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Furosemide-Induced Pseudoporphyria in a Patient with Chronic

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Furosemide-Induced Pseudoporphyria in a Patient with Chronic CASE REPORT | RELATO DE CASO Furosemide-induced pseudoporphyria in a patient with chronic kidney disease: case report Pseudoporfiria induzida por furosemida em paciente com doença renal crônica: relato de caso Authors ABSTRACT RESUMO 1 Giovana Memari Pavanelli Introduction: Pseudoporphyria is a rare Introdução: A pseudoporfiria é uma foto- Sibele Sauzem Milano1 photodermatosis with characteristics dermatose rara com características seme- Gabriela Sevignani2 similar to those of porphyria cutanea lhantes às da porfiria cutânea tardia, sem, Juliana Elizabeth Jung3 tarda, without, however, presenting ab- no entanto, apresentar anormalidades no Vaneuza Araujo Moreira Funke4 normalities in porphyrin metabolism. metabolismo da porfirina. Sua etiologia Marcelo Mazza do Nascimento2 Its etiology is related to chronic kidney está relacionada a doença renal crôni- disease, ultraviolet radiation and cer- ca, radiação ultravioleta e determinados tain medications. The aim of the pres- medicamentos. O objetivo do presente 1 Universidade Federal do Paraná, ent study is to describe a case of furo- trabalho é descrever um caso de pseudo- Complexo Hospital de Clínicas, semide-related pseudoporphyria in a pa- porfiria relacionada a furosemida em pa- Curitiba, PR, Brasil. 2 Universidade Federal do Paraná, tient with chronic kidney disease. Case ciente portador de doença renal crônica. Complexo Hospital de Clínicas, description: A 76-year-old male patient Descrição do caso: Paciente masculino, Departamento de Nefrologia, with stage 4 chronic kidney disease and 76 anos, com doença renal crônica está- Curitiba, PR, Brasil. in continuous use of furosemide pre- gio 4 e em uso contínuo de furosemida, 3 Laboratório Diagnose, Curitiba, sented ulcerated lesions with peripheral apresentou lesões ulceradas com eritema PR, Brasil. 4 Universidade Federal do Paraná, erythema and central hematic crust in periférico e crosta hemática central nas Complexo Hospital de Clínicas, the legs. On a skin infection suspicion, pernas. Por suspeita de infecção de pele, Departamento de Hematologia, treatment with quinolone and neomycin foi iniciado tratamento com quinolona e Curitiba, PR, Brasil. sulfate was initiated, without improve- sulfato de neomicina, sem melhora. Foi ment. A biopsy of the lesion was per- realizada então biópsia da lesão, com formed, with histopathological examina- exame histopatológico demonstrando tion demonstrating findings compatible achados compatíveis com porfiria, sem, with porphyria, although the patient did no entanto, o paciente apresentar níveis not present high porphyrin levels. The elevados de porfirinas. Foi então estabe- diagnosis of furosemide-induced pseu- lecido o diagnóstico de pseudoporfiria in- doporphyria was then established, with duzida por furosemida, com suspensão de medication suspension, and there was a medicação, e houve melhora significativa significant improvement of the lesions. das lesões. Discussão: Há poucos casos de Discussion: There are few cases of pseu- pseudoporfiria descritos, mas acredita-se doporphyria described, but it is believed que essa condição seja subdiagnosticada, that this condition is underdiagnosed, principalmente em pacientes com doen- especially in patients with chronic kid- ça renal crônica. Tanto achados clínicos ney disease. Both clinical and histopath- quanto histopatológicos se assemelham ological findings closely resemble por- muito à porfiria, diferenciando desta por phyria, differentiating it from normal níveis normais de porfirina no plasma, na levels of porphyrin in plasma, urine, or urina ou nas fezes. Conclusões: Embora feces. Conclusions: Although the lesions as lesões sejam majoritariamente benig- are mostly benign, they may increase nas, podem aumentar a morbimortalida- Submitted on: 12/18/2017. the morbidity and mortality of these pa- de desses pacientes, por isso um diagnósti- Approved on: 05/03/2018. tients, so a proper diagnosis and early co adequado e tratamento precoce são de treatment are extremely important. extrema importância. Correspondence to: Giovana Memari Pavanelli. Keywords: Porphyrias; Renal Insufficien- Palavras-chave: Porfirias; Insuficiência Email: [email protected] cy, Chronic; Furosemide. Renal Crônica; Furosemida. DOI: 10.1590/2175-8239-JBN-2017-0029 287 Pseudoporphyria by furosemide: case report INTRODUCTION Figure 1. [A] Ulcerated lesion in the posterior region of the right leg, with hematic crust and pus, erythema and peripheral skin Pseudoporphyria is a bullous photodermatosis with shedding, irregular borders; [B] Injuries in the healing process, with erythematous and scaly areas in the posterior region of the right leg. clinical and histological characteristics similar to those of porphyria cutanea tarda, but without abnormalities in porphyrin metabolism.1 It is an extremely rare disease in the general population, but may be a somewhat increased frequency in certain groups of risk.2 Among other causes, its etiology is associated with chronic kidney dialytic disease, exposure to ultraviolet radiation and to certain drugs. The drugs most frequently associated with pseudoporphyria are anti-inflammatory agents, especially naproxen, but also secondary to the use of antibiotics, antineoplastics and diuretics such as chlorthalidone, torasemide, bumetanide and furosemide.3 Except for photoprotection and suspension of possible medications involved, there is no specific treatment. This report aims to describe a case of furosemide- findings it compatible with porphyria. Laboratory related pseudoporphyria in a patient with chronic tests showed creatinine of 3.0 mg/dL, urea 144 mg/ stage 4-kidney disease. dL, calcium 11.5 mg/dL, Hb 9.0 g/dL, ferritin 1117 ng/mL and normal liver biochemistry. Urinary levels CASE PRESENTATION of porphyrin were normal - negative uroporphyrin at A 76-year-old male patient previously diagnosed with the 24-hour urine test - ruling out the diagnosis of systemic arterial hypertension and stage-4 chronic porphyria. kidney disease with indefinite etiology, only reporting Based on the histopathological findings associated a previous history of kidney stones. He began follow- with normal urinary porphyrin levels, the diagnosis up at the oncology department for marginal zone of pseudoporphyria was established. The ailment splenic lymphoma. Initially, no specific treatment for was attributed to furosemide and the medication was lymphoma was instituted, and clinical follow-up was discontinued. Five months after its suspension, there chosen. was a significant improvement in the lesions (Figure Two months after diagnosis, two ulcerated lesions 1B). of approximately 10 centimeters in diameter appeared in the posterior region of the legs, with peripheral DISCUSSION erythema and central hematic crust (Figure 1A). In 1964, Zelickson reported for the first time a The patient reported local pain and heat, worsening case of pseudoporphyria related to nalidixic acid. at the end of the day and in orthostatic position. After this first report, several other drugs have been There were no lesions in other regions of the body, associated with the disease, including diuretics.1,3 hyperpigmentation or hypertrichosis. He had been Pseudoporphyria has been reported in association under furosemide for 3 months, potassium citrate and with several diuretics, such as furosemide, torasemide, fluoxetine. bumetanide, chlorthalidone and the combination of Due to the suspicion of skin infection, treatment hydrochlorothiazide and triamterene. In addition, with oral quinolone and topical neomycin sulfate was other factors, such as chronic kidney disease, dialysis started, without improvements, and biopsy of the and excessive exposure to ultraviolet radiation, were lesion was indicated. Histopathological examination also associated with the onset of pseudoporphyria.3 revealed mild perivascular lymphocytic infiltrate There are less than 100 cases of pseudoporphyria and moderate solar elastosis, with hyalinization of described, but it is believed that the disease is not vascular walls of capillaries on the superficial dermis so uncommon, only underreported. In a study with the periodic Schiff acid staining (Figure 2), involving 363 hemodialysis patients, two presented 288 Braz. J. Nephrol. (J. Bras. Nefrol.) 2018;40(3):287-290 Pseudoporphyria by furosemide: case report Figure 2. [A] HE 4X - Panoramic histological cross-section of the skin, with discrete lymphocytic infiltrate around the blood vessels; [B] HE 10 X - Histological skin cross-section with areas of epidermal atrophy and moderate solar elastosis in the dermis; [C] PAS 40 X - Histological cross-section of the skin in PAS staining with digestion demonstrating hyalinization of vascular walls on superficial dermis capillaries; [D] PAS 40 X - Histological skin cross-section on PAS staining with digestion demonstrating hyalinization of the vascular walls of the superficial dermis capillaries. pseudoporphyria. Few cases have been reported in the most correct term for this condition is “therapy- patients with chronic non-dialytic kidney disease.4 induced photosensitivity”, since it is a drug reaction The condition is probably underdiagnosed in patients with specific characteristics.8 with chronic kidney disease, who have a wide range The typical clinical presentation is the presence of skin manifestations that are often poorly valued of blisters and vesicles on the hands, forearms, face, because they are multifactorial and may be related to legs or feet. However, there are reports of cases that electrolyte imbalance,
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