Toxic epidermal necrolysis–like acute cutaneous lupus erythematosus (TEN-like ACLE) in SLE patients: A report of two cases

Abstract

Background: Subacute cutaneous lupus erythematosus (SCLE) is characterized by photodistributed, nonscarring, annular or papulosquamous lesions. SCLE patients usually have elevated anti-Ro/SS-A antibodies. Roughly 15% to 20% of patients with new-onset SCLE are associated with the ''recent'' introduction of a drug. The clinical, histopathologic, and serologic features of patients with drug-induced SCLE (DI-SCLE) do not differ from those seen in patients with idiopathic disease. DI-SCLE has been reported with etanercept, adalimumab and infliximab, but to our knowledge golimumab has not previously been implicated. Observation: A 66-year-old woman with a history of rheumatoid arthritis, hypertension, anxiety/depression, Parkinsonism, and symptoms suggestive of Sj€ ogren syndrome was referred for evaluation of a 1-month history of a pruritic, burning rash on her extremities and upper trunk. This began approximately 2 to 3 weeks after receiving a golimumab injection subcutaneously for rheumatoid arthritis. She denied receiving other new medications during the preceding 3 months. She had a history of hydrochlorothiazide-induced SCLE 16 months prior that resolved upon discontinuation of this medication. Physical examination revealed erythematous, annular, scaly plaques present in a photodistribution on the arms, upper back, upper chest, and legs. A skin biopsy demonstrated scattered dyskeratotic keratinocytes, thickened basement membrane zone, and vacuolar interface dermatitis with associated superficial and mid-dermal lymphohistiocytic perivascular inflammatory infiltrate. Increased dermal mucin deposition was noted on colloidal iron staining. Pertinent laboratory findings included a positive ANA, elevated anti-Ro/SS-A antibody level, and elevated anti-La/SS-B antibody level. She was diagnosed with SCLE and treated with prednisone 40 mg daily tapered over 5 to 6 weeks, hydroxychloroquine 400 mg daily, desonide lotion, and photoprotection. Her disease has shown only partial resolution despite this regimen and discontinuation of golimumab. Comment: Our case suggests that golimumab should be added to the growing list of medications capable of inducing or exacerbating SCLE. Furthermore, the fact that our patient previously experienced hydrochlorothiazide-induced disease suggests that these offending medications are exacerbating an underlying predisposition to develop SCLE.Commercial support: None identified. Symmetric and erythematous morphea: A new subtype of generalized morphea(Poster reference number 4925) Morphea is a rare fibrosing disorder of the skin and underlying tissues. Morphea is classified based on clinical presentation in five subtypes: circumscribed, linear, generalized, pansclerotic, and mixed. Generalized morphea is defined as more than four indurated plaques larger than 3 cm and/or involving two or more of seven anatomic sites. We present a patient with large, symmetric, pigmented sclerotic lesions surrounded by pruritic reticular erythema. A previously healthy, 15-year-old female patient presented with a 1...