Azithromycin/hydroxychloroquine off label use

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 32-year-old woman developed pustular psoriasis during off label treatment with hydroxychloroquine and azithromycin for COVID-19 and during misuse of azithromycin for cutaneous eruptions.

The woman who had a positive family history of psoriasis. She was experiencing progressive annular skin lesions with small sterile pustules overlying painful, erythematous skin and urticarial eruptions, myalgia, and arthralgia from previous 10 days. Therefore, she was admitted. It was reported that, the lesions affected most parts of her body including the upper and lower limbs, face, trunk, forearm and also palms and soles. She did not reported fever, dyspnea or cough. She had developed, COVID-19 infection. Therefore, she had been receiving off label azithromycin and off label hydroxychloroquine [route and dosage not stated] 40 days previously. Thereafter, she developed an onset of her cutaneous eruptions [duration of treatment to reaction onset not stated].

Therefore, the woman started receiving another course of azithromycin without a prescription (misuse). On admission, the examination of skin showed tender, diffuse erythematous plaques with diffuse pustules, scale and crust formation over 75% of her body. There were pustules on the edges of expanding erythematous plaques or on erythematous skin. There was an obvious pitting in some finger nails. There was no organomegaly or lymphadenopathy. Initial laboratory tests were not remarkable except for a lymphopenia and elevated inflammatory markers including lactate dehydrogenase, C-reactive protein and erythrocyte sedimentation rate. She also revealed a positive SARS-CoV-2 test. A lung computed tomography (CT) scan revealed a normal result. Thereafter, a comprehensive diagnostic workup including anti-double stranded DNA antibody (anti-dsDNA), antinuclear antibodies (ANA) titer, antiSmith antibodies (anti-Sm), anti-ribonuclear protein antibody, antihistone antibodies (AHAs), anti-Ro/La antibodies and HLA-B27 revealed negative results. Moreover, test for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) were negative. Thereafter, she started receiving an empiric treatment with prednisolone, cyclosporine, hydroxyzine and clobetasol. Thereafter, histological examination from biopsy revealed intermittent parakeratosis and subcorneal microabscesses of Munro and exaggerated spongiform pustules of Kogoj, mild acanthosis and neutrophilic exocytosis. It was reported that, upper dermis had perivascular lymphocytes and neutrophils whiteout eosinophils which were compatible with pustular psoriasis. Hence a diagnosis of pustular psoriasis was confirmed. Afterwards, she left without any consent. However, on her follow-up in two weeks, it was revealed that her lesions were desquamating and she was in a relatively favorable condition. The development of pustular psoriasis was attributed to off label use of hydroxychloroquine and misuse of azithromycin.

» Editorial comment: Details of this case report have previously been published and processed for Adis PV [see Reactions 9999; 803617831 ]