J Rheum Dis.  2014 Dec;21(6):326-330. 10.4078/jrd.2014.21.6.326.

Leflunomide-induced Toxic Epidermal Necrolysis in a Patient with Rheumatoid Arthritis

• Je JH
• Lee HJ
• Na YJ
• Seo JH
• Seo YH
• Kim JH
• Choi SJ
• Lee YH
• Ji JD
• Song GG

• KMID: 2222939
• DOI: http://doi.org/10.4078/jrd.2014.21.6.326

Abstract

Leflunomide was licensed for the treatment of rheumatoid arthritis in 1998 and has been available in Korea since 2003. Allergic cutaneous reactions (rash, purpura) are common (<10%) side effects of leflunomide, but severe cases such as Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) are rarely reported. There has not been a report of SJS or TEN induced by leflunomide in Korea. Here we report a case of leflunomide-induced TEN in a patient with rheumatoid arthritis. Leflunomide was discontinued, and the TEN was treated with methylprednisolone, cholestyramine and immunoglobulin. The skin lesion eventually resolved over four weeks with residual post-inflammatory hyperpigmentation.

Keyword

Leflunomide; Toxic epidermal necrolysis; Rheumatoid arthritis

MeSH Terms

Arthritis, Rheumatoid*
Cholestyramine Resin
Humans
Hyperpigmentation
Immunoglobulins
Korea
Methylprednisolone
Skin
Stevens-Johnson Syndrome*
Cholestyramine Resin
Immunoglobulins
Methylprednisolone

Figure

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  Figure 1. Day 1, The patient had diffuse erythema of the face, erosion of the lips and oral mucosa, and erythematous macules and multiple clear, small, fluid-filled vesicles on her extremities.

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  Figure 2. H&E stain, ×200, subepidermal blister.

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  Figure 3. Day 6, The vesicles and macules changed to bullae, and Nikolsky's sign was present.

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  Figure 4. Day 8, Disrupted vesicles with crusting and spontaneous bleeding were evident during the re-epithelialization period.

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  Figure 5. Day 26, The skin lesions resolved with residual post-inflammatory hyperpigmentation.

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