Drug-Induced Lupus Erythematosus Differential Diagnoses

  • Author: Ivan D Camacho, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 27, 2012
 
 

Diagnostic Considerations

Drug-induced lupus erythematosus (DILE) is characterized by improvement upon withdrawal of the offending drug or agent in a patient with a previously normal immune system. No specific criteria establish the diagnosis of DILE, and excluding underlying autoimmune disease is not a simple process.

Obvious clinical or serologic evidence of DILE is not invariably present, even in rare cases of fatal DILE. Patients who have serologic and clinical findings that normally indicate systemic lupus erythematosus (SLE) might actually have DILE. The symptoms of both drug-induced SLE flares and DILE are temporally related to drug exposure, and the 2 conditions have similar manifestations. Thus, DILE is typically diagnosed by a process of elimination to rule out SLE. Renal idiopathic lupus should also be considered.

For proper diagnosis, the following factors should be preliminarily confirmed:

  • The patient has 1 or more clinical symptoms of SLE (eg, arthralgias, lymphadenopathy, rash, fever)
  • Antinuclear antibodies are present
  • The patient had no history of SLE before using the culprit drug
  • The drug was taken anytime from 3 weeks to 2 years prior to the appearance of symptoms
  • Clinical improvement is rapid when the drug is discontinued, whereas antinuclear antibodies and other serologic markers slowly decrease toward more normal levels

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Ivan D Camacho, MD  Assistant Professor of Dermatology, Department of Dermatology and Cutaneous Surgery, University of Miami, Leonard M Miller School of Medicine; Medical Director of Dermatology Clinic, Jackson Memorial Hospital

Ivan D Camacho, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Florida Medical Association, International Society of Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

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.

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.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey P Callen, MD Professor of Medicine (Dermatology), 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 Consulting fee Consulting; Celgene Honoraria Safety Monitoring Committee; GSK - Glaxo Smith Kline Consulting fee Consulting; TenXBioPharma Consulting fee Safety Monitoring Committee

Craig A Elmets, MD Professor and Chair, Department of Dermatology, Director, UAB Skin Diseases Research Center, University of Alabama at Birmingham School of Medicine

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; Astellas Consulting fee Review panel membership; Massachusetts Medical Society Salary Employment; Abbott Laboratories Grant/research funds Independent contractor; UpToDate Salary Employment; Biogen Grant/research funds Independent contractor; Clinuvel Independent contractor; Covan Basilea Pharmaceutical Grant/research funds Independent contractor; ISDIN None Consulting; TenX BIopharma Grant/research funds Independent contractor

Michael J Wells, MD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

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Erythematous macules and papules are seen on face, upper chest, and arms in photodistribution.
Dermis contains interface and superficial and deep perivascular lymphohistiocytic infiltrate (×100, hematoxylin-eosin).
Parakeratosis, apoptosis, and basal vacuolization (×200, hematoxylin-eosin).
Table 1. Comparison of Findings Between Drug-Induced Lupus Erythematosus and Systemic Lupus Erythematosus
FindingsSLEDILE
ClinicalAverage age of onset of 20-30 y



Affects blacks more than whites



Female-to-male ratio of 9:1



Average age of onset of 50-70 y



Affects whites more than blacks



Female-to-male ratio of 1:1



Laboratory Antihistone antibodies in 50%



Anti-dsDNA present in 80%



C3/C4 levels decrease



Cutaneous findings in >75%



Raynaud phenomenon in 50%



Antinuclear antibodies in >95%



Antihistone antibodies in >95%



Anti-ssDNA present



Anti-dsDNA rare C3/C4 levels normal



Cutaneous findings in ~25%



Raynaud phenomenon in 25%



Antinuclear antibodies in >95%



Immunofluorescence HistopathologyDirect immunofluorescence reveals granular deposition of IgG at dermoepidermal junction



Lymphohistiocytic interface dermatitis



Apoptosis basal vacuolization



Same as SLE



Same as SLE



DILE = drug-induced lupus erythematosus, IgG = immunoglobulin G; SLE = systemic lupus erythematosus.
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