Fever procainamide

About 30% of the patients on chronic procainamide dosing develop a systemic lupusfike syndrome consisting of arthralgia, myalgia, skin rash, and fever. Patients who are slow acetylator phenotypes may be prone to this condition. Some may exhibit pleuropneumonic involvement and hepatomegaly... 

The most common feature is arthralgia, in about 77% of cases, with pleural or lung involvement in about 75%. Other common features include myalgia, fever, hepatomegaly, pericarditis, arthritis, and splenomegaly. Skin rashes, adenopathy, and Raynaud s phenomenon occur in 5-10% of cases, and neuropsychiatric and renal involvement are rare. Thrombotic problems can occur because of the properties of anti-DNA and antiphospholipid antibodies (discussed in the next case report). The so-called lupus anticoagulant can be detected in people taking procainamide, even without clinical evidence of lupus... 

Fever occasionally occurs in patients taking procainamide (SEDA-1, 155) and has been attributed to an allergic reaction (57). 

D The prolonged administration of procainamide often leads to the development of a positive ANA test result, with or without symptoms of a lupus erythematous-like syndrome. The common symptoms of lupus erythematous-like syndrome are arthralgia, malaise, rash, fever, chills, and arthritis, which may occur more often in slow acetylators because they do not metabolize procainamide as well. If a positive ANA titer develops, assess the benefit/risk ratio related to continued procainamide therapy. 

Procainamide may induce a syndrome similar to systemic lupus erythematosus. This syndrome consists of arthralgias, myalgias, pleurisy, rash, fever, and elevated nuclear antibodies. Patients who are slow acetylators are at increased risk for developing this syndrome. While some studies have reported that less than one in 500 on chronic procainamide therapy developed this syndrome, others have reported this syndrome in up to 30% of patients on long-term therapy. Other side effects with chronic use include development of neutropenia, thrombocytopenia, hemolytic anemia, agranulocytosis, liver failure, a myasthenia-like syndrome, and psychosis with hallucinations. 

Quinidine and procainamide have both been shown to cause a syndrome resembling lupus. Symptoms may include polyarthritis, fever, and pleuritic chest pain. 

These interaetions are not elearly established, and the reaction appears to he rare and unpredictable. All that can he constructively said is that patients taking both drugs should he very closely monitored for any signs of hypersensitivity (e.g. skin reactions) or low white cell count (sore throat, fever), especially if they have renal impairment. The UK manufacturer of captopril recommends that diffeiential white hlood cell counts should be performed before adding allopurinol, then every 2 weeks during the first 3 months of treatment, and periodically thereafter. Similar caution and advice is given by the UK manufacturers of several other ACE inhibitors. For other possible interactions with ACE inhihitors that might result in an increased risk of leucopenia see also ACE inhihitors + Azathioprine , p.l8 and ACE inhibitors + Procainamide , p.33. 

Drug fever has been reported in about 11 patients but the true incidence is likely to be much higher (Robinson 1978). In a prospective study by Kosowsky et al. (1973) 5 out of the 39 patients who started treatment with procainamide developed a fever after 2-18 days. 

Fever with nausea and vomiting developed in a patient who had taken procainamide for V-k weeks the symptoms persisted for several days, but resolved within 24 hr on withdrawal of the drug (45 ). A further case of agranulocytosis which was thought to be caused by procainamide has been reported however, the patient had received no less than 20 other drugs, at least one of which has been known to cause agranulocytosis, so the case cannot be recorded as proven (46 ). 

Farber, H. I. (1974) Fever, vomiting and liver dysfunction with procainamide therapy. Postgrad. med., 56,155. 

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