Interferon-gamma-induced local leukocytoclastic vasculitis at the subcutaneous injection site

Abstract Cutaneous reactions associated with interferons (IFNs) treatment are either localized or generalized. The most common presentation of localized reactions at IFNs injection site is usually an erythematous patch or plaque. Local leukocytoclastic vasculitis presenting with cutaneous necrosis is extremely rare. We report a 19-year-old man with hepatitis B who had local leukocytoclastic vasculitis induced by interferon-gama injection at the injection site. After changing the injection sites and using the combined treatment of prednisone and colchicine, the previous lesion healed and no other cutaneous lesion occurred. We also made a mini review of such cases.

Drug-induced lupus with leukocytoclastic vasculitis: a rare expression associated with adalimumab

TNF alpha antagonist-induced lupus-like syndrome is a rare condition which predominantly affects women (4:1). The average age of onset is 46-51 years. It occurs after exposure to TNF alpha antagonist and disappears after discontinuation of such agents. The pathogenic mechanism for development of the TNF alpha antagonist-induced lupus-like syndrome is not fully defined. It is believed that the medication induces apoptosis, leading to an accumulation of nucleosomal antigens of apoptotic cells. This would cause autoantibodies to be produced by susceptible individuals. The most common cutaneous manifestations include maculopapular exanthem, malar rash, alopecia, photosensitivity and, more rarely, vasculitis. Extracutaneous manifestations include: fever, weight loss, arthritis or arthralgia, myositis and hematological abnormalities. Antinuclear antibody may be positive in 80% of cases and anti-histone antibody is considered a disease marker for TNF alpha antagonist-induced lupus-like syndrome. Treatment corresponds to drug discontinuation. We report a rare case of sub-acute cutaneous lupus erythematosus with leukocytoclastic vasculitis induced by adalimumab in a 42-year-old patient.

Vasculitis leucocitoclástica cutánea por posible hipersensibilidad a medicamento de uso crónico en el marco de una infección por virus de la hepatitis C / Leukocytoclastic cutaneous vasculitis due to possible hypersensitivity to cronic drug use in connection with an infection of hepatitis C virus

INTRODUCCIÓN: La Vasculitis leucocitoclástica cutánea (VLC) es una inflamación vascular, habitualmente de vénulas post-capilares. Posee baja incidencia. El signo más frecuente es púrpura palpable (PP). Puede ser primario, o secundario a infecciones, enfermedades sistémicas o fármacos. LaVLC por fármacos es un trastorno poco definido y difícilmente demostrable, la evidencia actual sugiere como criterio principal: asociación temporal fármaco-lesión. PRESENTACIÓN DE CASO CLÍNICO: Mujer, 60 años, antecedentes de Hipertensión Arterial (HTA) en tratamiento, alérgica a Enalapril,Metamizol, y Atenolol, ex-consumidora de anfetaminas, acudió a Urgencias Hospital Las Higueras (HLH), por cuadro de una semana de evolución de lesiones purpúricas, solevantadas, no pruriginosas, ubicadas desde tercio inferior del muslo al pie en extremidades inferiores (EEII), dolorosas EVA 9/10, atenuado con el frío. Lesiones evolucionaron a necrosis durante estadía intrahospitalaria. EcoDoppler descartó trombosis venosa profunda. Función hepática normal. Serología destacó Virus Hepatitis C (VHC) positivo confirmado por Instituto de Salud pública (ISP). Biopsia confirma VLC. Nuevo antecedente reveló inicio reciente de tratamiento con Furosemida; paciente suspendió medicamento. Egresó tras 29 días hospitalizada con dolor leve y lesiones de EEII en regresión. DISCUSIÓN:VLC es una entidad clínico-patológica de difícil abordaje, muchos casos resultan de etiología desconocida aun después de una detallada historia clínica. Es discutible si este caso de VLC se desencadenó por VHC o Furosemida, muchos casos son provocados por hipersensibilidad a medicamentos sumado a infección subyacente. Si bien la Furosemida, medicamento de alta prescripción en patologías GES, ha demostrado ser seguro, es necesaria la administración cuidadosa en pacientes con antecedentes de hipersensibilidad

INTRODUCTION: Leukocytoclastic cutaneous vasculitis (LCV) is a vascular inflamation, usually of post-capillary veins. It has low incidence. The most common sign is palpable purpura. It can be primary or secondary to infections, systemic diseases or drugs. Drug-induced LCV is poorly defined and a difficult to prove disorder. Current evidence suggests as the main criteria: drug-injury temporal association. CASE-REPORT: Female, 60 years old, history of arterial hypertension (AHT) in treatment; allergic to Enalapril, (Metamizol) Dipyrone, and Atenolol; former consumer of amphetamines. Attended to Hospital Las Higueras (HLH) Emergency on 04.18.2014, due to nonpruritic up thrust purpuric lesions, painful EVA 9/10 and attenuated with cold, located from the lower third of the thigh to the foot in lower limbs, one week of evolution. Lesions evolved to necrosis during hospital stay. Doppler ultrasound ruled out deep vein thrombosis. Normal liver function. Serology shows positive HCV confirmed later by IPH. Dermatological biopsy confirms LCV. New data reveals recent onset of treatment with Furosemida; patient stopped taking medication. Patient was discharged after 29 days in hospital with mild pain and lesions in lower limbs in regression. DISCUSION: LCV is a clinicopathological entity of difficult approach. A large number of cases are of unknown etiology entity even after a detailed medical history. It is debatable whether this event was triggered by HCV or Furosemide, because many cases are caused by drug hypersensitivity coupled with an underlying infection. Though furosemide, high prescription drug in GES pathologies, has been proven safe, careful administration in patients with known hypersensitivity is necessary

Cutaneous leukocytoclastic vasculitis in the presence of methimazole therapy / Vasculite leucocitoclástica cutânea na vigência de terapêutica com metimazol

Treatment with antithyroid drugs may be accompanied by side effects. We present a patient diagnosed with Grave's Disease who developed extensive vasculitis in the lower limbs during methimazole use. After suspension of the methimazole and the introduction of prednisone in immunesupressor doses the cutaneous lesions started to involute.

A terapêutica com drogas antitireoidianas pode ser acompanhada de efeitos colaterais. Apresentamos um caso de paciente com diagnóstico de Doença de Graves que na vigência da terapêutica com metimazol desenvolveu um quadro extenso de vasculite de membros inferiores. A partir da suspensão do metimazol e da introdução de prednisona em doses imunossupressoras as lesões cutâneas entraram em involução.

Comparative analysis of adverse events between infliximab and adalimumab in Crohn's disease management: a Brazilian single-centre experience / Análise comparativa dos eventos adversos entre infliximabe e adalimumabe no tratamento da doença de Crohn: experiência em um centro brasileiro

INTRODUCTION: Data is scarce regarding adverse events (AE) of biological therapy used in the management of Crohn's Disease (CD) among Brazilian patients. OBJECTIVES: To analyse AE prevalence and profile in patients with CD treated with Infliximab (IFX) or Adalimumab (ADA) and to verify whether there are differences between the two drugs. METHOD: Retrospective observational single-centre study of CD patients on biological therapy. Variables analysed: Demographic data, Montreal classification, biological agent administered, treatment duration, presence and type of AE and the need for treatment interruption. RESULTS: Forty-nine patients were analysed, 25 treated with ADA and 24 with IFX. The groups were homogeneous in relation to the variables studied. The average follow-up period for the group treated with ADA was 19.3 months and 21.8 months for the IFX group (p = 0.585). Overall, 40% (n = 10) of patients taking ADA had AE compared with 50% (n = 12) of IFX users (p = 0.571). There was a tendency towards higher incidence of cutaneous and infusion reactions in the IFX group and higher incidence of infections in the ADA treated group, although without significant difference. CONCLUSIONS: No difference was found in the AE prevalence and profile between ADA and IFX CD patients in the population studied. (AU)

INTRODUÇÃO: Há poucos dados sobre os eventos adversos (EA) da terapia biológica usada no tratamento da doença de Crohn (DC) entre os pacientes brasileiros. OBJETIVOS: Analisar a prevalência dos EA e o perfil dos pacientes com DC tratados com Infliximabe (IFX) ou Adalimumabe (ADA) e verificar se há diferenças entre esses dois fármacos. MÉTODO: Estudo observacional e retrospectivo de pacientes com DC em terapia biológica, realizado em centro único. As variáveis analisadas foram: dados demográficos, classificação de Montreal, agente biológico administrado, duração do tratamento, presença e tipo de EA e necessidade de interrupção do tratamento. RESULTADOS: Quarenta e nove pacientes foram analisados, 25 tratados com ADA e 24 com IFX. Os grupos eram homogêneos em relação às variáveis estudadas. O período médio de acompanhamento foi de 19,3 meses para o grupo tratado com ADA e de 21,8 meses para o grupo tratado com IFX (p = 0,585). No total, 40% dos pacientes (n = 10) que receberam ADA tiveram AE, em comparação com 50% dos pacientes (n = 12) que receberam IFX (p = 0,571). Houve uma maior incidência de reação cutânea e à infusão no grupo IFX e de infecções no grupo ADA, embora sem diferença significativa. CONCLUSÃO: Não houve diferença na prevalência de EA e no perfil dos pacientes com DC que receberam ADA e IFX. (AU)

Vasculite necrotizante como manifestação de hipersensibilidade ao propiltiouracil / Necrotizing vasculitis as a manifestation of hypersensitivity to propylthiouracil

O propiltiouracil (PTU), droga empregada no tratamento do hipertireoidismo, pode provocar reações adversas em 3 por cento a 12 por cento dos pacientes, desde reações leves e frequentes, até quadros incomuns, graves e fatais. Relata-se o caso de um paciente de 14 anos de idade, em uso de PTU há três anos, que apresentou febre, bolhas hemorrágicas e úlceras necróticas, evoluindo com lesões purpúricas e nódulos violáceos em membros inferiores. A avaliação laboratorial e histológica mostrou-se compatível com vasculite cutânea leucocitoclástica, padrão encontrado nas vasculites por reação de hipersensibilidade. Após a retirada da droga antitireoidiana e a introdução de prednisona, houve regressão progressiva das lesões cutâneas. A importância deste estudo é alertar sobre a ocorrência desta grave manifestação cutâneo-sistêmica (vasculite), por droga de uso frequente em medicina interna, cuja taxa de mortalidade é de 10 por cento. É obrigatório o diagnóstico precoce, visando à retirada da droga suspeita, e, se necessário, ao uso de corticosteroides e/ou imunossupressores.

Propylthiouracil (PTU), a thyonamide class drug commonly used to treat hyperthyroidism has been reported to cause adverse reactions in 3 percent to 12 percent of patients. The side effects have been described more frequently as mild, but ocasionally severe fatal reactions may occur. We report the case of a fourteen years old patient in use of PTU for the last three years who presented with fever, hemorrhagic blisters, necrotic ulcers, and that developed purpuric lesions and nodules in lower extremities. Laboratory and histopathologic findings were compatible with skin leukocytoclastic vasculitis, a pattern found in hypersensitivity reaction vasculitis. Suspension of PTU and introduction of prednisone, induced complete remission of symptoms and healing of the skin lesions. The importance of this study is to call attention to the occurrence of serious cutaneous manifestation with a mortality rate that might reach 10 percent, associated with a systemic drug frequently used in internal medicine. Early diagnosis and withdrawal of the suspected medication is mandatory. Administration of corticosteroids and/or immunosuppressives agents must be considered.

Vasculonecrotic reactions in leprosy

Multibacillary, lepromatous or borderline leprosy patients may present two types of vasculonecrotic reactions: Lucio phenomenon and that associated with erythema nodosum leprosum. Despite they can be distinguished through clinical and histological characteristics; both are often used as synonyms. It is said that leprosy reaction should be properly classified for therapeutic reasons, since it is well known that in Lucio phenomenon there is not a good response to thalidomide. The authors reported two cases of vasculonecrotic phenomena in lepromatous leprosy sharing clinical and histopathological characteristics of both reaction subtypes. The findings may indicate the spectral nature of the reaction phenomena in leprosy and emphasize the importance of the clinic-pathological correlation for proper classification. Our findings may contribute to the understanding of leprosy reactions pathogenesis, broaden the knowledge about their outcome with standard treatment, and provide the scientific background to design better therapeutic strategies for these complications.

Pericarditis y vasculitis secundarias a la administración de propiltiouracilo / Pericarditis and vasculitis secondary to the administration of propylthiouracil

Se describe un pacientes de 11 años de edad con bocio multinodular hipertiroídeo que después de 26 meses de tratamiento con Propiltiouracilo sufrió una reacción adversa con la droga, con evidencias de pericarditis, vasculitis y granulocitopenia. Los síntomas desaparecieron rápidamente al suspender la droga. Posteriormente fue sometido a tiroidectomía y tratamiento hormonal de reemplazo