Antitubercular drug-induced lichen planus: A case study with a mini literature review

Introduction

Drug-induced lichen planus is a cutaneous adverse effect that manifests as a systemic eruption of flat-topped, erythematous, or violaceous papules resembling lichen planus on the trunk and extremities. Although antitubercular therapy has been linked to cutaneous hypersensitivity reactions, the literature on such cases is scarce. Here, we present a case to contribute to this field, reporting on its presentation and management, and reviewing previous case studies.

Case Report

Our patient, a 63-year-old male, presented with black pigmented patches on the skin, having been diagnosed with pulmonary tuberculosis and on antitubercular therapy for the past two months. A diagnosis of ATT-induced lichen planus was made, and all ATT was stopped. The patient was treated with antihistamines, apremilast, tacrolimus, and corticosteroids, and rechallenge of each drug was performed consecutively. No new lesions appeared after rechallenge with isoniazid and rifampicin. However, ethambutol was not reintroduced due to strong suspicion, by exclusion, that it was the offending agent, whereas on rechallenge with isoniazid and rifampicin, the patient's skin lesions gradually improved with eventual resolution of hyperpigmentation.

Discussion and Conclusion

Lichenoid drug eruptions are characterized by type IV hypersensitivity reactions, and rechallenge is required to ensure safer treatment since the risk of disseminated and multi-drug-resistant tuberculosis increases with the cessation of antitubercular therapy.

Desvenlafaxine-Triggered Acneiform Eruptions on the Hand: A Compelling Case Report

A 45-year-old male developed a skin eruption after starting Desvenlafaxine for depressive symptoms associated with schizophreniform disorder. The patient developed a rash on the hand, hyperpigmentation, and itching, which resolved after discontinuing the medication. The Naranjo score suggested a probable link between desvenlafaxine and the skin reaction. Stable vital signs and normal labs supported this conclusion. The case underscores the importance of recognizing and reporting adverse drug reactions, even with generally safe medications like desvenlafaxine. Further research with larger samples is needed to explore this relationship in more depth.

Beyond Immunosuppression: The Intricate Relationship Between Tacrolimus and Microangiopathy

Tacrolimus, widely known as Prograf, has become the preferred immunosuppressant for preventing graft rejection in solid organ transplant recipients, particularly in steroid-sparing regimens. Its efficacy and reduced risk of acute and chronic rejection compared to cyclosporine have made it the preferred treatment option for transplant patients. However, tacrolimus has drawbacks as it is associated with adverse effects, such as renal tubular necrosis, kidney failure, hypertension, metabolic acidosis, and new-onset diabetes mellitus. Among the less common but potentially severe complications is thrombotic microangiopathy linked to tacrolimus usage. Identifying and addressing this condition early on is crucial given its severity and potential complications. Manifestations of this microangiopathy can vary, encompassing renal, neurological, cardiac, and respiratory symptoms, and, in some cases, presenting as pancreatitis, intestinal ischemia, or skin abnormalities. Although conventional management often involves plasma exchange as the primary therapeutic option, recent insights into the pathophysiology have led to newer drugs, such as eculizumab and belatacept, offering promising outcomes. In this narrative review, we delve deeper into the underlying pathophysiological mechanisms of tacrolimus-induced thrombotic microangiopathy and aim to provide clinicians with valuable recommendations for efficient and timely treatment strategies. By understanding the complexities of this condition and staying abreast of the latest advancements in therapeutic options, healthcare providers can optimize patient outcomes and ensure safer tacrolimus administration in solid organ transplant recipients.

The First Case of Daratumumab-Induced Fulminant Hepatic Failure

Drug-induced liver failure is a relatively uncommon condition with a vast spectrum of clinical manifestations, and it is a leading cause of acute hepatic failure in the United States. We describe the first case of fulminant hepatic failure induced by chemotherapeutic drug daratumumab, a common FDA-approved agent. A 77-year-old male, with a history of multiple myeloma, was admitted for left lower extremity cellulitis, two weeks after receiving his first intravenous infusion of daratumumab. He developed fulminant hepatic failure in the hospital a few days later. Despite multiple doses of N-acetylcysteine, his liver function continued to decline, and he expired shortly after.

Clinical Care Team's Guide for Awareness on Risk Assessment of Eltrombopag Complicating Acute Kidney Injury in Relapsed Immune Thrombocytopenic Patients: A Case Report

Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder caused by antigen-specific T cells and antiplatelet autoantibodies that inhibit platelet production in the bone marrow or destroy platelets in the spleen. ITP is a form of autoimmunity and is closely associated with inflammation. Corticosteroids are the first-line therapy for ITP, with a total response rate of 53-80%. However, corticosteroid therapy is associated with significant side effects and is often ineffective in patients with corticosteroid-resistant or -intolerant disease. Eltrombopag has been validated as a second-line option in ITP therapy. Despite several studies demonstrating the efficacy and safety of Eltrombopag in immune thrombocytopenia patients, the prevalence of Eltrombopag-induced acute kidney injury has been observed. This case report describes a patient who experienced acute kidney injury during Eltrombopag therapy. A sudden increase in serum creatinine to 6.7 mg/dL and metabolic acidosis occurred after eight weeks of Eltrombopag. The patient's renal failure had worsened, proteinuria was detected, and emergency hemodialysis was initiated. With vigilant kidney function screening and prompt treatment, the patient's renal function improved remarkably following cessation of Eltrombopag and initiation of hemodialysis. This case highlights the importance of comprehensive medication history-taking and vigilant kidney function screening in patients receiving Eltrombopag.

Azathioprine induced acute sialadenitis: A case report

Key clinical message

Patients presenting with acute sialadenitis need careful review of their medications. Azathioprine is one of such drugs, which can rarely induce acute sialadenitis. Prompt discontinuation of the medication leads to reversal of the patient condition.

Abstract

Acute sialadenitis is one of the rare adverse effects of azathioprine. We report a case of acute submandibular sialadenitis following initiation of azathioprine which resolved upon discontinuation of the drug.

Pulmonary hypertension in patients with multiple myeloma: A comprehensive review

Multiple myeloma (MM) is a common hematological malignancy resulting from clonal proliferation of plasma cells and is defined by criteria set forth by the international myeloma working group. Pulmonary hypertension (PH) is defined by an elevated mean pulmonary artery pressure >20 mmHg measured during right heart catheterization. Echocardiography-diagnosed PH is relatively common in patients with MM and has been associated with increased mortality, morbidity, and poor stem cell transplant outcomes. PH in patients with MM (PH-MM) is usually multifactorial in origin. MM disease-specific factors, host comorbidities, and treatment-related adverse effects are the key factors for the development of PH-MM. Pragmatically, patients with PH-MM can be grouped into either (i) PH in patients with a new diagnosis of MM or (ii) PH that develops or worsens along the way of MM treatment. In the latter group, drug-induced PH, venous thromboembolism, pulmonary veno occlusive disease, and cardiotoxicity should be considered as possible causes. PH-MM should be evaluated and managed in a multidisciplinary setting. Select individuals with PH-MM could be considered for pulmonary vasodilators at PH-specialized centers.

Risk factors and management of hyperuricemia after renal transplantation

Hyperuricemia (HUA) is a common complication after renal transplantation. Currently, there is no uniform consensus on factors which increase the risk for and treatment of HUA in renal transplant recipients. The purpose of this review is to summarize current and proposed risk factors and strategies to manage HUA after renal transplantation in order to assist renal function protection and prolong graft survival time.

Valproate Induced Acute Pancreatitis - A Unique Case Report

BACKGROUND

Valproate is widely prescribed medication for the control of seizures in pediatric population. It has been reported to be an important implication for drug induced pancreatitis. A case of valproate induced acute pancreatitis operated as surgical abdomen has been reported here.

CASE REPORT

A 13-year-old child presented to the emergency department with severe pain and abdominal distension associated with vomiting and constipation for four days. The patient's care givers did not disclose any medication history. Based on clinical examination and ultrasonography that revealed mild free fluid, provisional diagnosis of pyoperitoneum with peritonitis was made. An emergency exploratory laparotomy was undertaken during which acute pancreatitis was diagnosed intra-operatively. On further enquiry the caregiver revealed the history of valproate intake for last six months for generalized tonic‑clonic seizures. Valproate was discontinued and there was complete resolution of symptoms.

CONCLUSION

Both clinicians as well as care givers of paediatric patients receiving valproate should be watchful regarding this possible life-threatening complication to avoid delay in diagnosis and appropriate management.

A case series of emtricitabine-induced pure red cell aplasia

Background

Anaemia is common in patients with retroviral disease. New or worsening anaemia after initiation of antiretroviral (ARV) treatment has a broad differential diagnosis.

Objectives

We describe six patients who developed transfusion-dependent anaemia on first-line therapy (tenofovir, emtricitabine and efavirenz) and, by exclusion, implicated emtricitabine in the aetiology of the anaemia.

Method

We conducted a retrospective chart review of patients seen at the Infectious Diseases specialist clinic at King Edward VIII Hospital in KwaZulu-Natal between 2014 and 2016. We focused on patients with isolated, refractory and transfusion-dependent anaemia occurring after initiation of ARVs, in whom bone marrow biopsies were consistent with pure red cell aplasia (PRCA) without an identifiable secondary cause.

Results

All the patients were female, with a median (range) age and baseline CD4 cell count of 42.5 (23–61) years and 237 (83–329) cells/mm³, respectively. Before presenting with symptomatic anaemia, the duration on emtricitabine was 4.5 (2–8) months. At presentation, all patients had an HIV viral load of < 1000 copies/mL and a CD4 cell count of 314 (213–389) cells/mm³. The median time to recovery following the discontinuation of emtricitabine was 2 (1–4) months. After a median of 12 months, all patients were successfully rechallenged with emtricitabine and remained well for a follow-up period of 24 (7–36) months.

Conclusion

This study provides strong circumstantial evidence that emtricitabine plays an important role in the pathogenesis of reversible PRCA. The mechanisms through which emtricitabine induces PRCA remain unclear and require further study.

Anti-neutrophil cytoplasmic antibody associated glomerulonephritis complicating treatment with hydralazine

Hydralazine, a widely used therapy for hypertension and heart failure, can elicit autoimmune disease, including anti-neutrophil cytoplasmic antibody associated glomerulonephritis (ANCA-GN). We identified 80 cases of ANCA-GN complicating treatment with hydralazine, accounting for 4.3% (80/1858 biopsies) of ANCA-GN diagnosed between 2006 and 2019. Over three-fourths of patients were on hydralazine for at least one year, with mean daily dose of approximately 250 mg/day. ANCA testing revealed p-ANCA/myeloperoxidase-ANCA seropositivity in 98%, including 39% with dual p-ANCA/myeloperoxidase-ANCA and cANCA/anti-protinase 3-ANCA positivity, often accompanied by anti-nuclear antibody (89%), anti-histone antibody (98%), and hypocomplementemia (58%). Kidney biopsy revealed necrotizing and crescentic glomerulonephritis, similar to primary ANCA-GN, but significantly less frequently pauci-immune (77 vs. 100%) and more commonly associated with mesangial hypercellularity (30 vs. 5%), electron dense deposits (62 vs. 20%), and endothelial tubuloreticular inclusions (11 vs. 0%); all significant differences. On follow-up, 42 of 51 patients received induction immunosuppression: 19 reached the combined end-points of kidney failure or death and 32 had mean creatinine of 1.49 mg/dL at last follow-up. Thus, hydralazine-associated ANCA-GN often exhibits overlapping clinical and pathologic features of mild immune complex glomerulonephritis resembling lupus nephritis. With discontinuation of hydralazine and immunosuppression, outcomes are similar to primary ANCA-GN.

Drug-induced acanthosis nigricans: A systematic review and new classification

Drug-induced acanthosis nigricans is an uncommon subtype of acanthosis nigricans and the data on this topic is not well understood by clinicians as it is presently limited in the literature. Previous reports of drug-induced acanthosis nigricans have simply consisted of a list of drugs possibly implicated in causing acanthosis nigricans. Several drugs listed are based on single case reports without biopsy confirmation, report of clearing on stopping the drug or reporting on whether acanthosis nigricans recurred with drug rechallenge. A comprehensive literature search was conducted using PubMed, EMBASE(Ovid), Cochrane Library, Scopus, and Web of Science electronic databases. The authors screened the initial result of the search strategy by title and abstract using the following inclusion criteria: eligible studies included those with patients who developed acanthosis nigricans secondary to a drug. This study is the first to comprehensively review the drugs that have been implicated in the development of acanthosis nigricans. A total of 38 studies were included in the systematic review, and a total of 13 acanthosis nigricans inducing drugs were identified. Nicotinic acid and insulin were the two most significant drugs that were reported to cause acanthosis nigricans. By using the results of this study, we created a revised classification system of drug-induced acanthosis nigricans which can be used as a concise framework for clinicians to refer to.

A systematic review on treatment-related mucocutaneous reactions in COVID-19 patients

Most of drugs could have certain mucocutaneous reactions and COVID-19 drugs are not an exception that we focused. We systematically reviewed databases until August 15, 2020 and among initial 851 articles, 30 articles entered this study (20 case reports, 4 cohorts, and 6 controlled clinical trials). The types of reactions included AGEP, morbiliform drug eruptions, vasculitis, DRESS syndrome, urticarial vasculitis, and so on. The treatments have been used before side effects occur, included: antimalarial, anti-viral, antibiotics, tocilizumab, enoxaparin and and so on. In pandemic, we found 0.004% to 4.15% of definite drug-induced mucocutaneous reactions. The interval between drug usage and the eruption varied about few hours to 1 month; tightly dependent to the type of drug and hydroxychloroqine seems to be the drug with highest mean interval. Antivirals, antimalarials, azithromycin, and tocilizumab are most responsive drugs for adverse drug reactions, but antivirals especially in combination with antimalarial drugs are in the first step. Types of skin reactions are usually morbilliform/exanthematous maculopapular rashes or urticarial eruptions, which mostly may manage by steroids during few days. In the setting of HCQ, specific reactions like AGEP should be considered. Lopinavir/ritonavir is the most prevalent used drug among antivirals with the highest skin adverse reaction; ribarivin and remdisivir also could induce cutaneous drug reactions but favipiravir has no or less adverse effects. Logically the rate of dermatologic adverse effects among anivirals may relate to their frequency of usage. Rarely, potentially life-threatening reactions may occur. Better management strategies could achieve by knowing more about drug-induced mucocutaneous presentations of COVID-19.

Gliptin-Induced Bullous Pemphigoid: Canadian Case Series of 10 Patients

BACKGROUND

Bullous pemphigoid (BP) is a chronic immune-mediated vesiculobullous disorder. Recently, several reports have described dipeptidyl peptidase-4 inhibitors, also known as gliptins, as causative agents for drug-induced BP.

OBJECTIVE

To report and describe clinical and histologic characteristics of 10 cases of gliptin-induced BP.

RESULTS

We identified 10 patients with gliptin-induced BP. Nine were secondary to linagliptin, and 1 case was attributed to sitagliptin. All patients showed significant improvement after withdrawal of gliptin medications and proper medical treatment. There has been no evidence of relapse after 4 months of follow-up.

CONCLUSION

This report supports the proposed association between gliptins and BP. Physicians should be aware of this potential adverse effect, as gliptin-induced BP can be reversible once identified and the responsible medication is stopped. Early withdrawal of the offending drug and proper treatment can lead to rapid improvement and reduced morbidity.

Erythema multiforme: integrating the superfluous diagnosis to a veracious conclusion (case report)

Erythema multiforme (EM) is an acute, self-limiting hypersensitivity reaction that ranges from a mild cutaneous, exanthematous variant with minimal oral involvement to a progressive fulminating severe variant with extensive mucocutaneous epithelial necrosis (SJS & TEN). Knowing the etiological spectrum is the key for management in EM where sometimes leads to mortality. There are no specific diagnostic tests for EM, diagnosis is mainly clinically supported. Here in we report series of cases of EM with different etiological spectrum.

Acute interstitial nephritis and nephrogenic diabetes insipidus following treatment with sulfamethoxazole-trimethoprim and temozolomide

We report a case of acute interstitial nephritis with associated nephrogenic diabetes insipidus in a patient treated with temozolomide and sulfamethoxazole-trimethoprim for glioblastoma multiforme. Kidney biopsy demonstrated focal tubulointerstitial change with tubular dilatation, epithelial change and interstitial inflammation. The patient's kidney function improved with cessation of sulfamethoxazole-trimethoprim and treatment with hydrochlorothiazide for nephrogenic diabetes insipidus. Recommencement of temozolomide did not result in further deterioration in kidney function. In this case report, we discuss the novel association between sulfamethoxazole-trimethoprim-induced acute interstitial nephritis and nephrogenic diabetes insipidus, and suggest possible mechanisms involved.

Steroid-Induced Pancreatitis: Establishing an Accurate Association Poses a Challenge

The association between steroids and pancreatitis has been reported in the literature. However, due to its rarity, it can be challenging to make an early diagnosis. Hence, when diagnosing patients presenting with signs and symptoms of pancreatitis, there should be a high suspicion for medication-induced variants, after ruling out other common causes. In our report, we present the case of an individual with recurrent pancreatitis caused by the use of prednisone for musculoskeletal pain, the probable cause being steroids due to a high Naranjo score. The patient experienced clinical improvement with the resolution of pancreatitis after the steroids were discontinued.

Acyclovir-induced immune thrombocytopenia: Case report and review of the literature

There are a number of medications which can serve as catalysts for drug-induced immune thrombocytopenia (DIPT). A minimum of six different mechanisms have been put forward as the means by which drug-induced antibodies can encourage platelet destruction, thus emphasising the complexity of the pathogenesis of DITP. Acyclovir, has been widely used because of its highly potent prohibitive properties for infections caused by HSV and VZV. The common adverse effects of this drug are well known, the severe adverse reactions are mostly related to high dose intravenous administrations. The immune thrombocytopenia induced by acyclovir is unusual. The authors present a rare clinical case of acyclovir-induced immune thrombocytopenia in a 72-year-old female patient with typical herpes zoster treated with acyclovir. The clinical and laboratory findings, taken together with the transitory relationship between acycolvir and the start of thrombocytopenia, combined with the elimination of the other know sources of thrombocytopenia, allowed us to reach the diagnosis of acyclovir-induced immune thrombocytopenia. An international database search was employed to complete an extensive review of the current literature. Contemporary information on acyclovir-induced immune thrombocytopenia was collected by the analysis of present day review articles and accessible case reports. The authors found five published cases of acyclovir-induced immune thrombocytopenia. Analyzing these articles it was concluded that immune thrombocytopenia induced by acyclovir is rare, and an unusual side effect, with good prognosis. Prompt diagnosis is vital to appropriate management, therefore clinicians need to be cognisant of this rare potential adverse reaction.

Pregabalin-associated movement disorders: A literature review

Central nervous system adverse effects are commonly reported with pregabalin (PGB). On the other hand, movement disorders (MDs) associated with this drug were rarely described. However, their occurrence could significantly affect the quality of life of PGB users. This literature review aims to evaluate the clinical epidemiological profile, pathological mechanisms, and management of PGB-associated MDs. Relevant reports in six databases were identified and assessed by two reviewers without language restriction. A total of 46 reports containing 305 cases from 17 countries were assessed. The MDs encountered were as follows: 184 individuals with ataxia, 61 with tremors, 39 with myoclonus, 8 with parkinsonism, 1 with restless legs syndrome, 1 with dystonia, 1 with dyskinesia, and 1 with akathisia. The mean age was 62 years (range: 23-94). The male sex was slightly predominant with 54.34%. The mean PGB dose when the MD occurred was 238 mg, and neuropathic pain was the most common indication of PGB. The time from PGB start to MD was < 1 month at 75%. The time from PGB withdrawal to recovery was < 1 week at 77%. All the individuals where the follow-up was reported had a full recovery. The most common management was PGB withdrawal. In the literature, the majority of the cases did not report information about timeline events, neurological examination details, or electrodiagnostic studies. The best management for all MDs is probably PGB withdrawal. If the patient is on dialysis program, perhaps an increased number of sessions will decrease recovery time. Furthermore, the addition of a benzodiazepine could accelerate recovery.

Emtricitabine-induced pure red cell aplasia

Introduction

Anemia is common in HIV. Parvo B19 infection is a well-recognised cause of red cell aplasia. Other causes of persistent pure red cell aplasia (PRCA) include anti-retroviral drugs such as zidovudine and lamivudine. We describe a case of PRCA that strongly implicates emtricitabine as the probable cause.

Patient presentation

Patient was HIV positive and on treatment with a fixed drug combination consisting of tenofovir, emtricitabine and efavirenz for 3 months when she developed severe transfusion dependent anemia. The anemia, attributed to PRCA, was persistent and transfusion dependent for about one year.

Management and outcome

Replacement of emtricitabine with abacavir resulted in a prompt, complete and lasting resolution of the anaemia, suggesting an etiologic role of emtricitabine in the PRCA.

Conclusion

Emtricitibine is a rare cause of pure red cell aplasia.

Clinically significant incidental QTc prolongation is subject to within-individual variability

BACKGROUND

Prolonged QTc interval observed in daily practice is often deemed to be drug induced and might result in drug discontinuation, with possible therapeutic consequences. However, whether clinically significant prolonged QTc may be due to within-individual variability occurs has yet to be described.

METHODS

A retrospective cohort study documenting within-individual QTc variability in subjects attending annual routine medical evaluation. At each visit, QT interval was measured and corrected for heart rate using Bazett and three other commonly used formulae. Outcome measures were rates of ΔQTc ≥60 msec, absolute QTc ≥500 msec and QTc ≥25% from baseline.

RESULTS

A total of 188 subjects [54 (29%)] females were recruited. Mean age at first ECG was 54 ± 12.8 years with mean time interval of 12.2 ± 1.1 months between measurements. Mean Bazett QTc was higher compared to the other 3 formulae: 412 ± 20 vs. 400 ± 16 msec. Using Bazett formula, 18/188 (9.6%) and 5/188 (2.7%) subjects showed at least one measurement with ΔQTc ≥60 msec and QTc ≥500 msec, respectively. Of the former, 5/18 (27.8%) showed QTc ≥25% prolongation. In multivariate analysis, QTc ≥500 msec was significantly associated with number of measurements (HR: 5.01, 95%CI: 1.21-20.78, p = .026) with no effect of other known confounders. Lower rates were demonstrated with the other three formulae.

CONCLUSION

In clinical practice, significant prolonged QTc may be attributed to within-individual variability, particularly when adjusting the QT interval with Bazett correction. This should be taken into consideration when decisions on changing current drug regimens are to be made.

Insights Into the Pathogenesis of Sweet's Syndrome

Sweet's syndrome, also known as Acute Febrile Neutrophilic Dermatosis, is a rare inflammatory condition. It is considered to be the prototype disease of neutrophilic dermatoses, and presents with acute onset dermal neutrophilic lesions, leukocytosis, and pyrexia. Several variants have been described both clinically and histopathologically. Classifications include classic Sweet's syndrome, malignancy associated, and drug induced. The cellular and molecular mechanisms involved in Sweet's syndrome have been difficult to elucidate due to the large variety of conditions leading to a common clinical presentation. The exact pathogenesis of Sweet's syndrome is unclear; however, new discoveries have shed light on the role of inflammatory signaling, disease induction, and relationship with malignancy. These findings include an improved understanding of inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic contributions. Continued investigations into effective treatments and targeted therapy will benefit patients and improve our molecular understanding of inflammatory diseases, including Sweet's syndrome.

Successful Management of Clozapine-induced Akathisia with Gabapentin Enacarbil: A Case Report

The management of clozapine (CLZ)-induced adverse events affects patient prognoses. Akathisia is a relatively rare adverse event related to CLZ administration and thus the management of this syndrome is not well established. Here, we report a case of treatment-resistant schizophrenia wherein CLZ-induced akathisia was successfully managed with gabapentin enacarbil (GE). The patient was a 39-year-old woman who had been treated with atypical antipsychotics other than CLZ for three years with poor tolerability. Initiation of CLZ (400 mg/day) attenuated her psychotic symptoms, but was followed by moderate akathisia. Neither benzodiazepines nor biperiden improved the akathisia; however, akathisia was finally diminished with co-administration of GE. GE facilitated a dosage increase in CLZ (450 mg/day) for the improved management of pyschotic symptoms, and thus indirectly contributed to treatment of the patient’s schizophrenia. We suggest that GE is a useful candidate for the management of CLZ-induced akathisia. The improved management of treatment-induced akathisia and other adverse events can extend the potential application of CLZ for treatment-resistant schizophrenia.

Pulmonary arterial hypertension in patient treated for multiple sclerosis with 4-aminopyridine

4-Aminopyridine (4-AP) is a recent treatment indicated to improve walking in patient with multiple sclerosis. We report the first case of pulmonary arterial hypertension (PAH) that we attribute to the use of 4-AP. A 64-year-old woman with multiple sclerosis presented with dyspnea. After excluding other secondary causes of pulmonary hypertension, a diagnosis of severe PAH due to 4-AP was made based on right heart catheterization. History revealed that the dyspnea began with the initiation of 4-AP. After discontinuation of 4-AP therapy and initiation of ambrisentan and tadalafil, dyspnea and pulmonary arterial pressure have improved significantly and one specific PAH treatment was stopped. 4-AP is an outward rectifying potassium channel blocker with a vasoconstrictor effect in animal's pulmonary artery. According to the chronological sequence of events, the lack of other etiology, and its pharmacological plausibility, 4-AP is highly suspected to have induced our patient's PAH.

Case Report of Empagliflozin-Induced Cutaneous Polyarteritis Nodosa

Polyarteritis nodosa (PAN) is a rare vasculitis affecting medium-sized vessels. Cutaneous PAN is a clinical variant, and we report the first case of empagliflozin-induced cutaneous PAN in a 69-year-old man. After starting empagliflozin, the patient presented with tender subcutaneous nodules on his legs, which showed a medium-sized vessel vasculitis on histopathology. Upon cessation of this medication, he had full resolution of these nodules. This case illustrates that empagliflozin can induce cutaneous PAN, and further attention to this medication's association with cutaneous PAN is warranted.

Validation and Clinical Utility of the hERG IC50:Cmax Ratio to Determine the Risk of Drug-Induced Torsades de Pointes: A Meta-Analysis

BACKGROUND

Use of the QT interval corrected for heart rate (QTc) on the electrocardiogram (ECG) to predict torsades de pointes (TdP) risk from culprit drugs is neither sensitive nor specific. The ratio of the half-maximum inhibitory concentration of the hERG channel (hERG IC50) to the peak serum concentration of unbound drug (C_max ) is used during drug development to screen out chemical entities likely to cause TdP.

PURPOSE

To validate the use of the hERG IC50:C_max ratio to predict TdP risk from a culprit drug by its correlation with TdP incidence.

DATA SOURCES

Medline (between 1966 and March 2017) was accessed for hERG IC50 and C_max values from the antihistamine, fluoroquinolone, and antipsychotic classes to identify cases of drug-induced TdP. Exposure to a culprit drug was estimated from annual revenues reported by the manufacturer.

STUDY SELECTION

Inclusion criteria for TdP cases were provision of an ECG tracing that demonstrated QTc prolongation with TdP and normal serum values of potassium, calcium, and magnesium. Cases reported in patients with a prior rhythm disturbance and those involving a drug interaction were excluded.

DATA EXTRACTION AND SYNTHESIS

The Meta-Analysis of Observational Studies in Epidemiology checklist was used for epidemiological data extraction by two authors.

MAIN OUTCOME AND MEASURE

Negligible risk drugs were defined by an hERG IC50:C_max ratio that correlated with less than a 5% chance of one TdP event for every 100 million exposures (relative risk [RR] 1.0).

RESULTS

The hERG IC50:C_max ratio correlated with TdP risk (0.312; 95% confidence interval 0.205-0.476, p<0.0001), a ratio of 80 (RR 1.0). The RR from olanzapine is on par with loratadine; ziprasidone is comparable with ciprofloxacin. Drugs with an RR greater than 50 include astemizole, risperidone, haloperidol, and thioridazine.

CONCLUSIONS

The hERG IC50:C_max ratio was correlated with TdP incidence for culprit drugs. This validation provides support for the potential use of the hERG IC50:C_max ratio for clinical decision making in instances of drug selection where TdP risk is a concern.

Orofacial manifestations of adverse drug reactions: a review study

Background

Adverse reaction to medication is common and may have a variety of clinical manifestations in the oral cavity. The present review paper aimed to describe adverse drug reactions (ADRs) which might be encountered by dental practitioners in every discipline.

Methods

In this narrative review article, the specialized databases such as PubMed, PubMed Central, MEDLINE, EBSCO, Science Direct, Scopus, and reference books from the years 2000-2016 were used to find relevant documents by using MeSH terms: Adverse Drug Reaction, Drug induced, Medication Related, Mouth, Oral Manifestation, Tooth, Hard Tissue, Soft Tissue.

Results

The data were categorized in 4 groups as follows: saliva and salivary glands involvement, soft tissue (mucosal) involvement, hard tissue involvement, and non specific conditions (taste disorders, halitosis, neuropathies, movement disturbances, and infection). Most articles were about the adverse effect of drugs on the function of salivary glands, which often cause a decrease in saliva secretion. Other reactions were less common; meanwhile, the side effect of bisphosphonate was increasing in the alveolar bone, because of its unlimited prescription.

Conclusion

Oral health care providers should be familiar with such events, as they will be confronted with them in their practice.

Drug-induced eosinophilic pneumonia: A review of 196 case reports

BACKGROUND AND OBJECTIVE

Eosinophilic pneumonia (EP) is an important subset of patients who present with pulmonary infiltrates and eosinophilia (PIE). EP is classified by chronicity and etiology and drug-induced EP is the main cause of secondary EP. The primary goal of this review was to examine all the case reports published since the syndrome was defined in 1990. It remains unclear whether acute or chronic EP (AEP or CEP) represent different diseases, and the secondary goal of this review is to determine if there are factors that may help distinguish these 2 entities.

METHODS

PubMed (MEDLINE and Medical Subject Headings) was searched for case reports of drug-induced EP or PIE syndrome published between 1990 and 2017. Case reports were only included if the diagnostic criteria for AEP or CEP were fulfilled. For each case, data were extracted pertaining to age, sex, type of medication associated with the disease, time from the onset of symptoms to diagnosis, eosinophil counts in the blood, eosinophil fractions in bronchoalveolar lavage (BAL) fluid, initial chest radiograph and computed tomography results, use of mechanical ventilation, and use of steroid treatment and recurrence.

RESULTS

We found 196 case reports describing drug-induced EP. The leading cause was daptomycin. From our review, we found that AEP is more common in younger patients with no gender preference. Eosinophilia in the blood at the time of diagnosis characterized only the CEP patients (80% in CEP vs. 20% in AEP). Abnormal findings on radiographic imagine was similar in both syndromes. A significant portion of AEP patients (20%) presented with acute respiratory failure requiring mechanical ventilation. Most patients with EP were treated with steroids with a higher rate of relapse observed in patients with CEP.

CONCLUSION

AEP is a much more fulminant and severe disease than the gradual onset and slowly progressive nature of CEP. The pathogenesis of AEP and CEP remains unclear. However, there is significant clinical overlap among AEP and CEP that are associated with drug toxicity, suggesting the possibility that AEP and CEP are distinct clinical presentations that share a common pathogenic pathway.

Aceclofenac-Induced Erythema Annulare Centrifugum

Erythema annulare centrifugum (EAC) is characterised by slowly enlarging annular erythematous lesions and is thought to represent a clinical reaction pattern to infections, medications, and rarely, underlying malignancy. Causative drugs include chloroquine, cimetidine, gold sodium thiomalate, amitriptyline, finasteride, etizolam etc. We present a case of 40-year-old woman who presented to us with a 10 days history of nonpruritic, peripherally growing annular erythematous eruption. She had a history of recent onset of joint pain, for which she was taking aceclofenac 90 mg once a day for 5 days prior to the onset of the rash. This was confirmed on biopsy as EAC. The rash promptly subsided after stopping the drug. We report this case as there was no previous report of aceclofenac induced EAC.

A Drug-Induced Hybrid Electrospun Poly-Capro-Lactone: Cell-Derived Extracellular Matrix Scaffold for Liver Tissue Engineering

Liver transplant is the only treatment option for patients with end-stage liver failure, however, there are too few donor livers available for transplant. Whole organ tissue engineering presents a potential solution to the problem of rapidly escalating donor liver shortages worldwide. A major challenge for liver tissue engineers is the creation of a hepatocyte microenvironment; a niche in which liver cells can survive and function optimally. While polymers and decellularized tissues pose an attractive option for scaffold manufacturing, neither alone has thus far proved sufficient. This study exploited cell's native extracellular matrix (ECM) producing capabilities using two different histone deacetylase inhibitors, and combined these with the customizability and reproducibility of electrospun polymer scaffolds to produce a "best of both worlds" niche microenvironment for hepatocytes. The resulting hybrid poly-capro-lactone (PCL)-ECM scaffolds were validated using HepG2 hepatocytes. The hybrid PCL-ECM scaffolds maintained hepatocyte growth and function, as evidenced by metabolic activity and DNA quantitation. Mechanical testing revealed little significant difference between scaffolds, indicating that cells were responding to a biochemical and topographical profile rather than mechanical changes. Immunohistochemistry showed that the biochemical profile of the drug-derived and nondrug-derived ECMs differed in ratio of Collagen I, Laminin, and Fibronectin. Furthermore, the hybrid PCL-ECM scaffolds influence the gene expression profile of the HepG2s drastically; with expression of Albumin, Cytochrome P450 Family 1 Subfamily A Polypeptide 1, Cytochrome P450 Family 1 Subfamily A Polypeptide 2, Cytochrome P450 Family 3 Subfamily A Polypeptide 4, Fibronectin, Collagen I, and Collagen IV undergoing significant changes. Our results demonstrate that drug-induced hybrid PCL-ECM scaffolds provide a viable, translatable platform for creating a niche microenvironment for hepatocytes, supporting in vivo phenotype and function. These scaffolds offer great potential for tissue engineering and regenerative medicine strategies for whole organ tissue engineering.

Drug-Induced Takotsubo Cardiomyopathy

BACKGROUND

The most plausible hypothesis for takotsubo cardiomyopathy (TCM) is a catecholamine surge. Direct administration of catecholamines or medications causing catecholamine surge is frequently used in clinical practice.

METHODS

A Medline/PubMed database search was conducted for case reports or series of drug-induced TCM. All reported cases of drug-induced TCM were systemically identified and analyzed.

RESULTS

We identified 157 cases of drug-induced TCM. Fifty-seven (36.3%) cases were related to the administration of exogenous catecholamines. In 50 (31.9%) other cases, there was potential adrenergic effect. This included drugs with adrenergic vasoconstriction properties (3.2%), hyperadrenergic state due to alcohol or opioid withdrawal (7.7%), inhibitors of catecholamine reuptake (14.7%), anaphylactic reaction that is accompanied by catecholamine release (3.2%), and psychological or somatic stress coinciding with the administration of a drug that was thought to be the culprit (3.2%). Overall, 68.2% of these drug-induced TCM cases were catecholamine related. In 14 (8.9%) cases, the likely etiology of cardiomyopathy was chemotherapy-induced coronary vasospasm.

CONCLUSION

Our systematic review showed that over two-thirds of drug-induced TCM cases were due to direct or indirect catecholamine stimulation. The lowest effective dose and shortest duration of catecholamines should be utilized, and alternative therapies should be considered if feasible.

Amiodarone-Induced Pulmonary Toxicity - A Frequently Missed Complication

INTRODUCTION

Amiodarone is often used in the suppression of tachyarrhythmias. One of the more serious adverse effects includes amiodarone pulmonary toxicity (APT). Several pulmonary diseases can manifest including interstitial pneumonitis, organizing pneumonia, acute respiratory distress syndrome, diffuse alveolar hemorrhage, pulmonary nodules or masses, and pleural effusion. Incidence of APT varies from 5–15% and is correlated to dosage, age of the patient, and preexisting lung disease.

DESCRIPTION

A 56-year-old male with a past medical history of coronary artery disease and chronic obstructive pulmonary disease was admitted for a coronary artery bypass graft. Post-operatively, the patient was admitted to the ICU for ventilator management and continued to receive his home dose of amiodarone 400 mg orally twice daily, which he had been taking for the past 3 months. The patient was found to be hypoxemic with a PaO2 52 mmHg and bilateral infiltrates on chest x-ray. Patient also complained of new onset dyspnea. Physical exam found bilateral rhonchi with bibasilar crackles and subcutaneous emphysema along the left anterior chest wall. Daily chest x-rays showed worsening of bilateral interstitial infiltrates and pleural effusions. A chest high-resolution computed tomography on post-operative day 3 showed extensive and severe bilateral ground glass opacities. APT was suspected and amiodarone was discontinued. A course of oral prednisone without antibiotics was initiated, and after one week of treatment the chest film cleared, the PaO2 value normalized and dyspnea resolved.

DISCUSSION

APT occurs via cytotoxic T cells and indirectly by immunological reaction. Typically the lungs manifest a diffuse interstitial pneumonitis with varying degrees of fibrosis. Infiltrates with a ‘ground-glass’ appearance appreciated on HRCT are more definitive than chest x-ray. Pulmonary nodules can be seen, frequently in the upper lobes. These are postulated to be accumulations of amiodarone in areas of previous inflammation. Those undergoing major cardiothoracic surgery are known to be predisposed to APT. Some elements require consideration: a baseline pulmonary function test (PFT) did not exist prior. APT would manifest a restrictive pattern of PFTs. In APT diffusing capacity (DLCO) is generally >20 percent from baseline. A DLCO was not done in this patient. Therefore, not every type of interstitial lung disease could be ruled out. Key features support a clinical diagnosis: (1) new dyspnea, (2) exclusion of lung infection, (3) exclusion of heart failure, (4) new radiographic features, (5) improvement with withdrawal of amiodarone. Our case illustrates consideration of APT in patients who have extensive use of amiodarone and new onset dyspnea.

Severe Pulmonary Arterial Hypertension in Patients Treated for Hepatitis C With Sofosbuvir

Development of direct-acting antiviral agents against hepatitis C virus (HCV) has changed the management of chronic HCV infection. We report three cases of newly diagnosed or exacerbated pulmonary arterial hypertension (PAH) in patients treated with sofosbuvir. All patients had PAH-associated comorbidities (HIV coinfection in two, portal hypertension in one) and one was already being treated for PAH. At admission, all patients presented with syncope, World Health Organization functional class IV, right-sided heart failure, and extremely severe hemodynamic parameters. After specific PAH therapy, the clinical and hemodynamic properties for all patients were improved. Severity and acuteness of PAH, as well as chronology, could suggest a causal link between HCV treatment and PAH onset. We hypothesize that suppression of HCV replication promotes a decrease in vasodilatory inflammatory mediators leading to worsening of underlying PAH. The current report suggests that sofosbuvir-based therapy may be associated with severe PAH.

Neuroleptic-induced Parkinsonism: Clinicopathological study

BACKGROUND

Drug-induced parkinsonism is a well-known complication of several different drugs--the most common being neuroleptic-induced parkinsonism. However, very few autopsies have been reported in such cases.

METHODS

Patients assessed at Movement Disorders Clinic Saskatchewan are offered brain autopsy. Detailed clinical records are kept.

RESULTS

Brains were obtained from 7 drug-induced parkinsonism patients with parkinsonian symptom onset coinciding with use of drugs known to produce parkinsonism. Six were on antipsychotics and 1 was on metoclopramide. Three cases were treated with levodopa for parkinsonism. In two cases, parkinsonian features reversed after stopping the offending agent. Both had autopsy evidence of preclinical PD. In 4 of the remaining 5, dopamine-blocking drugs were continued until death. In 4 of those 5, brain histology revealed no cause for the parkinsonism, but 1 had mild SN neuronal loss without Lewy bodies.

CONCLUSION

This study shows that reversal of parkinsonism after discontinuing offending drugs does not indicate absence of underlying pathology. Neuroleptics can unmask preclinical PD in patients with insufficient SN damage for the disease to manifest clinically. Though the mechanism of sustained parkinsonian features after discontinuing neuroleptics remains to be established, it is unlikely that dopamine receptor block leads to retrograde SN neuronal degeneration. Furthermore, L-dopa does not appear to be toxic to SN.

Drug-induced fulminant hepatic failure in pregnancy

Liver disease in pregnancy can be classified as predating, co-incidental or unique to pregnancy. Medications are often overlooked as a significant cause of liver disease. We present the case of a 39-year-old patient who presented at 20 weeks with jaundice, elevated liver enzymes, and abnormal liver function progressing eventually to fulminant hepatic failure. The patient was on methyldopa and labetalol from 12 weeks' gestational age. Liver biopsy was consistent with drug-induced liver injury. Both methyldopa and labetalol have been associated with hepatotoxicity including liver failure. This case highlights the importance of including medications as a cause of liver failure in pregnant patients.

Aripiprazole Induced Acute Transient Bilateral Myopia: A Case Report

BACKGROUND

Aripiprazole is an atypical antipsychotic drug. Acute transient myopia is a rare response to systemic medication. Unspecified ocular side effects of aripiprazole have rarely been reported. To the best of our knowledge, only 3 cases of aripiprazole induced myopia and diplopia have been reported in the literature. The aim of this article is to present a case of aripiprazole-induced acute transient myopia.

CASE REPORT

A 30 year-old woman underwent treatment for 5 days with aripiprazole and presented with bilateral painless blurred vision. The patient's uncorrected visual acuity was 2/10 in both eyes and her best corrected visual acuity was 10/10 in both eyes with a refractive error of -3.00 diopters using a standard Snellen chart. Adding 2 mgs of biperiden a day to her treatment regimen decreased her blurred vision symptoms. After discontinuation of aripiprazole treatment and cross-switching to Paliperidon palmitate (75 mg/month) her blurred vision completely resolved. The same side effect did not re-occur when checked on her 6-month follow up.

CONCLUSION

Ophthalmologists as well as psychiatrists must be aware of this myopic shift and should also ask these patients about medicine usage, especially aripiprazole. Ophthalmologists should consult the prescribing psychiatrist and stop the drug immediately to reverse this temporary condition.

Telmisartan aggravates pustular psoriasis

Pustular psoriasis is characterized by abrupt onset of macroscopic pustules associated with erythema and symptoms of burning pain and constitutional symptoms. There are several precipitating factors, both physiological such as pregnancy and routinely prescribed drugs like antihypertensives, antifungals, corticosteroids and progesterone. We present a case of a 50-year-old male patient with pustular psoriasis, well controlled on oral methotrexate, who presented with sudden exacerbation of pustular psoriasis following the use of telmisartan. This case is presented due to the absence of prior reports of telmisartan aggravating pustular psoriasis.

Drug-induced autoimmune hemolytic anemia in a 78-year-old African-American man with chronic lymphocytic leukemia

PATIENT

78-year-old African-American man.

PAST MEDICAL HISTORY

Chronic lymphocytic leukemia first diagnosed in 2003, with a subsequent relapse in 2006 and another in 2010.

HISTORY OF PRESENT ILLNESS

In late 2011, the patient was admitted to the hospital for cholelithiasis, at which time his treating physician incidentally discovered severe anemia. The anemia worsened as time went on, and the patient became transfusion dependent. Hypogammaglobulinemia secondary to chronic lymphocytic leukemia (CLL) required that the patient receive intravenous immunoglobulin. Despite transfusion therapy, the anemia failed to lessen; laboratory results eventually led to the diagnosis of a drug-induced warm autoantibody that triggered hemolytic anemia.

MEDICATIONS

The patient had taken rituximab in 2003; rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone (R-CHOP) in 2006; fludarabine, cyclophosphamide, and rituximab (FCR) in 2010; and intravenous Immunoglobulin (IVIG) and prednisone in 2011.

Nonchemotherapy drug-induced neutropenia and agranulocytosis: could medications be the culprit?

Drug-induced agranulocytosis is a severe complication that has been implicated with most classes of medications. Medications such as clozapine, trimethoprim-sulfamethoxazole and methimazole have been more commonly associated with agranulocytosis than other agents. Although the pathogenesis isn't fully elucidated, it appears to be two-fold with a direct toxicity to the myeloid cell line and immune-mediated destruction. Patients may be asymptomatic at the time neutropenia is discovered or may present with more severe complications such as sepsis. In approximately 5% of cases drug-induced agranulocytosis may be fatal. Management of drug-induced agranulocytosis includes the immediate discontinuation of the offending medication, initiation of broad-spectrum antibiotics and consideration of the use of granulocyte colony-stimulating factors in high-risk patients.

Sodium valproate induced necrotising pancreatitis: A case report

Sodium valproate is one of the most common first-line antiepileptics prescribed for primary and secondary generalised seizures. However, serious complications associated with sodium valproate, such as acute pancreatitis, need to be considered when choosing this medication for treating epilepsy in certain populations such as children and persons with intellectual disability. We report a case of a 21-year-old man with intellectual disability who presented to the emergency department with an acute abdomen, vomiting and diarrhoea. He had to undergo an emergency exploratory laparotomy during which acute necrotising pancreatitis was diagnosed intra-operatively. We believe that the recent increase in sodium valproate dosage for his epilepsy was the cause of the pancreatitis. Carers of such persons should be adequately informed regarding possible life-threatening complications of medications prescribed to avoid delay in diagnosis and unwanted incidents.

Unilateral tremor induced by risperidone in a patient with acute mania: vitamin B12 deficiency as possible mediating factor

Identification and management of drug-induced movement disorders is a clinical challenge, more so when the clinical presentation is atypical. A young male with acute mania was under treatment with sodium valproate and risperidone. He developed tremors of right hand and neck. These were present at rest and exacerbated by mental activity, when under observation and during voluntarily initiated activity. There were no associated extra pyramidal symptoms or cerebellar signs. Investigations for other common causes of tremors did not reveal any evidence except for low value of serum vitamin B12 levels. The tremors persisted after the withdrawal of valproate, but resolved following the withdrawal of risperidone. It is a common dictum that drug-induced tremors are bilateral. This may not be true always as we found out in our case. These movements were probably induced by risperidone. This atypical presentation could be due to concurrent use of valproate and low serum vitamin B12 levels.

Influence of prescribed herbal and Western medicine on patients with abnormal liver function tests: a retrospective quasi-experimental study

Objectives:

The aim of this study was to investigate the safety and the efficacy of Korean herbal, western and combination medicine use in patients with abnormal liver function tests.

Methods:

We investigated nerve disease patients with abnormal liver function tests who were treated with Korean herbal, western and combination medicine at Dong-Eui University Oriental Hospital from January 2011 to August 2011. We compared aspartic aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and total bilirubin (T-bil) levels before and after taking medicine and excluded patients who had liver-related disease when admitted.

Results:

AST and ALT were decreased significantly in patients who had taken herbal, western medicine. AST, ALT and ALP were decreased significantly in patients who had taken combination medicine. Compare to herbal medicine, AST, ALT and ALP were decreased significantly in patients who had taken western medicine, and ALT and ALP were decreased significantly in patients who had taken combination medicine. There were no significant differences between western and combination medicine.

Conclusions:

This study suggests that prescribed Korean herbal medicine, at least, does not injure liver function for patients’, moreover, it was shown to be effective in patients with abnormal liver function tests.