Vancomycin Associated Purpuric Symmetrical Drug-Related Intertriginous and Flexural Exanthema: A Rare Association and an Uncommon Presentation.

Abstract

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE), which was previously called baboon syndrome, is a drug-induced rash that usually involves gluteal region and flexures of the body symmetrically.1 It is an uncommon and peculiar benign drug rash that may not require prior sensitization to the systemic agent and usually subsides on stopping the drug.2 The most common agents causing SDRIFE are antibiotics, especially beta-lactams.3 However, a plethora of non–beta-lactam antibiotics and other drugs may be the causative agents. The exact pathophysiology is unclear, but it is considered to be a type IV hypersensitivity reaction and can be explained by pharmacologic interaction with immunoreceptors, where drug binds to T-cell receptors without being presented by major histocompatibility complex molecules and without prior metabolism.4, 5 The latency may vary from a few hours to even up to a few days. Common presentation includes maculopapular erythema or plaques and, less commonly, blisters and pustules and rarely purpuric lesions.1, 6, 7 Herein, we present a rare case of vancomycin-associated purpuric SDRIFE, which is not only an uncommon association but also an uncommon presentation. A 48-year-old woman with hypertension and chronic kidney disease (on medications for the past 3 years) underwent a continuous ambulatory peritoneal dialysis catheter insertion procedure and was started on injection vancomycin. She developed mild itching, diffuse erythema, and multiple purpuric macules involving the inguinal region, medial thighs in a V-shaped manner, both the popliteal fossa (Figure 1a and b), inframammary region (Figure 1c and d), and axilla the day after starting the drug. There was no associated fever, systemic symptoms, deranged lab parameters, or any history of allergies to any substance/drug. Vancomycin was replaced by injection teicoplanin in view of increasing rash, and she was treated with topical emollients, midpotent topical steroids, and antihistamines. The rash started to resolve within the next 2 to 3 days and regressed completely within the next 6 days. Häusermann et al2 proposed the diagnostic criteria for SDRIFE, which involved exposure to a systemic agent (excluding contact allergens); well-defined erythema over the gluteal, inguinal, perianal or perigenital area, involving at least 1 other intertriginous area, with symmetrical involvement; and absence of systemic symptoms. Our patient fulfilled all the criteria and was diagnosed with vancomycin-associated purpuric SDRIFE. The “Naranjo” score calculated was 5 (category: probable) (Supplemental Information). However, a patch test performed after 6 weeks was negative. Vancomycin is known to cause various adverse effects such as anaphylaxis, linear IgA disease, drug rash eosinophilia and systemic symptoms, bullous dermatosis, and Stevens-Johnson syndrome/toxic epidermal necrolysis.8 Although multiple antibiotics may lead to SDRIFE, reports on vancomycin-associated SDRIFE were not found following a thorough literature search, and purpuric lesions are very rarely defined in SDRIFE. This case report highlights a rare cause of SDRIFE hitherto unreported and is one of the newer etiological agents of this condition. Because vancomycin is one of the commonly used antibiotics, especially in the intensive care unit setup, the awareness of this reaction is required, as purpuric morphology may be alarming to the physicians and may lead to unnecessary investigations. The awareness of this uncommon presentation of a less common side effect may facilitate early identification and contribute to optimal care of the patients. The patient in this article has given written informed consent to the publication of her case details and photographs. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request. Supplementary information Additional supplemental information can be found by clicking the Supplements link in the PDF toolbar or the Supplemental Information section at the end of the web-based version of this article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.