Correspondence

Toxic Erythroderma Due to Ticlopidine

N Engl J Med 1999; 340:1212April 15, 1999

Article

To the Editor:

Ticlopidine is used extensively for patients who undergo coronary angioplasty, stent deployment, or both. Most physicians are well aware of its potential side effects, such as diarrhea, neutropenia, or rash. We describe a case in which ticlopidine caused the unusual complication of toxic erythroderma.

A 65-year-old man presented with coronary ischemia due to high-grade stenosis of the proximal left anterior descending coronary artery. He was advised to undergo percutaneous coronary intervention. Ticlopidine (500 mg) was started one day before the procedure. The deployment of the stent was successful, and the patient received two more doses of ticlopidine, 250 mg each, on the day of the procedure. Pruritus and a mild rash on the back developed the next day, and ticlopidine was discontinued. The patient was treated with diphenhydramine and was discharged from the hospital.

Four days later he presented with a temperature of 38.5°C, blood pressure of 96/50 mm Hg, shaking chills, an erythematous and tender rash over most of the body, symmetric and severe swelling of the legs and scrotum, tachycardia, nausea, vomiting, and a distended abdomen. There was no mucosal involvement. Laboratory data showed a white-cell count of 23,000 per cubic millimeter, with a shift to the left and 29 percent band forms, and a few white cells in the urine. Blood and urine cultures were obtained and proved to be negative. The patient was treated with broad-spectrum antibiotics on day 1 for possible sepsis. He was subsequently given intravenous steroids, diphenhydramine, and histamine H₂ blockers and gradually improved over three days. The patient required another two weeks of treatment of oral steroids and diuretics and eventually recovered completely. He did not have complications from the stent while aspirin and atenolol were continued.

Because of the rare occurrence of this complication, we performed an extensive search of the literature and of the data base of the drug manufacturer, Roche Laboratories, but did not find similar case reports. Changes were recently made to the labeling of ticlopidine after a review of 60 cases by Bennett et al.1 regarding the potential for thrombotic thrombocytopenic purpura within one month of drug therapy. Other serious side effects have been reported, such as atypical microangiopathy involving myocardium and death,2 a fatal case of pancytopenia,3 and acute phenytoin toxicity followed by seizures.4 When treating patients with cardiovascular disease, clinicians should be familiar with this important drug and its rare but potentially serious or lethal side effects.

David H. Hsi, M.D.
David J. Mock, M.D.
Thomas A. Rocco, Jr., M.D.
Park Ridge Hospital, Rochester, NY 14626

4 References

1. 1

   Bennett CL, Weinberg PD, Rozenberg-Ben-Dror K, Yarnold PR, Kwaan HC, Green D. Thrombotic thrombocytopenic purpura associated with ticlopidine: a review of 60 cases. Ann Intern Med 1998;128:541-544
   Web of Science | Medline

2. 2

   Alba PM, Baez JM, Paz A, Monge M, Mendoza C. Atypical microangiopathy in a patient treated with ticlopidine. Haematologica 1998;83:380-381
   Web of Science | Medline

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   Gill S, Majumdar S, Brown NE, Armstrong PW. Ticlopidine-associated pancytopenia: implications of an acetylsalicylic acid alternative. Can J Cardiol 1997;13:909-913
   Web of Science | Medline

4. 4

   Privitera M, Welty TE. Acute phenytoin toxicity followed by seizure breakthrough from a ticlopidine-phenytoin interaction. Arch Neurol 1996;53:1191-1192
   Web of Science | Medline

Citing Articles (5)

Citing Articles

1. 1

   P. Bassas, R. Bartralot, V. García-Patos. (2009) Anticoagulación y antiagregación en Dermatología. Actas Dermo-Sifiliográficas 100:1, 7-16
   CrossRef

2. 2

   Ichiro Kurokawa, Makiko Umehara, Setsuko Nishijima. (2006) Lichen planus-type drug eruption resulting from ticlopidine. International Journal of Dermatology 0:0, 060720080827080
   CrossRef

3. 3

   Ichiro Kurokawa, Makiko Umehara, Setsuko Nishijima. (2005) Lichen planus-type drug eruption resulting from ticlopidine. International Journal of Dermatology 44:5, 436-437
   CrossRef

4. 4

   C. Martin Garcia, R. Carmena, R. Garcia, P. Berges, E. Camacho, M. P Cotter, B. de la Hoz. (2001) Fixed drug eruption from ticlopidine, with positive lesional patch test. Contact Dermatitis 44:1, 58-58
   CrossRef

5. 5

   &NA;. (1999) Ticlopidine. Reactions Weekly &NA;:748, 12
   CrossRef