Contrast-induced generalized bullous fixed drug eruption resembling Stevens-Johnson syndrome

Abstract

A 59-year-old woman with end-stage renal disease presented for suspected Stevens-Johnson syndrome that was ultimately diagnosed as generalized bullous fixed drug eruption (GBFDE) secondary to the administration of iodinated nonpolar radiocontrast. The patient had three previous episodes of a generalized bullous eruption after a thrombectomy, fistulogram, and an arteriovenous fistula revision, all requiring radiocontrast administration. Biopsies taken after previous eruptions demonstrated full-thickness epidermal necrosis, and she was diagnosed with Stevens-Johnson syndrome thought to be due to allopurinol. However, against medical advice she continued taking allopurinol and remained asymptomatic until the current presentation. Based on the clinical appearance and time frame of the eruptions, the patient was diagnosed with GBFDE due to radiocontrast. GBFDE, a rare variant of a fixed drug eruption, can be misdiagnosed as Stevens-Johnson syndrome due to their overlapping features of drug-induced whole-body blisters and variable degrees of epidermal necrosis.

A case of Stevens–Johnson syndrome‐like eruption suggesting clinical importance of body temperature and serum levels of receptor‐interacting kinase 3

“…5 The dense distribution of epidermal necrotic keratinocytes accompanying mild lymphocytic infiltration (Figure 1G, H), including Foxp3-positive cells in the upper dermis (Figure 1I), favored SJS. 2 Collectively, the present case exhibited a rather good general status and rapid response to treatment considering the clinical and histological findings, which were supported by the serum levels of biomarkers described above and that suggest pathogenesis of non-SJS/TEN. Serum levels of RIP3 have especially been reported to correlate with not only severity of SJS/TEN but also body temperature.…”

“…1 In addition to the rather good general status and rapid response to treatment, the short duration (i.e., half a day) was also inconsistent with SJS. 2 Further analyses using serum collected at the first visit to our department revealed the following. The low serum level of granulysin (2.5 ng/ml) was inconsistent with SJS.…”

Iodinated contrast-induced Stevens-Johnson syndrome: A report of a rare complication for a common imaging agent

“…Other possibilities were ruled out such as HSV, VZV and mycoplasma infections. Generalized Bullous J o u r n a l P r e -p r o o f 6 Fixed Drug Eruption (GBFDE) could also be considered given the similarity in presentations 16,17 but GBFDE has mucosal involvement in only 44-67% of patients whereas SJS/TEN almost always has mucosal involvement. Histopathology of GBFDE shows eosinophilic involvement which is less common in SJS/TEN.…”

“…A diagnosis of generalized bullous fixed drug eruption (GBFDE) could also be considered, given the similarity in presentations. 16 , 17 However, GBFDE will have mucosal involvement in only 44% to 67% of patients. In contrast, SJS and TEN will almost always have mucosal involvement.…”

A Review of Fixed Drug Eruption with a Special Focus on Generalized Bullous Fixed Drug Eruption

“…Antiepileptics such as phenytoin, carbamazepine, and phenobarbital are frequently implicated [ 5 , 9 ]. Agents other than medications, such as intravenous contrast and the influenza vaccine, have also been reported to cause FDE [ 24 , 25 ].…”