Churg-Strauss syndrome montelukast

Zafirlukast and montelukast are generally well tolerated. Rare elevations in serum aminotransferase concentrations and clinical hepatitis have been reported. An idiosyncratic syndrome similar to the Churg-Strauss syndrome, with marked circulating eosinophilia, heart failure, and associated eosinophilic vasculitis, has been reported in a small number of patients a direct causal association has not been established. 

Zafirlukast and montelukast are well tolerated. Zafirlukast increases plasma concentrations of warfarin and decreases the concentrations of theophylline and erythromycin. In rare cases, treatment of patients with CysLT receptor antagonists is associated with the development of Churg-Strauss syndrome, a condition marked by acute vasculitis, eosinophilia, and a worsening of pulmonary symptoms. Because these symptoms often appear when patients are given the leukotriene receptor antagonists when they are being weaned from oral corticosteroid therapy, it is not clear whether they are related to the action of the antagonists or are due to a sudden reduction in corticosteroid therapy. 

Of these agents, zileuton is the least prescribed because of reports of occasional liver toxicity. The receptor antagonists appear to have little toxicity. Reports of Churg-Strauss syndrome (a systemic vasculitis accompanied by worsening asthma, pulmonary infiltrates, and eosinophilia) appear to have been coincidental, with the syndrome unmasked by the reduction in prednisone dosage made possible by the addition of zafirlukast or montelukast. Of these two, montelukast is the most prescribed, probably because it can be taken without regard to meals and because of the convenience of once-daily treatment. 

A 50-year-old man with a history of severe asthma and tapering of prednisone took montelukast and developed an erythematous rash and mononeuritis multiplex skin biopsy confirmed the diagnosis of Churg-Strauss syndrome (10). 

Churg-Strauss syndrome has been reported with montelukast in a patient who had not taken oral glucocorticoids. Symptoms developed within 2 days of beginning treatment with montelukast (18). 

Solans R, Bosch JA, Selva A, Orriols R, Vilardell M. Montelukast and Churg-Strauss syndrome. Thorax 2002 57(2) 183-5. 

Gal AA, Morris RJ, Pine JR, Spraker MK. Cutaneous lesions of Churg-Strauss syndrome associated with montelukast therapy. Br J Dermatol 2002 147(3) 618-19. 

In an NIH workshop summary report on the relation between asthma therapy and Churg-Strauss syndrome, the authors concluded that no one compound or class of antiasthmatic agents was solely implicated. An association was found for pranlukast, montelukast, zafirlukast, the 5-lipoxygenase inhibitor zUeuton, inhaled... 

Hauser T, Mahr A, Metzler C, Coste J, Sommerstein R, Gross WL, Guillevin L, Hellmich B. The leucotriene receptor antagonist montelukast and the risk of Churg-Strauss syndrome a case-crossover study. Thorax 2008 63(8) 677-82. 

Wechsler ME, Finn D, Gunawardena D, et al. Churg-Strauss syndrome in patients receiving montelukast as treatment for asthma. Chest 2000 117(3) 708-713. 

Guilpain P, Viallard JF, Lagarde P, et al. Churg-Strauss syndrome in two patients receiving montelukast. Rheumatology (Oxford) 2002 41(5) 535-539. 

The second case was a 62-year old female asthmatic treated with salmeterol/fluticasone combination for the previous 5 years, and with montelukast during the previous 5 months [81 ]. The patient presented with sensory deficits in lower extremities and diffuse musculoskeletal and thoracic pain. She was diagnosed with Churg-Strauss syndrome, and met more than four of the American of Rheumatology criteria for Churg-Strauss. With discontinuation of montelukast and treatment with high dose steroids, the patient s symptoms rapidly improved and eosinophilia decreased within 72 h. 

Anar C, Unsal I, Ozanturk ME, HaKlgolar H, Yucel N. A case of Churg-Strauss syndrome treated with montelukast. Med Princ Pract 2012 21(2) 186-9. 

Man MA, Alexandrescu D, Pop M, Trofor A. Churg Strauss syndrome associated with montelukast—case report. Pneumologia April-June 2012 61(2) 113-6. 

---