Vasculitis in a fixed drug eruption due to paracetamol

Abstract

A 48-year-old man presented with a history of recurrent erythematous lesions on the trunk and limbs. Examination suggested a tixed drug eruption and this was conlirmed by oral challenge with paracetamol. The histology was unusual as il showed a leucocytoclastic vasculitis. Patients may have difficulty avoiding the offending drug because many drugs bought over the counter have similar names but difterent constituents. In addition, il may be difficult to persuade the patient that a specific drug is responsible for their skin problem. Case reportA 4S-year-o!d man presented with a history that, on four occasions in the previous 20 months, he had developed an uncomfortable, red rash. The rash recurred every 4-6 months. Forty-eight hours prior to the development ofthe rash, on each occasion, he had noticed 'tlu-like symptoms for which he had taken paracetamol or Beecham's Powder capsules (which contain paracetamol, caffeine and phenylephrine hydrochloride). The rash recurred at the same sites, lasted 2 days, and faded to leave residual areas of hyperpigmentation. Between those episodes, he denied ingestion of any medication.Examination at an acute stage showed well defined erythematous macules and plaques scattered over the trunk and limbs (I'ig, 1). The rash appeared purpuric, particularly on the feet and ankles, and there was some exfoliation but no blistering. One week after their onset the lesions faded to leave macular hyperpigmentation.The differential diagnosis included urlicarial vasculitis and a fixed drug eruption. Routine haematological and biochemical studies were normal. Tests for antineutrophil cytoplasmic antibody and extractable nuclear antigen were negative. Serum complement levels were normal. A skin biopsy was taken from a fresh erythematous lesion and showed on histology a leucocytociastic vasculitis affecting the superficial capillaries, with a mixed perivascular infiltrate containing lymphocytes, neutrophils and eosinophils (Fig, 21. There was some pigmentary incontinence but no basal cell degeneration or keratinocyte necrosis. Iron stains were negative.An oral challenge test was performed with 1 g para-790 cetamol. Thirty minutes after ingesting the drug, previously asymptomatic hyperpigmented macules became red and uncomfortable. He had no associated systemic symptoms and the rash faded over the next 4 days to leave hyperpigmented macules. He has no further problems since avoiding paracetamol. DiscussionOur patient has had a fixed drug eruption to paracetamol, and has the unusual histological linding of a leucocytoclastic vasculitis. Although paracetamol is well documented as a cause of a fixed drug eruption, only two cases were reported to the Medicines Control Agency (MCAl between 1963 and 1994. This probably refiects under-reporting. Figure L Erythematous macules present on the legs. (C; 1995 British Associalion of Dermatologists

Fixed drug eruption:state of the art

“…Rarely, the disease presents in an atypical form with unsharp margins (Figure 7), non‐pigmented, giant (> 20 cm in diameter), urticarial, papular, purpuric, targetoid (Figure 8), linear, reticular and butterfly‐like lesions [5–13].…”

“…Atypical histopathological reaction patterns such as leukocytoclastic vasculitis [9], neutrophilic reaction [14, 15] and a predominantly dermal reaction without pigment incontinence in what is termed non‐pigmented FDE have been reported [5]. In addition, cases with positive immunofluorescence have been described [16].…”

Churg-Strauss Syndrome Associated with Hypersensitivity to Acetaminophen

“…Acetaminophen may also occasionally induce allergic reactions like skin rashes or asthmatic attacks but vasculitis is an extremely rare complication. To our knowledge, only two cases of cutaneous leukocytoclastic vasculitis have been reported (7,8) by acetaminophen.…”

Image Gallery: Purpuric fixed drug eruption from ornidazole showing leukocytoclastic vasculitis

“…Oral provocation was positive with ornidazole but negative with other imidazoles . This was a unique patient as there is no previously reported case of purpuric fixed drug eruption showing vasculitis in the histopathology and vice versa …”