Linear immunoglobulin A disease and vancomycin: two real ancestral enemies?

Abstract

While typically seen in patients with end-stage renal failure and renal transplantation, calciphylaxis has been reported in patients without end-stage renal disease (i.e. nonuraemic calciphylaxis). 3 In a systematic review of 36 cases of nonuraemic calciphylaxis, primary hyperparathyroidism (28%), malignancy (22%), alcoholic liver disease (17%) and connective tissue disease (11%) were the most common underlying aetiologies. 6 To date, the association between calciphylaxis and pancreatic cancer has not been reported. One possible link between nonuraemic calciphylaxis and pancreatic cancer is the elevation and release of pancreatic enzymes, which results in lipolysis of subcutaneous adipose tissue, formation of free fatty acids and the subsequent saponification of fat by calcium salts. 7 A number of treatment strategies have been proposed in calciphylaxis. However, to date, no controlled prospective studies comparing these various treatments have been conducted. Traditional therapies include wound care in combination with intravenous sodium thiosulfate (STS), cinacalcet, sevelamer, bisphosphonates and/or hyperbaric oxygen therapy. Intravenous STS has gained favour as a generally well tolerated, effective therapeutic option that works by dissolving vascular calcium deposits through the creation of highly soluble calcium thiosulfate complexes. 8-10 Intravenous STS is generally well tolerated and has been shown to decrease mortality when used in combination with cinacalcet and sevelamer. [8][9][10] Sevelamer and cinacalcet also help to mitigate the endocrine abnormalities seen in calciphylaxis by acting as noncalcium phosphate binders and calcimimetics, respectively. 10 Our patient was started on oral cinacalcet 30 mg twice daily and intravenous STS 25 mg three times weekly. After 2 weeks of treatment with intravenous STS followed by 4 weeks of topical STS 10% soaks and aggressive wound care, the patient experienced considerable improvement in his lower extremity pain and leg ulcers. The patient was subsequently started on gemcitabine and paclitaxel for his pancreatic cancer, but he passed away several months later owing to complications of pneumonia. In summary, we present a case of nonuraemic calciphylaxis in a white man with pancreatic cancer. To our knowledge, this is the first reported patient with pancreatic cancer-associated calciphylaxis in the setting of normal kidney and parathyroid function, who also responded favourably to intravenous and topical STS, as well as oral cinacalcet. References1 Ng AT, Peng DH. Calciphylaxis. Dermatol Ther 2011; 24:256-62.2 Ross EA. Evolution of treatment strategies for calciphylaxis. Am J Nephrol 2011; 34:460-7. 3 Mochel MC, Arakaki RY, Wang G et al. Cutaneous calciphylaxis: a retrospective histopathologic evaluation. Am J Dermatopathol 2013; 35:582-6. 4 Weenig RH, Sewell LD, Davis MDP et al. Calciphylaxis: natural history, risk factor analysis and outcome. J Am Acad Dermatol 2007; 56:569-79. 5 Harris RJ, Cropley TG. Possible role of hypercoagulability in calciphylaxis: review...

Drug‐induced linear immunoglobulin A bullous dermatosis: A French retrospective pharmacovigilance study of 69 cases

“…However, lesions mimicking TEN favour a diagnosis of DILAD. In our study, a positive rechallenge observed in five patients is a strong argument favouring the reality of drug‐induced LABD . Likewise, 10 patients had a favourable outcome without any specific treatment (withdrawal of the putative drug only).…”

“…The concept of DILAD has been questioned , especially the link between VCM and LABD. For autoimmune blistering skin diseases, imputing a specific suspect drug is difficult.…”

“…Vancomycin (VCM) is the most frequent culprit drug , accounting for 46.2% of cases, but more than 100 LABD cases were induced by a wide range of drugs, especially antibiotics . Depending on publications, the time between the first drug intake and cutaneous symptoms varies from 24 h to 4 weeks but could exceed 780 days . In a retrospective study, Chanal et al .…”

Linear immunoglobulin A disease and vancomycin: letter in reply

“…Dear Editor , We read with interest the letter by Fortuna et al . about our paper ‘Linear IgA bullous dermatosis: comparison between drug‐induced and spontaneous forms' .…”

Old dog begging for new tricks: current practices and future directions in the diagnosis of delayed antimicrobial hypersensitivity

“…Earlier reports of high rates of penicillin/cephalosporin cross-reactivity were confounded by penicillin contamination of cephalosporin manufacturing [2,3,222]. Current literature supports that most cross-reactivity that occurs in the beta-lactam class occurs on the basis of shared R1 and/or R2 side-chains [85,149,150). Recent reports suggest patients with a history of delayed hypersensitivity to aminopenicillins most commonly cross react with aminocephalosporins sharing an R1 group such as cephalexin, cefaclor and cephadroxil and generally tolerate all other cephalosporins [223,224].…”