University Journal of Pre and Para Clinical Sciences

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1 ISSN Volume 2 Issue CASE REPORT- A RARE CASE OF DAPSONE HYPERSENSITIVITY SYNDROME VINOTH KUMAR CHITTARANJAN Department of Pharmacology, MADRAS MEDICAL COLLEGE AND GOVERNMENT GENERAL HOSPITAL Abstract : INTRODUCTIONDapsone is a leprostatic drug used in treatment of multibacillary and paucibacillary leprosy. A rare, fatal systemic hypersensitivity syndrome called Dapsone Hypersensitivity Syndrome characterized by fever, skin rash, eosinophilia, lymphadenopathy, hepatic, pulmonary and other systemic manifestations can complicate dapsone therapy. CASE REPORTA 26 year old male was admitted with complaints of fever, vomiting, rashes over both upper and lower limbs, swelling over both sides of neck. Patient developed above complaints after 5 weeks of initiation of multidrug therapy for leprosy. On examination pallor, jaundice, bilateral cervical lymphadenopathy, erythema and scaling of skin over both the extremities were present. Lab investigations showed eosinophilia and mild elevation of liver enzymes. A diagnosis of Dapsone hypersensitivity syndrome was made based on history of dapsone intake, followed by fever, skin rash, eosinophilia, lymphadenopathy and hepatitis. Tablet Dapsone was stopped immediately. He was started on IV Antibiotics, IV Dexamethasone, Tablet Paracetamol. After 7 days IV Dexamethasone was changed to T. Prednisolone 60 mg day and tapered and stopped over the next 4 weeks. The patient responded well to therapy.discussiondapsone is metabolized by two pathways, N-acetylation and N-hydroxylation. The formation of toxic intermediate metabolites such as hydroxylamines and possibly other compounds through N-hydroxylation pathway were responsible for dapsone syndrome. A high index of suspicion for early diagnosis, along with prompt treatment are essential to prevent fatalities. Keyword :Dapsone Hypersensitivity Syndrome, N-acetylation, N-hydroxylation IN- TRODUCTION: Dapsone (4,4 - diaminodiphenylsulfone) is a leprostatic drug commonly used in treatment of Multibacillary (MB) and Paucibacillary (PB) leprosy [1]. Dapsone was introduced for the treatment of leprosy patients by Robert Cochrane in 1947 in Chingelput, South India

2 . Lowe initially prescribed a daily dose of 300 mg orally, before a safe dose of 100 mg was established [2]. Commonly encountered adverse effects of this drug include skin hypersensitivity reactions, hemolytic anemia and methemoglobinemia. Other adverse effects include insomnia and psychosis. A rare, fatal systemic hypersensitivity syndrome characterized by fever, skin rash, eosinophilia, lymphadenopathy, hepatic, pulmonary and other systemic manifestations can complicate dapsone therapy. The features were first described by Lowe. Later Allday named these features as dapsone syndrome. This syndrome can cause irreversible organ damage or even death if not recognized early and managed properly [3]. Dapsone syndrome is also called Sulfone syndrome or Dapsone Hypersensitivity Syndrome(DHS) or Five week dermatitis.a case report on Dapsone Hypersenstivity syndrome can create awareness among the physicians for early diagnosis and prompt treatment which are essential to prevent fatalities caused by it. This case report was submitted after obtaining written informed consent from the patient and approval from the Institutional Human Ethic- C o m m i t t e e. CASE REPORT:A 26 year old male from Villupuram was admitted on 22/07/2013 in the Department of InternalMedicine at Rajiv Gandhi Government General Hospital, Chennai with complaints of fever, vomiting,rashes over both upper and lower limbs, swelling over both sides of neck for the past 5 days.diagnosed to have Paucibacillary leprosy and started on multidrug therapy consisting of Rifampicin600mg once a month, Dapsone 100mg Once daily for 6 months. Patient developed the abovecomplaints 5 weeks after the initiation of multidrug therapy for leprosy.on examination pallor, jaundice, bilateral cervical lymphadenopathy, erythema and scaling of skinover both the extremities were present. A hypopigmented patch with ill defined margin of dimensions5 3 cm was seen over the middle of the lateral aspect of right forearm. Touch sensation wasdecreased over the patch. No peripheral nerve thickening was seen. In Peripheral smear no malarial parasites were seen. FNAC of neck nodes showed Reactive lymphadenitis. Ultrasound study of the abdomen showed mild hepatomegaly. DIAGNOSIS: DAPSONE HYPERSEN- SITIVITY SYNDROME ( DHS ) A diagnosis of Dapsone hypersensitivity syndrome was made based on history of dapsone intake,followed by fever, skin rash, eosinophilia, lymphadenopathy and hepatitis. Tablet Dapsone wasstopped immediately. He was started on IV Antibiotics, IV Dexamethasone, Tablet Paracetamol. After3 days T.Paracetamol was stopped. After 7 days IV Antibiotic was stopped and IV Dexamethasonewas changed to T. Prednisolone 60 mg/ day (1 mg / kg / day) and tapered and stopped over the next4 weeks. The patient responded well to therapy and there was dramatic improvement in the clinicalfeatures during the above period. He was discharged with a regimen consisting of Rifampicin 600 mgonce a month & Clofazimine 300 mg once a month and 50 mg daily for 5 months. As per WHOcausality assessment scale [4] this adverse drug reaction was categorized

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4 as Probable. DISCUSSION: Dapsone is used for treatment or prophylaxis of several infections (leprosy, toxoplasmosis, malaria,cutaneous mycetoma), in several dermatological conditions (acne,dermatitis herpetiformis) and in immune thrombocytopenic purpura. Dapsone is one of the commonly implicated drugs in drug induced systemic hypersensitivity syndrome, apart from anticonvulsants, sulfonamides, allopurinol, non-steroidal antiinflammatory drugs and minocycline [5]. This drug hypersensitivity syndrome associated with Drug cutaneous mycetoma), in several dermatological conditions (acne,dermatitis herpetiformis) and in immune thrombocytopenic purpura.dapsone is one of the commonly implicated drugs in drug induced systemic hypersensitivity syndrome, apart from anticonvulsants, sulfonamides, allopurinol, non-steroidal anti-inflammatory drugs and minocycline [5]. This drug hypersensitivity syndrome associated with Drug Rash, Eosinophilia and Systemic Symptoms, is called DRESS syndrome. DHS is a rare adverse effect reported. DHS usually occurs 4-6 weeks after initiation of Dapsone therapy and can develop upto as long as six months after treatment initiation. The incidence ranges from 0.5% to 3% [6]. The commonest age group is years [7]. Manifestations of DHS include high grade fever, skin rash, lymphadenopathy, eosinophlia, hepatitis, acute pneumonitis, neurological and other systemic features of multi-organ dysfunction. Apart from the cutaneous lesions which are always found, the other features may not necessarily be present in all cases [8],[9]. The cutaneous manifestations of this syndrome show wide variations including erythroderma, papular erythematous eruptions, erythema multiforme, toxic epidermal necrolysis and Stevens-Johnson syndrome. Erythematous maculopapular rash and exfoliative dermatitis are present in majority of the cases.the diagnosis of DHS is based on clinical findings of fever, skin rash, lymphadenopathy, hepatitis and other systemic features, along with history of antecedent dapsone Exposure. In the present case, the diagnosis was based on typical clinical manifestations following 5 weeks of dapsone intake, after excluding other drug exposures and close differential diagnosis (viral hepatitis, EBV infections, complicated malaria) and was further supported by prompt response to systemic steroids. Dapsone syndrome has to be distinguished from the type II lepra reaction (erythema nodosum leprosum ) by the presence of a different kind of rash and the onset of jaundice [10]. Rechallenge with Dapsone is not recommended, as it can be hazardous.pathogenesis of DHS is unclear. There is some evidence to suggest that metabolic differences in the production and detoxification of reactive metabolites of dapsone play an important role in sulfonamide hypersensitivity reactions [11].Dapsone is metabolized by two pathways, N-acetylation and N- hydroxylation [12] (oxidation). The formation of toxic intermediate metabolites such as hydroxylamines and possibly other compounds through N- hydroxylation pathway are considered to be responsible for dapsone syndrome [13]. However, the production and detoxification of toxic metabolites of dapsone is influenced by genetic and environmental factors. Ageing and pre-existing liver disease (cirrhosis) offer relative protection against adverse affects because of decreased enzyme activity and therefore, decreased production of toxic metabolites.

5 The management involves immediate discontinuation of dapsone, systemic steroids (oral prednisolone 1 mg/kg/day or intravenous methylprednisolone in equivalent doses) with supportive care. Gradual tapering of prednisolone over more than a month is recommended because dapsone persists in the body up to 35 days [14]. Mortality as high as 12-23% has been reported in severe DHS [15].Early diagnosis, along with immediate treatment are essential to prevent mortality due to DHS. This case was presented for its clinical rarity and a knowledge about this will enlighten the treating physicians in managing this type of adverse drug reactions in the future. Conflict of interest - None. REFERENCES: 1 Brunton LL, Chabner BA, Knollman BC (Eds):Goodman and Gilman s The Pharmacological Basis of Therapeutics:12 th edn: McGraw-Hill, New York, Lowe J. Treatment of leprosy with diaminodiphenylsulfone. Lancet 1950;2: Vinod KV, Arun K, Dutta TK. Dapsone hypersensitivity syndrome: A rare life threatening complication of dapsone therapy. J Pharmacol Pharmacother 2013;4: The use of the WHO-UMC system for standardised case causality assessment. Acccessed from: Knowles SR, Shapiro LE, Shear NH. Reactive metabolites and adverse drug reactions: Clinical considerations. Clin Rev Allergy Immunol 2003;24: Kosseifi SG, Guha B, Nassour DN, Chi DS, Krishnaswamy G. The Dapsone hypersensitivity syndrome revisited : A potentially fatal multisystem disorder with prominent hepatopulmonary manifestations. J Occup Med Toxicol 2006; 1:9. 7 Prasad P V. A study of dapsone syndrome at a rural teaching hospital in South India. Indian J Dermatol Venereol Leprol 2001;67: Tomecki KJ, Catalan CJ. Dapsone hypersensitivity. Arch Dermatol 1981;117 : Hortaleza Ma AR, Salta-Ramos NG, Barcelona-Tan J, et al. Dapsone syndrome in a Filipino man. Lepr Rev 1995;66: Boopal Raj JM. Emergencies in leprosy, CME lectures on Emergency Dermatology, seventh South- Zone Conference of Indian Association of Dermatologists,Venereologists and Leprologists 1997; Shear NH, Spielberg SP, Grant DM. Difference in metabolism of sulfonamides predisposing to idiosyncratic toxicity. Ann Intern Med, 1986;105: Grossman SJ, Jollow DJ. Role of dapsone hydroxylamine in dapsone induced hemolytic anaemia. J Phamacol Exp Ther 1998;224: Prussik R, Shear NH. Dapsone hypersensitivity syndrome. J Am Acad Dermatol 1996;35:

6 14 Thappa D M, Sethuraman G. Dapsone (sulfone) syndrome (CME).Indian J Dermatol Venereol Leprol 2000;66: Pandey B, Shrestha K, Lewis J, Hawksworth RA, Walker SL. Mortality due to dapsone hypersensitivity syndrome complicating multidrug therapy for leprosy in Nepal. Trop Doct 2007;37: