eMedicine Specialties > Dermatology > Connective Tissue Diseases

Lupus Erythematosus, Drug-Induced: Differential Diagnoses & Workup

Author: Catharine Lisa Kauffman, MD, FACP, Georgetown Dermatology and Georgetown Dermpath
Coauthor(s): Arden E Fredeking, Georgetown University School of Medicine
Contributor Information and Disclosures

Updated: Aug 7, 2009

Differential Diagnoses

Lupus Erythematosus, Discoid
Lupus Erythematosus, Subacute Cutaneous
Neonatal Lupus Erythematosus

Other Problems to Be Considered

Renal idiopathic lupus
Systemic lupus erythematosus

Workup

Laboratory Studies

  • Test for the presence of antinuclear antibodies, which can appear in a homogeneous pattern in as many as 90% of patients with lupus erythematosus (LE).
    • When anti-ssDNA and anti-dsDNA are measured, the prevalence of anti-ssDNA is higher. This is a major difference from systemic lupus erythematosus (SLE); in SLE, antibodies tend to attack double-stranded DNA.
    • Antinuclear antibodies with homogeneous patterns are produced by procainamide, isoniazid, timolol, hydralazine, and phenytoin.
    • In contrast, speckled antinuclear antibody patterns are associated with anti-SSA/Ro antibodies, which can be produced in response to thiazide diuretics such as hydrochlorothiazide.
    • In persons with drug-induced lupus erythematosus, the antibodies also tend to attack histones (proteins typically found in cell nuclei); antihistone antibodies are indicated by a homogeneous pattern of antinuclear antibodies. They are present in more than 75% of patients with drug-induced lupus erythematosus induced by hydralazine and procainamide.
    • One example of an antihistone antibody that is often implicated in drug-induced lupus erythematosus is immunoglobulin G (anti-[H2A-H2B] DNA). Antihistone antibodies are much more likely to indicate drug-induced lupus erythematosus; however, they can also appear in as many as 50% of patients with SLE.
    • In persons with drug-induced lupus erythematosus, anti-Sm antibodies are rare. Complement levels are within the reference range, which is not usually the case in persons with SLE.
  • Further tests in the workup of a patient with possible drug-induced lupus erythematosus are as follows:
    • Urinalysis can be performed to evaluate for hematuria and proteinuria.
    • A BUN and creatinine evaluation is indicated.
    • C3 and C4 levels should be tested. Complement levels are often reduced in persons with SLE, as opposed to those with drug-induced lupus erythematosus; they tend to not be reduced in persons with drug-induced lupus erythematosus.
    • A CBC count should be performed to evaluate for anemia, which is present in most patients with SLE but is rare in those with drug-induced lupus erythematosus.
    • Liver function tests to can be performed to evaluate for hepatic involvement.

Imaging Studies

  • Use chest radiography to rule out pulmonary infiltrates.
  • Use echocardiography, if indicated, to rule out pericarditis.

Procedures

  • Skin biopsy
  • Renal biopsy if renal involvement is suggested

Histologic Findings

  • Skin biopsy and direct immunofluorescence typically reveal findings that are indistinguishable from SLE.
  • Histologic examination reveals variable epidermal atrophy, basal vacuolar degeneration, apoptotic or dyskeratotic keratinocytes, and lymphocytic interface dermatitis (see Media Files 2-3).

    The dermis contains an interface and a superficia...

    The dermis contains an interface and a superficial and deep perivascular lymphohistiocytic infiltrate (100X, hematoxylin and eosin stain).

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    The dermis contains an interface and a superficia...

    The dermis contains an interface and a superficial and deep perivascular lymphohistiocytic infiltrate (100X, hematoxylin and eosin stain).



    Parakeratosis, apoptosis, and basal vacuolization...

    Parakeratosis, apoptosis, and basal vacuolization (200X, hematoxylin and eosin stain).

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    Parakeratosis, apoptosis, and basal vacuolization...

    Parakeratosis, apoptosis, and basal vacuolization (200X, hematoxylin and eosin stain).

  • Direct immunofluorescence may reveal granular deposition of immunoglobulin G along the dermoepidermal junction.

More on Lupus Erythematosus, Drug-Induced

Overview: Lupus Erythematosus, Drug-Induced
Differential Diagnoses & Workup: Lupus Erythematosus, Drug-Induced
Treatment & Medication: Lupus Erythematosus, Drug-Induced
Follow-up: Lupus Erythematosus, Drug-Induced
Multimedia: Lupus Erythematosus, Drug-Induced
References
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References

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  26. Toepfer M, Sitter T, Lochmüller H, Pongratz D, Müller-Felber W. Drug-induced systemic lupus erythematosus after 8 years of treatment with carbamazepine. Eur J Clin Pharmacol. Apr 1998;54(2):193-4. [Medline].

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Further Reading

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Keywords

drug-related lupus, lupuslike syndrome, lupus-like syndrome, lupus erythematosus medicamentosus, drug-induced systemic lupus erythematosus, SLE, drug-induced SLE, drug-induced systemic lupus erythematosus, renal idiopathic lupus, DILE, LE, drug-induced LE, autoimmune disease,  procainamide, chlorpromazine, quinidine, acebutolol, amiodarone, bupropion, captopril, carbamazepine, chlorpromazine, diltiazem, docetaxel, ethosuximide, gemfibrozil, glyburide, gold salt, griseofulvin, hydantoins, hydralazine, hydroxychloroquine, interferons

interleukins, isoniazid, leuprolide acetate, lithium, lovastatin, mephenytoin, methyldopa, minocycline, nitrofurantoin, olanzapine, ophthalmic timolol, oral contraceptives, penicillamine, phenytoin, practolol, procainamide, propylthiouracil, quinidine, reserpine, rifampin, simvastatin, sulfasalazine, tetracycline, ticlopidine, tiotropium bromide inhaler, trimethadione, tumor necrosis factor, valproate, voriconazole, cimedtidine, hydralazine, hydrochlorothiazide, mesantoin, PABA, penicillin, phenylbutazone, sulfonamides, terbinafine, arthralgia, treatment, diagnosis

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Contributor Information and Disclosures

Author

Catharine Lisa Kauffman, MD, FACP, Georgetown Dermatology and Georgetown Dermpath
Catharine Lisa Kauffman, MD, FACP is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Royal Society of Medicine, Society for Investigative Dermatology, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Arden E Fredeking, Georgetown University School of Medicine
Arden E Fredeking is a member of the following medical societies: American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Medical Editor

Craig A Elmets, MD, Director of Dermatology, Departments of Dermatology, Pathology, and Environmental Health Sciences; Professor, The Kirklin Clinic, University of Alabama at Birmingham
Craig A Elmets, MD is a member of the following medical societies: American Academy of Dermatology, American Association of Immunologists, American College of Physicians, American Federation for Medical Research, and Society for Investigative Dermatology
Disclosure: Palomar Medical Technologies Stock None; Amgen Consulting fee Review panel membership; Astellas Consulting fee Review panel membership; Massachusetts Medical Society Salary Employment; Abbott Laboratories Grant/research funds Independent contractor

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology
Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting; Medicis Honoraria Consulting; Celgene Honoraria Consulting

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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