Multiple drugs

Abstract

Multiple drugsInfantile bullous pemphigoid: case report A case report of two infants described a 2-month-old girl, who developed infantile bullous pemphigoid following vaccination with .The girl presented with a widespread blistering rash, which had began on her feet the day after receiving her 2-month vaccinations:-DTaP-vaccine [DTap], Hib-vaccine [Hib], Rotavirus-W179-9-vaccine [Rotavirus; RV5], Pneumococcal-13-valent-CRM197-vaccine-conjugate [PCV13] and Poliovirus-vaccine-inactivated [Polio; IPV]. Examination showed oedematous, erythematous, polycyclic plaques distributed over the trunk, face, hands, extremities and feet, including involvement of both the ventral and dorsal surfaces of the feet and hands. Several overlying tense and ruptured bullae were noted. No mucosal lesions were noted. Skin biopsy showed neutrophilic and eosinophilic spongiosis with small clusters of neutrophils in the papillary dermal tips on hematoxylin-eosin staining. Perilesional biopsy for direct immunofluorescence revealed linear IgG and C3 along the dermoepidermal junction and weak linear IgA. Serum enzyme linked immunosorbent assay revealed normal BP230 and BP180 >100U. Indirect immunofluorescence performed revealed basement membrane zone IgG antibodies in an epidermal pattern on human salt-split skin substrate. WBC, platelets and absolute eosinophil counts were increased. She was diagnosed with infantile bullous pemphigoid, which was attributed to the vaccines she received.The girl was treated with methylprednisolone for 3 days followed by prednisolone. Due to ongoing new lesions, she was additionally treated with erythromycin and nicotinamide. Three weeks later, she still had widespread, active disease. Therefore, dapsone was added to existing therapy. She continued to have active cutaneous disease. WBCs, platelets and absolute eosinophils (further increased) counts were still elevated. Three weeks following the initiation of dapsone, she started to improve. Thereafter, her absolute eosinophil count normalized with decrease in platelet and WBC counts. Nicotinamide and erythromycin were stopped. Three months later, a steroid taper was started. Another month later, dapsone taper was started. A mild flare developed with an upper respiratory infection. Therefore, dose of dapsone was increased again to its prior dose, and nicotinamide and erythromycin were restarted. She was monitored for adrenal insufficiency. She successfully tapered off systemic steroids 6 months after initial presentation.