Drug-induced vasculitides

The objective of the study is to report a case of ocular manifestations in a patient with hydralazine-induced vasculitis.

An 88-year-old female was admitted for lower gastrointestinal bleeding. Nine days after admission, she developed bilateral conjunctival chemosis and injection, which rapidly progressed into grouped blistering eruptions of the periorbital skin, face, and neck. After extensive testing and evaluation, her constellation of findings was diagnosed as hydralazine-induced vasculitis. Treatment with intravenous steroids and discontinuation of hydralazine resulted in improvement of the cutaneous and ocular manifestations. Herein we describe the clinical course of an adult patient with symptoms and signs consistent with hydralazine-induced vasculitis to highlight that ophthalmological manifestations can be the first symptoms in patients with life-threatening dermatological conditions.

To our knowledge, this report is the first case of hydralazine-induced vasculitis initially presenting with ocular manifestations.

Drug-induced vasculitis and anticoagulant-related skin reactions are commonly encountered in the inpatient and outpatient settings. The spectrum of clinical presentation is broad and ranges from focal, skin-limited disease, to more extensive cutaneous and soft tissue necrosis, to potentially fatal systemic involvement. The prompt recognition of these adverse events can have a significant impact on patient morbidity and mortality. We highlight the key features of the clinical presentation with an emphasis on primary lesion morphology, distribution, and epidemiology of purpuric drug reactions. The proposed pathophysiology, histologic findings, and therapeutic interventions of these potentially life-threatening diseases are discussed.

Letrozole, an aromatase inhibitor, is a commonly used neo-adjuvant drug to treat hormone-sensitive breast cancer. There have been a few cases of aromatase inhibitor induced vasculitis but the first case of letrozole-induced vasculitis was reported from Switzerland in 2014 (Digklia et al.) [1].

We report the case of a 72-year-old woman with a small breast cancer. She was started on pre-operative letrozole (2.5 mg/d) whilst awaiting surgery. Ten days later she presented with burning pain and purpuric skin lesions which progressed to extensive ischaemic superficial necrosis of the lower limb skin, resolving over 3–4 months after local and systemic steroids. Histologically, it showed leucocytoclasis with evidence of eosinophilia consistent with a diagnosis of cutaneous leukocytoclastic small vessel vasculitis.

The initial clinical presentation was severe burning pain around the ankles and a spreading violaceous rash. Letrozole was stopped. Wide local excision (lumpectomy) and sentinel node biopsy were postponed because of the accompanying pneumonitis and gastrointestinal upset, and were carried out 3.5 months later. Fortunately, the tumour size did not increase, but appeared to reduce, and axillary lymph nodes remained negative, i.e., this patient’s cancer outcome does not seem to have been jeopardized.

Leukocytoclastic vasculitis is a hypersensitivity reaction that is usually self-resolving, though our case needed systemic steroid treatment. Letrozole is a commonly used drug in clinical practice and prescribers should be aware of this rare side effect, which in our case delayed treatment without any apparent harm and possibly reduced tumour size.

Autoimmune connective tissue diseases are complex multisystems and may be life threatening. Their aetiology is unknown but genetic, hormonal and environmental factors are important. In systemic lupus erythematosus (SLE), factors such as UV light and drugs, including oestrogen, may trigger the disease; silica exposure may also be important. Scleroderma is associated with silica exposure and drugs such as bleomycin and pentazocine may induce scleroderma-like diseases. Organic solvents such as vinyl chloride and epoxy resins may also be associated with scleroderma-like illnesses. The toxic oil syndrome and eosinophila-myalgia syndrome are best known examples of connective tissue diseases induced by chemical exposure. The systemic vasculitides and in particular cutaneous vasculitis may be induced by drugs and possibly environmental factors. A number of autoimmune connective tissue diseases may therefore be associated with exposure to drugs, chemicals and environmental factors and the risks associated with these should be minimised where possible.