Acetaminopheninduced leucocytoclastic vasculitis with erosive gastritis

Background: Acetaminophen is a non-steroidal anti-inflammatory drug (NSAID) widely used for its analgesic and antipyretic properties. Although it is relatively very safe, it has been associated with hepatotoxicity and other minor gastrointestinal adverse effects. In addition, it has also been reported that some NSAIDs can cause severe cutaneous adverse effects such as leucocytoclastic vasculitis (LCV). Case description: A 35 yearold female patient was admitted intointensive care unit (ICU) with multiple palpable purpura discretely located bilaterally all over the upper and lower limbs. Prior to its onset, the patient had an episode of severe headache and body pains for which she consumed over the counter (OTC) acetaminophen. The lesions worsened abruptly and a skin biopsy confirmed the presence of leucocytoclastic vasculitis. The patient also had a clinical evidence of erosive gastritis. The offending agent was immediately discontinued and the patient was successfully managed with corticosteroids and supportive therapy. However, the patient was not re-challenged with acetaminophen owing to severity of the reaction as well as for ethical reasons. Discussion and evaluation: An extensive review of the current case reveals the occurrence of erosive gastritis and LCV following the over the counter (OTC) use of acetaminophen. A thorough evaluation of patient’s clinical history, physical examination, laboratory and histological examination, confirmed acetaminophen induced LCV along with erosive gastritis. The present adverse drug reaction was classified as probable with a score of 6according to Naranjo’s scale causality assessment and is classified severe (level 5) according to Hartwig’s scale of severity assessment. Drug induced LCV is an extremely rare reaction. Although it has been reported with a few NSAIDs such as naproxen and Ibuprofen, to best of our knowledge, acetaminophen has never been associated with LCV. The case is also unique in its presentation of LCV occurring concurrently with erosive gastritis in the same patient. Conclusion: Acetaminophen is the most commonly used OTC drug worldwide. Despite its established safety, it can produce serious adverse effect such as leucocytoclastic vasculitis. Early diagnosis and drug with drawl are crucial to the resolution of the leucocytoclastic vasculitis.