Sulfasalazine
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Drug hypersensitivity syndrome: case report A 24-year-old man developed drug hypersensitivity syndrome during treatment with sulfasalazine for spondyloarthropathy. The man presented with a high fever and abdominal pain for 4 days. His fever had begun 2 weeks before admission, with a bitemporal throbbing pain at that time; he had been presumed to have a viral infection. However, his low-grade fever persisted until 4 days before his current presentation, when high fever and a progressive maculopapular skin eruption developed; he also had epigastric pain. His history included a diagnosis of chronic bilateral uveitis 2 years earlier, for which he had received topical corticosteroids and, later, oral prednisolone that had been tapered off over 11 months. Two months later, sulfasalazine [route not stated] was prescribe for spondyloarthropathy, starting at 1 g/day and gradually increasing to 2 g/day for 2 weeks prior to development of fever [duration of treatment before ADR not clearly stated]. Examination showed a body temperature of 38.5°C, cervical lymphadenopathy and pharyngitis with whitish patches on his soft palate and buccal mucosa. He had a scattered maculopapular rash on his extremities and trunk, and mild epigastrium tenderness. A complete blood count showed marked leukocytosis; total WBC count was 23 740/µL (50% neutrophils, 16% lymphocytes, 31% monocytes and 3% eosinophils). Peripheral blood smears showed atypical lymphocytes. Sulfasalazine was immediately stopped. On hospital day 3, the man developed severe abdominal pain and mild icteric sclera. Liver function tests showed direct hyperbilirubinaemia (total bilirubin, 3.34 mg/dL and direct bilirubin, 2.94 mg/dL). ASL [sic] and ALT levels were 536 and 734 U/mL, respectively, and serum alkaline phosphatase was 301 IU/L. An ultrasound showed gallbladder wall thickening with pericholecystic fluid collection; sonographic Murphy’s sign was positive. Ceftriaxone was administered. On hospital day 9, he developed hypotension (BP 70/40mm Hg) and received IV fluids. CT scans showed gallbladder collapse with a moderate amount of pericholecystic fluid (but no gallstones), minimal ascites, and hepatosplenomegaly. He received dexamethasone; his fever and abdominal pain ceased. Antihuman herpes virus-6 IgG was positive. Two days after starting corticosteroid therapy, a diagnosis of sulfasalazine-induced hypersensitivity syndrome was confirmed using interferon-γ enzyme-linked immunospot assay. Dexamethasone was switched to prednisolone and his liver function tests normalised in 1 months. On follow-up at 2 years, he had no complications. Author comment: "We report a case of sulfasalazineinduced hypersensitivity syndrome complicated with acalculous cholecystitis and hypotension, the diagnosis and treatment of which was delayed due to its atypical features." Phatharacharukul P, et al. A case of sulfasalazine-induced hypersensitivity syndrome confirmed by enzyme-linked immunospot assay. Allergy, Asthma and Immunology Research 5: 415-417, No. 6, Nov 2013. Available from: UR
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