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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 29-31

Dual drug reactions induced by a single drug: A rare phenomenon


Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India

Date of Submission01-Apr-2019
Date of Decision20-Apr-2020
Date of Acceptance09-Apr-2021
Date of Web Publication25-Jun-2021

Correspondence Address:
Angoori Gnaneshwar Rao
F12, B8, HIG-II APHB, Baghlingampally, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_17_19

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  Abstract 


It is rare to encounter a dual drug reaction induced by a single drug. Herein, we present a case of such dual drug reaction caused by Urtica urens, a homeopathic drug in a young farmer who consumed U. urens for relief from common cold. He was relieved of symptoms of drug reaction following dechallenge and symptomatic treatment.

Keywords: Dechallenge, dual drug reaction, fixed drug reaction, phototoxic drug reaction


How to cite this article:
Rao AG, Reddy VS, Fathima K, Tejal M, Muppirala D, Sunki P, Sruthi C H, Jhawar J, Myneni V. Dual drug reactions induced by a single drug: A rare phenomenon. Indian J Drugs Dermatol 2021;7:29-31

How to cite this URL:
Rao AG, Reddy VS, Fathima K, Tejal M, Muppirala D, Sunki P, Sruthi C H, Jhawar J, Myneni V. Dual drug reactions induced by a single drug: A rare phenomenon. Indian J Drugs Dermatol [serial online] 2021 [cited 2021 Nov 27];7:29-31. Available from: https://www.ijdd.in/text.asp?2021/7/1/29/319348




  Introduction Top


It is known that a single drug induces lone morphological pattern of drug reaction and is rare to encounter two morphological patterns of drug reactions induced by one drug in allopathy. Herein, we report a case of dual drug reactions induced by Urtica urens (annual nettle), a homeopathic medicine used to treat various conditions, such as hives, joint pains, enuresis, and gout.


  Case Report Top


A 27-year-old farmer was presented with erythema and burning on sun-exposed areas and a blister over the lower back of 2-day duration. He gives a history of taking U. urens (homeopathic drug) for body pains 2 days back followed by exposure to sunlight (work in fields). Subsequently, he noticed burning and redness over the sun-exposed areas which gradually resolved with peeling of the skin in 7–10 days. He gives a history of an episode of similar drug reactions to U. urens 6 months back. He denies a history of taking any other drug or colored food in the recent past. This episode of drug reaction may be an expression of rechallenge the patient attempted while considering the earlier reaction as a drug reaction to U. urens. Family history was negative for drug reactions. Examination revealed well-defined erythema of the skin over sun-exposed areas, neck, upper chest, front and back, shoulders, and upper arms [Figure 1]. The area covered by undergarment was spared. There were two hyperpigmented oval patches, one on the right loin and the other on the extensor aspect of the left wrist, surmounted by bullae [Figure 2] and [Figure 3]. Palms and soles were spared. Oral mucosa and genitalia were normal. Routine investigations including blood chemistry were unremarkable. HIV-1 and HIV-2 serology was nonreactive. Biopsy from the blister on the right loin showed basal layer hydropic change with interface dermatitis containing lymphocytes and neutrophils. Dermis showed edema and pigment-laden macrophages with perivascular lymphocytic infiltration, suggestive of fixed drug eruption (FDE) [Figure 4]. Biopsy from the sunburn area on the left scapular region showed acanthosis in the epidermis and perivascular lymphohistiocytic infiltrate in the dermis with occasional eosinophils [Figure 5]. The index case attained a score of 3 in the Naranjo's probability score on adverse drug reactions indicating that the adverse drug reaction to U. urens is possible in the index case. He was finally diagnosed with phototoxic drug reaction with fixed drug reaction possibly to U. urens.[1] Moreover, considering the earlier episode of drug reaction, the present episode could be contemplated as rechallenge which resulted in the same morphological pattern of drug reactions substantiates causal relation of drug reaction.. He was advised not to take U. urens in future and photoprotection and was managed with antihistamines and topical calamine lotion.
Figure 1: Erythema confined to sun-exposed areas and fixed drug eruption lesions on the extensor aspect of the left wrist and right loin

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Figure 2: Fixed drug eruption with bulla on the right loin

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Figure 3: Fixed drug eruption with multiple bullae on the extensor aspect of the left wrist

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Figure 4: Histopathological examination of biopsy from the blister on the right loin showing basal layer hydropic change with interface dermatitis containing lymphocytes and neutrophils. Dermis showed edema and pigment-laden macrophages with perivascular lymphocytic infiltration (H and E, ×100)

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Figure 5: Histopathological examination sunburn area showing acanthosis in the epidermis and perivascular lymphohistiocytic infiltrate in the dermis with occasional eosinophils (H and E, ×100)

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  Discussion Top


FDE is a localized type IV hypersensitivity reaction to a systemically introduced allergen, which clinically manifests with annular or oval erythematous patches usually involving oral and genital mucosa. An increased incidence of FDE has been reported among HLA-B22 individuals.[2] Analgesics, anticonvulsants, antibiotics, foods, and food additives have been incriminated in FDE.[3],[4] It resolves with hyperpigmentation and may recur at the same site on re-exposure.

Phototoxic drug reaction is due to the combined effect of drug and light, commonly caused by tetracyclines, fluoroquinolones, naproxen, sulfonamides, and ibuprofen. It is characterized by erythema and edema on sun-exposed areas such as V of the neck, extensor aspects of forearms, and dorsum of hands.

Principal components of U. urens are carbohydrates, proteins, lipids, sugars, anthocyanin, carotenoid, fiber, phenolics, flavonoids, tannins, ortho-diphenols, and flavonols. The phenolic component in U. urens is known to have antibacterial and antioxidant properties.

The adverse drug reaction in the index case to U. urens is possible as per the Naranjo's probability score of adverse drug reactions. The development of two different morphological patterns of drug reactions to a single drug (U. urens) in our patient is unique and novel.

Multiple-drug intolerance syndrome (MDIS) is characterized by adverse drug reaction to more than two chemically unrelated drugs which manifest with skin rash and systemic symptoms (e.g., psychiatric symptoms).[5] An incidence of 2%–5% was reported in population in North America and Europe.[6] It is more common in the elderly population as the lifetime drug exposure increases with age. The pathogenesis of MDIS is complex and not well understood.[7] Arellano et al. have proposed genetic polymorphism in CPY450 enzyme in their case of MDIS.[8]

Even though U. urens is a single drug, it contains many compounds and the dual drug reaction induced by it does not qualify to be labeled as MDIS as there is no systemic adverse reaction in the index case, reported in MDIS. As U. urens contains so many constituents, it may be possible that some components/metabolites of the drug are responsible for phototoxic reaction and some are responsible for the fixed drug reaction. The other explanation that may be offered is that phototoxic reaction could have been caused by some components of U. urens and FDE could have been caused by foods and coloring agents present in the foods inadvertently consumed by the patient.

In conclusion, the occurrence of dual morphological drug reactions to single drug is rare in allopathy; however, it should be suspected and evaluated in view of growing belief in various other systems of medicines such as homeopathy, Ayurveda, siddha, and unani which claim no side effects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239-245  Back to cited text no. 1
    
2.
Pellicano R, Ciavarella G, Lomuto M, Di Giorgio G. Genetic susceptibility to fixed drug eruption: Evidence for a link with HLA-B22. J Am Acad Dermatol 1994;30:52-4.  Back to cited text no. 2
    
3.
Sehgal VN, Srivastava G. Fixed drug eruption (FDE): Changing scenario of incriminating drugs. Int J Dermatol 2006;45:897-908.  Back to cited text no. 3
    
4.
Orchard DC, Varigos GA. Fixed drug eruption to tartrazine. Australas J Dermatol 1997;38:212-4.  Back to cited text no. 4
    
5.
Patriarca G, Schiavino D, Nucera E, Colamonico P, Montesarchio G, Saraceni C. Multiple drug intolerance: Allergological and psychological findings. J Investig Allergol Clin Immunol 1991;1:138-44.  Back to cited text no. 5
    
6.
Macy E, Ho NJ. Multiple drug intolerance syndrome: Prevalence, clinical characteristics, and management. Ann Allergy Asthma Immunol 2012;108:88-93.  Back to cited text no. 6
    
7.
Macy E, Ho NJ. Multiple drug intolerance syndrome: Prevalence, clinical characteristics, and management. Ann Allergy Asthma Immunol 2012;108:88-93.  Back to cited text no. 7
    
8.
Arellano AL, Martin-Subero M, Monerris M, Farré M, Montané E. Multiple adverse drug reactions and genetic polymorphism testing. Medicine 2017;96:45.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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