drug eruption

Ward Teaching“Drug Eruption”

Group members :

Nur Nadia

Nor Farhana

Raisul Maarif

Azwan

Andi Isra

Citra sari

Rizqah Humairah

Arifat Ladadu

PATIENT’S IDENTITY

Name : Mrs. H

Register no : 01 52 35

Gender : Female

Age : 43 years old

Marital status : Married

Religion : Muslim

Occupation : Unoccupied

Admission : Saturday, 7 Desember 2013

HISTORY TAKING

Anamnesis : Autoanamnesis

Chief complaint : feel itchy all over the body

Further Anamnesis :

She started feeling itching 4 days ago. The unusal lesion appear and cause the itching after 3 days she finished her 2nd chemotherapy of Ca. mammae. Her itching started from both of the leg and spread until her chest. She started her 2nd chemotherapy on Saturday 7 Dec 2013. After her 1st chemotherapy she didn’t experienced this symptom. The patient did not have a fever before or after the lesion appeared.

Systematical Anamnesis

Patient has same complaint before (-)

Trauma History (-)

Family history: same complaint (-)

Treatment history ointment used (-)

Drugs allergic (+)

History of insect bites (-)

Post chemotheraphy (+)

DERMATOLOGY STATUS

Location : Regio Facialis

Efflorescence : macule eritem

Location : Regio generalized

Efflorescence : macule eritem, papul erythem, erosion, macule, hiperpigmentation

Abdomen Inferior extremities

PunggungEkstremitas superior

Rash at the both cheeks

Diagnosis

Drug Eruption

Treatment

From Patient’s Status :

Methylprednisolone 4 mg (2-2-0)

Cetirizine 1x1

Hydrocortisone 2,5 % ( w) morning - everning

Asam salicil 2 % + inerson 2 tube add

From referencesSystemic :1. Corticosteroid: prednisone (1 tablet =5

mg), 3x 10 for adult Eritroderma 3x 10- 4x 10

2. AntihistamineTopical :3. Salicylate powder 2% + menthol ½-1%4. salicylate acid compression 1%5. hydrocortisone cream 1% or 2%6. Lanolin 10%

Discussion

Allergic drug eruption is an allergic reaction that occur to skin or mucutaenous because of using the systemic drug.

several type of clinical manifestation of drug eruption, as an example:

morbiliformis,

erythema multiform,

exanthema fikstum,

akneiformis eruption,

Urtikaria,

Purpura,

dermatitis eksfoliativa,

toxic epidermal necrosis,

Steven-Johnson syndrome.

Drugs that commonly cause serious reactions

• Allopurinol • Anticonvulsants • NSAIDs • Sulfa drugs • Bumetanide • Captopril • Furosemide • Penicillamine • Thiazide diuretics

in this patient she was given Cefadroxil (antibiotic) and mefenamate acid (nsaid) for her Ca mammae, which can cause an allergic reaction

Rates of reactions to commonly used drugs

Amoxicillin - 5.1%

Trimethoprim sulfamethoxazole - 4.7%

Ampicillin - 4.2%

Semisynthetic penicillin - 2.9%

Blood (whole human) - 2.8%

Penicillin G - 1.6%

Cephalosporins - 1.3%

Quinidine - 1.2%

Gentamicin sulfate - 1%

Diagnosis

I. ANAMNESIS• The drug that the patient consume• 1st symptom appear : acute or after several days• Itchy or not• Have fever or not

II. SKIN ABNORMALITIES• Distribution

• Universal• generalize

• Shape of the lesion

During history taking note and detail the

following:

All prescription and over-the-counter drugs, including topical agents, vitamins,

herbal, laxatives, oral contraceptives, vaccines, homeopathic medicines, etc. as these

may not be volunteered as medications

The interval between the introduction of a drug and onset of eruption

Route, dose, duration, and frequency of drug administration

Any improvement after drug withdrawal and any reaction with readministration

Test or Examination :

Lab Examination

Common drugs Eruption

Ampicillin,penicillin,phenylbutazone,sulpho-namides, gold, genta-mycin, cephalosporins,barbit-urates,thia-zides

- Morbilliform (exanthematous(: •It is the most common pattern •Lesions are symmetric, with confluent erythematous macules and papules that spare the palms and soles•It typically develops within 2 weeks after the onset of therapy


ACEI ,aspirin/NSAIDs,blood products,cephalosporins, cetirizine, dextran, infliximab, inhaled steroids, opiates, penicillin, radiologic contrast material, ranitidine, tetra-cycline, vaccines, zidovudine

- Urticaria:•It is the 2 nd most common eruption•Occurs as small wheals that may coalesce or have cyclical or gyrate forms•Lesions appear within 36h of intake and resolve rapidly when the drug is withdrawn


Beta-lactam antibiotics, macrolides, and mercury

- Acute generalized exanthematous pustulosis : Acute-onset fever and generalized scarlatiniform erythema occur with many small, sterile, nonfollicular pustules. The clinical presentation is similar to pustular psoriasis


Aspirin, cephalosporins, cytotoxics,heparin

- Purpura:•Can occur alone or as a component of vasculitis


Gold,ACE inhibitors, thiazides, bismuth, barbiturates, griseofulvine,metro-nidazole

- Pityriasis rosea-like:•Eruption is similar to PR•Itching is severe not responding to antihist-amines•There is no tendency of spontaneous remission


Sulfonamides,penicillin, tetracyclines, aspirin/NSAID, barbiturates, cetirizine, ciprofloxacin, dapsone, fluconazole, hydroxyzine, loratadine, metronidazole, oral contraceptives, phenytoin, vancomycin

- Fixed drug eruptions:• Lesions recur in the same area ½ -8 h after the drug is reused •Circular, violaceous, edematous plaques that resolve with macular hyperpigmentation•Hands, feet&genitalia are the most common sites but perioral and periorbital lesions may occur

PATOGENESIS

Skin reaction to medications (drugs) :

1. Immunologic Mechanism

2. Non Immunologic Mechanism

Allergic drug erruption : allergy to medications through immune process

There are 4 reaction types

1. Type I / Anafilactic

Strong affinity of IgE to mast cells and basophils

Others effect:

- Urtikaria

- Angineurotic edema

- anafilactic shock

2. Type II (Cytotoxic)

The combination between IgG & IgM with antigen attached to the cell

Activation of complement system

Lysis (tissue damage)

3. Type III (Immune Complex)

Aq + Ab Aq – Ab

Settles in the body tissues

Complement activation Inflammation

Lisis Release of “Anafilatoxin”

Release of Mediators (Enzymes that cause tissue damage)

4. Reaksi Tipe IV (Slow cellular allergic type 12 – 48 hours)

Reaction of Limphocyte T + Ag

There are two forms of reaction: :

- Tuberkulin antigen located around the blood vessels in the dermis

- Contact Ag + Limphocyte T

Lymphokine

Differential Diagnosis

Erythema multiform

e

Viral exanthem

Stevens-Johnson

syndrome

Toxic epidermal necrolysis

Complication

Ekskoriasis and 2nd infection by bacterial from the

scratch actually is a complication that always

happened. Generally, infection is caused by

streptococcus pyogenes. Impetigo also can

appear, general or local allergy reaction, as an

example edema and vesicobullous reaction.

Prognosis

Most cases resolve without complications but it

may take 10 to 14 days for the rash to disappear.

Patients with exanthematous eruptions will have

mild desquamation as the rash resolves.

.

drug eruption

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