Drug Eruption Fix Print
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DRUG ERUPTION(IN HIV/AIDS PATIENT)
Indah Febrini Triana J. C 111 08 148
Ashari Mohpul C 111 08 319
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CASE REPORT
Name : Mrs. O
Age : 26 years old
Address : Kampung Melawang,
Sudiang
Marital status : Married
Admission date : 25thAugust 2012
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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.
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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
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DERMATOLOGYSTATUS
Location: Region generalized
Efflorescence: erythema macula
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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
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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.
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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)
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TREATMENT
Systemic : Chlorpheniramine maleate
(CTM) 3x1
Metil prednisolon 4mg 3x1
Topical : Salicylic powder for neck area
PROGNOSTIC :The prognosis of this patient is dubia
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DISCUSSION
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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
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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.
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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.
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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).
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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
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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
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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.
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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
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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
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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
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STAGINGOF HIV/AIDS
Stage I asymptomatic or Persistentgeneralized lymphadenopathy (PGL)
Stage II - mild disease
Stage III - moderate disease
Stage IV - advanced
immunocompromise
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P C C O S S E C S O
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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
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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
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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.
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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.
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DIFFERENTIAL DIAGNOSIS
Erytroderma : Pityriasis rubra pilaris, psoariasis and
cutaneous T-cell lymphoma
Pityriasis rubra
pilaris
Psoariasis Cutaneous T-cell
lymphoma
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MANAGEMENT
Systemic :
o Kortikosteroid : 3x10 mg till 4 x 10 mg for a
day
o Histamint agent for itchness
Topycal : Ianolin Zalp 10 %.