A 65-year-old immigrant from Eastern Europe comes to the physician because of a four-week history of low-grade fever, multiple joint pains, and a well-demarcated erythematous rash on his face and trunk. The patient denies hair loss, mucosal ulceration, or photosensitivity. His serum test is positive for the presence of anti-nuclear antibody (ANA) in very high titers. The patient reports a past medical history of coronary artery disease, congestive heart failure, and "cardiac rhythm abnormalities." This patient should be specifically questioned about the intake of which of the following medications?

Question

A 65-year-old immigrant from Eastern Europe comes to the physician because of a four-week history of low-grade fever, multiple joint pains, and a well-demarcated erythematous rash on his face and trunk.  The patient denies hair loss, mucosal ulceration, or photosensitivity.  His serum test is positive for the presence of anti-nuclear antibody (ANA) in very high titers.  The patient reports a past medical history of coronary artery disease, congestive heart failure, and "cardiac rhythm abnormalities."  This patient should be specifically questioned about the intake of which of the following medications?

Quizplus · Accepted Answer

11ec160b_3b9d_04a2_9249_075a52d47f24_MD0001_00 Drug-induced lupus erythematosus (DILE) should be considered in patients presenting with signs and symptoms of systemic lupus erythematosus (SLE). Both hydralazine and procainamide are categorized as high-risk drugs for the development of DILE. Procainamide is metabolized via hepatic acetylation. Individuals who are "slow acetylators" are at greatest risk for DILE, while individuals who metabolize the drug more rapidly are less likely to experience this adverse effect. Drug-induced lupus erythematosus occurs in up to 20% of patients taking procainamide. The presence of autoantibodies can be used to help differentiate DILE from SLE. Although anti-histone antibodies are very common in DILE, they are seen in only 50% of SLE patients. Likewise, anti-dsDNA antibodies are present in 80% of SLE patients, but are rarely seen in DILE. Anti-nuclear antibodies are frequently positive in both diseases. (Choice A) The most notable side effects of amiodarone include thyroid dysfunction, lung fibrosis, and liver toxicity, as well as a blue or grey discoloration of the skin. (Choice B) The most frequently encountered adverse effects of nonselective beta-blockers are negative inotropy and bronchoconstriction in patients with asthma or COPD. (Choice C) The adverse effects of lidocaine are characteristically nonfocal neurologic signs such as tremor, drowsiness, and change in mental status, although lidocaine can also lead to generalized seizures. (Choice E) Verapamil is a calcium channel blocker and class 4 antiarrhythmic. The most frequently noted adverse reactions include negative inotropy, constipation, and gingival hyperplasia. (Choice F) Adenosine is used as a vasodilator in chemical cardiac stress tests and as a fast acting antiarrhythmic for stopping acute supraventricular tachycardias. Adenosine has an extremely short half-life, and its immediate adverse effects include chest burning, flushing, and transient hypotension. Educational objective: Procainamide and hydralazine have the highest risk of causing drug-induced lupus erythematosus (DILE), which is characterized by the development of lupus-like symptoms in addition to positive ANA and anti-histone antibodies. Unlike with SLE, anti-dsDNA antibodies are rarely seen. __________ References: Drug-induced lupus. (http://www.ncbi.nlm.nih.gov/pubmed/8842756) Drug-induced lupus erythematosus: incidence, management and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/21513360)

A 65-Year-Old Immigrant from Eastern Europe Comes to the Physician