Leflunomide
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Drug reaction with eosinophilia and systemic symptoms: case report A 56-year-old woman developed drug reaction with eosinophilia and systemic symptoms (DRESS) during treatment with leflunomide for rheumatoid arthritis. The woman had rheumatoid arthritis, primary hypertension and type 2 diabetes mellitus. She had been receiving various medications. Four weeks previously, she started receiving leflunomide tablet 20 mg/day [route not stated] for worsening of arthritis. She presented to hospital with low grade fever and generalised red rash as well as scaling. Laboratory tests showed the following: deranged LFT with serum bilirubin 2.4 mg/dL, ALT 339 IU/L and AST 227 IU/L, haemoglobin 11.2 g/dL, peripheral eosinophilia of 2054/mm3 and total leukocyte count 13400/mm3. A suspicion of drug induced exfoliative dermatitis due to leflunomide was made. Therefore, the woman’s leflunomide therapy was discontinued. She received prednisolone with tapering. A near complete resolution of the rash and normalisation of the investigation parameters were observed. Following an asymptomatic interval of 5 days, she again exhibited a high grade fever along with generalised itchy red rash, multiple painful oral ulcers and scaling all over her body. After 2 days, she developed multiple purpuric lesions over both her legs progressing within 72 hours with involvement of the entire lower limbs with super‑imposed flaccid fluid filled blisters rapidly coalescing with each other. She was hospitalised. Examination showed high grade fever and pallor along with generalised significant lymphadenopathy as well as bilateral pitting pedal oedema. Systemic examination showed coarse crackles over lower zone of her right lung with diminished breath sounds. Dermatological examination showed diffuse facial oedema, erythema and scaling with involvement of >90% of the body surface. Multiple purpuric macules with targetoid morphology and multiple coalescing clear fluid containing flaccid bullae distributed symmetrically all over her lower limbs. In addition, she had oral candidiasis. A bed side Tzanck smear from a bulla showed necrotic keratinocytes. Peripheral blood smear showed eosinophilia of 1550 /mm3, normocytic normochromic anaemia and atypical lymphocytes. LFT was deranged with serum bilirubin 2.2 mg/dL, AST 139 IU/L, ALT 156 IU/L and reduced serum albumin (1.8 g/dL). Her serum procalcitonin increased (23 ng/mL). Chest X‑ray was indicative of right sided lobar pneumonia with pleural effusion. Skin biopsy was indicative of marked spongiosis, few apoptotic keratinocytes with predominantly eosinophilic and lymphocytic perivascular and dermal infiltrate. On the basis of these findings, she was diagnosed with DRESS (with involvement of >50% of the body surface area) due to leflunomide. Stevens‑Johnson syndrome toxic epidermal necrolysis was ruled out due to absence of epidermal detachment and typical mucosal involvement. Therefore, she was treated with prednisolone, unspecified antibiotics and supportive therapy. Subsequently, a good cl
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