Drug Eruption Fix Print

7/27/2019 Drug Eruption Fix Print

1/30

DRUG ERUPTION(IN HIV/AIDS PATIENT)

Indah Febrini Triana J. C 111 08 148

Ashari Mohpul C 111 08 319


2/30

CASE REPORT

Name : Mrs. O

Age : 26 years old

Address : Kampung Melawang,

Sudiang

Marital status : Married

Admission date : 25thAugust 2012


3/30

ANAMNESIS

Chief complaint : itchiness and red spot all over

the body

Brief anamnesis: Patient came to hospital with a

complain of itchiness and red spot all over the body

since 4 days ago. The itchiness began after the

patient consumed a few drugs. Then appears red

spot from the arms to the entire body. The patient

felt itchy on her mouth, neck, and forehead too.

This patient has history of taking ARV, Piracetam,and Amoxicillin since a month ago. Family history (-

). History of drugs and foods allergy not known.


4/30

PRESENT STATUS

General status: Moderately ill

Consciousness: Composmentis

Nutritional status: Good

Vital signs: BP : 100/70mmHg

HR : 80x/minute

RR : 20x/minute

Temp : 36,8C


5/30

DERMATOLOGYSTATUS

Location: Region generalized

Efflorescence: erythema macula


6/30


7/30

LABORATORYRESULTS

SGOT : 12 U/L

SGPT : 12 U/L

Albumin : 4.0 g/dl

Ureum : 8 mg/dl Creatinine : 0.62 mg/dl

Total bilirubine : 0.26 mg/dl

Bilirubin direct : 0.07 mg/dl

CD4 absolut : 127 sel/ Ul

VCT : reaktif


8/30

RESUME

A 26 years old woman came to hospital with acomplain itchiness and red spot all over the bodysince 4 days ago. The itchiness began after thepatient consumed a few drugs. Then appears red

spot from the arms to the entire body. The patientfelt itchy on her mouth, neck, and forehead too.This patient has history of taking ARV, Piracetam,and Amoxicillin since a month ago. Patient is

treated for her underlying disease which isHuman Immunodeficiency Virus(HIV). Familyhistory (-). History of drugs and foods allergy notknown.


9/30

RESUME (2)

Internal status in normal range. Dermatology

status: regio location generalized, erhytema

macula efflourescene. Vital status in normal

range. Obstetry status: pregnancy (22-24weeks)

Diagnosis : Drug eruption : type IV ( based

on Immunological Mechanisms)


10/30

TREATMENT

Systemic : Chlorpheniramine maleate

(CTM) 3x1

Metil prednisolon 4mg 3x1

Topical : Salicylic powder for neck area

PROGNOSTIC :The prognosis of this patient is dubia


11/30

DISCUSSION


12/30

DRUG ERUPTIONS

Introduce :ADR ( Adverse Drug Reaction) = an undesirable

clinical manifestation resulting from administration

of a particular drug; this includes reactions due to

overdose, predictable side effects and

unanticipated adverse manifestations

ACDRs (adverse cutaneous drug reactions) = ADRs

in Cutaneous = DRUG ERUPTIONS


13/30

INCIDENCE

In USA (1969 2002) = about 2.3 million case reports

ADRsDrug eruptions = 24% of all ADRs ( other study :

29%)

A survey of ACDRs among in-patients :o

one-third were fi xed drug reactionso one-third were exanthematous

o 20% were urticaria or angio-oedema

ACDRs :Antimicrobial agents (42%);antipyretic/antiinflammatory analgesics (27%); drugs acting onthe central nervous system accounting for10% of reactions.

ACDRs : Amoxicillin (51 cases/ 1000 exposed),trimethoprimsulfamethoxazole (33 cases/1000 exposed)and ampicillin (33 cases/1000 exposed.


14/30

MECHANISMS

Drug reactions may arise as a result of

immunological allergy directed against the drug

itself, a reactive metabolite or some contaminant of

the drug or, more commonly, by non-immunological

mechanisms, such as pseudoallergic reactionscaused by nonimmune-mediated degranulation of

mast cells and basophils.


15/30

CLASSIFICATION (1)

Type A : Drug reactions may be predictable

Type B : Drug reactions unpredictable

Type C : reactions include those associated with

prolonged therapy (e.g. analgesic nephropathy) Type D : reactions consist of delayed reactions (e.g.

carcinogenesis and teratogenicity).


16/30

CLASSIFICATION (2)

Non-immunological : Predictable :

1. Overdosage

2. Side effects

3. Cumulation4. Delayed toxicity

5. Facultative effects

6. Drug interactions

7. Metabolic alterations

8. Teratogenicity

9. Non-immunological activation of effector pathway

10. Exacerbation of disease

11. Drug-induced chromosomal damage

Unpredictable:1. Intolerance

2. Idiosyncrasy


17/30

CLASSIFICATION (3)

Immunological (unpredictable) :

IgE-dependent drug reactions

Immune complex-dependent drug reactions

Cytotoxic drug-induced reactions Cell-mediated reactions

Miscellaneous :

JarischHerxheimer reactions

Infectious mononucleosisampicillin reaction


18/30

IMMUNOLOGICAL MECHANISMS

IgE-dependent (type I) drug react ions:pruritus, urticaria, bronchospasm and laryngeal oedema, and insevere cases anaphylactic shock with hypotension and possiblydeath.

An t ibod y-mediated (type I I) drug react ions :fever, arthritis,

nephritis, neuritis, oedema, and an urticarial or papular rash.

Immune complex-dependent (type I I I ) drug react ions

:Urticaria and anaphylaxis, Serum sickness,Vasculitis, Arthus reaction.

Cell-mediated (type IV) react ions :morbilliform and bullousACDRs, fixed drug reactions, lichenoid reactions, LE-likereactions, dress syndrome and erythema multiforme, StevensJohnson syndrome and TEN, involve T-lymphocyte responses toaltered self.


19/30

TYPESOFCLINICALREACTION Exanthematic (maculopapular) reactions

Purpura

Annular erythema

Pityriasis rosea-like reactions

Exfoliative dermatitis/ erythroderma : thickening of skin resulting inincreased skin folds, universal redness, a fine brawny scaling.

Psoriasiform eruptions

Anaphylaxis and anaphylactoid reactions Urticaria

OTHER CLINICALS:

Fixed drug eruptions.

LE-like syndrome induced by drugs.

Erythema multiforme StevensJohnson syndrome

TEN.

Lichenoid drug eruptions

Drug-induced pemphigus


20/30

DRUGS CAUSING ERYTHRODERMAAND

EXFOLIATIVE DERMATITIS

Allopurinol

p-Aminosalicylic acid

Ampicillin

Barbiturates

Captopril Carbamazepine

Cefoxitin

Chloroquine

Chlorpromazine

Cimetidine Diltiazem

Gold

Griseofulvin

HydantoinsIsoniazid

Lithium

Nitrofurantoin

Penicillamine

Penicillin Phenylbutazone

Quinidine

Streptomycin

Sulphonamides

Sulphonylureas Thioacetazone

(thiacetazone)

Zidovudin


21/30

ACDRSVS AIDS

Patients with AIDS : increased risk for ADRs

Patients with AIDS : more likely to have particularly severe

reactions, ranging from erythema multiforme to toxic

epidermal necrolysis (TEN) (especially with sulphonamides,

clindamycin, phenobarbital (phenobarbitone) and

chlormezanone) and to demonstrate multiple cutaneous

drug reactions.

Antiretroviral therapy (including abacavir, non-nucleoside

reverse transcriptase inhibitors such as nevirapine, andprotease inhibitors such as amprenavir) : implicated

hypersensitivity


22/30

STAGINGOF HIV/AIDS

Stage I asymptomatic or Persistentgeneralized lymphadenopathy (PGL)

Stage II - mild disease

Stage III - moderate disease

Stage IV - advanced

immunocompromise


23/30

P C C O S S E C S O


24/30

PRINCIPAL CUTANEOUS SIDE EFFECTSOF

ARV DRUGSNucleoside reverse transcriptase inhibitors

(NRTIs) :o All NRTIs: Pruritus, xanthem, urticaria

o Abacavir: HLA B5701 hypersensitivity syndrome, SJS, TEN, Kawasaki syndrome,anaphylaxis, lipodystrophy

o Didanos ine (ddI, DDI): Vasculitis, purpura, SJS, anaphylaxis, Ofujispapuloerythroderma, gynaecomastia, lipodystrophy, acral erythema, diaphoresis

o Emtrici tabin e (FTC): Hyperpigmentationo Lam ivud ine (3TC): Vasculitis, anaphylaxis, angio-oedema, allergic contact dermatitis,

gynaecomastia, lipodystrophy, diaphoresis

o Stavudin e (d4T): Lipodystrophy, gynaecomastia, neutrophilic eccrine hidradenitis,tendon xanthomas, diaphoresis

o Tenofovir: Maculopapular toxic erythema, diaphoresis

o

Zalcitabin e* (ddC, DDC): Anaphylaxis, angio-oedema, acne, photosensitivity,erythroderma, granuloma annulare, bullous eruption, diaphoresis

o Zido vu din e (AZT, ZDV): Exanthem, erythema multiforme and SJS, polymyositis,erythroderma, porphyria cutanea tarda, purpura, vasculitis, insect bite reaction,discoloration of the skin (also mucosa and nails) especially in dark-skinned individuals),neutrophilic eccrine hidradenitis, acne, bullous eruption, lipodystrophy, bromhidrosis,diaphoresis


25/30

PRINCIPAL CUTANEOUS SIDE EFFECTSOF ARV DRUGS

(2)

Non-nucleos ide reverse transc r iptaseinh ibito rs (NRTIs) :

All NNRTIs : Pruritus, exanthem, SJS/TEN

Delavirdine : Xerosis, urticaria, angio-oedema, dermatitis,vesicobullous eruption, purpura, vasculitis, seborrhoea,gynaecomastia, diaphoresis

Efavirenz : Eczema, photosensitivity, gynaecomastia,leukocytoclastic vasculitis, urticaria, flushing, folliculitis

Nevirapine : DRESS, angioedema, anaphylaxis,lipodystrophy

Fus ion inh ib i tors Enfuvir t ide: Injection site reactions, xerosis, pruritus,

exanthem, acne, herpes simplex, papillomas, ecchymosis,paraesthesia


26/30


27/30

ACDRS VS PREGNANCY

The fetus is particularly at risk from drug-induced

developmental malformations during the period of

organogenesis (the third to the tenth week of gestation)

Sex hormones, psychotropic drugs,

benzodiazepines, tetracycline, rifampicin,

penicillamine and the folate antagonist

pyrimethamine are possibly teratogenic and should

be avoided in the first trimester of pregnancy.


28/30

RECOMMENDED EXAMINATION

Provocation tests : Provoking the lesion with the

suspected drug confirms the diagnosis, prevents

recurrences, and allays the anxiety of the patient

regarding venereal origin of the disease.

Patch tests are performed on the patient's normal

and prelesional skin with the drug in a petrolatum

base.

A biopsy shows hydropic degeneration of the

epidermal basal cells and pigmentary incontinence.


29/30

DIFFERENTIAL DIAGNOSIS

Erytroderma : Pityriasis rubra pilaris, psoariasis and

cutaneous T-cell lymphoma

Pityriasis rubra

pilaris

Psoariasis Cutaneous T-cell

lymphoma


30/30

MANAGEMENT

Systemic :

o Kortikosteroid : 3x10 mg till 4 x 10 mg for a

day

o Histamint agent for itchness

Topycal : Ianolin Zalp 10 %.

Documents

Drug Eruption Fix Print