J Korean Med Sci.  2012 Jul;27(7):818-821. 10.3346/jkms.2012.27.7.818.

Methimazole-Induced Bullous Systemic Lupus Erythematosus: A Case Report

• Seo JY
• Byun HJ
• Cho KH
• Lee EB

• KMID: 2157931
• DOI: http://doi.org/10.3346/jkms.2012.27.7.818

Abstract

Bullous systemic lupus erythematosus (SLE) is a kind of LE-non-specific bullous skin disease that is rarely induced by a medication. We describe the first case of bullous SLE to develop after administration of methimazole. A 31-yr-old woman presented with generalized erythematous patches, multiple bullae, arthralgia, fever, conjunctivitis, and hemolytic anemia. Biopsy of her bulla showed linear deposition of lgG, lgA, C3, fibrinogen, and C1q at dermo-epidermal junction. She was diagnosed as bullous SLE and treated with prednisolone, dapsone, hydroxychloroquine, and methotrexate. Our experience suggests that SLE should be considered as a differential diagnosis when bullous skin lesions develop in patients being treated for hyperthyroidism.

Keyword

Bullous Systemic Lupus Erythematosus; Drug-Induced Lupus Erythematosus; Methimazole; Graves Disease

MeSH Terms

Adult
Anti-Inflammatory Agents/therapeutic use
Antirheumatic Agents/therapeutic use
Antithyroid Agents/*adverse effects/therapeutic use
Blister/chemically induced/pathology
Drug Therapy, Combination
Female
Graves Disease/diagnosis/drug therapy
Humans
Hydroxychloroquine/therapeutic use
Immunosuppressive Agents/therapeutic use
Lupus Erythematosus, Systemic/chemically induced/*diagnosis/drug therapy
Lupus Nephritis/diagnosis/drug therapy
Methimazole/*adverse effects/therapeutic use
Mycophenolic Acid/analogs & derivatives/therapeutic use
Prednisolone/therapeutic use
Skin/pathology
Anti-Inflammatory Agents
Antirheumatic Agents
Antithyroid Agents
Immunosuppressive Agents
Hydroxychloroquine
Mycophenolic Acid
Prednisolone
Methimazole

Figure

• 

  Fig. 1 Gross view of the skin lesion. (A-C) Generalized itchy erythematous to brownish polymorphic patches on the back, legs and arm. (C, D) Discrete tense bullae on her right arm.

• 

  Fig. 2 Histopathology of the skin lesion. (A, B) Histopathologic examination of the skin biopsy specimen showed a subepidermal blister with abundant neutrophils (H&E stain, × 100). (C) Direct immunofluorescence examination showed linear deposition of IgG at the dermo-epidermal junction (× 100).

Reference

1. Hess E. Drug-related lupus. N Engl J Med. 1988. 318:1460–1462.

2. Vassileva S. Bullous systemic lupus erythematosus. Clin Dermatol. 2004. 22:129–138.

3. Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield NF, Schaller JG, Talan N, Winchester RJ. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1982. 25:1271–1277.

4. Yell JA, Allen J, Wojnarowska F, Kirtschig G, Burge SM. Bullous systemic lupus erythematosus: revised criteria for diagnosis. Br J Dermatol. 1995. 132:921–928.

5. Marzano AV, Vezzoli P, Crosti C. Drug-induced lupus: an update on its dermatologic aspects. Lupus. 2009. 18:935–940.

6. Kim BS, Hong YM, Park SM, Park IW, Lee BH, Jeong JH, Lee CW. A case of angiotensin converting enzyme inhibitor-induced systemic lupus erythematosus. J Rheum Dis. 2011. 18:288–291.

7. Shin JA, Huh CW, Kwon JE, Kim HJ, Ahn CM, Chang YS. A case of docetaxel induced subacute cutaneous lupus erythematosus. Tuberc Respir Dis. 2009. 66:380–384.

8. Sontheimer RD, Henderson CL, Grau RH. Drug-induced subacute cutaneous lupus erythematosus: a paradigm for bedside-to-bench patient-oriented translational clinical investigation. Arch Dermatol Res. 2009. 301:65–70.

9. Sakata S, Nakamura S, Nagai K, Komaki T, Kawade M, Niwa T, Miura K. Two cases of systemic lupus erythematosus associated with hyperthyroidism. Jpn J Med. 1987. 26:373–376.

10. Park CO, Goo J, Ahn SK. A case of propylthiouracil-induced lupus erythematosus. Korean J Dermatol. 2006. 44:467–469.

11. Kim JW, Kim JS. A case of propylthiouracil-induced lupus erythematosus accompanied by antineutrophil cytoplasmic antibody-positive vasculitis. Korean J Dermatol. 2005. 43:496–500.

12. Lee J, Yoo B, Lim YJ, Kim SH, Lim M, Cho YS, Shong YK, Moon HB. A case of propylthiouracil-induced lupus. J Korean Rheum Assoc. 1999. 6:75–78.

13. Wang LC, Tsai WY, Yang YH, Chiang BL. Methimazole-induced lupus erythematosus: a case report. J Microbiol Immunol Infect. 2003. 36:278–281.

14. Thong HY, Chu CY, Chiu HC. Methimazole-induced antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and lupus-like syndrome with a cutaneous feature of vesiculo-bullous systemic lupus erythematosus. Acta Derm Venereol. 2002. 82:206–208.

15. Condon C, Phelan M, Lyons JF. Penicillamine-induced type II bullous systemic lupus erythematosus. Br J Dermatol. 1997. 136:474–475.

16. Fleming MG, Bergfeld WF, Tomecki KJ, Tuthill RJ, Norris M, Benedetto EA, Weber LA. Bullous systemic lupus erythematosus. Int J Dermatol. 1989. 28:321–326.

17. Srivastava M, Rencic A, Diglio G, Santana H, Bonitz P, Watson R, Ha E, Anhalt GJ, Provost TT, Nousari CH. Drug-induced, Ro/SSA-positive cutaneous lupus erythematosus. Arch Dermatol. 2003. 139:45–49.

18. Bonsmann G, Schiller M, Luger TA, Ständer S. Terbinafine-induced subacute cutaneous lupus erythematosus. J Am Acad Dermatol. 2001. 44:925–931.

19. Antonov D, Kazandjieva J, Etugov D, Gospodinov D, Tsankov N. Druginduced lupus erythematosus. Clin Dermatol. 2004. 22:157–166.

20. Patrício P, Ferreira C, Gomes MM, Filipe P. Autoimmune bullous dermatoses: a review. Ann N Y Acad Sci. 2009. 1173:203–210.