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Drugs Dan > Drug causes of disease > Flashcards

Drug causes of disease Flashcards

1
Q

Which drugs cause drug-induced SLE?

A

Dopey Minnows Eat CCHIIPPPS and alfalfa sprouts
Methyl DOPA
Minocycline (can occur 2 years after starting, young females. Associated with P-ANCA).
Etanercept (Ant-TNF’s can induce ANA or unmask native anti-dsDNA disease, usually not Anti-histone+)
Carbamazepine
Chlorpromazine
Hydralazine esp slow acetylators
Isoniazid, IVIg
Phenytoin
Procainamide esp fast acetylators
Sulfonamides
+ Quinidine
Alfalfa sprouts (L-Canavanine) can induce SLE

Especially remember MyHyPIE
Minocycline
Hydralazine - high risk
Procainamide - highest risk
Isoniazid
Etanercept/TNFalpha blockers
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2
Q

Which drugs cause a lichenoid drug eruption?

A

HANG (the) dopey PCT
Hydrocholthiazide + other diuretics (spironolactone, frusemide)
Antimalarials & quinidine
NSAIDS
Gold salts
Methyldopa
Penicillamine
Captopril and other ACE inhibitors + Beta blockers
TNFα inhibitors (ifliximab, etanercept, adalimumab)

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3
Q

Which drugs cause a pityriasiform drug eruption?

A 
BIG MACO
Bismuth, barbiturates, Beta blockers
Immunization – BCG (isotretinoin reported but not confirmed)
Gold, griseofulvin
Metronidazole
Arsenic, Allopurinol, Aspirin, Acetaminophen (paracetamol)
Captopril (pos other ACE inhibitors)
Omeprazole
\+ HCZ
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4
Q

Which drugs and other factors can flare psoriasis?

A 
BLAIN Ace
Beta-blockers
Lithium
Antimalarials
Interferons
NSAIDs
ACE inhibitors
Also;
TNFα inhibitors can cause palmoplantar psoriasis
withdrawal of steroids
Irritants - tar, dithranol
UV
Low calcium
Infection
Emotional upset
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5
Q

Which drugs cause Exanthematous drug eruptions?

A

Funny(pheny) Gent with a Gold Pen eats Carbs at the Sulphur Cafe

Phenytoin
Gentamicin
Gold
Penicillins
Carbamazepine
Sulphonides (eg sulphamethoxasole in Bactrim, thiazide diuretics)
Cephalosporins
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6
Q

T/F

Minocycline causes PPDs

A

False

Minocycline can pigment existing PPD and cause ITP mimicking PPD but doesn’t cause PPD

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7
Q

Which drugs cause PPD?
How often is PPD due to a drug?
What else apart from drugs causes PPD?

A

PAN AM ABCD
Paracetamol
Aspirin
NSAIDs
Ampicillin
Meprobamate (anxiolytic-causes Schamberg-like purpura)
ACEI, Beta-blockers, Ca-channel blockers, Diuretics

Drugs cause up to 14% of cases
Also;
Tartrazine food colourant
Creatine supplements

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8
Q

Which drugs cause an Acneiform/Papulo-pustular/folliculitis drug eruption

A 
E-SOLIDS
EGFR inhibitors
Steroids
OCP (esp if androgen-like progestins)
Lithium
Iodides
Danazol/androgens
SSKI
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9
Q

Whic drugs cause fixed drug eruptions?

A 
BARBwire PANTS (helps remember penis is comon site and it can be painful)
Barbituates
Phenolphthalein laxatives
Aspirin
NSAIDs inc ibuprofen 
Tetracyclines
Sulphonamides esp TMP-SMX
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10
Q

What are the causes of pseudoporphyria?

A

Naproxen is number 1 cause
Can be any of same drugs as for phototoxic rcn
NODD – Naproxen, OCP, Doxy, Dapsone
TV FANS – Tetracyclines, VitB6 (pyridoxine), Frusemide, Amiodarone/Aspirin, NSAIDs, Sulphonylureas
Also; renal dialysis

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11
Q

What are the drug causes of erythema nodosum?

A 
SHOPS IN Gold Mine
Sulphur drugs; Sulphonamides, sulphonylurea, SMX-TMP
Halides (Bromides, iodides) 
OCP
Penicillin 
Salicylates
Isotretinoin, IFN-gamma
NSAIDs
Gold, G-CSF
Minocycline
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12
Q

Which drugs cause gingival hyperplasia?

A

Phenytoin (50%)
Nifedipine (25%)
Cyclosporin (25%)

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13
Q

Which drugs can trigger Bullous pemphigoid?

A 
Fluid Sores Caused By Prescriptions
Frusemide
Spironolactone
Ciprofloxacin
Beta blockers
Penicillin and Penicillamine, Pembrolizumab (keytruda)
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14
Q

Which drugs can cause livedo reticularis?

A

Heparin or warfarin (intravascular thrombosis)
Quinidine (+other cause sof drug-induced SLE)
Noradrenaline (vasosconstricts)
Amantadine (causes stasis)
Interferon
Levamisole (in cocaine cut in S. America) can cause retiform pupura

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15
Q

Which drugs can cause eruptive xanthomas?

A 
IP HERO - X in xanthoma like Xmen superheroes
Indomethacin
Prednisone
HAART
(O)Estrogens
Retinoids
Olanzapine
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16
Q

Which drugs can cause pompholyx?

A

Aspirin
OCP
IVIg

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17
Q

Which drugs can cause linear IgA disease?

A 
CAVE
Captopril
Ampicillin (+other beta lactams penicillins), Amioderone
Vancomycin, Voltaren (diclofenac)
Epileptics (phenytoin)
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18
Q

Which drugs can cause vasculitis?

A 
Anti BHP – biotics, hypertensives and psychotics
\+ NSAIDs, aspirin
\+ Derm drugs;
Retinoids
Dapsone
tetracyclines
MTX, CsA, AZA, cyclophos
Anti-TNFs
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19
Q

What are the Drug/toxin causes of PPK?

A

IV TALC, Flu vac BaCH
Iodine, Imatinib
Verapamil, Venlafaxine
TNFα inhibitors (can be palmoplantar psoriasis)
Arsenic
Lithium
Ca channel blockers
‘flu vaccination
BRAF inhibitors - vemurafenib, dabrafenib
Chronic hand-foot syndrome;
- 5-FU and Prodrugs; capecitabine, tegafur
Hyperkeratotic hand-foot syndrome reaction (HFSR);
- multikinase inhibitors; sorafenib>pazopanib

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20
Q

Which drugs can cause acquired icthyosis?

A 
Fishy SNACcH (Ichthyosis means fish scales) 
Statins	
Nicotinamide
Allopurinol
Cimetidine
Clofazamine
Hydroxyurea
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21
Q

Which drugs can cause a widespread eruption resembling generalised pustular psoriasis

A

Halides

TNFα inhibitors

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22
Q

Photosensitizing drugs?

ie causes of phototoxic drug eruptions, pseudoporphyria or photo-onycholysis

A 
Think of Adam and Eve in the sun - whats their twitter?
AT FIG PANTS
Amioderone
Thiazides
Frusemide
Itraconazole
Griseofulvin
Psoralens, phenothiazine 
Acitretin, isotretinoin
NSAID;esp proprionic acid derivative;naproxen, piroxicam
Tetracyclines (doxy), topical calcineurin inhibitors
Sulphonamides
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23
Q

Drugs causing pemphigus?

A 
Thiols + ABC PIN
Thiols – Captopril, Ramipril, Penicillamine, Gold, Piroxicam (Feldene, an NSAID)
ACEI + ARIIB
Beta lactams
Chloroquine + HCQ
Propanolol
IFN
Nifedpine

Drugs can induce or exacerbate pemphigus vulgaris or folliaceus or erythematosus or herpetiformis
Folliaceus most common drug-induced type
Onset is weeks-months after drug started
Half of pts with thiol-drug induced disease improve quickly after drug withdrawn
Only 15% of those caused by non-thiols do so

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24
Q

Drugs causing SJS/TEN?

A

SATAN
Sulphur drugs – co-trimoxazole, sulphonamides
Allopurinol – esp if dose >200mg/day or renal impairment
Tetracyclines
Anticonvulsants - barbiturates, phenytoin, lamotrigine, carbamazepine
NSAIDs (esp COX2 + oxicams), Nevirapine

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25
Q

Drugs causing SCLE?

A 
GATCH
Griseofulvin, terbinafine
ACEI
TNFα inhibitors 
Ca channel blockers
HCZ - Thiazides
Also;
NSAIDs
Docetaxel,
5-FU + prodrugs
IFN
statins
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26
Q

Drugs which cause skin pigmentation?

A 
Sumphasalazine turns skin yellow-orange
The rest go shades of grey/brown/black/blue
Amioderone
Minocycline, doxycycline
HCQ (antimalarials)
Hydroxyurea
clofazimine
chlorpromazine, imipramine
phenytoin
Bismuth
Silver (argyria), Gold
Alkylating agents (cyclophosphamide etc)
bleomycin, doxorubicin, danorubicin
Antimetabolites - 5-fU, capecitabine, MTX, hydroxyurea 
OCP - melasma
Iron injections - local hyperpigmentation or brown discolouration
hydroquinone - ochronosis

Other chemo pigmentation rcns;
Serpentine supravenous hyperpigmentation - 5-FU, Doxorubicin, Docetaxel, Vinorelbine, alkylating agents
Mucosal hyperpigmenation – 5-FU, Busulfan, cyclophosphamide, hydroxyurea
Nail hyerpigmentation – 5-FU (can cause transverse melanoncyhia), cyclophosphamide, Hydroxyurea, Daunorubicin, Doxorubicin, MTX, Bleomycin

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27
Q

What drugs can flare/unmask native SLE?

A 
BIG TOPS (TOP are most important)
Beta blockers
Itraconazole
Griseofulvin
TNFα inhibitors 
Oestrogens, testosterone
Penicillamine
Sulphonamides
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28
Q

Drug causes of AGEP?

A 
Do My Pits Pus Today?
Diltiazem
Macrolides
Penicillins/beta lactams
Plaquenil
Terbinafine and azole antifungals
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29
Q

Drug causes of eosinophilic fasciitis

A

Phenytoin
Atorvatsatin
Simvastatin

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30
Q

Drug causes of pemphigus erythematosus

A

Mostly thiols - Captopril, Ramipril, Penicillamine, Gold, Piroxicam (Feldene, an NSAID)
gold penny ram cap
also propanolol

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31
Q

Which drugs can cause acute or chronic telogen effluvium?

A 
ABCD ROME (from ASM, 2014)
ACEi
B-blockers
anti-Coagulants
anti-Depressants
Retinoids (acitretin>isotretinoin)
OCP/hormones
Minoxidil
anti-Epileptics
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32
Q

Drug causes of DLE

A 
DING 5alpha 
Dapsone
Isoniazid
NSAIDs
Griseofulvin, Voriconazole
5-FU + prodrugs
TNFα inhibitors
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33
Q 
Which drugs can cause all types of lupus?
Unmask/flare native SLE
Drug-induced SLE
SCLE
Chronic cutaneous LE (DLE)
A

Griseofulvin

TNFα inhibitors

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34
Q

Drug causes of (T cell) pseudolymphoma

A 
‘Epileptic meds plus ABC’
Carbamazepine, Phenytoin, Sodium valproate
ACEi, Allopurinol, Amitriptyline
Beta-blockers, Benzodiazepines
calcium channel blockers
\+ many more in literature

Often single lesion
can cause exfoliative erythroderma
Drug-induced pseudolymphoma is almost always T cell predominant

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35
Q

Drug/toxin causes of anagen effluvium

A 
3C's and T-BAG toxins
Chemo – 5FU, high dose MTX, doxorubicin, bleomycin.  Starts 2-4 wks into chemo
Colchicine
CsA
Thallium
Bismuth
Arsenic
Gold
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36
Q

T/F

AGEP has been triggered by Kentucky fried chicken

A

False

Lacquer chicken has triggered AGEP

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37
Q

What are the skin adverse effects of HRT?

A

melasma, spider naevi, pseudoporphyria, DLE, photosensitivity, pompholyx, acanthosis nigricans, urticaria, EM, contact derm to oestrogen creams or adhesive patches

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38
Q

Interstitial granulomatous drug eruption causes

A 
common
ABCD STAT
ACEI – enalapril, lisinopril
Beta blockers – atenolol, propanolol, labetolol, metoprolol
Calcium channel blockers – verapamil, diltiazem, nifedepine
Diuretics - Frusemide (+HCTZ)
Statins – Simva, Prava, Lova
TNFα blockers 
Antihistamines (H1 or H2), Anakinra 
Thalidomide, lenalidomide
Uncommon
HCTZ
Carbamazepine
Diazepam
Bupropion
Ganciclovir
Darifenacin
Sennosides (senna)
onset after months-years of taking the drug
Can mimic Interstitial granulomatous dermatitis or Palisaded neutrophilic and granulomatous dermatitis clinically and histologically
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39
Q

Drug causes of dermatomyositis

A

PHD TO BOOST (the) CV
Penicillamine, Hydroxyurea, Diclofenac
Tamoxifen, TNFα blockers, Benzalkonium Chloride
Carbamazepine, cyclophosphamide, Vaccination (BCG)
- Statins sometimes included but really just cause myositis

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40
Q

Who is at increased risk of drug reactions?

A

Women
More prescribed meds
Older age
Immunosuppressed (esp immune mediated reactions – paradoxically)
Malignancy
AIDS
Connective tissue disease – Sjogrens, SLE, RA

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41
Q

What is a drug intolerance?

A

an expected drug reaction occurring to an exaggerated extent and at a lower dose than that expected to cause the reaction

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42
Q

What is a hapten?

A

A small molecule which can elicit an immune response but only when bound to a larger molecule esp a protein

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43
Q

What is an anaphylactoid reaction?

A

a reaction that involves histamine release and resembles anaphylaxis but is not caused by IgE-mediated type 1 hypersensitivity reaction

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44
Q

What is an idiosyncratic drug side effect?

A 
unpredictable response not due to immunological mechanism.  Can be due to a genetic variation in the metabolism pathway of the drug  e.g
DRESS
TEN
Drug-induced lupus
Drug reactions in HIV pts
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45
Q

T/F

eskimos and Japanese are often slow acetylators

A

F
Fast acetylators
some Mediterranean jews are slow acetylators

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46
Q

T/F

Fast acetylators are at increased risk of procainamide-induced lupus-like syndrome

A

T
occurs due to an acetylation metabolite of procainamide
but slow acetylators more at risk or lupus-like syndrome overall

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47
Q

What drugs are more risky for slow acetylators?

A

Hydralazine – lupus like syndrome
Bactrim hypersensitivity in HIV pys
Isoniazid – pellagra-like syndrome and peripheral neuritis
Dapsone - haemolysis

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48
Q

Which immunological drug reactions are type 1?

A

– IgE mediated

– anaphylaxis, urticaria, angioedema

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49
Q

Which immunological drug reactions are type 2?

A

– Ab mediated

– petechiae in drug-induced thrombocytopenia e.g penicillins, quinine, sulphonamides

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50
Q

Which immunological drug reactions are type 3?

A

– immune complex mediated

– serum sickness, vasculitis, some urticarias

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51
Q

Which immunological drug reactions are type 4?

A

– delayed type hypersensitivty (cell mediated)

– exanthematous, lichenoid, FDE, ?SJS/TEN

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52
Q

T/F

Hypersensitivty means immune reaction to an drug or other exogenous agent

A

T

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53
Q

T/F

Exanthematous and urticarial are the 2 most common types of drug eruptions

A

T

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54
Q

Why should you monitor ANA + LFTs in any pt on minocycline for over 1 year?

A

risk of ANCA positive drug-induced lupus

check ANCA if symptomatic

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55
Q

What is Vancomycin red man syndrome?

A

specific vancomycin infusion reaction where there is flushing and may be angio-oedema AKA ‘red neck syndrome’

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56
Q

How long do hypersensitivity drug reactions take to appear after starting a drug?

A

1-3 weeks typically but can be longer
most often within 6 weeks
SJS/TEN is same time period
Serum-sickness like reaction is same time period

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57
Q

How long do anaphylactoid drug reactions take to appear after starting a drug?

A

Up to 3 weeks

contrast to mins-hrs after last dose for true urticarial and anaphylactic reactions

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58
Q

When do Fixed drug eruptions appear?

A

1st episode 1-2 wks after starting drug

subsequently 8hr - 24 hrs

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59
Q

T/F

An Exanthem is a widespread rash usually accompanied by fever + sometimes other systemic features

A

T
AKA Morbiliform or Maculopapular drug eruption
Most common type of drug eruption
pt usuallly has low grade fever

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60
Q

T/F

Exanthematous drug eruptions classically occur 4-14 days after starting drug

A

T

but can be up to 6 weeks

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61
Q

How is exanthematous drug eruption distinguished from viral exanthem?

A

often indistinguishable;
Drug eruption usually favoured in adults
Viral exanthem usually favoured in kids
Drug rcn more polymorphic;
– often confluent areas on trunk; macules, papules or urticarial lesions on limbs, can be purpuric lesions on lower legs/feet
- Can involve palms and soles, can be mainly flexural, often spares face
- Can be scarlatiniform on trunk
- Can be rubelliform
- Can be annular plaques or atypical targetoid lesions
Drug rcn more likely to be itchy
Eos in blood favours drug
- viral infcn may have high lymphocytes or sometimes neuts
Biopsy sometimes helps - in drug;
Mild superficial perivascular lymphocytic infiltrate
Eos in 30%
Lichenoid in 50%

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62
Q

Apart from viral exanthem what DDs should be considered in an exanthematous drug eruption?

A

Facial oedema and eosinophilia – think DRESS (however onset usually later; 14-40 days)
Mucosal involvement and dusky lesions – think early SJS/TEN – look for Nikolsky sign
Toxic erythemas – exclude on basis of Hx and clinical features
- Scarlet fever
- Toxic shock syndrome
- Acute GvHD
- Kawasaki disease
Still’s disease

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63
Q

T/F

you must always stop the presumed drug cause in an exanthematous drug eruption

A

F
If drug is very important and there is no substitute you can try to ‘treat through’
Be cautious in case it is in fact evolving TEN or DRESS
May progress to erythroderma if drug not stopped

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64
Q

What are drug and toxin causes of erythroderma?

A 
All Bloody Scarlet + toxins
Allopurinol, Ampicillin/penicillins
Barbiturates, Carbamazepine, Phenytoin
Sulphasalazine, Sulphonamides
Arsenic, Gold, Mercury, Lithium
\+ many more listed
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65
Q

T/F

Red man syndrome means erythroderma

A

F
2 specific meanings. Either;
vancomycin infusion reaction where there is flushing and may be angio-oedema
Or;
chronic erythroderma in old men of unknown aetiology often with palmoplantar keratoderma, dermatopathic LNs and high IgE ?actinic reticuloid/ chronic light reactors

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66
Q

T/F

Urticaria is most common type of acute cutaneous drug reaction

A

F

second most common after exanthematous

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67
Q

what are the 4 ways drugs can cause an acute urticarial eruption?

A
  1. Allergic/immunological (inc anaphylaxis) - type 1 response
  2. Non-allergic/non-immunological (inc anaphylactoid) – direct mast cell degranulators and other, unknown mechanisms (pseudoallergens)
  3. Serum-sickness like reaction w/ urticarial rash (type 3 immune rcn)
  4. Urticarial vasculitis (usually also type 3 immune rcn)
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68
Q

How can drugs cause or exacerbate chronic urticaria?

A

Chronic urticaria or angio-oedema e.g. ACE inhibitors

Exacerbation of chronic urticaria despite not being the original cause (esp pseudoallergens) e.g. Aspirin, NSAIDs

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69
Q

Which drugs are high risk for anaphylaxis?

A

Mainly antibiotics; Penicillins, cephalosporins, sulphonamides, tetracyclines (esp mino)
biologics
radiocontrast media

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70
Q

T/F

RAST testing is dangerous if testing for cause of anaphylaxis

A

T
have resucitation equipment ready
Useful test but limited by availability of preparations

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71
Q

Which drugs are direct mast cell degranulators?

A

Vancomycin, opiates, atrocurarium, polymixin, dextran, Iodine radiocontrast dye
(alcohol and strawberries also release histamine)

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72
Q

Whic drugs act as pseudoallergens to cause urticaria?

A

Aspirin, NSAIDs, ciprofloxacin, phenylbutazone

73
Q

T/F

Aspirin is classic cause of anaphylactoid reaction

A

T

74
Q

Which drugs cause urticarial vasculitis?

A 
UV Makes Noisy Fun in the CBD
MTX
NSAIDs
Fluoxetine
Cimetidine
Biologics
Diltiazem
75
Q

what is serum-sickness-like reaction?

A

drug reaction of unclear aetiology. May involve immune-complex deposition similar to true serum-sickness
May think of as a more acute form of urticarial vasculitis
starts 1-3 weeks after exposure
urticarial (or sometimes morbilliform) rash w/ lesions which may last >24hrs and may be tender and resolve with bruising, fever, oral oedema, lymphadenopathy, symmetrical arthralgia, myalgias, mild proteinuria

76
Q

What are the causes of serum-sickness-like reaction?

A 
drugs;
Penicillins (inc amoxicillin), Cephalosporins (esp cefclor), sulphonamides, tetracyclines, ciprofloxacin, NSAIDs, carbamazepine, phenytoin, propanolol, allopurinol, barbiturates, bupropion, thiouracil 
Radiocontrast media
Infection (esp HepB or C)
Vaccinations (Hep B and tetanus toxoid)
rarely foods
77
Q

What drug most commonly causes angio-oedema?

A

ACE inhibitors - 1-2 per 1000 pts prescribed ACEI
- can occur after first dose or after years
Other are;
ARIIBs
Penicillins - 2nd most common after ACEIs
NSAIDs
radiocontrast media
monoclonal Abs,

78
Q

T/F

drugs can sometimes trigger/unmask angio-oedema due to another cause

A

T
always consider this before ascribing reaction to drug entirely
e.g. acquired C1q esterase inhibitor deficiency

79
Q

T/F

drug induced angio-oedema is more common in asian pts

A

F

Higher risk if black or Hx of idiopathic angio-oedema

80
Q

What drug is most often responsible for anaphylaxis?

A

penicillin

81
Q

How are drug photosensitivty reactions classified?

A

Classification – systemic drugs
- Phototoxicity (most common for systemic agents)
- Photoallergy (rare for systemic agents)
- Drug-induced photosensitive dermatosis e.g. lupus, pellagra, porphyria
- Drug induced UV-recall eruption
Classification – topical drugs
- Phototoxic contact dermatitis (rare for topical agents)
- Photoallergic contact dermatitis (Most common for topical agents); includes Riehls melanosis

82
Q

T/F

Photoallergic drug reactions cause an exaggerated sunburn like reaction

A

F

Phototoxic drug reactions cause an exaggerated sunburn like reaction

83
Q

T/F

Pseudoporphyria and Photo-onycholysis are variants of Phototoxic drug reactions

A

T

84
Q

T/F

Drugs causing phototoxic reactions are also known as photosensitizers

A

T

85
Q

which drugs most commonly cause photo-onycholysis?

A

psoralens, OCP, tetracyclines and fluoroquinolones

86
Q

What topical drugs cause phototoxicity?

A

Unusual for topicals - photallergy more common
True phototoxicity should be due to UVR-activation of drug e.g. coal tar also medical dyes such as fluorescin or methylene blue
Photosensitivity to topicals is often due to thinning and inflammation of skin e.g. efudix and topical retinoids
Most contact photosensitizers are foods and plants

87
Q

T/F

changing to evening dosing may be enough to prevent phototoxicity

A

T

if drug has short half life

88
Q

T/F

photoallergic drug reactions are usually lichenoid

A

F
clinical and histo usually more eczematous like allergic contact dermatitis and can be bullae or vesicles. Sometimes lichenoid = lichenoid photodrug allergy

89
Q

T/F

most systemic agents which cause photoallergy also cause phototoxicity

A

T
remember same list of ‘photosensitizers’
esp sulpha drugs and thiazides

90
Q

Topical drug photoallergic reactions are a kind of allergic contact dermatitis triggered by UV exposure

A

T

photoallergic contact dermatitis

91
Q

T/F

berloque dermatitis is a kind of photoallergic contact dermatitis

A

T
Typically due to fragrances containing bergapten fragrance
Bergapten is 5-methoxypsoralen and is found in the fragrance Bergamot oil as well as other fruits and plants e.g. figs (Ficus carica), celery (Apium graveolens), lemon oil, Tromso palm (H laciniatum), Queen Anne’s lace (Ammi majus), and giant Russian hogweed (H mantegazzianum)

92
Q

T/F

Topical steroids are the most common topical drug photoallergens

A

F

Oxybenzone (a benzaphone sunscreen) is most common topical photoallergen

93
Q

which drugs can cause pellagra?

A

PIP

Pellagra – isoniazid, phenytoin

94
Q

which drugs can cause UV-recall (photorecall) rcns?

A

MTX
piperacillin, tobramycin, vancomycin, ciprofloxacin
Docetaxel with or without cyclophopshamide, paclitaxel, etoposide, suramin, sorafenib

95
Q

Which drugs caise ANCA positive cutaneous vasculitis?

A

‘wear ANKLE chains in Her Majesties Prison’
Hydralazine
Minocycline
Propylthiouracil
+ cocaine - causes ANCApos (in >80%) vasculitis that mimics WG and can have facial midline destructive lesions

96
Q

List some drug causes of purpura (other than drug-induced vasculitis)

A

Cytotoxic drugs – BM suppression induced purpura
Bleomycin – thrombocytopenia
Aspirin – platelet inhibition
Heparin – see later re HITTs
Warfarin – increased INR
tPA assoc w/ painful purpura
TMP-SMX (bactrim) can cause an acral purpuric eruption similar to the papular-purpuric glove and socks syndrome
Numerous other drugs can cause thrombocytopenia or altered coagulation causing purpura

97
Q

T/F

eosinophilia is seen in drug-induced systemic vasculitis

A

T
in 80%
also seen in 25% of non-drug vasculitis

98
Q

What is ‘granulomatous lichenoid dermatitis’ ?

A

Variant of lichenoid drug eruption
Red-purple papules and plaques
Histo shows lichenoid drug eruption with granulomatous histiocytic infiltrate with multinucleated giant cells.
Usually but not always a drug induced reaction pattern esp to antibiotics, ACE inhibitors, beta blockers, statins and NSAIDs.

99
Q

what is the latent period for lichenoid drug eruptions?

A

1 month to 3 years after starting drug

100
Q

T/F

lichenoid drug eruptions resolve in 3-6 months after stopping drug

A

F
usually 1-4 months
but up to 2 years if due to gold

101
Q

How does lichenoid drug differ clinically from LP?

A

older ave age of onset - 65 for drug, M=F
Generalized distribution; often spares classic LP sites
often photodistributed
mucosa usually spared
Not typical LP appearance; Can look more eczematous/psoriasiform/pityriasiform
usually no Wickham’s striae
hyperpigmentation very uncommon in drug rcn

102
Q

How does lichenoid drug differ histologically from LP?

A

Lichenoid Drug;
Lichenoid infiltrate w/ Civatte bodies high up in epidermis
May have eos and/or plasma cells
May extend to deep vascular plexus
May be parakeratosis
May be some spongiosis
LP;
Lichenoid reaction
Mild inflammation confined to papillary dermis
w/out parakeratosis
rarely eos or plasma cells (but presence of eos doesn’t=drug)

103
Q

T/F

chelation therapy is of no use in Gold drug reactions

A

F
Can use EDTA or dimercaprol (=BAL-British Anti-Lewisite)
- used for gold, arsenic, mercury and lead poisoning and Wilsons disease

104
Q

T/F
Photoallergic drug eruptions are caused by a delayed type hypersensitivity response (Cell mediated) to a UVR-induced metabolite of the drug which acts a hapten

A

T

105
Q

What drug is classic cause of widespread eczematous eruption which can involve flexures resembling atopic dermatitis

A

Carbamazepine

106
Q

T/F

Eczematous drug eruptions are an exogenous eczema

A

F

Classified as endogenous as not due to something contacting the skin

107
Q

What is systemic contact-type dermatitis medicamentosa’?

A

An eczematous reaction to an oral drug due to prior contact sensitization to the drug or to a cross reacting chemical
Often first or most severely affects site of prior ACD
Often symmetrical
E.g;
phenothiazines (parabens ACD)
Gentamicin (neomycin ACD)
Disulfiram (thiuram ACD)
Can be Baboon syndrome e.g. mercury, nickel, penicillins

108
Q

T/F

Inhalation of tincture of benzoin (Friar’s Balsam) can cause reaction in pts sensitized to balsam of Peru

A

T

Kind of systemic contact-type dermatitis medicamentosa

109
Q

What is ‘Endogenic contact eczema’?

A

ACD occurring to a substance in topical form after initial sensitization to the drug taken orally
E.g.
penicillin, methyldopa, allopurinol, indomethacin, sulphonamides, gold, quinine, clonidine, chloramphenicol, bleomycin

110
Q

Which drug eruptions are neutrophilic?

A 
Neutrophilic eccrine hidradenitis + PASH
PG
AGEP
Sweets
Halogenodermas (bromoderma, iododerma, fluoroderma)
111
Q

T/F

drugs are a major cause of pyoderma gangrenosum

A 
F
v rare
G-CSF or GM-CSF most common
Can be Isotretinoin
Possibly;
MTX
AZA
hydralazine
112
Q

T/F

Neutrophilia on blood often absent in drug-induced cases Sweets

A

T

may be because many due to G-CSF in neutropenic chemo patients (given to try to reverse the neutropenia)

113
Q

What systemic features may be seen in AGEP?

A

Fever - classical feature
AKI - next most common
Liver - cholestatic or hepatitic picture, can be hepatomegally or steatosis
Lungs – hypoxia w/ bilat effusions
Rare multiorgan dysfunction–can be DIC and death

114
Q

T/F
Neutrophilic eccrine hidradenitis is a neutrophilic inflammation of eccrine sweat glands triggered by drugs or rarely by infection

A

T

115
Q

Which drugs most typically trigger Neutrophilic eccrine hidradenitis?

A 
Chemo drugs
Typically follows chemo esp cytarabine for AML – onset 1-2 weeks after chemo
MTX, cyclophosphamide, anthracyclines, 5FU, bleomycin, vinca alkaloids, imatinib
sites of bleomycin injection
Rare causes;
G-CSF (esp in HIV), paracetamol
In Behcets
strep, staph, gram neg bacilli, HIV
116
Q

what does Neutrophilic eccrine hidradenitis look like

A

Erythematous papules and plaques on trunk and extremeties and face
Can be linear, annular, targetoid or polymorphic, can be purpuric and pustular

117
Q

What are the histo findings of Neutrophilic eccrine hidradenitis?

A

Eccrine glands show vacuolar degeneration in secretory and ductal cells sparing acrosyringium
Neutrophilic infiltrate
May see some eccrine squamous syringometaplasia (squamous metaplasia of cuboidal epithelial cells of eccrine ducts)

118
Q

what is treatment of Neutrophilic eccrine hidradenitis?

A

stop drug if drug cause
resolves in days-weeks
steroids orally if severe
dapsone

119
Q

T/F

aromatic anticonvulsants; phenytoin, carbamazepine and phenobarbitol cross react in 40-80% of cases

A

T

Non-aromatics usually don’t; sodium valproate, topiramate, Gabapentin, levetiracetam, ethosuximide, tiagabine

120
Q

T/F

fixed drug eruptions are due to humoral immunity mechanisms?

A

F

cell-mediated

121
Q

what are most common sites for FDE?

A

face, lips, hands, feet, genitals
can be intraoral
trunk rare

122
Q

In FDE rechallenge always results in return of rash at same site

A

F
Usually at exactly same site and sometimes at additional sites
but may be a refractory period when readministration doesn’t cause a reaction

123
Q

T/F

generalized FDE is a morbiliform rash rather than a macule

A

F

means many typical lesions of FDE

124
Q

which drugs high risk for FDE?

A 
SCANT
Sulphonamides esp TMP-SMX
Cacium channel blockers
Aspirin
NSAIDs inc ibuprofen 
Tetracyclines
125
Q

T/F

histo can differentiate drug-induced linear IgA disease from sporadic form

A

F
clinical and histo the same
always think of drugs as many reported drug causes
e.g.
CAAVVE – Captopril, Ampicillin, Amioderone, Vanc, Voltaren, Epileptics
Resolves in 2-5 wks after stopping drug

126
Q

T/F

drug induced types account for 20% of all pemphigus

A

F

up to 10% of pemphigus cases in developed countries

127
Q

T/F

direct and indirect may be negative in drug-induced pemphigus

A

T
esp if penicillamine cause;
perilesional direct IF negative in up to 10% of penicillamine induced pemphigus
Sometimes indirect IF also negative – 30% of penicillamine cases but is more often posiitve the same frequency as sporadic forms

128
Q

T/F

thiols account for 80% of drug induced pemphigus cases

A

T

captopril, Ramipril, penicillamine, gold, Piroxicam (Feldene, an NSAID)

129
Q

T/F

drug-induced BP affects younger pts than sporadic BP

A

T

130
Q

what is Symmetrical Drug-Related Intertriginous and Flexural Exanthem (SDRIFE)

A

A drug allergy rash without systemic symptoms which may be called baboon syndrome.
Most often due to antibiotics or contrast media
Criteria are ;
Exposure to a systemic drug but not chemo agent – can occur after initial or repeated dose
Sharply demarcated area of gluteal/perianal area and/or V-shaped erythema of genital/ inguinal area
At least one other flexural site involved
Symmetrical
No systemic signs or symptoms

131
Q

what are DDs of SDRIFE?

A

Systemic contact type dermatitis Baboon syndrome

Toxic erythema of chemotherapy

132
Q

T/F
Pseudolymphomatous drug hypersensitivity syndrome is a drug eruption which simulates lymphoma clinically and histologically

A

T

133
Q

which drugs cause Pseudolymphomatous drug hypersensitivity syndrome?
what is the natural history?

A

Anticonvulsants – phenytoin, carbamazepine, phenobarbital, mephenytoin, valproate, trimethadione
Antipsychotics – chlorpromazine, promethazine
ACEIs and ARIIBs
Allopurinol
Imatinib
Ibuprofen/NSAIDs
Starts weeks – years after starting drug; mostly in first 7 weeks
Completely resolves within weeks of stopping drug, sometimes takes months

134
Q

what are clinical features of Pseudolymphomatous drug hypersensitivity syndrome?

A

Lesions on skin are solitary or multiple and can be localized or widespread
Red-violet papules, plaques or nodules
Can present as erythroderma – looks like Sezary syndrome
Often lymphadenopathy

135
Q

What is histo of Pseudolymphomatous drug hypersensitivity syndrome?
What features help distinguish from true lymphoma?

A

Histo
Dense lymphocytic infiltrate in dermis mimics lymphoma
Can be band-like and mimic MF
Mainly T cells, usually polyclonal
Nuclei may look atypical with cerebriform outline
Can be epidermotropism and Pautrier-like microabscesses
Features which help distinguish from true lymphoma;
spongiosis, apoptotic keratinocytes, papillary dermal oedema, eos in epi, RBCs

136
Q

T/F
Interstitial granulomatous drug reaction is easily distinguished from Interstitial granulomatous dermatitis or Palisaded neutrophilic and granulomatous dermatitis clinically and histologically

A

F

clinical and histo mimics these - always consider drug and try to stop meds

137
Q

What is the cause of Warfarin (coumarin/coumadin) skin necrosis?
who is at risk?
whta are clinical features and management?

A

Due to reduced protein C function causing coagulation and ischaemic infarcts
inc risk if hereditary protein C deficiency (protein C and S are vit K-dependent and are inhibited by warfarin more quickly than the anticoagulant effect esp protein C as short half life)
1 in 10,000 warfarin pts
Esp pts in 50s-60s
F:M = >4:1
Usually starts 2-5 days after starting drug
Starts as pain then red, painful plaques esp breast, thighs, buttocks
Turn into haemorrhagic blisters and necrotic ulcers or eschar
Stop warfarin
Reverse with vitamin K
Give heparin to anticoagulate (as still need anticoagulation)
Can give intravenous protein C concentrates or activated protein C

138
Q

T/F

Warfarin blue toe syndrome is due to Coumadin necrosis

A

F

Due to cholesterol emboli due to anticoagulation – not limited to warfarin alone

139
Q

T/F

Heparin Induced Thrombocytopenia (+ Thrombosis) Syndrome is a cell mediated reaction

A

F
antibody mediated;
binding of antibodies to heparin and platelet factor 4 to form PF4/heparin complexes (HIT complexes) which stimulate platelet aggregation and consumption
5-30% of pts who develop HIT-IgG Abs will develop clinical HIT(T)S

140
Q

T/F

HITS/HITTS is only cuased by unfractionated heparin

A

F

can be UFH or Lmolwt Heparin

141
Q

T/F

It is safe for pts with HITS/HITTS to be given warfarin

A

F
Don’t use warfarin/Coumadin as can precipitate limb gangrene due to initial prothrombotic effects
can give dabigatran, danaparoid, lepirudin, argatroban

142
Q

T/F

Pts who had HITS/HITTS more than 100 days ago may not get it again if rechallenged

A

T

but high risk if less than 100 days ago

143
Q

T/F
In HITS/HITTS Drop in platelet count but may not be apparent unless there is a pre-treatment baseline
and a drop of >50% should lead to suspicion of HIT

A

T

144
Q 
T/F
HITT syndrome (the thrombotic variant) causes cutaneous necrosis which occurs at injection sites and at distant sites including internal organs e.g. CNS (stroke), MI, PE
A

T

skin lesions are macular purpura with central necrosis and retiform extensions at the margins

145
Q

which drugs can cause isolated mucosal ulceration?

A

Nicorandil, penicillamine, gold, phenylbutazone, captopril, phenindione, piroxicam, phenobarbitol and topical bleach (sodium hypochlorite)
Foscarnet can cause penile urethra ulceration by contact toxicity as excreted

146
Q

T/F

chemo drugs usually cause hair loss by triggering telogen effluvium

A

F
most often anagen effluvium, rarely TE
e.g. Antimetabolites, vinca alkaloids, alkylating agents, topoisomerase inhibitors
also arsenic, gold, bismuth
NB - most non-chemo drug alopecia is due to acute or chronic telogen effluvium
Bisulfan causes characterisitic irrevrsible hairloss

147
Q

T/F

anabolic steroids are the main drug cause of hirsuitism

A 
T
also;
Combing Cheeks Makes Pam Angry
•	Corticosteroids
•	Cyclosporin
•	Minoxidil
•	Phenytoin
•	Androgens
148
Q

Which drugs cause hypertrichosis?

A

cyclosporine, phenytoin, minoxidil, diazoxide, corticosteroids, androgens, penicillamine, psoralens, streptomycin
Also Bimatoprost (lumigan, latisse) eye drops which cause eyelash growth
trichomegaly of eyelashes also caused by EGFR inhibitors
(long, thick, rigid hairs)

149
Q

what effect does chloroquine have on hair?

A

Reversible greying in red/blonde haired people

150
Q

what effect does etretinate have on hair?

A

darkening, lightening, curling, kinking

151
Q

What are effects of retinoids on nails?

A

thinning, fragility, onycholysis, onychoschizia, nail shedding, onychomadesis, ingrowing nails, periungual granulation tissue, paronychia

152
Q

What are effects of tetracyclines on nails?

A

yellow discolouration + onycholysis + photo-onycholysis

Psoralens cause same things

153
Q

what drugs cause gingival hyperplasia?

A

CsA, nifedipine, phenytoin, felodepine, verapamil, diltiazem

154
Q

what are ‘Ara-C ears’?

A

bilateral red swollen ears due to Cytarabine

155
Q

which chemo drugs cause inflammation of ‘keratoses’?

A

AKs – 5-FU, capecitabine, pentostatin
Seb Ks – Cytarabine, Taxanes
DSAP – 5-Fu + prodrugs, Taxanes

156
Q

T/F

Doxorubicin (with ketoconazole) can cause sticky skin

A

T
Acquired cutaneous adherence
can also be caused by retinoids

157
Q

what is serpentine supravenous hyperpigmentation ? what drugs are responsible?

A

sclerosis and hyperpigmentation along the vein following IV infusion
- 5-FU, Doxorubicin, Docetaxel, Vinorelbine, alkylating agents

158
Q

What is Taxane-induced HFS?

A

distinct subtype of acral ertyhema (HFS)
5-10% ot pfts on taxanes e.g. Docetaxel, Paclitaxel
Erythematous plaques on dorsal hands, achilles tendons and malleoli (not palms and soles like in other drugs so nota cause of PPK)
+ often have associated nail toxicity
– onycholysis, Beau lines, nail melanosis, subungual haemorrhage, paronychia.

159
Q

What are AEs of EGFR inhibitors?

A

Eg. Cetux, pmab, erlotinib, gefitinib
‘EGFR makes(MEK) a fast car’ (rhymes) - if you have a fast car you get ‘MPH PRIDE’
Mucositis
Photosensitivity
Hair changes eg hypertrichosis, hirsuitism, trichomegally of eyelashes + Alopecia (androgenetic or rarely scarring)
Papulopustular eruption
Regulatory changes in hair
Itching
Dryness
Easy breaking nails (brittle) + paronychia + onycholysis + pyogenic granulomas

NB; MEK inhibitors have same side effects eg. Seletanib, trametinib

160
Q

What are AEs of BRAF inhibitors?

A

Eruptions (75%)
squamoproliferative lesions - kAs, SCCs, verrucal keratoses
photosensitivity
KP-like reaction, seb derm-like eruption,
Grover’s
hyperkeratotic hand-foot reaction, panniculitis, melanocytic lesions, vitiligo
Cymotrichous (wavy hair)

161
Q

what are the grades of hyperkeratotic hand foot sundrome due to multikinase inhibitors?
what is the mangement of each grade?

A

E.g. Sorafenib, sunitinib, pazopanib, vandetanib
Grade 1 – painless mild changes. Rx: emollients, keratolytics, gel/foam shoe inserts
Grade 2 – painful changes limiting instrumental ADLs. Rx: as for grade 1 + potent TCS for 7-10 days and consider 50% dose reduction
Grade 3 – severe pain and limits self-care ADLs. Rx: as per grade 2 + local antiseptic baths + stop drug for at least 1 week and restart when HFSR toxicity grade 0/1

162
Q

T/F

combined use of BRAF and MEK inhibitor has worse side effect profile than either alone?

A 
F
AE profile than single agent therapy but regular derm check ups still recommended
Much lower SCC risk
Much lower verrucal keratosis risk
Much lower Grover’s disease risk
Increased folliculitis
Other AEs at similar rates
163
Q

T/F

side effect profile of MEK inhibitors same as BRAF inhibitors

A

F

same as EGFR inhibitors

164
Q

what are cutaneous AEs of mTOR inhibitors such as rapamycin?

A

Mouth ulcers
Inflammatory eruptions – common. Can be morbilliform, eczematoid or acneiform. Erythematous follicular pustules and papules most common. Onset first 2 wks. Trunk>limbs>face. Variable histo. Onset, course + Rx similar to EGFR inhibitor rash.
Others – nail toxicity esp paronychia, pyogenic granuloma-like lesions, alopecia, facial hypertrichosis, poor wound healing, pruritus, xerosis, oedema, vasculitis.

165
Q

what are main mucocutaneous AEs of vismodegib?

A

alopecia (60%) - usually mild

dysguesia (up to 75%) - treat w/ zinc

166
Q

What are the major AEs of imunomodulatory agents; Ipalimumab (CTLA-4 inhibitor used for melanoma) and programmed death 1 inhibitors (Nivolumab, Pembrolizumab)

A

Autoimmune dermopathy (40%) is most common immune side effect, followed by colitis.
Pruritis in 30% or fewer, morbilliform eruption in 10-50%
Vitiligo-like melanoma-associated hypopigmentation – portends good prognosis
Rarely – prurigo nodularis, lichenoid exanthems, papulopustular eruptions, pyoderma-gangrenosum-like ulcerations, photosensitivity, XRT recall, DRESS, TEN
Also; diarrhoea/colitis, pruritus/dermatitis, endocrine problems/hypophysitis, hepatitis, neuritis, death (esp from severe colitis)
Symptoms mainly dose-dependent and resolve after Rx

167
Q

Drug reactions are common in HIV and independent of CD4 count

A

F

common but more so if CD4 count between 100-400

168
Q

what are AEs of multikinase inhibitors eg sorafenib?

A

Inflammatory eruptions
Hyperkeratotic hand-foot skin reaction (HFSR)
stomatitis
hair changes
genital eruptions eg psoriasifrom rash
Uncommon;
seb-derm like facial rash, yellowing of skin, facial oedema, pyoderma gangrenosum-like lesions, eruptive naevi, hyperkeratotic squamoproliferative lesions like in BRAF inhibitors, asymptomatic nail splinter haemorrhages, acute folliculitis, dryness, photosensitivity

169
Q

whta drugs cause SJS/TEN or DRESS?

A

Sulphur drugs – co-trimoxazole, sulphonamides
Allopurinol
Tetracyclines
Anticonvulsants - barbiturates, phenytoin, lamotrigine, carbamazepine
NSAIDs - esp COX2 + oxicams

170
Q

In what conditons can you see a Jarisch-Herxheimer reaction?

A 
Classically associated with penicillin treatment of early syphilis
Also seen in;
Borreliosis/erythema chronicum migrans (penicillin or minocycline)
Leptospirosis
Onchocerciasis (diethylcarbamazine)
Strongyloides (thiabendazole)
Q fever
Bartonellosis & cat scratch disease
Brucellosis
Tularaemia
Typhoid fever
Trypansomiasis
171
Q

What is the Wolff-Chaikoff effect?

A

Ingesting large amounts of iodine inhibits iodination of thyroglobulin in the thyroid and thyroid hormone levels are reduced.
Can occur when using potassium iodide
Patients on KI may also get an iodide goitre

172
Q

which drug can cause Dupuytrens contracture?

A

Phenytoin

the ‘pyt’ in both words is very similar

173
Q

T/F

starting TNFα blockers can trigger frontal fibrosing alopecia

A

T

174
Q

which drugs can cause hypertrichosis?

A

Phenytoin, cyclosporine, EGFR inhibitors
oral or topical minoxidil
systemic or topical corticosteroids
topical latanoprost

175
Q

what are skin side effects of BRAF inhibitors?

A 
GP VACKS
Grovers of folliculitis
PPK, Panniculitis, Photosensitivity
Vitiligo, Verrucal keratoses, Verruca vulgaris
AK, Acneiform rash, Alopecia
Cysts, Cymotrichous (wavy hair)
Keratosis Pilaris
SCC
176
Q

Lithium can trigger or flare which skin conditions?

A

Psoriasis
Dariers
HS

177
Q

What loop diuretic can be recommended for pts who develop allergy to frusemide?

A

Ethacrynic acid
Unlike the other loop diuretics, ethacrynic acid is not a sulfonamide and thus, its use is not contraindicated in those with sulfa allergies

178
Q

Which drugs cause a scarletiniform drug eruption?

A

penicillin, beta lactams, allopurinol, barbiturates, codeine, quinidine, mercury, indandiones

Drugs Dan (3 decks)

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