Reações cutâneas graves adversas a drogas: aspectos relevantes ao diagnóstico e ao tratamento - Parte II

Abstract

As reações cutâneas graves adversas à droga são as que geralmente necessitam de internação hospitalar, por vezes em unidade de terapia intensiva ou de queimados, com observação minuciosa dos sinais vitais e da função de órgãos internos. O objetivo é descrever estas reações facilitando o seu reconhecimento e tratamento. Fazem parte deste grupo a Síndrome de Hipersensibilidade à Droga (SHD), a Pustulose Exantemática Generalizada Aguda (PEGA), a Necrose Cutânea induzida por Anticoagulante, as Vasculites de Pequenos Vasos (VPV), a Vasculite de Hipersensibilidade ao Propiltiouracil (VHP) e as Reações tipo Doença do Soro (RDS). A SHD tem-se tornado de elevada relevância clínica devido ao uso amplo dos anticonvulsivantes aromáticos e da dapsona, utilizada no tratamento de doenças como a acne e a hanseníase. A PEGA é determinada principalmente pelos derivados beta-lactâmicos e tem como principal diagnóstico diferencial a psoríase pustulosa generalizada. As VPV tegumentares podem refletir uma doença multissistêmica subjacente, com danos graves em órgãos nobres, como os rins, pulmões e sistema hematológico, com morbidade elevada e possível letalidade. Abordamos as características clínicas e o tratamento destas reações adversas à droga.

Propylthiouracil-Induced Vasculitis With Antineutrophil Cytoplasmic Antibody

“…5 Classically, the symptoms appear under a classic tetrad of fever, sore throat, arthralgia, and skin lesions. 1,5,6 Our patient developed some constitutional symptoms preceding the cutaneous vasculitis.…”

“…5 The time between initial PTU treatment and the onset of vasculitis has varied widely from 1 week to 13 years. 5,6 Our patient developed cutaneous lesions after 1 year of PTU introduction. There is no association with patient age, and the increasing reports of female gender may be due to the greater prevalence of thyroid disease in female patients.…”

“…Many of the lesions develop overlying hemorrhagic bullae and progress to central necrosis, leading to significant tissue loss that simulates the clinical presentation of fulminant purpura observed in states with disseminated intravascular coagulation, antiphospholipid syndrome, polyarteritis nodosa, and other thrombophilic states ( Figure 4). 5,6 There is a predilection for the distal extremities, the face, the breasts, and most characteristically, the lobes and helices of the ears that mimic the leprosy type reaction of Lucio's phenomenon. 6 Various systemic disturbances have been reported.…”

“…5,6 There is a predilection for the distal extremities, the face, the breasts, and most characteristically, the lobes and helices of the ears that mimic the leprosy type reaction of Lucio's phenomenon. 6 Various systemic disturbances have been reported. Arthralgia, synovitis, and migratory polyarthritis are the most common extracutaneous manifestations as reported by our case.…”

“…1,2,5,8 Laboratory tests often demonstrate anemia, leucopenia, and thrombocytopenia in the blood count; increase of erythrocyte sedimentation rate, C-reactive protein, urea, creatinine, elevated liver enzymes, hypoalbuminemia, alterations in the coagulation time, prothrombin time and partial thromboplastin time. 5,6 Numerous immunologic abnormalities have been identified, including the most characteristic of these, positive ANCA titers. Positivity can also be present of the anti-SSA, anti-DNA double helix, anticardiolipin, anti-smooth muscle antibodies, antimitochondrial, parietal and antiadrenargic anticells, rheumatoid factor, besides hypocomplementemia, cryoglobulinemia and hyperglobulinemia.…”