CASE REPORT

DRUG ERUPTION

Preceptor :
dr. Stanley Setiawan, Sp.KK

Author :
Temmy Hadinata Wiranegara
1261050052

DEPARTMENT OF DERMATOLOGY AND VENEREOLOGY

PERIOD DECEMBER 10TH 2017 – JANUARY 20TH 2018

FACULTY OF MEDICINE

CHRISTIAN UNIVERSITY OF INDONESIA

JAKARTA

2017
 CHAPTER I

FOREWORD

BACKGROUND
Drug eruption is an allergic condition due to drug, the drug prescribed by
physician or another free-sold drugs, include herbal drugs. The definition of drug is a
substance used to diagnosis, prophylaxis, and treatment. Topical drugs can make a
similiar condition to drug eruption, because the absorption of skin.
Drug eruption can be mild to severe which is threatening life. The cases about
adverse drug reaction are increasing in society day by day.
Adverse drug reaction can be manifested to allergic drug eruption. Drug reaction
that manifested to the skin called allergic drug eruption. One kind of drug could be
induced more than one eruption, and one kind of eruption can be induced by multiple
drugs. Drugs enter the body through mouth, nose, ears,vagina, injection, mouthwash,
eye drops, and topical drugs.
 CHAPTER II

LITERATURE

I. DEFINITION
Allergic drug eruption is an allergic reaction which manifested on the
surface of the skin or other mucosal usually after sistemic drugs.
The definition of drug is a substance used to diagnosis, prophylaxis, and
treatment.

II. PATHOGENESIS
Skin reaction to allergic condition mechanism through both immunologic or
non – immunologic pathway. Allergic drug reaction is an allergic condition
through immunologic pathway.
This condition appears to patient with hypersensitivity to the drugs. The
drugs as antigen to the body and has low weight molecule.
Hypersensitivity reaction is causing after the drug has been metabolized in
the body and reactive chemically.
There are 2 pathway of immunologic drug reaction :
1. Phase 1 reaction : oxidation – reduction response
2. Phase 2 reaction : conjugation response
Oxidation - reduction response involved enzyme cytokines P450,
protaglandine synthesis, and tissue peroxidase.
Phase 2 reaction intermediated by enzyme, ex hydrolase, glutation-S-
transferase (GST) and N-asetyl-transferase (NAT). The drugs could be inducing
immunologic reaction after metabolized drugs is transported by carrier protein.
Carrier protein and metabolized drugs stimulate T cell lymphosite which
stimulate B cell lymphosite to forming antibody.

III. CLASSIFICATION
There are 4 types of immunologic reaction according to Coomb and Gell’s
theory. Allergic reaction is due to one of this immunologic reaction type.
1. Type 1 ( Fast reaction, anaphylaxtic reaction )
 This type is most common in society. First reaction can be asymptomatic, the
next exposure inducing the reaction. IgE antibody forming in this reaction and
has high affinity to mastocyte and basophyll.
After the same drugs exposure, antigen stimulates degranulation of cell
mass and basophyll with some mediators, such as hystamine, serotonine,
bradykinin, and heparin.
These mediators has some effects such as urticaria and angioedema. Severe
condition such as anaphilaxtic shock could be happen. Penicilline is a main drug
causing of this type.

2. Type 2 ( Cytostatic reaction )

This reaction cause by an antigen after conjoined to IgM and IgG on cell
surface. This reaction causing a cytolitic or cytotoxic by complements.
This combined complements aiming to cell target such as erythrocyte,
leukocyte, thrombocyte, inducing cell destruction. For the examples penicilline,
cephalosporin, streptomycin, sulphonamide, isoniazid.
Allergic drug eruption causing by this type is purpura, if the targeting cell is
thrombocyte.

3. Type 3 ( Immune complex reaction )

This type is characterized by antigen, antibody (IgG & IgM) in circulation
that activate the complement. The activated complement releasing mediators and
enzyme inducing cell destruction. For the examples penicilline, erythromycin,
sulphonamide, salycilic, and isoniazid.

4. Type 4 ( Slow reaction )

This type involved lymphocyte, APC (Antigen Presenting Cell) and
Langerhans cell representing T lymphocyte. T cell lymphocyte sensitized by
antigen. This type called slow reaction which is inducing 12 – 48 hours after
exposure. For the example is allergic contact dermatitis.

IV. DIAGNOSIS
Allergic drug eruption diagnosis based on the following criteria :
1. Anamnesis : consuming drugs history, include herbal/traditional drugs,
the time when drugs consumed, itchy sensation, and fever.
 2. Physical examination : distribution may be simetrically or regional, the
efloresence may be erythema, urticaria, purpura, exanthema, papul,
erythroderma, erythema nodosum.
The most common drugs causing allergic condition are penicillin group
(ampycilline, amoxicilline, cloxacilline), sulphonamide, analgetic and antipiretic
drugs such as salycilic acid, methamezole, methampyrine, and paracetamol.

V. CLINICAL FEATURES
1. Maculopapular eruption or morbiliform rash
Maculopapular eruption or morbiliform rash can be induced by all kind
of drugs. It’s often simetrically and generalize eruption consist of erythema,
pruritic, fever, malaise, and pain on the joint.
The rash appear in 1 – 2 weeks after drugs consumption. This eruption
usually caused by ampicilline, NSAID, sulphonamid, and tetracycline.

2. Urticaria and angioedema

Urticaria shown by urticari on the skin surface, sometimes acompanied
by angioedema.
In angioedema form, it could be threatening if happening in the glotis
and lead to asphyxia. The chief complain in patient may be itchy and feels
warm on the rash, ususally appear suddenly and disappear slowly in 24
hours. Patient may be fever, malaise, and headache.
Angioedema may be appear on lips, eyelid, genital externa, hands and
feet. Often cause by penicilline, acetilsalycilic acid, and NSAID.

3. Fixed Drugs Eruption (FDE)

FDE is often to found in society. Physical examination might be found
erythema, vesicle, round or oval shape, and numular size. The lesion turn to
hyperpigmentation patch after recovery. From it’s name, the efloresence
appear on the same skin surface area in the body. Predilection area in this
disorder usually around the mouth, sometime on the penis and might be
wrong to sexual transmitted disease, efloresence may be erosion, feels warm,
and local erythema. Often cause by sulphonamide, barbiturate, trimethoprim,
and analgetic.

4. Erythroderma (exopholiative dermatitis)

 Erythroderma is an universal eythema and squamous. It can be cause by
other condition exclude drugs allergic, such as psoriasis, Hodgkin
lymphoma, leukemia.
In allergic condition, erythroderma appear without squama. Squama comes
up after recovery. This condition often cause by sulphonamide, penicillin,
Phenylbutazone.

5. Purpura
Purpura is a condition of bleeding in the skin, below surface of the skin
and not disappear on applying pressure. Purpura eruption may be represent
allergic to single drug. Usually simetrical around feet, ankle, or legs.
Efloresence is brownish red colorred rash.

6. Vasculitis
Vasculitis is a condition of inflamation of vessels. The skin disorder may
be palpable purpura on the capillary vessel.
Distribution is simetrical on low extremity and sacrum. It may be fever,
myalgia, and anorexia. It’s often cause by penicillin, sulphonamide, NSAID,
anti depresant agent, and anti arythmia.
Skin disorder are erythema and pain nodes with fever and malaise.
Predilection area is extensor on the foot. It’s often cause by sulphonamide,
oral contraseption.

7. Photoallergic reaction
Clinical finding of this condition is same to allergic contact dermatitis,
predilection area is sun exposed area and spreading to other location. It’s
often caused by phenotiazin, sulphonamide, NSAID, and griseofulvin.

8. Acute generalized exanthematous pustulosis

Acute Generalized Exanthematous Pustulosis (AGEP) is rare condition,
it may cause by drugs allergic, acute enterovirus infection, mercury
hypersensitivity, and contact dermatitis.
Efloresence are pustules, erythematous skin, purpura, and lesion
resembling to “target lesion”. It’s appears when fever (>38° C), and recover
< 7 days following by desquamation in few days.
In histopatologic examination, clinical findings is intraepidermal pustule
or subcorneal, followed by dermal edema, vasculitis, perivascular
 polimorphonuclear infiltrate, with eosinophyl or focal necrosis of
keratinocyte cells.

VI. MEDICATION
1. Sistemic
a. Corticosteroid
Corticosteroid is very important for this condition. Prednisone (1 tablet
= 5 mg). In urticaria, erythema, medical dermatitis, purpura, erythema
nodosum, and AGEP cause drug allergic, dosage recommendation 3 x
10 mg daily. In erythroderma 3-4 times daily.

b. Anti Histamine
Anti histamine with sedative effect can be given to, if there is itchy
sensation. Except to uriticaria, it has low effect compare to steroid.

2. Topical
Topical drugs depend on skin conditiion, wheter is dry or wet. If skin is
dry such as urticaria and erythema, can be given with powder such as
salycilic powder 2% with antipruritic agent, menthol ½ - 1%. If skin in wet
condition like medical dermatitis, can be given with solution for compress,
salycilic acid solution 1%.
In purpura and erythema nodes topical treatment is no necessary. In
exanthema fixum, can be compressed if the skin is wet or corticosterod
cream if the skin is dry, hydrocortisone 1 – 2%.
In erythroderma with generalized erythem and squamous skin, lanolin
10% can be given.

VII. PROGNOSIS
Drug eruption will recover soon after stop using the causing drugs. However,
ini some condition such as eythroderma and disorder like Lyell syndrome and
Steven – Johnson syndrome, the prognosis may become worse, it depend on the
lesion.
 CHAPTER III

PATIENT STATUS

I. PATIENT IDENTITY

a. Medical Record : 00 09 10 26
b. Name / Gender : Ms. A / Female
c. Age : 20 years old
d. Address : Cawang Otista, East Jakarta
e. Occupation : Printing Office Employee
f. Educational : SMA
g. Tribe : Java
h. Religion : Islam

II. ANAMNESIS

a. Chief complaint
Redness patch since 1 week.

b. History of complaint
Female, 20 years old, came to dermatologist clinic on UKI Hospital, with chief
complaint, redness patch on both hands skin, it’s appears simetrically and
spreading to upper limbs since 2 week. In the early about 1 months ago, patient
came to the primary health facility and diagnosed with typhoid fever. After the
theraphy, patients finds redness patch on her hands and feels itchy. She went to
primary health facility with additional complaint such as cough and heartburn
sensation. The physician gave her amoxicillin, ambroxol, ranitidine, and
prednisone. After 1 week, the problem still same and becoming swollen, but
swollen disappear after few days. The physician in primary health facility
decided to reffered her to the hospital.
c. History of past illness
Patient never have same illness before. No allergic condition such as asthma or
other hypersensitivity history.

d. History of family condition

None
 e. History of daily behavior
None

PHYSICAL EXAMINATION

a. General status
LoC : Compos mentis
Blood Pressure : 120/80 mmHg
Heart Rate : 80 x/min
Respiration Rate : 21 x/min
Temperature : 36,5°C
Weight : 60 Kgs
Height : 160 cm

b. Head : Normocephali, black hair, normal growth

c. Neck : Lymph nodes not enlarged

d. Thorax :
 Inspection : Normal shape
 Palpation : Vocal fremitus (+)
 Percussion : Resonant
 Auscultation : Vesicular, rales - /-, wheezing -/-, SI & SII regular,
Murmur (-), Gallop (-)

e. Abdomen :
 Inspection : Flat tummy
 Auscultation : Bowel sound (+) 6x/min
 Percussion : Tymphani
 Palpation : Defence Muscular (-), abdominal pain (-)

f. Extremities : Edema -, CRT<2”, warm extremities

g. Dermatological status

 Distribution : Regional
 Location : Regio Antebrachi dextra et sinistra

It seems patch erythema with clear edge, it has lenticular size and some
rash confluence to plaque size with irregular shape, it spreading
simetrically on both hands in region antebrachi dextra et sinistra.
h. Working Diagnosis
Drug Eruption

i. Differencial Diagnosis
Contact dermatitis, urticaria caused by food allergy

j. Treatment
1) Non medicinal
 Educate patient about the disease and how to prevent it.
 Stop the recent treatment and looks carrefully causal agent
 Start to using allergic therapies
2) Medicinal
 Sistemik : Prednisone tab 3x10 mg
CTM tab 1x4 mg
 Topical : Bethametasone dipropoinate cream 0,05%

PRESCRIPTION

R/ Bethametasone dipropionate cream 0,05% no. I tube

S u e
R/ Prednisone tab 5 mg no. X
S 3 dd tab II
R/ CTM tab 4 mg no. X
S 1 dd tab I hs
 Pro : Ms. A
Age : 20 years

k. Prognosis
Ad vitam : dubia ad bonam
Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam
Ad cosmeticum : dubia ad bonam
CHAPTER IV

DISCUSSION

Allergic drug eruption is an allergic reaction which manifested on the

surface of the skin or other mucosal usually after sistemic drugs.
There are 4 types of immunologic reaction according to Coomb and Gell’s
theory. Based on this case, Type 1 Coombs and Gell’s theory (Fast reaction) is a
pathway to this condition.
This type is most common in society. First exsposure can be asymptomatic,
the next exposure inducing the reaction. IgE antibody forming in this reaction
and has high affinity to mastocyte and basophyll.
After the same drugs exposure, antigen stimulates degranulation of cell mass
and basophyll with some mediators, such as hystamine, serotonine, bradykinin,
and heparin.
These mediators has some effects such as urticaria and angioedema.
Severe condition such as anaphilaxtic shock could be happen. Penicilline is a
main drug causing of this type.
In this case, female 20 years old, chief complain is redness patch since 2
weeks after consumed medicine in primary health facility. The physician gave
her amoxicillin, ambroxol, ranitidine, and prednisone and her skin became
swollen and more red than before. Based on literature, penicillin group like
amoxicilllin is the main causal agent for drug eruption. Although patient said she
never feels same complaint like this before, however the theory proved
amoxicilline has allergic effect.
 Anamnesis
Theory Case
Allergic drug eruption diagnosis based on Female, 20 years old, chief complaint,
the following criteria : redness patch on both hands skin, it’s
1. Anamnesis : consuming drugs history, appears simetrically and spreading to
include herbal/traditional drugs, the time upper limbs since 2 week.
when drugs consumed, itchy sensation,
In the early about 1 months ago, patient
and fever.
came to the primary health facility and
diagnosed with typhoid fever. After the
Physical examination : distribution may be
theraphy, patients finds redness patch on
simetrically or regional, the efloresence
her hands and feels itchy. She went to
may be erythema, urticaria, purpura,
primary health facility with additional
exanthema, papul, erythroderma, erythema
complaint such as cough and heartburn
nodosum.
sensation. The physician gave her
amoxicillin, ambroxol, ranitidine, and
The most common drugs causing
prednisone.
allergic condition are penicillin group
After 1 week, the problem still same and
(ampycilline, amoxicilline, cloxacilline),
becoming swollen, but swollen disappear
sulphonamide, analgetic and antipiretic
after few days. The physician in primary
drugs such as salycilic acid, methamezole,
health facility decided to reffered her to
methampyrine, and paracetamol.
the hospital.

DERMATOLOGICAL STATUS
Theory Case
Urticaria shown by urticari on the skin  Distribution: Regional
surface, sometimes acompanied by
angioedema.  Location : Regio Antebrachi dextra
The chief complain in patient may be et sinistra
itchy and feels warm on the rash, ususally
It seems patch erythema with clear
appear suddenly and disappear slowly in 24
edge, it has lenticular size and some
hours. Patient may be fever, malaise, and
rash confluence to plaque size with
headache.
Angioedema may be appear on lips, irregular shape, it spreading

eyelid, genital externa, hands and feet. simetrically on both hands in region

Often cause by penicilline, acetilsalycilic antebrachi dextra et sinistra.

acid, and NSAID.

REFERENCE

1. Hamzah M. Erupsi Obat Alergik. In: Djuanda A, Hamzah M, Aisah S, editors. Ilmu
Penyakit Kulit dan Kelamin. Edisi 6. Penerbit Fakultas Kedokteran Universitas
Kristen Indonesia, Jakarta. 2013. :154-8
2. American Academy of Dermatology. Drug Rashes. AAD. 2012. Available on:
https://www.aad.org/File%20Library/Main%20navigation/.../PDFs/Drug-
Reactions.pdf