Non-opioid analgesics/opioid anagesics
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Erythema multiforme, palmar pruritus and cutaneous lesions: case report A 47-year-old woman developed erythema multiforme (EM) during treatment with tramadol/paracetamol for low back pain. Additionally, she developed palmar pruritus during treatment with paracetamol and cutaneous lesion following administration of tramadol. The woman, who had low back pain, had been receiving tramadol/paracetamol 37.5mg/325mg [Pazital; acetaminophen/ tramadol] every 8 hours. However, 4 weeks following treatment initiation, she developed an eruption with symmetrical distribution of target lesions on the palms, soles, arms and torso. Three days later, she developed lesions in oral mucosa and presented to the dermatology department. She was diagnosed with drug-induced EM. The woman was treated with unspecified antihistamines, prednisone, fusidic acid/ hydrocortisone [fusidic acid/hydrocortisone acetate; Fucidine], lidocaine and betamethasone/gentamicin [Diprogenta; betamethasone dipropionate/gentamicin sulfate]. Her lesions resolved within 2 months and no sequelae or hyperpigmentation was noted. Histopathological examination of the biopsy specimen (right palm) demonstrated necrotic keratinocytes throughout the epidermis. In addition, lichenoid infiltrate rich in lymphocytes, with interface damage, lymphocytic exocytosis and blood extravasation were also noted. Thus, the diagnosis of druginduced EM was confirmed. Thereafter patch tests were performed with paracetamol [acetaminophen] 5%, etoricoxib 10% and tramadol 5% and the results were negative at 48 and 96 hours. Subsequently lymphocyte transformation test (LTT) indicated a mild positive result for tramadol/paracetamol (stimulation index; SI 2.25), while it was negative for paracetamol, tramadol and etoricoxib. Anamnesis revealed she had taken tramadol/paracetamol few weeks prior to reaction and developed micropapules on her palm; however, it resolved over the following 5 days. She also received paracetamol with ibuprofen a month following resolution of the reaction and developed palmar pruritus; however, it resolved following discontinuation of the drug. Further, she received ibuprofen and tolerated well. Hence, dose-graded drug provocation tests were performed, and she developed typical cutaneous lesions on the palm over one hour following intake of tramadol 40mg. However, the test results were negative for paracetamol and etoricoxib. Subsequent LTT indicated an SI of 2.08 and 2.04 for tramadol/paracetamol and 4.56 (10 µg/mL) and 5.67 (25 µg/mL) for tramadol, and
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