NSAIDs linked to IgA-mediated hypersensitivity vasculitis and purpura fulminans-like eruption
  • Guy Levenberg
    Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
  • Jonathan Bleier
    Department of Internal Medicine D, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
  • Avshalom Leibowitz
    Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Internal Medicine D, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
  • Ophira Salomon
    Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Thrombosis and Haemostasis Institute, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
  • Mudi Misgav
    Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Thrombosis and Haemostasis Institute, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
  • Nancy Agmon-Levin
    Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Clinical Immunology, Angioedema and Allergy Institute, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
  • Ronen Shavit
    Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Clinical Immunology, Angioedema and Allergy Institute, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel

Keywords

NSAIDs, Vasculitis, Purpura Fulminans, IgA Vasculitis, Drug Hypersensitivity

Abstract

Background: IgA vasculitis and hypersensitivity reactions following exposure to non-steroidal anti-inflammatory drugs (NSAIDs) are very rarely associated with purpura fulminans (PF). The latter is a coagulation event characterised by decreased levels of protein C and a rapidly progressive purpuric rash, often leading to ischaemia, amputations and death.
Case summary: A previously healthy 66-year-old man presented with a vasculitic rash and abdominal pain following exposure to naproxen (NSAID), which quickly deteriorated to purpura fulminans-like eruption and skin necrosis, mainly involving the face and hands. The presence of IgA sediments on skin biopsy and decreased levels of complement as well as protein C pointed to an immune-mediated inflammatory process. Dramatic clinical escalation with immediate risk to organs and life required an aggressive and broad-spectrum therapeutic approach in an intensive care setting. Clinical improvement and complete reconstitution of protein C were achieved following plasma exchange with fresh frozen plasma (FFP) and immunosuppression with glucocorticoids with no persistent organ damage.
Conclusions: This rare case illustrates the catastrophic cross links between NSAIDs, IgA-mediated hypersensitivity vasculitis and purpura fulminans-like syndrome. A high index of suspicion is required for the evaluation of environmental exposures such as drugs and infections in patients with vasculitis and/or purpura. A rapid and comprehensive therapeutic approach should be implemented to avoid multi-organ damage, amputations and death. Complete avoidance of the offending agent is key for future prevention of recurrence.

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    Published: 2023-10-18
    Issue: 2023: Vol 10 No 11 (view)

    How to cite:
    1.
    Levenberg G, Bleier J, Leibowitz A, Salomon O, Misgav M, Agmon-Levin N, Shavit R. NSAIDs linked to IgA-mediated hypersensitivity vasculitis and purpura fulminans-like eruption. EJCRIM 2023;10 doi:10.12890/2023_004072.