Penicillamine Corticosteroids

Pemphigoid-type Pemphigoid-type reactions characterized by bullous lesions have required discontinuation of penicillamine and treatment with corticosteroids. 

In a nested case-control study in Mexican patients with rheumatoid arthritis encompassing 1274 patient years, the risk factors were determined for acquiring infectious diseases (378). In addition to the cumulative doses of methotrexate and the duration of corticosteroids use, the mean daily dose of penicillamine was a risk factor. In one patient the infection was secondary to neutropenia. Tests for a possible immunoglobulin deficiency were not performed. 

Cegla, U.H., Kroidl, R.F., Meier-Sydow, J. et al. (1975). Therapy of the idiopathic fibrosis of the lung. Experiences with three therapeutic principles corticosteroids in combination with azathioprine, D-penicillamine, and para-amino-benzoate. Pneumonologie 152, 75-92. 

Goodman, M. and Tumer-Warwick, M. (1978). Pilot study of penicillamine therapy in corticosteroid failure patients with widespread pulmonary fibrosis. Chest 74, 338. 

Although leukopenia is associated with Felty s syndrome, it also may result from toxicity of gold, sulfasalazine, penicillamine, immunosuppressive drugs, and biologic agents. Leukocytosis is seen commonly as a result of corticosteroid treatment. 

Although there have been many reports describing how patients with EMS have been treated, results were not successful in the majority of patients. Basically, the treatment of EMS has consisted of discontinuation of L-tryp-tophan and administration of corticosteroids, nonsteroidal anti-inflammatory drugs, and several other drugs, such as D-penicillamine and colchicine, cyclophosphamide, AZA (azathioprine), methotrexate, amitriptyline, acetaminophen, aspirin, naproxen, diphenhydramine, cyclobenzaprine, and fluoxetine.2132 56 In general, it was concluded that prednisone was helpful in the acute phase of the disease. Slow improvement was reported in 79% of the 193 patients. However, no treatment was clearly valuable in the management of the later phase of the syndrome.55... 

There are 12 other cases of maeromastia and gynaecomastia on record associated with the use of penicillamine, in some of which the second trigger may possibly have been a corticosteroid or cimetidine. Maeromastia appears to be an unusual adverse effect of penicillamine and there would seem to be no general reason for patients taking penicillamine to avoid oral contraceptives. 

D-Penicillamine is used in the treatment of rheumatoid arthritis. Several types of pulmonary toxicities have been described with this agent. A pulmonary-renal syndrome similar to Goodpasture s syndrome has been rarely described and is fatal in 50% of the cases. Hemoptysis and hematuria are present in an acute fashion and warrant prompt discontinuation of the drug. Anti-glomerular basement membrane antibodies are not found and the role of plasmapheresis in undetermined. Treatment with corticosteroids or immunosuppressive agents may be of benefit (21). Bronchiolitis obliterans with or without organizing pneumonia has also been reported, but is also described with rheumatoid arthritis. Hypersensitivity pneumonitis and the subacute onset of pulmonary fibrosis have been... 

The patient, a 66-year-old man, was treated with 500 mg penicillamine daily for rheumatoid arthritis. After 6 months of treatment a bullous and crythcmatosquamous eruption developed on the trunk, scalp and arms. The Nikolsky phenomenon was positive. An erythematosquamous balanitis was present stomatitis did not develop. On cytological examination acantholytic cells were present. Histological examination revealed both aspects of toxicoderma and pemphigus. Intercellular immunofluorescence was positive in the superficial layers of both affected and apparently normal skin. Electron microscopic examination confirmed acantholysis. Anti-intercellular substances and anti-striational antibodies were detected in the serum ANF and LE cells were absent. The disorder rapidly disappeared after withdrawal of penicillamine, and a course of treatment with a corticosteroid. 

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