CASE REPORT - s- syndrome in association with Plaquenil treatment for RA

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Rheumatology 2002; 41: 473-474

Letters to the Editor

s– syndrome in association with hydroxychloroquine

treatment for rheumatoid arthritis

M. J. Leckie and R. G. Rees

Department of Rheumatology, St 's NHS Trust, St 's Hospital,

Praed Street, London W2 1NY, UK

SIR, Hydroxychloroquine is widely used in the treatment of rheumatoid

arthritis and systemic lupus erythematosus, with very few reported

side-effects. We report the case of a 65-yr-old woman who developed

s– syndrome 2 weeks after commencing treatment with

hydroxychloroquine. Our patient had a 9-yr history of rheumatoid

arthritis with multiple episodes of relapse and remission. She also

had a medical history of hypertension (treated with bendrofluazide).

Over the course of her disease, she had been treated with prednisolone

at doses ranging from 5 to 20 mg, but was intolerant of gold

(diarrhoea), sulphasalazine (nausea and vomiting), penicillamine

(proteinuria) and methotrexate (mouth ulcers, nausea and

constipation). In March 2001, she had a flare in her arthritis, with

pain, morning stiffness and active synovitis of her wrists, knees and

ankles, and an acute inflammatory response (erythrocyte sedimentation

rate 62 mm/h, C-reactive protein 140 g/l). She was therefore started

on hydroxychloroquine at a dose of 200 mg twice daily. Within 2 weeks,

whilst she was on holiday in Tenerife, she developed a pruritic rash

over her abdomen, which she described as ‘targets’. She stopped the

hydroxychloroquine but within 24 h the rash had become exfoliating,

and she developed oral ulceration and hypotension. This required a

3-day hospital admission and treatment with intravenous followed by

high-dose oral (60 mg) and topical steroids, which resulted in gradual

improvement. On her return to the UK (6 weeks after starting

hydroxychloroquine), she was seen in clinic with a persisting

exfoliating rash and eczematous patches. This was treated with

emollients and topical steroids. Viral serology on her return to the

UK showed negative HSV IgG and Mycoplasma IgM titres. Since the acute

phase of her disease, the steroids have been reduced to 20 mg daily

but the rash, although improving, persists.

s– syndrome is a severe form of erythema multiforme

characterized by a systemic illness with lesions in mucus membranes

[1]. The disease has been related to some drugs, such as the

sulphonamides, penicillin, salicylates, anti-retroviral drugs and

anticonvulsants, and there is an association with Herpes simplex and

Mycoplasma pneumoniae infections [2].

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Read the full article here:

http://rheumatology.oxfordjournals.org/cgi/content/full/41/4/473

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