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Drug-Induced Papuloerythroderma: Analysis of T-Cell Populations and a Literature Review

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Drug-Induced Papuloerythroderma: Analysis of T-Cell Populations and a Literature Review Acta Derm Venereol 2009; 89: 618–622 CLINICAL REPORT Drug-induced Papuloerythroderma: Analysis of T-cell Populations and a Literature Review Kazunari SUGita1, Kenji KABASHIMA1,2, Motonobu NAKAMURA1 and Yoshiki TOKURA1 Department of Dermatology, 1University of Occupational and Environmental Health, and 2Kyoto University Graduate School of Medicine, Kyoto, Japan Papuloerythroderma of Ofuji is characterized by coale­ of solid papules, which typically spare the skin folds, scent solid papules that spare the skin folds. Although cu­ presenting the so-called “deck-chair” sign. Although its taneous lymphomas and internal malignancies are known association with cutaneous T-cell lymphoma as well as associated conditions, the causative agents are unclear in visceral carcinomas has been documented in a consi- most cases. A number of recent reports have documente d derable number of cases, the aetiology of the condition that drugs can induce papuloerythroderma. We review­ is unclear in the vast majority of patients (2). However, ed the reported cases and our own cases of drug­induc­ recent reports have indicated that drugs are causative ed papulo erythroderma, together with our data from agents for papuloerythroderma (3, 4) and have suggested lympho cyte transformation tests and T­cell subsets of that drug-reactive T-helper (Th) 2 cells play an important peri pheral blood. All of the 9 patients were male, and the role in the pathogenesis (5). causative drugs were various. Provocation tests were po­ The populations of circulating T cells can be skewed sitive in all 6 patients examined. Whereas drug patch tests upon occurrence of T-cell-mediated drug eruptions (6, were negative in all 5 cases tested, the patients’ peripheral 7). In the usual development of drug eruption, peripheral blood lymphocytes responded well to the culprit drug in T cells react with a causative drug, migrate to the skin, 4 of 5 patients tested. The patients had higher percenta­ and trigger dermatitis as a consequence of immuno- ges of circulating CCR4+CD4+ T helper (Th) 2 cells than logical or inflammatory responses (8). In this article, CXCR3+CD4+ Th1 cells. Drug­induced papuloerythro­ we review the clinical, laboratory, and histological derma seems to be mediated by Th2 cells reacting with the features and the clinical outcome of drug-induced causative drug. Key words: drug eruption; allergy; T cells. papuloerythroderma in the literature, including our own 4 published cases. We also characterize circulating (Accepted May 27, 2009.) T-cell populations in patients with drug-induced papulo- Acta Derm Venereol 2009; 89: 618–622. erythroderma, focusing on the in vitro T-cell response to the causative drug and the Th1/T cytotoxic (Tc)1 or Kazunari Sugita, Department of Dermatology, University Th2/Tc2 polarization. of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan. E-mail: [email protected] MateRIALS AND METHODS Blood samples were taken from our patients with drug-induced papuloerythroderma (cases 5, 6, 8 and 9 in Table I), with infor- Papuloerythroderma was first described in 1984 by Ofuji med consent before treatment. Peripheral blood mononuclear (1). This distinct disorder is characterized by coalescence cells (PBMCs) were isolated from heparinized venous blood of Table I. Reported cases of drug-induced papuloerythroderma Case Age (Ref) (years) Sex Country Past or associated diseases Causative drugs Other drugs Latency period 1 (15) 60 M Spain Allergic rhinitis, conjunctivitis Nicardipine hydrochloride, Trichlormethiazide 2 weeks nifedipine 2 (3) 31 M Japan AIDS Dideoxyinosine ND 1 month 3 (16) 66 M Japan None Cellulose ND Obscure 4 (17) 75 M Japan Right eye injury Isoniazid Rifampicin, streptomycin, 1 week ethambutol 5 (5) 70 M Japan Cerebral infarction Aspirin Carvedilol 10 yearsa 6 (9) 79 M Japan Chronic eczema, heart failure Furosemide ND 4 months 7 (13) 80 M Japan Pneumonia, diabetes mellitus Ranitidine hydrochloride Codeine phosphate, trapidil 2 weeks 8 (18) 78 M Japan Hypertension, angina pectoris Eperisone hydrochloride ND 2 years and 5 monthsa 9 (14) 82 M Japan Hypertension, prostate cancer Leuprorelin acetate Diltiazem hydrochloride 5 yearsa aIntermittently administered for the period. ND: not described. Acta Derm Venereol 89 © 2009 The Authors. doi: 10.2340/00015555-0712 Journal Compilation © 2009 Acta Dermato-Venereologica. ISSN 0001-5555 p Carlos, CA, USA). Carlos, CA,USA). CA, USA) and analysed with FlowJo San software (TreeStar, and collected on a (BD FACSCanto Biosciences, San Diego, mAbs or control isotype-matched controls, cells were washed After incubation for 30 min at 4ºC with as the staining buffer. before harvesting, 1 narrowband ultraviolet (UV)-B irradiation. narrowband ultraviolet(UV)-B irradiation. and/or prednisolone systemic as such treatment, initial the with remission partial achieved patients Most drug. drugs were causative, and there was no preponderant of procedure in variety case of 4 A was not described. detail The 6). and 5 (cases cases our in procedure same drug at one-fifthof the daily dose (5). We used the The oral challeng test was performed with the culprit lymphocyte transformation test (cases 5, 6, 7 and 8). of reactions positive and 9) and 6 5, 4, 3, 1, (cases test provocation of results positive 2), (case eruptions the of regarding the administration of the drug and the onset timing the on based confirmed was drug causative The disease. heart of history a had patients the of One-third periods were given the causative drug intermittently. to 10 years, although some patients with long latency 61 to100years,withamedianageof72years. from varied diagnosis at age the patients, these In (10). 4.7:1) ratio (male/female patients female 3 and male 14 were there causes, of irrespective papuloerythroderma of study retrospective a In male. were patients All years. 82 to 31 from ranging years, 69 was diagnosis at patients induced papuloerythroderma. The mean age of the 9 drug- of cases reported the summarizes II and I Tables review Literature RESU with 10% heat-inactivated foetal calf serum (FCS), 5 St (Sigma-Aldrich, 1640 medium, culture as Briefly, (9). modification some with proliferation assay was performed as previously described, L St Co., Chemical (Sigma Ficoll-Hypaque of means by patients Diego, CA, USA) at 2 at USA) CA, Diego, anti-CXCR3, anti-CCR4 mAb (all from PharMingen, San noclonal antibody (mAb) and phycoerythrin (PE)-conjugated (FITC)-conjugated anti-CD4, anti-CD8 or anti-H Cells were double-stained with fluorescein isothiocyanate was measuredinaliquidscintillationcounter. Heights, I tion containing 0.1% NaN 0.1% containing tion in triplicate at 37ºC and 5% CO performed were Cultures Cmax. around performed was dilution drugs was determined by referring Cmax, and serial 10-times ted to suspend them in the medium. The concentration of the compounds dissolved in culture medium, which were sonica culprit drugs used for the assay were unmodified parent drug non-essential amino acids, and 1 mM sodium pyruvate. The mM 2 2-mercaptoethanol, ouis, MO, USA) An density gradient centrifugation. < Data Data were analysed using an unpaired two-tailed Flow cytometry was performed as described previously (7). Flow cytometrywasperformedasdescribedpreviously(7). The latency period of the skin rash varied from 1 week 1 from varied rash skin the of period latency The 0.05 wasconsideredtobesignificant. L TS L , USA) was After added. harvesting, radioactivity µ Ci µ g/10 3 L H-thymidine (Amersham, Arlington Arlington H-thymidine (Amersham, 3 L ouis, MO, USA) was supplemented supplemented was USA) MO, ouis, and 1% foetal calf serum was used used was serum calf foetal 1% and -glutamine, 25 mM HEPES, 1 mM mM 1 HEPES, mM 25 -glutamine, 6 cells. Hanks’ balanced salt solu salt balanced Hanks’ cells. 2 for 3 days. Eighteen hours L A-D × in vitro R R 10 t mo -test. -test. PMI- –5 M - - - Table II. Laboratory data and clinical course in the reported cases Provocation test Patch test Lymphocyte transformation test Causative Other Causative Causative Clinical Case (Ref) Eosinophils Histology drugs drugs drugs Other drugs drugs Other drugs Treatment course 1 (15) 2500/μl Perivascular infiltrate of lymphocytes Positive ND ND ND ND ND ND Remission and eosinophils 2 (3) ND CD8+ T cells, eosinophils, and giant ND ND ND ND ND ND PUVA Remission Drug-induced papuloerythroderma cells in the dermis 3 (16) ND ND Positive ND ND ND ND ND Oral steroid ND 4 (17) 5000/μl Perivascular infiltrate of lymphocytes Positive Negative Negative Negative (rifampicin, Negative ND Oral steroid Remission and eosinophils (Rifampicin) ethambutol) 5 (5) 816/μl Exocytosis of CD4+ T cells and Positive NT Negative Negative (carvedilol) Positive Negative (carvedilol) Narrowband Remission perivascular infiltrate of lymphocytes UVB 6 (9) 678/μl Perivascular infiltrate of lymphocytes Positive ND Negative ND Positive ND Topical steroid Improvement and eosinophils 7 (13) 2737/μl Perivascular infiltrate of lymphocytes ND ND Negative Negative (codeine Positive Negative (codeine Oral steroid Remission Acta Derm Venereol 89 Acta DermVenereol and eosinophils phosphate, trapidil) phosphate, trapidil) 8 (18) ND Perivascular infiltrate of lymphocytes ND ND Negative ND Positive ND Oral steroid Remission and eosinophils 9 (14) 1128/μl Perivascular infiltrate of lymphocytes Positive NT ND ND ND ND Oral steroid Improvement and eosinophils ND: not described, NT: not tested, LTT: lymphocyte transformation test; UVB: ultraviolet B; PUVA: psoralen UVA. 619 620 K. Sugita et al. Fig. 1. Clinical appearance and histology of typical papuloerythroderma (case 5). (a) Diffuse coalesced papules on the lower legs. (b) Histological picture showing lymphocytic infiltrate intermingled with eosinophils in the upper dermis and exocytosis of lymphocytes. (haematoxylin- eosin, original magnification× 100). The eruptions were different from the usual acute examined, skin patch tests of the culprit drugs did not type of drug exanthema, as they were chronically seen, yield any positive findings (Table II). presumably in association with pre-existing eczematous In our cases 5 and 9, the patients took several drugs.
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