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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 94-97

Photoallergic reaction to cephalosporin: Hitherto unreported


Department of Dermatology, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India

Date of Submission02-Jun-2022
Date of Acceptance22-Dec-2022
Date of Web Publication5-Jan-2023

Correspondence Address:
Meghana Madhukar Phiske
Department of Dermatology, MGM Medical College and Hospital, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_13_22

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  Abstract 

Photoallergic reactions are Type IV hypersensitivity reactions localized to photo-exposed areas, with generalization in severe cases. Diagnosis is based on history, photo-patch testing and clinico-histopathological correlation. A 47-year-old man developed multiple, erythematous plaques over V-area of neck, retroauricular area, extensor aspect of both forearms after oral cefixime post-cholecystectomy. He had similar episode of lesser severity two months ago after oral Cefixime. Histopathology showed acanthotic epidermis, foci of spongiosis causing vesiculation with lymphocytes. Upper dermis showed infiltrate of lymphocytes and neutrophils along with perivascular infiltrate. Diagnosis was photoallergic reaction to Cefixime. Lesions completely subsided with oral steroids, hydroxychloroquine, antihistamines, sunscreen and emollients over two months. Cephalosporins have multiple side-effects including hypersensitivity, rash, Steven–Johnson syndrome and toxic epidermal necrolysis. Cephalosporin induced photoallergy is not reported. Hence, cephalosporins should be added to the existing list of systemic drugs causing photoallergic reactions.

Keywords: Cefixime, cephalosporin, photoallergic reaction


How to cite this article:
Kalathil AA, Phiske MM, Someshwar S. Photoallergic reaction to cephalosporin: Hitherto unreported. Indian J Drugs Dermatol 2022;8:94-7

How to cite this URL:
Kalathil AA, Phiske MM, Someshwar S. Photoallergic reaction to cephalosporin: Hitherto unreported. Indian J Drugs Dermatol [serial online] 2022 [cited 2023 Feb 8];8:94-7. Available from: https://www.ijdd.in/text.asp?2022/8/2/94/367116




  Introduction Top


Drug-induced photosensitivity refers to cutaneous adverse drug reaction (CADR) resulting from combined effects of chemical and light.[1] These include photoallergic and phototoxic reactions.

Photoallergic reactions are dose-independent Type IV hypersensitivity reactions.[2] They are localized to photo-exposed areas, with generalization occurring in severe cases. Orally, non-steroidal anti-inflammatory drugs (NSAIDs) and antimicrobials and topically, benzophenones, cinnamates in sunscreens are implicated in photoallergic reactions.[3] Photoallergic reactions are rare, occurring sporadically owing to individual susceptibility to a drug.

In India, cephalosporins are commonly prescribed antibiotics (13.15%) and Kotwani et al. reported that the most commonly prescribed cephalosporins are of third generation (cefuroxime and cefixime) due to their better clinical efficacy and lesser adverse effects.[4],[5]

[Table 1] enlists the CADR of individual class of cephalosporins.[5],[6]
Table 1: CADR to common cephalosporins[5],[6]

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Among cephalosporins, cefotaxime and ceftazidime have been associated with photo-induced telangiectasia and sunburn susceptibility, respectively.[7]

To the best of our knowledge, cephalosporin induced photoallergy has not been reported in literature. Our case highlights a unique case of photoallergic reaction to oral Cefixime.


  Case History Top


A 47-year-old male, office worker, presented with red itchy lesions initially on neck with subsequent spread to sun exposed areas of upper limbs and chest, 3 days after taking oral Cefixime. There was intermittent sun exposure owing to travel for work.

Patient had undergone cholecystectomy, post which he received IV cefotaxime for 5 days followed by oral cefixime for 7 days post operatively. Although IV cefotaxime was well tolerated, 3 days after starting oral Cefixime, he developed above complaints, without any systemic symptoms and signs.

He denied ingestion of any other medication apart from oral cefixime. He had taken oral cefixime 45 days ago, post second sitting of endoscopic retrograde cholangiopancreatography, after which he developed similar but milder lesions which resolved with topical potent steroids. Apart from this episode patient denied any drug reaction in the past or in the family.

Cutaneous examination revealed multiple, well defined, round to irregular erythematous plaques with raised borders and central mild hyperpigmentation over V-area of neck and retroauricular area [[Figure 1]A and B]. Similar erythematous papules and plaques, with pseudovesiculation were seen symmetrically on extensor aspects of bilateral forearms [[Figure 2]A and B].
Figure 1: (A) Multiple, erythematous plaques with raised borders and central mild hyperpigmentation over V area of neck. (B) Multiple, erythematous plaques with raised borders and central mild hyperpigmentation over retroauricular area

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Figure 2: (A) Multiple, erythematous papules and plaques with raised borders seen over right forearm. (B) Multiple, erythematous papules, and plaques with raised borders with pseudovesiculation seen symmetrically on extensor aspects left forearm

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Biopsy from erythematous plaque on forearm revealed basket weave hyperkeratosis overlying an acanthotic epidermis. Foci of spongiosis causing vesiculation with lymphocytes in the foci were seen in the epidermis. Upper dermis showed dense infiltrate of lymphocytes and neutrophils and perivascular infiltrate. Mid and deeper dermis showed mild peri-appendageal lymphocytes [[Figure 3]A–E], suggesting photoallergic reaction. Naranjo (causality score 7) and World Health Organization-Uppsala Monitoring Centre criteria (probable) confirmed the causality to be Cefixime.
Figure 3: (A) H&E, 4X: Basket weave hyperkeratosis overlying acanthotic epidermis, focal marked spongiosis, upper and mid dermal perivascular infiltrate. (B) H&E, 4X: Perifollicular and periappendageal infiltrate in the deeper dermis. (C) H&E, 10X: Marked foci of spongiosis causing vesiculation with lymphocytes in the foci and dense upper dermal infiltrate. (D) H&E, 40X: Foci of spongiosis causing vesiculation. (E) H&E, 40X: Dense neutrophilic and lymphocytic infiltrate in the upper dermis

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With the final diagnosis of photoallergic reaction to Cefixime, he was started on oral corticosteroids in tapering dose, oral hydroxychloroquine, anithistamines, sunscreen, and emollients, with complete clearance of lesions at the end of two months [[Figure 4]A–D]. No further similar complaints were reported by patient over telephonic conversation at the end of 4 months.
Figure 4: (A) Complete resolution of lesions without residual pigmentation over extensors of bilateral (B/L) forearms. (B) Complete resolution of lesions without residual pigmentation over volar aspect of B/L forearms. (C) Complete resolution of lesions without residual pigmentation over V area of neck. (D) Complete resolution of lesions without residual pigmentation over B/L retroauricular region

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  Discussion Top


Photoallergic reactions were first reported in the early 1960s, to halogenated salicylalinide.[8]

[Table 2] enlists the common systemic and topical drugs implicated for photoallergic reaction.[3]
Table 2: Common systemic and topical drugs causing photoallergic reaction [3]

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They can occur at all ages. Males are more commonly affected due to greater chances of exposure to the antigen.[3]

Events of the pathogenesis are summarized in [Flow Chart 1].[3]
Flow Chart 1: Events in the pathogenesis of photoallergic reactions

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In sensitized individuals, exposure to the photoallergen and sunlight results in the development of a pruritic, eczematous eruption within 24–48 h after exposure. The distribution of the eruption is predominantly confined to sun-exposed areas such as “V” of the neck. Although sparing of the “Wilkinson’s triangle” behind the earlobe is a distinctive feature, in severe cases, it may spread to the covered areas.

Diagnosis is based on history, presentation on photo-exposed areas and histopathology which shows epidermal spongiosis, moderate lymphohistiocytic infiltrate with epidermal cell necrosis. Photopatch tests can be confirmatory, being positive only in 7%–20%.[9],[10] Management is symptomatic with withdrawal of offending agent, use of protective clothing, sunscreens, antihistamines, topical and systemic corticosteroids based on the severity of the lesions.


  Conclusion Top


In India, Cephalosporins are one of the frequently prescribed antibiotics, with known cutaneous adverse effects such as exanthems, urticaria, fixed drug eruption, erythema multiforme, Steven–Johnson syndrome, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis. Photoallergic reactions are seldom reported with cephalosporins, with only telangiectasia and sunburn being reported with cefotaxime and ceftazidime.

With photo-patch test having limited role, high degree of clinical suspicion and clinico-histopathological correlation is diagnostic.

Thus, in the existing list of systemic drugs causing photoallergic reactions, cephalosporin group of drugs like cefixime should be an important addition.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

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.



 
  References Top

1.
Ibbotson SH Shedding light on drug photosensitivity reactions. Br J Dermatol 2017;176:850-1.  Back to cited text no. 1
    
2.
Onoue S, Seto Y, Sato H, Nishida H, Hirota M, Ashikaga T, et al. Chemical photoallergy: Photobiochemical mechanisms, classification, and risk assessments. J Dermatol Sci 2017;85:4-11.  Back to cited text no. 2
    
3.
Krupashankar DS, Shashikala K Photodermatology and photodermatoses. In: Sacchidanand S, Oberoi C, Inamdar Arun C, editors. IADVL Textbook of Dermatology. 4th ed. Mumbai: Bhalani Publishing House; 2015. p. 887-932.  Back to cited text no. 3
    
4.
Farooqui HH, Selvaraj S, Mehta A, Heymann DL Community level antibiotic utilization in India and its comparison vis-à-vis European countries: Evidence from pharmaceutical sales data. PLoS One 2018;13:e0204805.  Back to cited text no. 4
    
5.
Kumar R, Karki R, Barakoti H, Dc N Drug utilization evaluation of cephalosporins in medicine ward of a tertiary care teaching hospital, Nepal. World J Pharm Pharm Sci 2020;9:1066-76.  Back to cited text no. 5
    
6.
Litt JZ, Shear NL Litt’s Drug Eruption & Reaction Manual. 24th ed. Boca Raton, FL: Taylor & Francis Group; 2018. p. 377.  Back to cited text no. 6
    
7.
Blakely KM, Drucker AM, Rosen CF Drug-induced photosensitivity—An update: Culprit drugs, prevention and management. Drug Saf 2019;42:827-47.  Back to cited text no. 7
    
8.
Lozzi F, Di Raimondo C, Lanna C, Diluvio L, Mazzilli S, Garofalo V, et al. Latest evidence regarding the effects of photosensitive drugs on the skin: Pathogenetic mechanisms and clinical manifestations. Pharmaceutics 2020;12:1104.  Back to cited text no. 8
    
9.
Jindal N, Sharma NL, Mahajan VK, Shanker V, Tegta GR, Verma GK Evaluation of photopatch test allergens for Indian patients of photodermatitis: Preliminary results. Indian J Dermatol Venereol Leprol 2011;77:148-55.  Back to cited text no. 9
    
10.
Margarida G Photopatch testing. In: Johansen J, Frosch P, Lepoittevin JP, editors. Contact Dermatitis. 5th ed. Berlin, Heidelberg: Springer; 2010. p. 519-31.  Back to cited text no. 10
    


    Figures

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

  [Table 1], [Table 2]



 

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