Dados do Trabalho

Title

HIDROXYCHLOROQUINE INDUCED ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Hydroxychloroquine (HCQ) has many benefits in systemic lupus erythematosus (SLE) patients as improvement in lipid profile, insulin resistance, lower risk of flare and better overall survival. The acute generalized exanthematous pustulosis (AGEP) is a rare disease, characterized by abrupt onset on the skin of nonfollicular sterile pustules over an area of edematous erythema. In the vast majority of cases (90%), the etiology is the use of medications, especially antibiotics such as penicilins and macrolides. Despite being considered a safe medication, HCQ may cause side effects which might lead to the discontinuation of this use, including AGEP described in 1/5.000.000 of patients.

Case report

A.A.P.S, 25 years, female, presented to the emergency with five days complaint of fever (38°C) and erythematous and painless papules initially on her face and trunk with coalescence and cephalocaudal dissemination leading to the entire involvement of the thorax and the extensor surface of the upper limbs and progression in 24 hours to pustules. She started hydroxychloroquine 5mg/kg/day during the 3 preceding weeks for the treatment of SLE diagnosed seven months ago (at the time, presented thrombocytopenia, arthralgia, rash malar and antinuclear antibody positive 1:320 fine dotted nuclear). Laboratory tests revealed predominantly polymorphonuclear leukocytosis (22.400/ 84%) with a slight increase of erythrocyte sedimentation rate (ESR 30mm) and abnormal creatine levels (2,25mg/dL) characterized as a pre-renal pattern. Skin biopsy showed subcorneal pustular dermatosis, with histopathological analysis compatible with AGEP. The patient was maintained without hydroxychloroquine and prednisone 1mg/kg (60mg) and antibiotic with coverage of skin infections (cefazolin) were prescribed. Seven days after the hospital admission, the patient demonstrated signs of clinical and dermatological improvement with partial recovery of affected areas. The kidney function return to the baseline levels, leukocyte count normalized and patient remained afebrile.

Conclusion

This report describes a rare adverse event (AGEP) after the use of HCQ which is one of the pillars of the treatment in SLE. The recognition of this diagnosis in the context of SLE is important to avoid reexposure to antimalarial drugs