Terbinafine Induced Lupus Erythematosus With Progression to Lupus Nephritis

Abstract

Drug-induced lupus erythematosus (DILE) is a syndrome that manifests with symptoms similar, but with less severity, to that of systemic lupus erythematosus (SLE). Many medications are reported to be involved in DILE; however, terbinafine (Lamisil) is not a well-known causative agent of this syndrome. In this case report, we present a 22-year-old male patient with no prior medical history presented with worsening fever, rash, joint pain, and weight loss a couple of weeks after starting terbinafine. He underwent an extensive workup which revealed worsening kidney function, proteinuria, and microscopic hematuria, for which he underwent a renal biopsy which revealed class IV lupus nephritis. He was treated with prednisone taper and immunosuppressants with subsequent resolution of his symptoms. Close monitoring for the development of DILE symptoms is recommended after starting terbinafine, especially in patients with a known personal or family history of SLE.

Drug-induced lupus erythematosus

“…Di-LE may account for approximately 15% of all LE cases 3 . It occurs mainly between 55 and 60 years of age 7 , mostly in females and Caucasians 8 , but there are also rare pediatric cases reported in patients under treatment with infliximab, carbamazepine 4 , and valproic acid 9 .…”

“…Genetic susceptibility is evident in Di-LE, but risk factors are different for each drug. Human leukocyte antigens (HLA) DR2, DR3, DR4 2 , and HLA-B8 3 have been associated with an increased risk for Di-LE induced by minocycline, terbinafine, and hydralazine 2 . Hereditary complement deficiencies, namely, C4 null allele 2 and selective immunoglobulin A (IgA) deficiency, particularly with concomitant HLA-B8 and DR3 acerca da sua patofisiologia ainda é algo escassa, o que torna difícil de prever os fármacos mais prováveis de a causar antes que haja número suficiente de relatos para estabelecer uma ligação.…”

“…A family history of SLE or Di-LE 11 or a personal history of another connective tissue disease 12 may also be considered a risk factor, as reported for terbinafine 3 .…”

“…Central nervous system, renal, gastrointestinal, and hematological manifestations are rare 3 and also less frequent than in idiopathic SLE 2 , except for neurological involvement for quinidine (up to 30%) 27 and lupus nephritis-like syndromes induced by hydralazine [28][29][30] , sulfasalazine, penicillamine, anti-TNFα, propylthiouracil, apixaban 31,32 , and also to phytotherapeutic agents 33 and anti-neutrophil cytoplasmic antibodies (ANCAs) vasculitis associated with hydralazine 30 .…”

“…It occurs after chronic exposure to a particular drug (usually over months or years of use) and tends to resolve after drug discontinuation 2 . This entity has been gaining more and more relevance in clinical practice, currently considered to represent approximately 15% of all causes of LE 3 .…”