JAGS
OCTOBER 2014–VOL. 62, NO. 10
earlier positive clinical effects of rivastigmine, another oral acetylcholinesterase inhibitor, galantamine, was started after 1 month. Four days after initiation of galantamine treatment, he developed a rash at the previous location. Galantamine treatment was discontinued, and the rash disappeared. After 2 weeks, oral memantine, a N-methyl-Daspartate receptor inhibitor, was initiated as an alternative treatment, and he experienced no adverse drug reactions.
DISCUSSION A suspected side effect with a cross-reaction of acetylcholinesterase inhibitors is described in this case-report. Oral treatment with galantamine caused skin lesions similar to those from the patch with rivastigmine. According to the Naranjo algorithm, the likelihood that the adverse drug reaction was due to the suspected drug was probable.5 Two cases of individuals with allergic dermatitis after administration of rivastigmine patches are previously described. In one, transdermal rivastigmine was replaced with oral rivastigmine, and the rash grew.6 In the other, transdermal rivastigmine treatment was discontinued, and after disappearance of the rash, oral rivastigmine was administered under anesthesiological surveillance. In this case, the skin lesions reappeared at the same location, after which rivastigmine treatment was discontinued in any form.7 Recurrent dermatitis at a previously sensitized site after reexposure at a new site has been reported with nickel, gold, and chromate.8 No case reports were found of recurrent dermatitis after switching to oral therapy of a different acetylcholinesterase inhibitor, such as galantamine in this case. Locally induced T-cells at the site of the allergic dermatitis could have caused the reappearance of the rash at the previously sensitized site with the use of a different oral acetylcholinesterase inhibitor. Allergic dermatitis is a T-cell-mediated delayed type of hypersensitivity, and even with disappearance of the skin lesions, T-cells can be detected at this site for at least 21 days after the skin rash.8,9 In this case, no skin biopsy was performed. To the knowledge of the authors, this is the first reported case in which oral administration of galantamine lead to reappearance of an allergic dermatitis on a site that had previously been sensitized by transdermal rivastigmine. This case shows that, in the case of local side effects, sensitization can occur. Screening for recurrent local effects after switching from a patch to oral therapy of the suspected drug or to a drug from the same therapeutic drug group may be useful. Nienke M. S. Gol€ uke, MSc Department of Geriatric Medicine, University Medical Centre, Utrecht, the Netherlands Astrid M. van Strien, MD Paul J. L. Dautzenberg, MD, PhD Department of Geriatric Medicine, Jeroen Bosch Hospital ‘s-Hertogenbosch, the Netherlands Naomi Jessurun, PharmD LAREB, Netherlands Pharmacovigilance Centre ‘s-Hertogenbosch, the Netherlands
LETTERS TO THE EDITOR
2013
Carolina J. P. W. Keijsers, MD Department of Geriatric Medicine, University Medical Centre, Utrecht, the Netherlands Department of Geriatric Medicine, Jeroen Bosch Hospital ‘s-Hertogenbosch, the Netherlands
ACKNOWLEDGMENTS Conflict of Interest: Paul JL Dautzenberg was on the 2012 advisory boards for Eli Lilly and Novartis, received sponsorship for a memory congress from 2001 to 2013 from Novartis, and participated in Phase III medication trials from MSD, Novartis, and Janssen-Cilag during the conduct of the study. All other authors declare no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work. Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors contributed to the drafting of the manuscript. Data collection: Dautzenberg, van Strien. Study supervision: Keijsers. All authors approved the final version. Sponsor’s Role: No sponsor.
REFERENCES 1. European Public Assessment Report. Exelon 2013. European Medicine Agency Science Medicines Health [on-line]. Available at http:// www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/ 000169/human_med_000777.jsp&mid=WC0b01ac058001d124 Accessed April 2, 2014. 2. Darreh-Shori T, Jelic V. Safety and tolerability of transdermal and oral rivastigmine in Alzheimer’s disease and Parkinson’s disease dementia. Expert Opin Drug Saf 2010;9:167–176. 3. Wouters CJ, Dautzenberg L, Thissen A et al. Galantamine of rivastigmine pleister. Een beschrijvend onderzoek op een geheugenpolikliniek in Nederland. Tijdschr Gerontol Geriatr 2010;41:146–150 (Dutch). 4. Summary of Product Characteristics. Reminyl Tablets 2013. Electronic Medicines Compendium [on-line]. Available at http://www.medicines.org.uk/emc/ medicine/10335/SPC/Reminyl+Tablets/ Accessed April 2, 2014. 5. Narnajo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30: 239–245. 6. Makris M, Koulouis S, Koti I et al. Maculopapular eruption to rivastigmine’s transdermal patch application and successful oral desensitization. Allergy 2010;65:925–926. 7. Grieco T, Rossi M, Faina V et al. An atypical cutaneous reaction to rivastigmine transdermal patch. J Allergy 2011;2011:752098. 8. Nuare A, Cruz PD. Recall dermatitis at patch test sites in alopecia areata treated with diphencyprone. Dermatitis 2012;23:98–99. 9. Moed H, Boorsma DM, Tensen CP et al. Increased CCL27-CCR10 expression in allergic contact dermatitis: Implications for local skin memory. J Pathol 2004;204:39–46.
CONSTIPATION: AN UNUSUAL PRESENTATION OF ULCERATIVE PANCOLITIS IN AN ELDERLY ADULT To the Editor: Ulcerative colitis (UC), along with Crohn’s disease (CD), is one of the major types of inflammatory bowel disease. UC has a bimodal age distribution; the
2014
LETTERS TO THE EDITOR
OCTOBER 2014–VOL. 62, NO. 10
JAGS
present in the current case, and the diagnosis of ischemic colitis was excluded radiologically and histologically. In conclusion, UC should be among the differential diagnoses for not only chronic diarrhea, but also for constipation in elderly adults. Clinical presentation may not correlate with the severity of endoscopic findings. € € urk, MD Omer Ozt€ Seyfettin K€ okl€ u, MD Osman Y€ uksel, MD Department of Gastroenterology, School of Medicine, Hacettepe University, Ankara, Turkey
ACKNOWLEDGMENTS
Figure 1. Severe colitis on colonoscopy.
prevalence is highest between the second and fourth decades, and the second peak occurs in older adults.1,2 A 77-year-old woman was admitted to the gastroenterology department with a complaint of constipation for the previous 6 months. Past medical history was unremarkable. Physical examination was normal other than lower abdominal pain during deep palpation. Laboratory findings showed normal biochemical tests and hemoglobin 11.8 g/dL (normal 12.6–17.4 g/dL), sedimentation rate 23 mm/h (normal 0–25 mm/h), and C-reactive protein 0.4 mg/dL (normal
OCTOBER 2014–VOL. 62, NO. 10
earlier positive clinical effects of rivastigmine, another oral acetylcholinesterase inhibitor, galantamine, was started after 1 month. Four days after initiation of galantamine treatment, he developed a rash at the previous location. Galantamine treatment was discontinued, and the rash disappeared. After 2 weeks, oral memantine, a N-methyl-Daspartate receptor inhibitor, was initiated as an alternative treatment, and he experienced no adverse drug reactions.
DISCUSSION A suspected side effect with a cross-reaction of acetylcholinesterase inhibitors is described in this case-report. Oral treatment with galantamine caused skin lesions similar to those from the patch with rivastigmine. According to the Naranjo algorithm, the likelihood that the adverse drug reaction was due to the suspected drug was probable.5 Two cases of individuals with allergic dermatitis after administration of rivastigmine patches are previously described. In one, transdermal rivastigmine was replaced with oral rivastigmine, and the rash grew.6 In the other, transdermal rivastigmine treatment was discontinued, and after disappearance of the rash, oral rivastigmine was administered under anesthesiological surveillance. In this case, the skin lesions reappeared at the same location, after which rivastigmine treatment was discontinued in any form.7 Recurrent dermatitis at a previously sensitized site after reexposure at a new site has been reported with nickel, gold, and chromate.8 No case reports were found of recurrent dermatitis after switching to oral therapy of a different acetylcholinesterase inhibitor, such as galantamine in this case. Locally induced T-cells at the site of the allergic dermatitis could have caused the reappearance of the rash at the previously sensitized site with the use of a different oral acetylcholinesterase inhibitor. Allergic dermatitis is a T-cell-mediated delayed type of hypersensitivity, and even with disappearance of the skin lesions, T-cells can be detected at this site for at least 21 days after the skin rash.8,9 In this case, no skin biopsy was performed. To the knowledge of the authors, this is the first reported case in which oral administration of galantamine lead to reappearance of an allergic dermatitis on a site that had previously been sensitized by transdermal rivastigmine. This case shows that, in the case of local side effects, sensitization can occur. Screening for recurrent local effects after switching from a patch to oral therapy of the suspected drug or to a drug from the same therapeutic drug group may be useful. Nienke M. S. Gol€ uke, MSc Department of Geriatric Medicine, University Medical Centre, Utrecht, the Netherlands Astrid M. van Strien, MD Paul J. L. Dautzenberg, MD, PhD Department of Geriatric Medicine, Jeroen Bosch Hospital ‘s-Hertogenbosch, the Netherlands Naomi Jessurun, PharmD LAREB, Netherlands Pharmacovigilance Centre ‘s-Hertogenbosch, the Netherlands
LETTERS TO THE EDITOR
2013
Carolina J. P. W. Keijsers, MD Department of Geriatric Medicine, University Medical Centre, Utrecht, the Netherlands Department of Geriatric Medicine, Jeroen Bosch Hospital ‘s-Hertogenbosch, the Netherlands
ACKNOWLEDGMENTS Conflict of Interest: Paul JL Dautzenberg was on the 2012 advisory boards for Eli Lilly and Novartis, received sponsorship for a memory congress from 2001 to 2013 from Novartis, and participated in Phase III medication trials from MSD, Novartis, and Janssen-Cilag during the conduct of the study. All other authors declare no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work. Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors contributed to the drafting of the manuscript. Data collection: Dautzenberg, van Strien. Study supervision: Keijsers. All authors approved the final version. Sponsor’s Role: No sponsor.
REFERENCES 1. European Public Assessment Report. Exelon 2013. European Medicine Agency Science Medicines Health [on-line]. Available at http:// www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/ 000169/human_med_000777.jsp&mid=WC0b01ac058001d124 Accessed April 2, 2014. 2. Darreh-Shori T, Jelic V. Safety and tolerability of transdermal and oral rivastigmine in Alzheimer’s disease and Parkinson’s disease dementia. Expert Opin Drug Saf 2010;9:167–176. 3. Wouters CJ, Dautzenberg L, Thissen A et al. Galantamine of rivastigmine pleister. Een beschrijvend onderzoek op een geheugenpolikliniek in Nederland. Tijdschr Gerontol Geriatr 2010;41:146–150 (Dutch). 4. Summary of Product Characteristics. Reminyl Tablets 2013. Electronic Medicines Compendium [on-line]. Available at http://www.medicines.org.uk/emc/ medicine/10335/SPC/Reminyl+Tablets/ Accessed April 2, 2014. 5. Narnajo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30: 239–245. 6. Makris M, Koulouis S, Koti I et al. Maculopapular eruption to rivastigmine’s transdermal patch application and successful oral desensitization. Allergy 2010;65:925–926. 7. Grieco T, Rossi M, Faina V et al. An atypical cutaneous reaction to rivastigmine transdermal patch. J Allergy 2011;2011:752098. 8. Nuare A, Cruz PD. Recall dermatitis at patch test sites in alopecia areata treated with diphencyprone. Dermatitis 2012;23:98–99. 9. Moed H, Boorsma DM, Tensen CP et al. Increased CCL27-CCR10 expression in allergic contact dermatitis: Implications for local skin memory. J Pathol 2004;204:39–46.
CONSTIPATION: AN UNUSUAL PRESENTATION OF ULCERATIVE PANCOLITIS IN AN ELDERLY ADULT To the Editor: Ulcerative colitis (UC), along with Crohn’s disease (CD), is one of the major types of inflammatory bowel disease. UC has a bimodal age distribution; the
2014
LETTERS TO THE EDITOR
OCTOBER 2014–VOL. 62, NO. 10
JAGS
present in the current case, and the diagnosis of ischemic colitis was excluded radiologically and histologically. In conclusion, UC should be among the differential diagnoses for not only chronic diarrhea, but also for constipation in elderly adults. Clinical presentation may not correlate with the severity of endoscopic findings. € € urk, MD Omer Ozt€ Seyfettin K€ okl€ u, MD Osman Y€ uksel, MD Department of Gastroenterology, School of Medicine, Hacettepe University, Ankara, Turkey
ACKNOWLEDGMENTS
Figure 1. Severe colitis on colonoscopy.
prevalence is highest between the second and fourth decades, and the second peak occurs in older adults.1,2 A 77-year-old woman was admitted to the gastroenterology department with a complaint of constipation for the previous 6 months. Past medical history was unremarkable. Physical examination was normal other than lower abdominal pain during deep palpation. Laboratory findings showed normal biochemical tests and hemoglobin 11.8 g/dL (normal 12.6–17.4 g/dL), sedimentation rate 23 mm/h (normal 0–25 mm/h), and C-reactive protein 0.4 mg/dL (normal
