Cefuroxime induced lymphomatoid hypersensitivity reaction

Abstract

A symptomatic case of tongue base varices in a patient with portal hypertension secondary to liver cirrhosis is presented. There are no previously documented cases in the world literature. Oesophageal varices may not be the only source of expectorated blood in a patient with portal hypertension. (Postgrad Med J 2000;76:576-577) Keywords: portal hypertension; lingual; tongue; varicose vein Case reportAn 82 year old women with known portal hypertension secondary to cirrhosis of the liver was referred to the otolaryngology outpatient department with a two month history of daily haemoptysis and bloodstained pharyngeal secretions; this occurred mostly on early morning coughing. There was no history of weight loss, dysphagia, dysphonia, or throat pain. She had already been investigated for a pulmonary cause of the haemoptysis and none was found. In keeping with her history, liver function tests and the prothrombin time were abnormal. She also had a history of well controlled essential hypertension. Chest radiography showed cardiomegaly, but the jugular venous pressure was not raised and there was no other clinical manifestation of heart failure.Indirect laryngoscopy revealed varicose vessels in the tongue base, mainly on the left side (see fig 1). These appeared friable and one area revealed a propensity to bleed on examination. The rest of the ear, nose, and throat examination was normal.After perioperative cover with fresh frozen plasma, vitamin K, and tranexamic acid she underwent ablation of the varicosities using a 15 watt continuous carbon dioxide laser under general anaesthesia (see fig 2). She had an uneventful recovery and has remained symptom free. AnatomyThe dorsal lingual veins drain the tongue base through two or more tributaries. These course inferiorly, join together and form the lingual vein, which accompanies the lingual artery. These vessels pass between genioglossus and hyoglossus and the vein empties into the internal jugular vein just above the level of the greater cornu of the hyoid bone. (2) Periumbilical veins-veins contained in the falciform ligament anastomose with superior and inferior epigastric veins of the anterior abdominal wall. Excessive dilatation of these veins are evident as caput medusa.(3) Haemorrhoids-the superior rectal vein anastomoses with the middle rectal vein which drains into the internal iliac vein. In addition the middle rectal veins anastomose with the inferior rectal veins which drain into the internal pudendal vein. Increased shunting results in internal and external haemorrhoids. Thus, there is no recognised anastomosis between lingual venous drainage and the portal circulation. DiscussionA varicosity is a condition indicating an enlarged and tortuous vein. Previously described lingual varices referred to sublingual varices on the ventral surface of the tongue or floor of mouth. These were ascribed to the use of dentures, and vitamin C deficiency in an elderly population. 3Burket associated the occurrence of lingual varices with cardiorespiratory disease,...

Cefuroxime Axetil Associated Oral Eruption: A Case Report

“…However, the b-lactam ring of cephalosporins is well known to impart a degree of instability to the cephalosporin molecule; the ring can open up, conjugate with proteins, become a hapten and immunogenic, and thus induce a delayed type of hypersensitivity reaction. 2 In this case, there is a temporal association between the administration of cefuroxime and the occurrence of rash. The sign of lip edema appeared after 2 days of dose of cefuroxime axetil.…”

“…Among all, cutaneous reactions are reported very frequently, which include urticaria, angioedema, erythema multiforme, exanthema, pruritus, pustular eruptions, glossitis, vaginitis, Henoch-Schonlein purpura with systemic manifestations, and acute generalized exanthematic pustulosis. 2 Sometimes, it causes severe skin and mucosal reactions like Stevens Johnson syndrome and toxic epidermal necrolysis, 3 and congenital fixed drug eruption in a newborn was also reported. 4 Here, we report a case of cefuroxime axetil induced oral eruption during treatment of respiratory tract infection.…”

Inflammatory Dermatopathology

“…In this regard, CD30 expression has been reported in non-neoplastic cutaneous disorders rich in lymphocytes, such as atopic dermatitis, 24 drug reactions, 25,26 scabies 27,28 and molluscum contagiosum infection. 29 In addition, we have recently described the presence of CD30ϩ atypical lymphoid cells in a wide variety of common nonneoplastic cutaneous inflammatory cell infiltrates rich in neutrophils and eosinophils.…”

“…25 CD30ϩ atypical lymphoid cells have been described in one case of an eosinophil-rich rash due to cefuroxime. 26 Atypical perivascular CD30ϩ lymphoid infiltrates have been described in 2 cases of eruptions following chemotherapy for B-cell lymphoma and myeloid leukemia. These infiltrates were reactive in nature and resolved without recurrence in a 12-24 months follow-up.…”

CD30+ Lymphomatoid Drug Reactions

“…Given the time course regarding cefepime, along with a previous report of cephalosporin induced CD30+ drug reactions. 20 Cefepime was felt to be the most likely offending agent.…”