Drug-induced vasculitis: clinical, histopathologic findings, and prognostic outcomes. A cross-sectional study in the inpatient setting
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Date
2019
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Abstract
Background: Drug-induced vasculitis represents 10% of all causes of vasculitis, and 10-20% of all adverse drug reactions. Its most common feature is cutaneous vasculitis but it may have systemic involvement. There is scant information of this pathology in the inpatient setting. Aim: To describe the clinical manifestations, complications, management, and evolution of drug-induced vasculitis in an inpatient setting from a tertiary hospital in Chile. Methods: All patients hospitalized with the diagnosis of drug-induced vasculitis between 2010 to 2018 and evaluated by a dermatologist were included. Review of clinical files including signs and symptoms, images, laboratory parameters, biopsies, and treatments was made.Results: Twenty-eight patients with drug-induced cutaneous vasculitis were included. Mean age was 59.2 years; 60.7% were female. Most commonly implicated drugs were nonsteroidal anti-inflammatory drugs (39.3%) and antibiotics (32.1%). Mean time of onset since the beginning of the drug was 10.7 days. Palpable purpura was present in all patients; vesicles/bulla in 7.1% of patients. 35.7% presented pruritus and 25% had painful lesions. The most common systemic finding was acute kidney injury (39.3%). Peripheral eosinophilia was present in 21.4% of patients. Tissue eosinophilia was found in 39.3% of cases. Most common infiltration pattern was mixed neutrophils and lymphocytes (54.2%). Mean hospitalization time was 6.41 days. 47.6% of cases required systemic corticosteroids, 22.4% were hospitalized in an intensive care unit. There was no mortality. Eosinophilia was associated with more frequent systemic involvement (P ¼.017) and cutaneous pain (P ¼.005), and with a tendency to more prolonged hospitalizations (P ¼.05). Patients with blisters tended to have longer latencies since the beginning of the drug (P ¼.07) and more eosinophil count (P ¼.05). Discussion: Skin biopsy has a key role in the diagnosis of drug-induced vasculitis. Although it has been proposed that a tissue eosinophilia ratio $5 is highly suggestive of this entity, eosinophils are not always present in the biopsy, so it should not be mandatory for the diagnosis. Peripheral eosinophilia has a significant statistical correlation with cutaneous pain and systemic involvement. All cases presented good response and rapid resolution of the disease after discontinuation of the culprit drug and therapy with topical or systemic corticosteroids. Week 24 in pts continuing their initial BKZ dose and were maintained through the study; responses were similar across the 3 highest dose groups at Week 48. Rapid improvements were observed for all response criteria in pts re-allocated to BKZ 160 or 320mg. In BKZ-treated pts na€ıve to TNFi, response rates at Week 12 and 48 (respectively) were: ACR50 24-53%, 31-81%; ACR20 55-70%, 63-89%; PASI90 26-59%, 68-100%; PASI100 22-55%, 55-75% (PASI100 analyses were post hoc). There was no apparent relationship between dose and TEAEs. Serious AEs were reported by 9/206 (4%) pts up to Week 48 (8/206 [4%] receiving BKZ). The most common TEAE up to Week 48 was nasopharyngitis (25/206 [12%]). No deaths, or cases of IBD or MACE, were reported. Conclusion: Dual neutralization of IL-17A and IL-17F with BKZ provided substantial improvements in both musculoskeletal and skin outcomes; response rates increased after Week 12 (primary analysis) and were sustained from Week 24 to 48, with a safety profile consistent with previous BKZ studies.