Krishnamoorthi

Clinical pharmacist, Kauvery Hospital, Cantonment, Trichy

Background

Anaphylaxis causes the immune system to release a flood of chemicals that can cause to go into shock, Blood pressure drops suddenly and the airways narrow, blocking. Signs and symptoms include a rapid weak pulse, skin rash, nausea and vomiting. It is a severe life-threatening allergic reaction, it happens within seconds or minutes after exposure to the allergen. This case report is about the patient who suffered from acute anaphylactic reaction and the clinical outcomes after the treatment.

Case Presentation

A 54-year-old female presented with one day history of swelling, itching, rashes, and fever. She was on treatment for rheumatoid arthritis with sulfasalazine. Patient had itching and rashes all over body, and swelling over the face. She also had nausea and vomiting after intake of food. She had loose stools and haematuria. She had abdominal pain after a travel and was treated for AGE with antibiotics.

On local examination: patient had maculopapular rash over whole body with facial edema. Patient was conscious, oriented and afebrile.

 

Vitals and Lab Investigations

Laboratory results showed:

  • Haemoglobin – 12.5
  • Leukocytes count – 25700 cells/cumm,
  • Prothrombin time – 16.1 sec,
  • Acetone Plasma – Positive
  • Elevated bilirubin total – 3.05mg/dl,
  • SGOT – 100.9U/L,
  • SGPT – 155.6U/L,
  • Alkaline Phosphatase – 245.8U/L,
  • Gamma glutamyl Transferase – 138U/L,
  • IgE – 807 Iu/ml.

Echo Impression

Patient had thick walled gall bladder, minimal ascites, and minimal right pleural effusion.

Diagnosis

Sulfasalazine Induced Skin Reactions

Treatment

Patient was managed with Inj. Piptaz 4.5 gm, Inj. Dexa 4 mg, Inj. Avil 2 ml , Hydrocort 100 mg ,Calapure Lotion, Kenacort Oral base Gel, Inj. Thiamin 100 mg, Inj. Vitamin C 1.5 gm, Tab. Rantac 150 mg, Tab. Montair LC, Tab. Allegra, Tab. NBF. Patient positively responded to the prescribed regimen and was discharged with recommended medications.

Discussion

  • Sulfasalazine is widely used in the treatment of inflammatory diseases such as Ulcerative Colitis (UC) and Rheumatoid Arthritis. It can cause serious systemic adverse reaction of which 10% may develop DHS (Drug Hypersensitivity Syndrome) which can be fatal.
  • The early rash manifests as scattered red macules and maculopapular rashes that usually appears in face and then extends to trunk and limbs. The rash gradually increases from top to bottom; patient often present with itchy skin, fever, facial swelling and generalized lymphadenopathy.
  • The exact pathogenesis of DHS is unclear, but it is generally believed to be mediated by CD 8+T cells. The diagnostic criteria in Europe and Japan are widely used in clinical practice. DHS can be diagnosed to characteristic of Chinese population.
  • Delayed onset rash, more than 3 weeks from medication to rash can occur with lymphadenopathy, fever > 38°C, Visceral damage can occur Eg; Alanine transaminase level twice the normal value, interstitial nephritis, interstitial pneumonia, haematological abnormalities, eosinophil count >1.5×10/L.
  • Glucocorticoids and gamma globulin are the main drugs used to treat DHS. Methylprednisolone, 1.0-1.5 mg/kg/d, t was used for this patient, the dose of which was gradually reduced after disease control was achieved. The use of glucocorticoids may be required for 5 to 10 weeks. Hyperglycemia is a well-known complication under such circumstances
  • Symptoms may relapse after Corticosteroid use. In recent years Immunoglobulin has been widely used in the treatment of severe drug eruptions. The general dosage is 0.2-0.4g/kg/d for 3-5 days. The dosage can be increased to 0.6-0.8 mg/kg/d. if required
  • Immunoglobulins can significantly relieve symptoms, reduce the risk of infection, reduce the glucocorticoid dosage, and improve rescue and cure rates. Therefore, the early use of glucocorticoids and high-dose gamma globulin can reduce patient mortality rates.

Conclusion

Drug Induced Hypersensitivity causes considerable morbidity and at times mortality. The healthcare providers and patients need to be aware about the problem. Early assessment and correct management saves this patient’s life.

Reference

  • Mennicke M, Zawodniak A, Keller M, et al. Fulminant liver failure after vancomycin in a sulfasalazine-induced DRESS syndrome: fatal recurrence after liver transplantation. Am J Transplant. 2009; 9:2197–202.
  • Poland GA, Love KR. Marked atypical lymphocytosis, hepatitis, and skin rash in sulfasalazine drug allergy. Am J Med. 1986; 81:707–8.
  • Musette P, Janela B. New insights into drug reaction with eosinophilia and systemic symptoms pathophysiology. Front Med (Lausanne). 2017; 4:179–179.
  • Tohyama M. Drug-induced hypersensitivity syndrome. Nippon Rinsho. Japanese J Clin Med. 2012; 70:498–502.
  • Brooks H, Taylor HG, Nichol FE. The three week sulphasalazine syndrome. Clin Rheumatol. 1992; 11:566–8.

Krishnamoorthi
Clinical pharmacist, Kauvery Hospital, Cantonment, Trichy

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