Nimesulide-Induced, Multifocal, Urticarial Fixed Drug Eruption Confirmed by Oral Provocation Test

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T. violaceum in 26.66% of the cases and T. mentagrophytes in 6. Gujrathi UK, Sivarajan k, Khubani H. Dermatophytosis in 13.13% of the cases (2/15). This is comparable with other Loni. Ind J Med Microbiol 1996;14:116-7. studies showing T. rubrum as the most common isolate[4] 7. Veer P. Patwardhan NS, Damle AS. Study of onychomycosis: isolated from glabrous skin of the body, groins and feet as Prevailing fungi and pattern of infection. Ind J Microbiol 2007;25:53-6. reported earlier.[5] The most prevalent clinical type seen was 8. Fitzpatrick Tb, Johnson RA, Wolff K, Polono MK. Colour Atlas tinea cruris (60%) followed by tinea corporis (33.33%). This and Synopsis of clinical dermatology. 3rd Edition (McGraw is in agreement with other published reports.[6] The second Hill) 1997. Chapter 25. most common isolate in this study was T. violaceum, which is in contrast with other studies,[2,4] in which T. mentagropytes was the second most common isolate. The presence of non- dermatophytic fungi, i.e, Fusarium spp. and Exophiala spp. NNimesulide-induced,imesulide-induced, mmultifocal,ultifocal, was reported in this study. uurticarialrticarial fi xxeded ddrugrug eeruptionruption The most common isolate in the scalp hair samples was T. ccononfi rrmedmed bbyy ooralral pprovocationrovocation ttestest violaceum (62.5%) and T. rubrum was the least common isolate in our hair samples as reported earlier.[2] The striking feature among the culture-positive cases of onychomycosis in this Sir, study was that T. violaceum was the most common isolate Fixed drug eruption (FDE) is a common subset of cutaneous (22.22%), which is in contrast to other studies from India.[7] C. reactions that arise due to various drugs. Multifocal FDE krusei is a lesser known species of Candida which is currently (MFDE) is defined by skin eruptions at more than one emerging as a pathogen and C. krusei was isolated from one site. Nimesulide is a cyclooxygenase (COX) inhibitor with case in this study. Scopulariopsis spp. which is reported to a high degree of selectivity to COX-2. Although commonly be a ubiquitous soil fungus causing nondermatophytic nail prescribed, there is only one reported case of nimesulide- [1] infections in a majority of cases,[8] was isolated from one induced MFDE in a child. case of onychomycosis in our study. Our study shows that dermatophytes as well as other fungi may cause infection A 41-year-old old female was referred to our clinic because of the skin, hair or nails, hence, a high index of suspicion is of the sudden appearance of numerous, erythematous, required to implicate and identify the isolates. urticarial plaques with slight desquamation on the trunk and extremities over the last 18 hours. According to her history, MM.. MMathur,athur, VV.. PP.. BBaradkar,aradkar, AA.. DDe,e, she usually received paracetamol for her dysmenorrhea; SS.. TTaklikar,aklikar, SS.. GGaikwadaikwad however, over the last eight months, she started using Department of Microbiology, Lokmanya Tilak Municipal Medical piroxicam or nimesulide over the counter. At the time of College, Sion, Mumbai, India the examination, a 3-mm punch biopsy was performed and

AAddressddress fforor ccorrespondence:orrespondence: Dr. V. P. Baradkar, Lecturer, Department histological examination confirmed the diagnosis of FDE. of Microbiology Lokmanya Tilak Municipal Medical College, Sion, Mumbai 400 022 India. E-mail: [email protected] The patient was not able to link the eruption with the intake of any drugs. An oral provocation test was suggested, she RREFERENCESEFERENCES consented and an appointment was scheduled a month after the remission of the lesions. 1. J. Chander Textbook of Medical Mycology. 2nd Edition (Mehta Publisers) 2002:91-112. 2. Peerapur BV, Inamdar AC, Pushpa PV, Srikant B. Nimesulide seemed to be the most probable causative Clinicomycological study of Dermatophytosis in Bijapur. Ind agent based on her history. A dose of 25 mg was initially J Med Microbiol 2004;22:273-4. administered and an additional dose of 25 mg was given after 3. Hunda MM, Chakraborty N, Bordoloi JN. A clinicomycological an hour as the patient was free of eruptions. Approximately study of superficial mycosis in upper Assam. Ind J Dermatol 30 minutes after the 2nd dose, we noticed the appearance of Venerol Leprol 1995;61:329-32. a widespread, slightly itching erythema which was localized 4. Kannan P, Janaki C, Selvi GS. Prevalence of dermatophytes on the trunk. After an hour, we administered a third dose of and other fungal agents isolated from clinical samples. Ind J Med Microbiol 2006;24:212-5. 25 mg nimesulide (a total of 75 mg) and multiple, urticarial, 5. Tandon S, Dewan SP. Mohan U, Kaur A, Malhotra. Mycological erythematous plaques appeared within 15–20 minutes aspects of dermatomycosis. Ind J Dermatol Venerol Leprol [Figure 1]. Oral provocation tests were also performed with 1996;62:336-7. piroxicam and paracetamol and were negative.

Indian J Dermatol Venereol Leprol | July-August 2008 | Vol 74 | Issue 4 403 Letters to Editor

RREFERENCESEFERENCES

1. Sarkar R, Kaur C, Kanwar AJ. Extensive fixed drug eruption to nimesulide with cross-sensitivity to sulfonamides in a child. Pediatr Dermatol 2002;19:553-4. 2. Shiohara T, Mizukawa Y. Fixed drug eruption: A disease mediated by self-inflicted responses of intraepidermal T cells. Eur J Dermatol 2007;17:201-8. 3. Puavilai S, Chunharas A, Kamtavee S. Drug eruptions: The value of oral rechallenge test and patch test. J Med Assoc Thai 2002;85:263-9. 4. Barbaud A, Reichert-Penetrat S, Trechot P, Jacquin-Petit MA, Ehlinger A, Noirez V, et al. The use of skin testing in the investigation of cutaneous adverse drug reactions. Br J Figure 1: Erythematous, pruritic plaques with slight desquamation Dermatol 1998;139:49-58. after administration of nimesulide 5. Ozkaya-Bayazit E. Topical provocation in fixed drug eruption due to metamizol and naproxen. Clin Exp Dermatol Nimesulide is a well tolerated, nonsteroidal, anti-inflammatory 2004;29:419-22. sulfonamide drug, used with or without medical prescription. The most common reported side effects include nausea, vomiting, and diarrhea while skin rash and pruritus are the IIdiopathicdiopathic generalizedgeneralized anhidrosis:anhidrosis: most usual cutaneous adverse reactions. A ffeatureeature ooff ppanautonomicanautonomic failurefailure FDE characteristically occurs each time the offending drug is administrated, although the number of involved sites may increase. The pathogenesis of the disease is still obscure. Sir, It seems that a large homogenous population of CD8 (+) Anhidrosis refers to the absence of sweating in the T cells are distributed along the epidermal basal layer in presence of appropriate stimuli. Anhidrosis may result FDE and have the capacity to produce large amounts of IFN- from abnormalities of sweat glands or from autonomic [1] gamma. These cells are likely to play a significant role in dysfunction. It can be both congenital or acquired, and FDE lesions.[2] can be generalized or localized in nature. Chronic idiopathic anhidrosis has also been described as a forme fruste of acute Linking of a drug with FDE may be difficult when the patient panautonomic neuropathy.[2] We are reporting here a case of is receiving more than one drug. The rechallenge test panautonomic dysfunction in a patient who presented with seems to represent the most reliable method of identifying idiopathic generalized anhidrosis. causative drugs even though it is not 100% reliable and probably hazardous.[3] Patch testing at the site of a previous A 40 year-old woman presented with a history of recurrent lesion yields a positive response in up to 43% of patients[4], bouts of high fever for the preceding 15 years. There was while the reliability of topical provocation on previously a generalized lack of sweating since childhood, except involved and uninvolved skin is variable.[5] over the left half of her face, which also eventually became anhidrotic for the last 15 years. On presentation, she had a The early diagnosis of any drug eruption is very important for total absence of sweating, heat intolerance, as well as fecal all patients. Although the most useful tool in the diagnosis and urinary urgency. Cutaneous examination showed shiny, of drug reactions, the rechallenge test should be carefully smooth, hairless, dry skin. No sweating was visible even performed when properly after FDE is determined. on provocation (with vigorous exercise and by taking hot drinks) and the result of the iodine-starch test was negative. EEfstathiosfstathios RRallis,allis, EEvgeniavgenia SStavropoulou,tavropoulou, Systemic examination revealed that the right pupil was IIoannisoannis ParaskevopoulosParaskevopoulos1 irregularly dilated, the light reflex was absent in both the Departments of Dermatology and 1Allergology, Army General eyes although the accommodation reflex was intact; the Hospital, Athens, Greece extraocular muscle function was normal. In addition, she

AAddressddress fforor ccorrespondence:orrespondence: Dr. Efstathios Rallis, 11 Pafsaniou Str, had postural hypotension. There was evidence of cardiac 11635, Athens, Greece. E-mail: [email protected] dysautonomia in the form of a decrease in heart rate variability

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