Hydroxycloroquine is a foe friend in a drug induced systemic lupus erythematosus?

Abstract

Introduction: The golden standard in the management of systemic lupus erythematosus (SLE) is the hydroxycloroquine. The main listed side effects of hydroxycloroquine are the ocular toxicity and in lupus with myositis overlaps the desquamation. Clinical case: A female patient known with a history of sterility and upper respiratory tract infection (started on June 2015 and resolved in December 2015) on treatment with Amoxicillin and symptomatics presents in January 2016 with parotid swelling and sicca symptoms. Corroborating the history (photosensibility, amoxicillin intake, parotid swelling, sicca symptoms, mother diagnosed with psoriasis) with the immunology panel (positive antibodies for SSA, SSB, RO-52, dsDNA and histone) the patient was diagnosed with secondary Sjogren Syndrome Associated with drug induced SLE. Hydroxicloroquine Associated with low doses of Prednisone was started. After the first dose, the patient complained about pruritus and extended erythematosus plaque. She was admitted in the ER. She was put on high doses of corticosteroids and the hydroxycloroquine was stopped. A skin biopsy was performed showing a pattern characteristic for toxic dermatitis. Results from a prior parotid biopsy are expected. The patient was admitted in the Department of Rheumatology to start a new drug treatment. Conclusion: Four major questions arised from the history of our patient. Did we missed something prior the onset of the treatment with hydroxycloroquine? Was the Amoxicillin to be blamed for the drug induced lupus? Are we dealing with a secondary Sjogren syndrome with complications – eg. lymphoma? What is the best treatment to be started?