A Strikingly Unusual Drug reaction

A
Strikingly
Unusual
Drug
reaction
Dr. Sunitha V Ittaman
Dr. Chukka Enwezor
Dr. John Melski
Introduction
  Drug
reactions range from exanthems to lethal
conditions: Anaphylaxis, Steven Johnsons and Toxic
Epidermal Necrolysis
  Rare manifestations
Case
  60
year old obese Italian American gentleman
with history of Atrial fibrillation on Warfarin
  Right shoulder swelling, pain & chills x3
weeks
  Diagnosed as septic arthritis
  Blood culture : MSSA
  TEE: Negative
  Home Medications: Allopurinol, lisinoprilHCTZ, metoprolol, warfarin,vicodin,ibuprofen
Timeline
ADMISSION
Day
1
DISCHARGE
2
Unasyn
3
4
5
6
7
RE-ADMISSION
8
9
First admission
Day 1
Timeline
ADMISSION
Day
1
DISCHARGE
2
Unasyn
3
4
5
6
7
RE-ADMISSION
8
9
 Day
of discharge
Timeline
ADMISSION
Day
1
DISCHARGE
2
Unasyn
3
4
5
6
7
RE-ADMISSION
8
9
Chief complaints
  Worsening
rash
  Itching
  Burning
  chills
pain
Physical Exam
  Afebrile,
Pulse:100-110,Irregularly irregular
  Integument: Nonblanchable coalescent papules on
both arms, with central erosions
  Purpuric macules and papules confluent with
serous and hemorrhagic bullae and annular
vesicles on both lower limbs.
  Other systems: Unremarkable
Readmission(left arm)
Left forearm
Left leg
Hand
Splinter hemorrhages
Splinter hemorrhage
Investigations
  CBC,
CMP normal
  IgA, IgG high
  C3,C4 normal
  ESR 54, CRP 11.2
  Blood culture negative
Leukocytoclastic Vasculitis (Day 1)
Readmission (Day 6)
Immunofluorescence study
Diagnosis
Linear IgA bullous dermatosis (LABD)
Linear IgA Bullous Dermatosis
Mucocutaneous autoimmune subepidemal blistering disorder
  Incidence : 1-2 cases/million
  Idiopathic/drugs: Vancomycin
  IgA antibody against basement membrane protein: 97 and 120 KD
  Dermatitis herpetiformis/ bullous pemphigoid like lesions
  Lesions develop within 24 hours to 15 days after the first dose
  New blisters often form at the periphery of resolving lesions
 
Course
  Discontinued
Vancomycin
  Dapsone , topical
steroid
  Rash better in 2
weeks
  tapered off and
discontinued
Dapsone in 6
weeks
COURSE
Intriguing aspects
 2
different dermatological reactions in the
same time frame!
 IgA bullous disease rarely reported with
vasculitis
 Is it the continued exposure that
transformed the rash / was IgA bullous
disease there from the beginning?
References
 
 
 
 
 
 
http://www.dermnetnz.org/immune/linear-iga.html
Chen, Matten et, al:Linear IgA Bullous Dermatosis, Eplasty. 2013 Jul
2;13:ic49. Print 2013
Verma , Vasudevan et,al:Linear IgA disease in an adult with unusual
clinical features:Indian Dermatol Online J. 2013 Apr-Jun; 4(2): 115–118.
Pastuszczak,et,al;Drug-induced linear IgA bullous dermatosis after
discontinuation of cefuroxime axetil treatment.J Dermatol Case Rep.
2012 December 31; 6(4): 117–119.
Battistella et,al:Acquired bullous dermatosis associated with IgA
multiple myeloma Indian journal of Dermatology Venerology and
leprology 2013, 79:5
Dermatitis Herpetiformis and linear I gA bullous dermatosis :Clinical
Dermatology, 5th ed.; Chapter 16 - Vesicular and Bullous Diseases
Normal skin
Linear IgA bullous dermatosis