Ward Teaching Drug Eruption

Group members :

Nur Nadia Nor Farhana Raisul Maarif Azwan Andi Isra

Citra sari
Rizqah Humairah Arifat Ladadu

PATIENTS IDENTITY

Name Register no Gender Age

: Mrs. H : 01 52 35 : Female : 43 years old

Marital status : Married

Religion
Occupation Admission

: Muslim
: Unoccupied : Saturday, 7 Desember 2013

HISTORY TAKING

Anamnesis Chief complaint

: Autoanamnesis : feel itchy all over the body

Further Anamnesis : She started feeling itching 4 days ago. The unusal lesion appear and cause the itching after 3 days she finished her 2nd chemotherapy of Ca. mammae. Her itching started from both of the leg and spread until her chest. She started her 2nd chemotherapy on Saturday 7 Dec 2013. After her 1st chemotherapy she didnt experienced this symptom. The patient did not have a fever before or after the lesion appeared.

Systematical Anamnesis

Patient has same complaint before (-) Trauma History (-) Family history: same complaint (-) Treatment history ointment used (-) Drugs allergic (+)

History of insect bites (-)

Post chemotheraphy (+)

DERMATOLOGY STATUS

Location Location

: Regio Facialis : Regio generalized

Efflorescence : macule eritem Efflorescence : macule eritem, papul erythem, erosion, macule, hiperpigmentation

Abdomen

Inferior extremities

Ekstremitas superior

Punggung

Rash at the both cheeks

Diagnosis
Drug

Eruption

Treatment
From Patients Status :

Methylprednisolone 4 mg (2-2-0)

Cetirizine 1x1
Hydrocortisone 2,5 % ( w) morning - everning Asam salicil 2 % + inerson 2 tube add

From references Systemic : 1. Corticosteroid: prednisone (1 tablet =5 mg), 3x 10 for adult Eritroderma 3x 10- 4x 10 2. Antihistamine Topical : 1. Salicylate powder 2% + menthol -1% 2. salicylate acid compression 1% 3. hydrocortisone cream 1% or 2% 4. Lanolin 10%

Discussion

Allergic drug eruption is an allergic reaction that occur to skin or mucutaenous because of using the systemic drug. several type of clinical manifestation of drug eruption, as an example: morbiliformis,

erythema multiform,
exanthema fikstum, akneiformis eruption, Urtikaria,

Purpura,
dermatitis eksfoliativa, toxic epidermal necrosis, Steven-Johnson syndrome.

Drugs that commonly cause serious reactions

Allopurinol Anticonvulsants NSAIDs Sulfa drugs Bumetanide Captopril Furosemide Penicillamine Thiazide diuretics in this patient she was given Cefadroxil (antibiotic) and mefenamate acid (nsaid) for her Ca mammae, which can cause an allergic reaction

Rates of reactions to commonly used drugs

Amoxicillin - 5.1%

Trimethoprim sulfamethoxazole - 4.7%

Ampicillin - 4.2% Semisynthetic penicillin - 2.9% Blood (whole human) - 2.8% Penicillin G - 1.6% Cephalosporins - 1.3% Quinidine - 1.2% Gentamicin sulfate - 1%

Diagnosis
I. ANAMNESIS The drug that the patient consume 1st symptom appear : acute or after several days Itchy or not Have fever or not II. SKIN ABNORMALITIES Distribution Universal generalize Shape of the lesion

During history taking note and detail the following:

All prescription and over-the-counter drugs, including topical agents, vitamins, herbal, laxatives, oral contraceptives, vaccines, homeopathic medicines, etc. as these may not be volunteered as medications
The interval between the introduction of a drug and onset of eruption Route, dose, duration, and frequency of drug administration Any improvement after drug withdrawal and any reaction with readministration

Test or Examination :

Lab Examination

Eruption - Morbilliform (exanthematous(: It is the most common pattern Lesions are symmetric, with confluent erythematous macules and papules that spare the palms and soles It typically develops within 2 weeks after the onset of therapy

Common drugs Ampicillin,penicillin, phenylbutazone,sulphonamides, gold, genta-mycin, cephalosporins, barbiturates, thiazides

Eruption - Urticaria: It is the 2 nd most common eruption Occurs as small wheals that may coalesce or have cyclical or gyrate forms Lesions appear within 36h of intake and resolve rapidly when the drug is withdrawn

Common drugs ACEI ,aspirin/NSAIDs,blood products,cephalosporins, cetirizine, dextran, infliximab, inhaled steroids, opiates, penicillin, radiologic contrast material, ranitidine, tetra-cycline, vaccines, zidovudine

Eruption

Common drugs

- Acute generalized Beta-lactam antibiotics, exanthematous pustulosis : macrolides, and mercury Acute-onset fever and generalized scarlatiniform erythema occur with many small, sterile, nonfollicular pustules. The clinical presentation is similar to pustular psoriasis

Eruption
- Purpura: Can occur alone or as a component of vasculitis

Common drugs
Aspirin, cephalosporins, cytotoxics,heparin

Eruption
- Pityriasis rosea-like: Eruption is similar to PR Itching is severe not responding to antihist-amines There is no tendency of spontaneous remission

Common drugs
Gold,ACE inhibitors, thiazides, bismuth, barbiturates, griseofulvine, metronidazole

Eruption - Fixed drug eruptions: Lesions recur in the same area 8 h after the drug is reused Circular, violaceous, edematous plaques that resolve with macular hyperpigmentation Hands, feet&genitalia are the most common sites but perioral and periorbital lesions may occur

Common drugs Sulfonamides,penicillin, tetracyclines, aspirin/NSAID, barbiturates, cetirizine, ciprofloxacin, dapsone, fluconazole, hydroxyzine, loratadine, metronidazole, oral contraceptives, phenytoin, vancomycin

PATOGENESIS
Skin reaction to medications (drugs) : 1. Immunologic Mechanism 2. Non Immunologic Mechanism Allergic drug erruption : allergy to medications through immune process

There are 4 reaction types

1. Type I / Anafilactic Strong affinity of IgE to mast cells and basophils Others effect:

- Urtikaria
- Angineurotic edema - anafilactic shock

2. Type II (Cytotoxic) The combination between IgG & IgM with antigen attached to the cell Activation of complement system Lysis (tissue damage)

3. Type III (Immune Complex) Aq + Ab Aq Ab

Settles in the body tissues Complement activation Lisis Inflammation

Release of Anafilatoxin Release of Mediators (Enzymes that cause tissue

damage)

4. Reaksi Tipe IV (Slow cellular allergic type 12 48 hours)

Reaction of Limphocyte T + Ag There are two forms of reaction: : - Tuberkulin the dermis - Contact antigen located around the blood vessels in Ag + Limphocyte T

Lymphokine

Complication
Ekskoriasis and 2nd infection by bacterial from the

scratch

actually

is

complication
infection is

that

always
by

happened.

Generally,

caused

streptococcus pyogenes. Impetigo also can appear, general or local allergy reaction, as an example edema and vesicobullous reaction.

Prognosis
Most cases resolve without complications but it may

take 10 to 14 days for the rash to disappear. Patients

with exanthematous eruptions will have mild desquamation as the rash resolves. .