total of 130 and 333 AEs were published in case reports of doxycycline and minocycline, respectively. In 24 doxycycline clinical trials (n = 3833) and 11 minocycline trials (n = 788), the ranges in incidence of AEs were 0% to 61% and 11.7% to 83.3%, respectively. Gastrointestinal AEs were most common with doxycycline; central nervous system and gastrointestinal AEs were most common with minocycline. From January 1998 to August 2003, the FDA MedWatch data contained 628 events for doxycycline and 1099 events for minocycline reported in the United States. Approximately 47,630,000 doxycycline and 15,234,000 minocycline new prescriptions were dispensed in the United States during that period, yielding event rates of 13 per million for doxycycline and 72 per million for minocycline, based on FDA data.

CONCLUSIONS

Between 1998 and 2003, doxycycline was prescribed 3 times as often as minocycline. The incidence of AEs with either drug is very low, but doxycycline had fewer reported AEs. Although more head-to-head clinical trials are needed for a direct comparison of AE frequency, these preliminary data from separate reports suggest the possibility that AEs may be less likely with doxycycline than minocycline.

Oral mucosal pigmentation secondary to minocycline therapy: report of two cases and a review of the literature

Minocycline is a semisynthetic broad-spectrum antimicrobial agent that was first introduced into clinical practice in 1967. The most common use of minocycline is for the long-term treatment of acne vulgaris. A well-recognized side effect of minocycline treatment is pigmentation, which has been reported in multiple tissues and fluids including thyroid, skin, nail beds, sclera, bone, and teeth. While there have been several reports of oral pigmentation following minocycline therapy, these have been, for the most part, pigmentation of the underlying bone with the overlying oral mucosa only appearing pigmented. We report two cases of actual pigmented oral mucosal lesions on the hard palate secondary to minocycline therapy with the accompanying histopathology, followed by a discussion of minocycline-induced oral pigmentation and a differential diagnosis of these lesions.

[Minocycline-induced neutrophilic alveolitis?]

A 53-year-old man was treated for hypoxic pneumonia. Alveolar lavage revealed neutrophilic alveolitis and search for an infectious agent was negative. Lung biopsy revealed discrete endo-alveolar edema and polymorphous infiltration in moderately thickened alveolar walls. After 17 days, an ineffective antibiotic regimen was replaced by corticosteroids. Clinical and radiological signs improved in a few days and pneumonia did not recur after corticosteroid withdrawal. The most likely causal agent was minocycline which the patient had received for two Years for the treatment of rhinophyma. Minocycline had been interrupted several weeks when the pulmonary disorder developed after re-introduction of minocycline. Different clinical manifestations of minocycline-induced lung disease have been described including eosinophilic pneumopathy, bronchiolitis obliterans with organized pneumonitis, and hypersensitivity pneumonitis. There has only been one report of polymorphonuclear neutrophils observed in the lavage fluid.

Panniculitis. Part I. Mostly septal panniculitis

The panniculitides represent a group of heterogeneous inflammatory diseases that involve the subcutaneous fat. The specific diagnosis of these diseases requires histopathologic study because different panniculitides usually show the same clinical appearance, which consists of subcutaneous erythematous nodules on the lower extremities. However, the histopathologic study of panniculitis is difficult because of an inadequate clinicopathologic correlation, and the changing evolutionary nature of the lesions means that biopsy specimens are often taken from late-stage lesions, which results in nonspecific histopathologic findings. In addition, large-scalpel incisional biopsies are required. However, we believe that by obtaining appropriate biopsy specimens and with adequate clinicopathologic correlation, a specific diagnosis may be rendered in most cases of panniculitis. It must be accepted that all panniculitides are somewhat mixed because the inflammatory infiltrate involves both the septa and lobules; however, in general the differential diagnosis between a mostly septal and a mostly lobular panniculitis is straightforward at scanning magnification. Mostly septal panniculitides with vasculitis include leukocytoclastic vasculitis involving the small blood vessels of the septa; superficial thrombophlebitis resulting from inflammation and subsequent thrombosis of large veins of the septa; and cutaneous polyarteritis nodosa, which is a vasculitis involving arteries and arterioles of the septa of subcutaneous fat with few or no systemic manifestations. Often septal panniculitides with no vasculitis are the consequence of dermal inflammatory processes extending to the subcutaneous fat, such as necrobiosis lipoidica, scleroderma, subcutaneous granuloma annulare, rheumatoid nodule, and necrobiotic xanthogranuloma. However, in other cases, the inflammatory process is primarily located in the fibrous septa of the subcutis with or without involvement of the overlying dermis. The most frequently seen septal panniculitis is erythema nodosum, which, in fully developed lesions, is characterized histopathologically by Miescher's radial granulomas in the septa.

Perinuclear antineutrophilic cytoplasmic antibody-positive cutaneous polyarteritis nodosa associated with minocycline therapy for acne vulgaris

Minocycline is an oral antibiotic widely used for the long-term treatment of acne vulgaris. Unusual side effects of this medication include two overlapping autoimmune syndromes: drug-induced lupus and autoimmune hepatitis. In addition, in a few patients livedo reticularis or subcutaneous nodules have developed in association with arthritis and serum perinuclear antineutrophil cytoplasmic antibodies (P-ANCA) during long-term minocycline therapy. We report the cases of two young women receiving long-term minocycline therapy (>3 years) in whom P-ANCA-positive cutaneous polyarteritis nodosa developed. Both patients presented with a violaceous reticulated pattern on the lower extremities. Histologic examination of biopsy specimens from a reticulated area and a subcutaneous nodule showed necrotizing vasculitis of medium-sized arteries in the deep dermis, consistent with the diagnosis of polyarteritis nodosa. The cutaneous lesions rapidly resolved on discontinuation of minocycline and initiation of prednisone therapy. A high index of suspicion and testing for antineutrophil cytoplasmic antibody in addition to the standard antinuclear antibody panel can facilitate diagnosis of minocycline-related autoimmune disorders.

Treatment of minocycline-induced cutaneous pigmentation with the Q-switched Alexandrite laser and a review of the literature

Cutaneous pigmentation associated with minocycline ingestion is an unusual adverse effect for which few treatments have been described. Within the past few years, treatment with different Q-switched lasers has been reported in the literature. The purpose of this therapeutic intervention was to determine whether the Q-switched Alexandrite laser could clinically and histologically improve pigmentation associated with minocycline ingestion. A patient with type II minocycline pigmentation was treated with the Q-switched Alexandrite (755 nm) laser and then evaluated clinically and histologically to determine the outcome of this intervention. Treatment with the Q-switched Alexandrite (755 nm) laser provided excellent clinical and histologic clearing of minocycline pigmentation. One year after completion of laser treatment, the skin has remained clinically clear with no recurrence. The Q-switched Alexandrite laser (755 nm) should be considered for treatment of type II minocycline pigmentation.

Minocycline-induced autoimmune syndromes: an overview

OBJECTIVE

To increase awareness of minocycline-induced autoimmune syndromes.

METHODS

Review of relevant publications from the American and European literature.

RESULTS

Four minocycline-induced syndromes have been described in 82 patients: serum sickness, drug-induced lupus, autoimmune hepatitis, and vasculitis. Aside from sporadic cases of serum sickness, all other syndromes occurred in patients treated for acne. Drug-induced lupus and hepatitis were by far the most common events (66 cases). Except for serum sickness, which presented shortly (mean, 16 days) after minocycline, the autoimmune syndromes manifested after protracted use (mean, 25.3 months). As expected, the patients with acne were young (mean, 19.7 years). The most frequent symptoms were arthralgia, followed by arthritis, fever, and rash (73, 45, 38, and 29 patients, respectively). Serologically, antinuclear antibodies were the most common finding (63 positive of 68 tests); perinuclear anti-neutrophilic cytoplasmic antibodies (pANCA), when assayed, were similarly frequent (20 of 24 tests). Surprisingly, anti-histone antibodies were uncommon, even among patients with drug-induced lupus (4 of 31 tests). The clinical and serological features of the separate syndromes may overlap. The diagnostic value of pANCA, as well as its possible role in minocycline-induced autoimmunity, are discussed.

CONCLUSIONS

Minocycline has the potential to evoke a variety of clinical and serological autoimmune expressions. The number of published reports may underestimate the frequency of this condition, which should be suspected and investigated in young patients with autoimmune manifestations.

Erythema nodosum secondary to meningococcal septicaemia

We report a case of erythema nodosum (EN) secondary to Neisseria meningitidis infection in a 77-year-old woman. Histology of two biopsy specimens from two different lesions showed characteristic features of EN. Blood culture showed Neisseria meningitidis group C.

Clinical and immunological study of 7 patients with minocycline-induced autoimmune phenomena

PURPOSE

Prolonged treatment with minocycline for acne vulgaris has been associated with the development of arthralgia, arthritis, and other autoimmune phenomena. We characterized the clinical, laboratory, and immunological profiles of seven patients with this syndrome.

SUBJECTS AND METHODS

Clinically the patients were studied with special emphasis on prior minocycline treatment, presenting symptoms, physical findings, course, and outcome. Laboratory tests included fluorescent antinuclear and antineutrophil cytoplasmic (ANCA) antibodies, as well as antibodies to myeloperoxidase, bactericidal permeability increasing protein, elastase, cathepsin G, lactoferrin, cardiolipin, and histone.

RESULTS

All 7 patients presented with polyarthritis or arthralgia, morning stiffness, and fever after 6 to 36 months of minocycline treatment. The skin was involved in five patients (three with livedo reticularis and two with subcutaneous nodules). Two patients had chronic active hepatitis. Increased titers of perinuclear ANCA (p-ANCA) were detected in all seven patients; five patients had fluorescent antinuclear antibodies, two had antihistone autoantibodies and one had anticardiolipin antibodies. Antigenic characterization of p-ANCA disclosed antibodies to bactericidal permeability increasing protein in one patient, to elastase in three patients, and to cathepsin G in five patients. Symptoms resolved in five patients upon discontinuation of minocycline; the other two patients were treated with corticosteroids and also achieved remissions.

CONCLUSION

Minocycline-induced autoimmune syndrome is characterized by reversible polyarthralgia or arthritis, morning stiffness, fever, frequent skin involvement, occasional chronic active hepatitis, and increased titers of p-ANCA with various minor p-ANCA-related antigens.

Minocycline-induced cutaneous pigmentation

BACKGROUND

Minocycline-induced cutaneous pigmentation is an adverse effect that may be more common than is generally realized. It is usually reported in patients undergoing chronic minocycline therapy for acne vulgaris.

OBJECTIVE

The case of a 69-year-old woman taking minocycline for rheumatoid arthritis is presented, and its differential diagnosis discussed in order to characterize the clinical features of minocycline-induced cutaneous pigmentation.

CONCLUSION

Patients undergoing minocycline therapy for rheumatoid arthritis may develop bluish-grey pigmentation over the legs and forearms. Cutaneous pigmentation is a well recognized adverse effect of minocycline therapy that is usually reported in young patients on chronic therapy for acne vulgaris. However, the antiinflammatory properties of minocycline have also made it useful in the management of various inflammatory conditions such as rheumatoid arthritis.1 We report the case of a 69-year-old woman who developed progressive cutaneous pigmentation, affecting mainly the legs, approximately 3 months after beginning minocycline therapy for rheumatoid arthritis.

Erythema nodosum and associated diseases. A study of 129 cases

BACKGROUND

Erythema nodosum (EN) is associated with many infectious diseases. The purpose of this study was to evaluate the relative prevalence of associated diseases in a large series of EN, and to review the previously described causes of EN.

MATERIALS AND METHODS

A total of 157 inpatients with a diagnosis of EN made in Strasbourg, France between 1960 and 1995 were studied retrospectively, but only 129 patients with confirmed EN were evaluated. A biopsy was taken in 30 patients with atypical clinical symptoms. Chest radiography, blood cell count, throat swab, and anti-streptolysin dosage were performed systematically. Viral investigations and serodiagnoses for various bacterial infections were carried out in approximately half of the patients. All investigations were analyzed retrospectively and compared with the world literature.

RESULTS

The female: male ratio was 5 : 1 and the mean age was 31 years. We found 28% confirmed streptococcal infections, 11% sarcoidosis, 1.5% enteropathies, 1.5% Chlamydia infections, 0.8% Mycoplasma infections, 0.8% Yersinia infections, 0.8% hepatitis B, and 0.8% tuberculosis (one case). The causative factor could not be determined in 55% of patients.

CONCLUSIONS

Our data confirm the predominance of streptococcal infections and sarcoidosis among patients with EN. Tuberculosis has virtually disappeared, since the last case was observed in 1962. Various viral or bacterial diseases are rarely associated with EN, but all patients were not thoroughly investigated. A large and prospective study should be performed in order to determine the true prevalence of associated diseases in EN. In the absence of specific symptoms, exhaustive investigations are not cost-effective.

Severe minocycline-induced eosinophilic pneumonia: extrapulmonary manifestations and the use of in vitro immunoassays

OBJECTIVE

To report a severe and unusual reaction to minocycline and the use of in vitro immunologic assays.

CASE SUMMARY

A 46-year-old white man developed severe respiratory distress with pulmonary infiltrates on chest X-ray and eosinophilia in blood, bronchoalveolar lavage fluid, and biopsied lung tissue during exposure to minocycline. Additional manifestations included pleuropericardial effusion, liver function abnormality, and bone marrow eosinophilia. Macrophage inhibition factor and mast cell degranulation assays were positive to minocycline.

DISCUSSION

The patient's manifestations were compatible with the diagnosis of eosinophilic pneumonia. After excluding other possible etiologies, minocycline was identified as the offending agent. Generalized damage was suggested by the presence of a combination of extrapulmonary manifestations previously not reported. Results of the in vitro immunologic assays supported the hypersensitivity nature of the disease and confirmed the diagnosis.

CONCLUSIONS

Minocycline-induced eosinophilic pneumonia may involve extrapulmonary sites. It is suggested that in vitro immunoassays be used for confirmation of the diagnosis rather than rechallenge or invasive procedures.

Minocycline induced arthritis associated with fever, livedo reticularis, and pANCA

OBJECTIVE

To describe a novel iatrogenic immunological reaction produced by minocycline.

CASE REPORTS

The clinical course and laboratory results of three women who presented with similar rheumatological manifestations after a prolonged exposure to minocycline are described. All three presented a unique reaction manifested by fever, arthritis/arthralgia and livedo reticularis during treatment with minocycline for acne vulgaris. The clinical syndrome was associated with high titre of serum perinuclear anticytoplasmatic antibodies (p-ANCA) and antimyeloperoxidase antibody (anti-MPO). Symptoms resolved after stopping the drug and recurred promptly after rechallenge in all three patients.

CONCLUSIONS

Minocycline, which is widely used in the treatment of acne, often without adequate supervision, may induce arthritis and livedo vasculitis associated with anti-MPO.

Safety of long-term high-dose minocycline in the treatment of acne

Minocycline is widely used as a second-line antimicrobial for acne vulgaris. Some patients require doses of up to 200 mg daily to control their acne. To assess the long-term safety of minocycline when used at higher doses, 700 patients treated with minocycline at doses of 100 mg daily, 100/200 mg on alternate days and 200 mg daily, were recruited. The mean duration of treatment was 10.5 months. Side-effects were monitored and full blood count, blood urea, electrolytes and liver function tests were carried out on 200 of the 700 patients. Side-effects were recorded in 13.6%, and included vestibular disturbance, candida infection, gastrointestinal disturbance, cutaneous symptoms (pigmentation, pruritus, photosensitive rash and urticaria) and benign intracranial hypertension. Pigmentation was the only side-effect found to be significantly increased in patients taking higher doses of minocycline, as compared with lower doses (P < 0.01). All patients with pigmentation had taken a total cumulative dose of over 70 g. No significant abnormalities were found in any of the haematological and biochemical profiles. We conclude that minocycline, at doses of up to 200 mg/day, is safe, long-term, for acne, when such doses are clinically necessary.

Minocycline and pulmonary eosinophilia

Images

Lingual hyperpigmentation associated with minocycline therapy

Minocycline can cause hyperpigmentation of the conjunctiva, oral mucosa, and skin. Pigmentation of the oral mucosa may also be associated with a variety of endogenous or exogenous factors. Lingual pigmentation may be seen in Addison's disease, amalgam tatoo, malignant melanoma, Peutz-Jegher's syndrome, and other diseases. Two women who had isolated pigmentation of the tongue while taking minocycline are described; no other drug-induced pigmentation of their oral mucosa or skin occurred. Minocycline-induced pigmentation should be added to the differential diagnosis of isolated lingual hyperpigmentation.

Minocycline-induced oral pigmentation

Oral mucosal pigmentation is an infrequently reported side effect of minocycline. Two patients with minocycline deposition within teeth and bone, demonstrated by fluorescence microscopy, are described. Minocycline is the only tetracycline reported to cause discoloration of the oral mucosa. This may be the result of deposition of an insoluble degradation product of minocycline in the underlying bone. Pigmentation is not necessarily dose-dependent and may take months or years to resolve.