Here we describe a caseof a woman who had DM after treatment withlacosamide. To our knowledge, drug-induced DMfrom lacosamide has not been reported previously

Gaffney, Rebecca G.

Tarazi, Meera

Werth, Victoria P.

English

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsStudent Papers & Posters Student Materials7-1-2018Drug-induced dermatomyositis after lacosamide: Acase report.Rebecca G. GaffneyCorporal Michael J. Crescenz VAMC; University of Pennsylvania; Rutgers Robert Wood Johnson Medical SchoolMeera TaraziCorporal Michael J. Crescenz VAMC; University of Pennsylvania; Thomas Jefferson University, meera.tarazi@jefferson.eduVictoria P. WerthCorporal Michael J. Crescenz VAMC; University of PennsylvaniaLet us know how access to this document benefits youFollow this and additional works at: https://jdc.jefferson.edu/student_papersPart of the Dermatology CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inStudent Papers & Posters by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationGaffney, Rebecca G.; Tarazi, Meera; and Werth, Victoria P., "Drug-induced dermatomyositis afterlacosamide: A case report." (2018). Student Papers & Posters. Paper 37.https://jdc.jefferson.edu/student_papers/37CASE REPORTDrug-induced dermatomyositis afterlacosamide: A case reportRebecca G. Gaffney, BA,a,b,c Meera Tarazi, BA,a,b,d and Victoria P. Werth, MDa,bPhiladelphia, Pennsylvania and New Brunswick, New JerseyKey words: dermatomyositis; drug induced; lacosamide.INTRODUCTIONDermatomyositis (DM) is an autoimmune con-nective tissue disease characterized by cutaneousmanifestations, muscle inflammation, and proximalmuscle weakness. DM may develop in patients afteran environmental insult initiates an autoimmunereaction in genetically predisposed individuals.1Environmental triggers of DM cited in the literatureinclude ultraviolet radiation, viruses, vaccines,medical devices, emotional stress, and drugs.2Although the role of drug-induced DM is notwell established, many drugs have been implicatedin the development of DM. A review of 70 casereports by Seidler and Gottlieb3 identified hydro-xyurea, penicillamine, and hydroxymethylglutarylCo-A reductase inhibitors as the most commondrugs described in drug-induced DM. Otherdrugs included phenylbutazone, cyclophospha-mide, etoposide, imatinib mesylate, interferon-a2b,omeprazole, phenytoin, tegafur, alfuzosin, etaner-cept, and gemfibrozil.3 Here we describe a caseof a woman who had DM after treatment withlacosamide. To our knowledge, drug-induced DMfrom lacosamide has not been reported previously.CASEA 49-year-old white woman with a history ofpartial seizures presented to her dermatologist with a3-month history of rash and proximal muscleweakness in February 2017. The patient had a red,pruritic rash on her chest 1 month after starting150 mg of lacosamide twice daily for her seizures.The rash traveled to her bilateral ears, elbows, hands,and the nasal bridge over the next 2 months withmild transient proximal muscle weakness during thistime. Clinical evaluation found antinuclearantibodies (1:160) with speckled pattern. Serumstudies for Smith, RNP, SS-A/Ro, SS-B/La, Mi-2, andJo-1 were negative. Additionally, creatinine kinaseand aldolase were within normal limits. Antithyroidperoxidase antibodies were significantly elevated at305 IU/mL (normal level, \35 IU/mL); however,thyroid function test results were within normallimits. A biopsy of the proximal interphalangeal jointfound a lichenoid dermatitis with positive granularC5B-9 and weaker IgM and C3 deposition along thebasement membrane zone on direct immunofluo-rescence. She was prescribed topical steroids andreferred to a private rheumatology practice forfurther assessment. The patient was given apreliminary diagnosis of autoimmune thyroiditisand DM by her rheumatologist in March 2017 andwas prescribed 10 mg/d of prednisone with a 5-mgtaper each month. She completed her prednisonetaper before presenting to our clinic in May 2017.On presentation, the patient reported minimallyimproved skin symptoms since taking prednisone.Abbreviations used:AED: antiepileptic drugANA: antinuclear antibodiesCDASI: Cutaneous Dermatomyositis Disease Areaand Severity IndexDM: dermatomyositisHCQ: hydroxychloroquineFrom Corporal Michael J. Crescenz VAMCa; Department ofDermatology, University of Pennsylvania, Perelman School ofMedicineb; Rutgers Robert Wood Johnson Medical School, NewBrunswickc; and Sidney Kimmel Medical College, ThomasJefferson University, Philadelphia.dFunding sources: This work was supported by the United StatesDepartment of Veterans Affairs (Veterans Health Administra-tion, Office of Research and Development and BiomedicalLaboratory Research and Development).Conflicts of interest: None disclosed.Correspondence to: Victoria P. Werth, MD, Department ofDermatology, University of Pennsylvania, Perelman Center forAdvanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard,Philadelphia, PA 19104. E-mail: werth@pennmedicine.upenn.edu.JAAD Case Reports 2018;4:584-5.2352-5126Published by Elsevier on behalf of the American Academy ofDermatology, Inc. This is an open access article under the CCBY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).https://doi.org/10.1016/j.jdcr.2018.03.009584The remainder of review of systems was negative.Physical examination was significant for erythemaon the chest, elbows, right ear, extensor upper arms,and erythematous plaques or Gottron papules overthe proximal interphalangeal joints. There wereproximal fingernail fold telangiectasias ondermoscopy. She had 5/5 muscle strength in bothupper and lower extremities. She was prescribed400 mg/d of hydroxychloroquine (HCQ) andcontinued with topical steroids.On follow-up examination 3 months later, thepatient’s skin findings were unchanged from those ofher previous visit, and she had a documentedCutaneous Dermatomyositis Disease Area andSeverity Index (CDASI) score of 13. Despite herlimited improvement, the patient was kept on thesame dose of HCQ but was instructed to stop takinglacosamide by her neurologist. Four months afterdiscontinuing lacosamide, the patient presented toour clinic with significant improvement of her skineruption. On examination, the patient’s CDASI scoredecreased 7 points from her last visit to a score of 6.Her pulmonary function test results were withinnormal limits, and pelvic ultrasound scan found abenign fibroid. Given the improvement of hersymptoms after withdrawal of lacosamide, thepatient was kept on the same dose of HCQ.DISCUSSIONBiopsy-proven DM developed in our patient1 month after starting lacosamide and had persistentsymptoms despite treatment with prednisone and3 months of maximum-dose HCQ. After being off oflacosamide for 4 months, her CDASI improved 7points from a score of 13 to a score of 6, a decreasethat is defined as significant clinical improvementbased on CDASI validation studies.4 These findingsfulfill the World Health Organization causalityassessment criteria for a ‘‘probable causal relation-ship’’ between lacosamide and the development ofDM.5 Although the patient did not have concurrentlung disease or malignancy based on screening tests,she will still require routine monitoring.Given the known association of autoimmunethyroiditis with DM, the patient was likely geneticallypredisposed to DM development, and lacosamidemay have acted as an environmental trigger.6Lacosamide, a third-generation antiepileptic drug(AED), acts on neuronal voltage-gated sodiumchannels and has only been previously describedto cause cutaneous manifestations throughhypersensitivity reactions.7 The mechanism fordrug-induced DM remains unclear; however, it hasbeen proposed that certain drugs may inflict damageto endothelial cells leading to release of cellularantigens and epitope spreading, which causes anautoimmune reaction.2 Though early generations ofAEDs have actually been found to dampen theimmune response, lacosamide is a newer drug andits effects on nonneuronal cells and the immunesystem have not been studied.8CONCLUSIONAlthough lacosamide has not been reportedpreviously to induce dermatomyositis, we havefound a temporal relationship in the developmentof dermatomyositis with lacosamide exposure andimprovement of symptoms upon withdrawal of thedrug. Physicians should be aware of this relationshipand consider lacosamide as a possible etiologicfactor in development of dermatomyositis.REFERENCES1. Miller FW, Cooper RG, Vencovsky J, et al. Genome-wideassociation study of dermatomyositis reveals genetic overlapwith other autoimmune disorders. Arthritis Rheum. 2013;65(12):3239-3247.2. Mamyrova G, Rider LG, Ehrlich A, et al. Environmental factorsassociated with disease flare in juvenile and adult dermato-myositis. Rheumatology (Oxford). 2017;56(8):1342-1347.3. Seidler AM, Gottlieb AB. Dermatomyositis induced by drugtherapy: a review of case reports. J Am Acad Dermatol. 2008;59(5):872-880.4. Anyanwu CO, Fiorentino DF, Chung L, et al. Validation of theCutaneous Dermatomyositis Disease Area and Severity Index(CDASI): characterizing disease severity and assessingresponsiveness to clinical change. Br J Dermatol. 2015;173(4):969-974.5. The use of the WHO-UMC system for standardised casecausality assessment World Health Organization.6. Wang H, Tao L, Li H, Deng J. Dermatomyositis related toautoimmune thyroiditis. J Eur Acad Dermatol Venereol. 2011;25(9):1085-1093.7. Koubeissi MZ, Vismer M, Ehrlich A. Lacosamide-induced rash.Epileptic Disord. 2014;16(3):380-383.8. Godhwani N, Bahna SL. Antiepilepsy drugs and theimmune system. Ann Allergy Asthma Immunol. 2016;117(6):634-640.JAAD CASE REPORTSVOLUME 4, NUMBER 6Gaffney, Tarazi, and Werth 585

Drug-induced dermatomyositis after lacosamide: A case report.

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Drug-induced dermatomyositis after lacosamide: A case report.

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