Maculopapular exanthema

Atypical manifestations reported Maculopapular exanthema and time course resembles drug allergy... 

Fig. 1 Methods to study delayed drug hypersensitivity reactions in humans, (a) T cells - mainly from the peripheral blood, but also from tissue sections (skin, kidney), proliferate when exposed to drugs in cell culture. The proliferating cells can be expanded and then cloned by limiting dilutions, and functional and phenotypic analysis performed to evaluate how drugs are stimulatory for T cells and which functions they perform, (b) Immunhistology of skin (and kidney) using antibodies to cell surface and cytokines, etc. the example shows that in a maculopapular exanthema both CD4+ and CD8+ T cells also express perforin...

Examples Allergic rhinitis, asthma, systemic anaphylaxis Some drug allergies (eg.. penicillin) Serum sickness, Arthus reaction Tuberculin reaction, contact dermatitis (with IVc) Chronic asthma, chronic allergic rhinitis Maculopapular exanthema with eosinophilia Contact dermatitis, Maculopapular and bullous exanthema, hepatitis AQEP Beh t disease... 

Type IVb. Corresponds to the Th2-type immune response. Th2 T cells secrete the cytokines EL-4, EL-13, and EL-5, which promote B cell production of IgE and IgG4, macrophage deactivation as well as mast cell and eosinophil responses. The high production of EL-5 leads to an eosinophilic inflammation, which is the characteristic inflammatory cell type in many drug hypersensitivity reactions (Pichler 2003). In addition, there is a link to type I reactions because Th2 cells boost IgE production by EL-4/EL-13 secretion. Thus, type IVb reactions may actually be involved in the late phase allergic inflammation of the bronchi or nasal mucosa (asthma and rhinitis), which were initiated by IgE on mast cells or basophils. Another in vivo correlate might be infestations with nematodes, eosinophU-rich maculopapular exanthema, or other T cell-dependent diseases with hypereosinophilia. 

Fig. 5 Cytotoxicity of CD8+ versus CD4+ T cells cytotoxic CD4+/CD8+ T cells recognize the drug in association with MHC and kill the respective target cell if the killing is restricted to MHC class II (CD4+ T cells), only activated cells will be killed. If the Idlling process is targeted to MHC class I (CD8+ T cells), all nucleated cells, and in particular all keratinocytes (or hepatocytes), can be killed. This might explain the difference between the milder maculopapular exanthema and the more severe bullous exanthema...

In patients exposed to drugs outside of these three drug groups, maculopapular exanthema was observed in only 1.21% (35/2891). In the combination of cotrimoxazole with other penicillins and of all three drug groups, the small number of observations does not permit any conclusion. 

The increase of maculopapular exanthemas by aminopenicillins in infectious mononucleosis and in lymphatic leukosis... 

The practical conclusion of these observations is if a patient starts with, for example, a maculopapular exanthema due to an important drug, it is probably less dangerous to continue the treatment under close observation, than to stop treatment and to start the next application of the drug in several days or weeks. Alternatively, if the case history indicates an adverse reaction in connection with an earlier treatment period with a given drug or group of drugs, the first new application should be preceded either by a small test dose or possibly by skin or laboratory tests. 

Honeycutt and Huldin (1963) pointed out that after isoniazid there occur morbilliform or maculopapular exanthemas, which only in rare cases proceed to dermatitis herpetiformis but are often combined with fever, swollen lymph nodes, eosinophilia, and icterus. In some cases there are hypersensitivity reactions which resemble systemic lupus erythematosus. In general, hypersensitivity reactions after isoniazid may present as fever, hepatitis, and morbilliform, maculopapular, pur-pura-like, and urticarial exanthemas (Fellner 1970). Hematologic reactions (agranulocytosis, eosinophilia, thrombocytopenia, and anemia) may also occur. 

Cutaneous side effects reported are urticaria, fixed drug eruption, maculopapular exanthemas and pigmentary purpura Uses water-soluble prodrug for intravenous administration resulting in the liberation of paracetamol. ABCD A... 

Examples of disease states Erythema urticaria angioedema respiratory symptoms GI symptoms anaphylaxis Drug-induced hemolytic anemia, thrombocytopenia, agranulocytosis (immune form) Serum sickness Drug-induced vasculitis Allergic contact dermatitis Psoriasis Maculopapular exanthema AGEP FDE DRESS SJS TEN EM... 

Fig. 2.7 Generalized maculopapular exanthema following the introduction of amoxicillin therapy showing lesions on the trunk (a) and targeted lesions on the hands and forearms (b). The patient had positive patch tests to amoxicillin and ampicillin and negative tests to benzyl-penicillin, dicloxacUlin, and a number of cephalosporins. From Gonpalo M, in Johansen JD, Frosch PJ, Lepoittevin J-P, editors. Contact Dermatitis. 5th ed. Berlin Springer-Verlag 2011. With kind permission from Springer Science+Business Media...

A case of maculopapular exanthema induced by amoxicillin with lesions on the trunk and hands is shown in Fig. 2.7 together with a clinical description in Sect. 2.2.4.3. Lymphocytes (CLA-n, CD3-H, DR+, CD25+) expressing adhesion molecules are attracted from the blood by adhesion molecules expressed by endothelial cells and keratinocytes and by chemokines such as CCL27 (also called cutaneous T cell-attracting chemo-kine CTACK). 

Non-immediate reactions to quinolones occur but they are not encountered as often as immediate reactions and in-depth studies are so far few. Some of the more often-seen delayed reactions are fixed drug eruptions and maculopapular exanthemas where a T cell mechanism has been demonstrated. Specific T cell clones were identified from patients with ciprofloxacin-induced maculopapular exanthems and about half of the clones proved cross-reactive with related drugs. Reexposure studies in patients with exanthems revealed that cross-reactivity is in fact lower than this. Cellular tests such as lymphocyte transformation tests were judged to be not very useful. However, the lymphocyte transformation test was said to have confirmed the involvement of T cells when peripheral blood... 

Allergies to macrolide antibiotics are said to occur with an incidence of 0.4-3 %. Apart from the very occasional case report of anaphylaxis, the most commonly seen symptoms include urticaria, often generalized, angio-edema, pruritus, asthma, tachycardia, and delayed cutaneous reactions presenting as maculopapular exanthema. 

Delayed-type cutaneous reactions to clindamycin include pruritus, exanthematous rash, generalized maculopapular exanthema, erythroderma, generalized exanthematous pustulosis, and Stevens-Johnson syndrome. 

Apart from immediate or so-called type I reactions, nonimmediate or so-called type IV reactions may occur after ICM administration. The latter allergy subgroup manifests either with maculopapular exanthema, fixed drug eruption or other very rare conditions such as Stevens-Johnson syndrome [13-15]. 

Paraesthesia, dysgeusia, dyspepsia, increased urinary frequency Ocular Conjuclival h)fperaemia, reduced visual acuity, stinging sensation, blurred vision, secondary ACG, choroidal effusion, transient myopia Skin Maculopapular exanthema, AGEP... 

Skin An 85-year-old male treated with acenocoumarol for stroke/systemic embolism prevention due to atrial fibrillation presented 6 weeks later with maculopapular exanthema of the trunk and limbs as well as purple lesions and blisters on the distal parts of his legs. Acenocoumarol was discontinued and enoxaparin, corticosteroids and antihistamines were administered one month later, the lesions had disappeared and laboratory parameters were normalized. This is a first report of drug reaction with eosinophilia and systemic symptoms for acenocoumarol [4 ]. 

In a case report, two patients with multiple sclerosis (MS) developed maculopapular exanthema related to the administration of glatiramer acetate (GA) which was thought to be due to delayed-type hypersensitivity reaction [25A]. 

A case has been reported of a persistent skin disorder due to gold therapy (53 ). The patient, a 17-year-old-girl, complained after i.v. administration of 920 mg gold of an itching maculopapular exanthema. Excerbation was noted after another (final) gold injection, and alopecia developed. Three years later brown spots were still present, particularly on pressure points. 

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