Granuloma annulare as a possible new adverse effect of topiramate

BackgroundGranuloma annulare (GA) is a relatively common, self-limiting condition that can be associated with disorders such as diabetes mellitus, malignancy, and thyroid disease, and with the use of some drugs. Topiramate is approved for the prevention of migraine. Its adverse effects include somnolence, fatigue, paresthesia, anorexia and weight loss, and other abnormalities.ObjectivesWe report a 50-year-old woman in whom topiramate at 50mg/d was initiated in January 2010.Case reportOne month after starting topiramate, the patient presented with painless nodules on the left ankle, which later spread to the left leg. Histopathology of a punch biopsy revealed lymphohistiocytic infiltrate, collagen degeneration, and mucin deposition, all of which are characteristic of GA. Two weeks after the discontinuation of topiramate, the lesion resolved. Two years later, the patient resumed topiramate. Two weeks later, a new GA appeared in the same area and disappeared within a few weeks of discontinuation of the drug.ConclusionsAssociations between the use of topiramate and a GA-like reaction have been reported in recent years. Based on the present case, it would appear that an actual association between GA and topiramate is possible given that: (i) the GA appeared only after the initiation of topiramate; (ii) the GA resolved after the discontinuation of topiramate; (iii) the GA reappeared with the resumption of topiramate in the same area and with the same characteristics as previously; and (iv) the lesion healed after topiramate was suspended

Epidemiology of granulomatosis with polyangiitis (Wegener's granulomatosis) in Northern Italy: a 15-year population-based study

To investigate the epidemiology of granulomatosis with polyangiitis (GPA) over a 15-year period in a defined area of northern Italy

Epidemiology and clinical course of Behçet's disease in the Reggio Emilia area of Northern Italy: a seventeen-year population-based study

To investigate the epidemiology and clinical course of Behçet's disease (BD) over a 17-year period in a defined area of northern Italy

[Entre deux, la Compagnie Virevolt. Les affranchis, La Flèche. 2007 / photographies de Joël Verhoustraeten]

The treatment of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is based on remission-induction and remission-maintenance. Methotrexate is a widely used immunosuppressant but only a few studies explored its role for maintenance in AAV. This trial investigated the efficacy and safety of methotrexate as maintenance therapy for AAV.In this single-centre, open-label, randomised trial we compared methotrexate and cyclophosphamide for maintenance in AAV. We enrolled patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA), the latter with poor-prognosis factors and/or peripheral neuropathy. Remission was induced with cyclophosphamide. At remission, the patients were randomised to receive methotrexate or to continue with cyclophosphamide for 12 months; after treatment, they were followed for another 12 months. The primary end-point was relapse; secondary end-points included renal outcomes and treatment-related toxicity.Of the 94 enrolled patients, 23 were excluded during remission-induction or did not achieve remission; the remaining 71 were randomised to cyclophosphamide (n = 33) or methotrexate (n = 38). Relapse frequencies at months 12 and 24 after randomisation were not different between the two groups (p = 1.00 and 1.00). Relapse-free survival was also comparable (log-rank test p = 0.99). No differences in relapses were detected between the two treatments when GPA+MPA and EGPA were analysed separately. There were no differences in eGFR at months 12 and 24; proteinuria declined significantly (from diagnosis to month 24) only in the cyclophosphamide group (p = 0.0007). No significant differences in adverse event frequencies were observed.MTX may be effective and safe for remission-maintenance in AAV.clinicaltrials.gov NCT00751517

Demographic and clinical characteristics of the patients at study entry.

<p>Demographic and clinical characteristics of the patients at study entry.</p

Subgroup analysis of the Kaplan-Meier estimate of the time from remission to first relapse or death (during the planned 24 month-follow-up) in the cyclophosphamide (CYC) and methotrexate (MTX) groups.

<p>The <i>upper panel</i> shows the analysis in patients with GPA or MPA (granulomatosis with polyangiitis or microscopic polyangiitis) while the <i>lower panel</i> shows the analysis in patients with EGPA (eosinophilic granulomatosis with polyangiitis).</p

Relapse frequencies during the planned 24-month follow-up period.

<p>Relapse frequencies during the planned 24-month follow-up period.</p

Adverse events during the planned 24-month follow-up period.

<p>Adverse events during the planned 24-month follow-up period.</p