Clinical Therapeutics
Conclusion:  Fenofibrate-photo-induced hypersensitivity is a known
adverse effect of the drug. Besides, clinicians should be aware of the
possibility of oral hyperpigmentation related to fenofibrate.
Generalized bullous fixed Drug
eruption: a case series
H. Ben Romdhane1; S. Larif1; R. Slim1; N. Fathallah1;
C. Belajouza2; N. Ghariani2; and C. Ben Salem1
1 reaction characterized by rash, fever, internal organ involvement occur-
Faculty of Medicine of Sousse, Tunisia; and 2Farhat Hached
University Hospital of Sousse, Tunisia
Introduction:  Generalized bullous fixed drug eruption (GBFDE) is
a rare and severe form of fixed drug eruption (FDE) that may be
misdiagnosed with other forms of bullous drug eruptions (BDE).
Herein, we report three cases of GBFDE.
Case Reports:  Case 1: An 89-year-old man developed an indurated
edematous plaque on his arm 1 day after acetaminophen ingestion.
There was an extension of the lesion with occurrence of flaccid vesi-
cles. There was a previous history of recurrent reaction in the same
sites. The rash resolved after acetaminophen withdrawal. Case 2:
A 48-year-old woman presented with well-defined bullous lesions
and ovular patches spread diffusely over her arms, trunk and face,
which appeared 1 day after the consumption of mefenamic acid.
The diagnosis of GBFDE was considered especially with a reported
history of a previous reaction occurring in the same site. A patch
test with mefenamic acid revealed a positive reaction. Case 3: A
51-year-old man developed well-limited bullous lesions located on
the trunk, arms and scrotum, 24h after mefenamic acid intake. He
reported two other previous episodes occurring in the same site. The
role of mefenamic acid was confirmed by a patch test on a residual
pigmented lesion.
Discussion:  Differential diagnosis to GBFDE is BDE such as Stevens-
Johnson syndrome and toxic epidermal necrolysis. A history of
hyperpigmented and bullous lesions occurring at the same sites
related to drug consumption may be helpful in diagnosing GBEDE.
Positive rechallenge with the suspected drug is useful with FDE but
it may be dangerous with GBFDE as lesions may be extensive and
more severe. Patch tests on lesional skin may be a safe alternative to
identify the incriminated drug in GBFDE.
Conclusion:  Clinicians should be aware of the risk of GBFDE. Patch
test may be a useful tool in identifying GBFDE.
Hypersensitivity to Amoxicillin after
allopurinol-induced hypersensitivity
syndrome: a co-sensitization to
unrelated drugs
N. Fathallah1; R. Slim1; S. Larif1; A. Aounallah2; N. Ghariani2;
R. Nouira2; and C. Ben Salem1
1 after prick skin tests.
Faculty of Medicine of Sousse, Tunisia; and 2Farhat Hached
University Hospital of Sousse, Tunisia
Introduction:  Allopurinol hypersensitivity syndrome is a rare but
severe adverse drug reaction. Although cross-reactivity reactions are
reported with chemically related drugs, drug hypersensitivity after a
history of DRESS syndrome induced by chemically unrelated drugs is
exceptional. Herein, we point out a possible co-sensitization to chem-
ically and antigenically unrelated drugs: amoxicillin and allopurinol.
Case description:  A 76-year-old female with a 10-year history of
hypertension and a six-year history of chronic renal failure was
initiated on allopurinol for the treatment of hyperuricemia. Three
weeks later, the patient developed generalized exanthema with fever
and cervical lymphadenopathy. Biochemical investigation revealed
hypereosinophilia with cytolysis.
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Allopurinol-induced hypersensitivity syndrome was suspected
and the drug was withdrawn. All symptoms were relieved after two
weeks. Four months later, the patient exhibited an extensive pruritic
skin rash associated with fever and hypereosinophilia, 2 days after
amoxicillin intake for respiratory tract infection. Symptoms disap-
peared few days after amoxicillin withdrawal. We noted that our
patient was previously exposed to amoxicillin without any history of
hypersensitivity to the drug or to other beta-lactam drugs.
Discussion:  Allopurinol hypersensitivity syndrome is a severe adverse
ring 2 to 6 weeks after drug initiation. It is more frequently associated
with chronic renal insufficiency in relation to the accumulation of
allopurinol’s metabolite leading to tissue damage. Hypersensitivity to
amoxicillin after allopurinol-related DRESS, two drugs without any
chemical or antigenic similarity, are rare and are due at least in part, to
the administration of amoxicillin during the period of immunological
depression following the hypersensitivity to allopurinol.
Conclusion:  Clinicians should be cautious when prescribing amoxi-
cillin to a patient with a previous history of hypersensitivity syndrome
to allopurinol.
Hypersensitivity to penicillins diagnosed
with delayed reading prick tests
S. Larif; N. Fathallah; R. Slim; H. Zayani; and C. Ben Salem
Faculty of Medicine of Sousse, Tunisia
Background:  Penicillins are widely prescribed class of antibiotics
because of their activity spectrum and cost effectiveness. Nevertheless
they can be prohibited because of allergic reactions. In these cases,
skin tests can be useful and have to be applied according to the
pathomechanism of the allergy-induced by the drug. In immediate
beta-lactam drug allergy, an Ig E-mediated reaction can be demon-
strated by a positive skin prick test with a reading at 20 mn. Herein,
we report a case of hypersensitivity to penicillin diagnosed with a
delayed reading prick tests.
Case Report:  A 27 year old female with an unconfirmed history of
anaphylaxis reaction to beta-lactamins in the age of 3 years is presented
to our department in order to confirm this allergy. Clinical investiga-
tion included a skin Prick test to co-amoxicillin, oxacillin, ampicillin
and cefotaxim. The reading at 20 mn and 30 mn was negative. We have
proposed for our patient intradermal test (IDT) but she refused. Forty-
eight hours later, warm pruritic and erythematous nodules appeared in
the area of the co-amoxicillin and ampicillin prick tests.
Conclusion: Skin prick tests are the safest and easiest tests for
detecting immediate drug reactions. The result is evaluated after15-
20 mn. If negative, IDT can be performed. We present evidence
that prick skin tests should be evaluated certainly after 20 mn but
even after 24 and 48 hours. Both patients and clinicians should be
aware of the risk of switching from negative to positive reactions
Nummular eczema secondary to
interferon BETA-1B therapy in a patient
with multiple Sclerosis
S. Larif1; N. Fathallah1; R. Slim1; H. Zayani1; N. Ghariani2; and
C. Ben salem1
1
Faculty of Medicine of Sousse, Tunisia; and 2Farhat Hached
University Hospital of Sousse, Tunisia
Introduction:  Interferon beta-1b is an immunomodulatory drug with
proven efficacy in the treatment of multiple sclerosis (MS). Herein,
we report an unusual case of nummular eczema following exposure
to interferon beta-1b in a middle-aged woman with MS.
Volume 37 Number 8S

Case Description:  A woman in her 40S was diagnosed with the
relapsing remitting form of MS. Four months after the first dose
of interferon beta-1b (8 million units, one time weekly), the patient
was seen in the dermatology clinic for evaluation of pruritus and
multiple eczema-like lesions on the legs and bottom. Physical exami-
nation findings revealed erythematous nummular patches on the legs
and bottom with linear excoriations (Figure 1). Involved skin biopsy
revealed a mild epidermal hyperplasia with spongiosis and lympho-
cyte exocytosis, overlying parakeratosis and a perivascular lympho-
cytic dermal infiltrate including rare eosinophils. Interferon beta-1b
was withdrawn, and the patient received 0.05% betamethasone
dipropionate ointment. There was an improvement of the lesions.
Two months later, interferon was readministrated and few days later
the patient noted an aggravation of the previous lesions with develop-
ment of new lesions. Interferon was definitely stopped.
Discussion:  In our case, the pathogenic role of the interferon beta-1b
seems likely, because the lesions occurred during the course of treat-
ment, regressed after withdrawing the treatment, reappeared after the
reintroduction of interferon, and other evident etiologies of eczema
were absent. Skin manifestations resulting from treatment with inter-
feron beta-1b consist principally of injection-site reaction with lesions
varying from sclerotic dermal plaques to erythematous plaques to
cutaneous ulcers. The etiology of nummular eczema is multifactorial,
involving allergic, environmental, emotional, and nutritional factors.
Drugs such as isotretinoin, interferon alfa-2b and ribavirin are rarely
reported to be a trigger factor.
Conclusion:  Physicians should be aware of this side effect induced
by interferon beta-1b.
Anticonvulsivant-induced dress
syndrome in Children: two cases
N. Fathallah1; A. Mlika2; R. Slim1; S. Larif1; H. Zayani1;
L. Boughammoura2; and C. Ben Salem1
1
Faculty of Medicine of Sousse, Tunisia; and 2Farhat Hached
University Hospital of Sousse, Tunisia
Introduction:  Drug Rash with Eosinophilia and Systemic Symptoms
(DRESS) is a severe drug-induced hypersensitivity syndrome associ-
ated with multisystem involvement. It may occur in both adults and
children. However, it is poorly known by pediatricians and rarely
reported in children. We report two cases of DRESS syndrome-
induced by anticonvulsivants occurring in children.
Case Reports:  Case 1: A 9-year-old boy with a medical history of
partial seizures treated by carbamazepine presenting with three days
history of generalized erythema and facial edema associated with
fever, lymph node enlargements and hypereosinophilia, one week
after CBZ initiation. Case 2: A 7 year-old boy presented a generalized
exanthema with fever, hypereosinophilia and cytolysis three weeks
after lamotrigine initiation for the treatment of partial seizures.
Discussion:  DRESS-syndrome is a rare drug-induced hypersensitiv-
ity reaction. Compared to adults, fewer cases involving children are
reported in the literature. Nevertheless, it is considered to be a pedi-
atric emergency owing to its potential life-threatening consequences.
In children, DRESS syndrome may mimic infectious, neoplastic and
immunologic conditions. This may delay the diagnosis and the
prompt management. DRESS syndrome is characterized by diffuse
maculopapular rash, lymphadenopathy, multivisceral involvement,
eosinophilia and/or atypical lymphocytes. The pathophysiology of
DRESS syndrome remains unclear. It has been recently classified
under a delayed type IVb hypersensitivity reaction where T-helper
type 2 cells play a significant role. Early recognition of the syndrome
and withdrawal of the culprit drug may be the key step to preventing
mortality or substantial organ damage.
August 2015
Poster Presentations
Conclusion:  In children, increase in awareness enables early recog-
nition of anticonvulsant-induced DRESS syndrome so as to reduce
morbidity and mortality.
Pharmacogenetic tests: new tools for
old questions in adverse Drug reactions?
N. Fathallah; R. Slim; S. Larif; and C. Ben Salem
Department of clinical Pharmacology, Matebolic biophysics,
professional toxicology and applied Environmental Laboratory
LR12ES02, Faculty of Medicine of Sousse, Sousse University,
Tunisia
Background:  The interindividual variability to the standard dose of
certain drugs remains a major problem in clinical practice. It manifests
either by a therapeutic insufficiency or the occurrence of side effects
that are a considerable cause of morbidity and mortality. The variability
is related mainly to genetic factors. Pharmacogenetics is a recognized
discipline within pharmacology that involves testing relevant human
genes, whose products are involved with the inter-individual variability
of a drug’s pharmacokinetics, pharmacodynamics and human leukocyte
antigen profile. The promise of pharmacogenetics is to improve the
therapeutic efficacy of drugs while reducing the incidence and sever-
ity of adverse drug effects, and drive the optimum drug selection for
therapy. The aim of this overview is to provide the situation today of
using pharmacogenetic testing in elucidating adverse drug reactions.
Methods:  Literature review using Pubmed system is conducted and
articles concerning pharmacogenetics and adverse drug reactions are
selected from 2000 to 2014.
Results:  Most adverse drug reactions are type A reactions and repre-
sent major causes of hospitalization, in some cases leading to death.
Pharmacogenetic tests seem to have an important role in minimizing
adverse drug reactions. However, the use of these tests faces substantial
challenges and it is not usually used. In our overview, we provide a list of
the most implicated drugs in adverse drug reactions that are metabolized
by enzymes with variant alleles associated with a poor metabolism pro-
file. Our findings reveal that pharmacogenetic test, for some polymor-
phisms, may be considerably efficacious in preventing adverse effects.
Conclusion:  Most of side effects can be avoided if pharmacoge-
netic tests become routinely applicable. Although differences in
drug response are increasingly recognized, there is an urgent need to
translate the knowledge in this area into clinical recommendations.
Pharmacogenetic tests may be a safe and reproducible tool in the
prevention of adverse drug reaction.
Hypolipidemia and Antidiabetic effect
of aqueous extract of Mesocarp
layer (spongy layer) of cocos
nucifera nut in white albino rats
and medicinal evaluation of the
extract using Phytochemical analysis,
Gas Chromatography and Mass
Sectrophotometer (GC-MS)
S.S. Onasanya1; R.O. Tijani1; and O.A. Jokotaga2
1
Moshood Abiola Polytechnic, Ojere, Abeokuta, Ogun State,
Nigeria; and 2Abraham Adesanya Polytechnic, Ijebu igbo, Nigeria
Background:  This study investigated the effect of the aqueous extract
of the mesocarp layer of Cocos Nucifera on blood sugar level and
lipid profile in normal and Streptozocin- induced diabetes rats and in
rats fed on a high fat diets {HFD} after which Phytochemical analysis
and Gas chromatography-Mass Spectrophotometric evaluation of
the extract was done.
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permission.