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PARACETAMOL ALLERGY: A CASE REPORT

Abdulsamet Tanik1* and Ahmet Günay1

1Department of Periodontology, Faculty of Dentistry, Dicle University, Diyarbakir, Turkey.

*Corresponding Author: Abdulsamet Tanik Department of Periodontology, Faculty of Dentistry, Dicle University, Diyarbakir, Turkey. Email ID:

Article Received on 31/12/2016 Article Revised on 20/01/2017 Article Accepted on 08/02/2017

ABSTRACT

Adverse reactions to medications prescribed or administered in dental practice can be worring. Others, such as allergic and pseudoallergic reactions, are generally unpredictable and unrelated to normal drug action. Paracetamol and other NSAIDs ranks after antibiotic drugs in the world as a potential hypersensitivity occur. It is usually oral mucosa by allergic reactions more sensitive than skin reactions and hypersensitivity reactions may lead to intense erythematous lesions of the attached gingiva. In this case report with a diagnosis of a rare allergy paracetamol combination preparations 51-year-old female patient presented.

KEYWORD: Paracetamol allergy, Allergic reactions, Analgesic intolerance

INTRODUCTION should be used. Generally, in acute pain in the oral cavity, non-narcotic (non-steroidal anti-inflammatory Paracetamol is used throughout the world due to its drugs [NSAID] and paracetamol) derivative drugs are analgesic and antipyretic effects. It is a drug widely used. NSAIDs exhibit anti-inflammatory, analgesic and available with and without prescription. However, partial anti-pyretic effects. The efficacy of these drugs is paracetamol toxicity is known to be the most common shown through cyclooxygenase (COX-1, COX-2) cause of drug-related liver failure. Repeated incorrect inhibition.[6,7] treatments, unintentional errors or intentional intake of

the drug may cause the development of hepatic NSAIDs frequently used in dentistry include ibuprofen, toxicity.[1] acetylsalicylic acid, diflunisal, etodolac, mefenamic acid,

ketoprophene, ketorolac, flurbiprofen and paracetamol.[8] In 2005, 28 million drugs containing a paracetamol Paracetamol is used mostly for its analgesic effect and is component were distributed. In 2003, prescriptions were the most commonly used NSAID for pregnant patients obtained for 89 million paracetamol derivatives. Despite and children. Recent studies have shown paracetamol to regular use of this drug, many cases of over-sensitivity have an effect on the brain and spinal cord by inhibiting have been reported. In 2009, the American Toxicology COX-3.[9] It does not damage thrombocytes or the Association reported that 401 cases on the toxicology gastrointestinal system. As paracetamol is metabolised in data system were from paracetamol and paracetamol- the liver, it can cause toxicity in patients with liver derived drugs.[2,3] disease.[10]

Associated with current increasing use of drugs, In comparison with other drugs, over-sensitivity analgesics are the most significant cause of sensitivity reactions are caused by paracetamol less often. It has reactions following antibiotics.[4] generally been reported to cause urticaria, angio-oedema,

maculopapillary rash, bronchospasm, rhinitis, and Dentistry constitutes a signifiant area of drug use. When occasionally, vasculitis, toxic epidermal necrolysis and infections which form in the oral cavity are not treated anaphylactic reactions.[5,11,12] appropriately, they can become extremely painful and

may even create a threat to life. In the treatment of Patients who experience allergic reactions to NSADs are infections, there is a need for antimicrobial agents in more predisposed to have a reaction to paracetamol. addition to surgical operations.[5] While there are those who advocate that paracetamol

allergy occurs through IgE reactions, the other possibility Most disorders of the teeth and related tissues are caused has focussed on the inhibition of COX-3 enzyme by the by inflammation. If the source of the problem is drug.[13] inflammation, an anti-inflammatory derivative drug

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Tanik et al. World Journal of Pharmaceutical and Medical Research

Several methods and applications are used in the determination of allergic reactions. Skin tests used for allergies are used to determine sensitivity against an allergen. These are the most important diagnostic tools as they are easy to apply, low-cost and are reliable.[14]

Apart from the paracetamol preparates used in Turkey, there are several analgesic drugs which are combined with paracetamol. The case is here presented of a patient who developed drug allergy to the combined use of paracetamol-chlorpheniramine-pseudoephedrine- dextromethorphan.

CASE REPORT

A 51-year old female presented at the Periodontology Clinic of Dicle University Dentistry Faculty with the complaints of a burning sensation in the mouth, swelling in the gingiva and bleeding of the gums. In the detailed anamnesis taken from the patient, it was learned that 2

days previously she had consulted a doctor with the Figure 2: Redness and erythema in the hands. complaints of influenza and after examination had been prescribed with Gripamol 325 mg (Paracetamol, Koçak, The patient also reported itching pain on the body. In the Tekirdağ, Turkey). The patient stated that she had not intra-oral examination, erythemous lesions were seen in previously experienced any allergic reaction to any the gums which were of a soft consistency and there was medication. Informed consent was obtained from the inflammation, with oedema and discharge (Fig. 3). patient. In the oral examination, there was seen to be an epithelial rash on the skin around the mouth and cracks had formed on the lips and there was redness and swelling of the hands (Fig. 1,2).

Figure 3: Erythemous lesions and inflammation in the gingiva of the lingual regon of the lower jaw.

Following a detailed examination, periodontal treatment was applied to the patient who was then referred to the Figure 1: Rash on the skin around the mouth. Medical Faculty Dermatology Department for allergy testing. As reaction to the paracetamol combined preparates was suspected, a skin prick test was applied (Perfalgan 10 mg/mL, Bristol Myers Squibb, New York, USA). Results in the applied prick test of swelling and redness reactions ≥ 3mm were evaluated as positive. An allergic reaction associated with paracetamol was determined as a result of the prick test. The patient was told that it was necessary to terminate the use of www.wjpmr.com 24

Tanik et al. World Journal of Pharmaceutical and Medical Research

paracetamol. It was also recommended that care was to other analgesic drugs.[11] For patients with aspirin taken against allergen food and drink and that the doctor allergy, an alternative drug should be recommended. should prescribe anti-allergic drugs. A follow-up High-dose paracetamol and aspirin in particular interact appointment was made for 15 days later. with other NSAIDs.[16]

At the follow-up examination, the rash around the mouth Reactions associated with NSAIDs and paracetamol have and the redness and swelling in the hands were observed been reported to be seen more often in asthma to have recovered (Fig. 4,5). patients.[17] Although gender has no effect on atopy and paracetamol, greater sensitivity has been reported in males.[11]

The development of drug-related over-sensitivity reactions constitute significant causes of morbidity and mortality.[18] Paracetamol allergy is seen at lower rates in children than in adults. The most common clinical findings of allergic reactions are urticaria, angio-oedema, rhinitis and asthma.[18] Diagnosis is confirmed by skin prick tests. In the current patient, as they emerged in the late stage, symptoms were seen more as skin rash, redness in the hands and swelling and oedema in the gingiva.

Skin symptoms have been reported in 97.6 % of reactions which develop associated with paracetamol, in 10 % of anaphylactic shock, as early symptoms in 30.9 % of cases and as late symptoms in 63.1 %.[18] In other studies, urticaria, angio-oedema and skin symptoms have

Figure 4: Recovery of the rash around the mouth been most commonly seen, followed by respiratory symptoms and anaphylactic reactions have been reported after 15 days. [19,20] to develop more rarely.

In the current case, symptoms emerged in the late stage following the use of paracetamol preparates. As an adverse reaction could develop against other cycloxygenase inhibitors, this patient should not use COX-1 and COX-2 inhibitors.

In patients with suspected drug allergy, determination with the appropriate allergological tests is of great importance. Otherwise, patients may unnecessarily avoid drugs to which they do not have an actual allergy and it may cause inappropriate treatment with the use of unecessary drugs.[18]

Generally, the oral mucosa is more sensitive to allergic reactions than the skin and extremely sensitive reactions may cause intense erythemous lesions in the gums.[21] In drug-related allergies, when the drug is terminated the Figure 5: Recovery of the redness and swelling in the allergic symptoms start to recover. In the current case, hands after 15 days. the rash which had formed on the skin and the redness in the hands were observed to have recovered after 15 days. DISCUSSION

Most allergic reactions are seen with symptoms in the With the presentation of this case it was aimed to form of skin rash, urticaria and angio-oedema. Lesions emphasise the importance of diagnostic allergy tests in which do not seem to be dangerous may transform to adults who could develop an adverse reaction to paracetamol and that tests should be planned for the use life-threatening systemic reactions, so allergic reactions require emergency interventions.[15] The onset of of different drugs in cases determined with an allergy as syptoms is rapid and with rapid progression can cause a result of the tests. These tests are of great importance in severe reactions. Paracetamol-related sensitivity respect of preventing sensitivity reactions which the reactions are seen less frequently compared to reactions patient could experience in the future. www.wjpmr.com 25

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