Delayed hypersensitivity reaction resulting in maculopapular-type eruption due to entecavir in the treatment of chronic hepatitis B

Several clinical trials have demonstrated the potent antiviral efficacy of entecavir (ETV), and this relatively new nucleoside analogue drug has rapidly become a frequently prescribed therapy for chronic hepatitis B (CHB) worldwide. While the studies have also shown a good overall safety profile for ETV, adverse drug reactions (ADRs) in patients with advanced cirrhosis have been reported and represent a broad spectrum of drug-induced injuries, including lactic acidosis, myalgia, neuropathy, azotemia, hypophosphatemia, muscular weakness, and pancreatitis, as well as immune-mediated responses (i.e., allergic reactions). Cutaneous ADRs associated with ETV are very rare, with only two case reports in the publicly available literature; both of these cases were classified as unspecified hypersensitivity allergic (type I) ADR, but neither were reported as pathologically proven or as evaluated by cytokine release analysis. Here, we report the case of a 45-year-old woman who presented with a generalized maculopapular rash after one week of ETV treatment for lamivudine-resistant CHB. The patient reported having experienced a similar skin eruption during a previous three-month regimen of ETV, for which she had self-discontinued the medication. Histopathological analysis of a skin biopsy showed acanthotic epidermis with focal parakeratosis and a perivascular lymphocytic infiltrate admixed with interstitial eosinophils in the papillary and reticular dermis, consistent with a diagnosis of drug sensitivity. A lymphocyte stimulation test showed significantly enhanced IL-4, indicating a classification of type IVb delayed hypersensitivity. The patient was switched to an adefovir-lamivudine combination regimen and the skin eruption resolved two weeks after the ETV withdrawal. This case represents the first pathologically and immunologically evidenced ETV-induced delayed type hypersensitivity skin reaction reported to date. Physicians should be aware of the potential, although rare, for cutaneous ADRs associated with ETV treatment.

Cutaneous manifestations during recent pandemic,co-infection or pre or post COVID-19 manifestation-managed by Ayurveda

Background:Unique cutaneous manifestations simulating viral infection like intense itching,rashes,maculo popular eruptions etc are noted.Etiological factors,underlying pathology,prevalence,whether it manifests in initial stage or post covid or if it predicts associated severity,linked symptoms,later complications,adverse drug reactions and many other associated issues need to be reported and evaluated.Method:Reporting five cases with varied cutaneous manifestations during July 2020 from India.Frostbite like skin lesion,maculo papular eruptions in two cases,two rash like manifestations were considered and managed by Ayurveda.Patient who lived in same house as covid infected person,travelled from red zone,who tested positive for COVID-19 infection.Results:Itching and redness were the predominant symptoms which reduced quickly in 6 to 8 hours,eruptions gradually reduced in 3 to 6 days.Conclusions:Cutaneous mani-festations during the pandemic suspected or confirmed COVID-19 infection 5 cases reported from India,managed by Ayurveda indicates post COVID-19 needs to be managed to improve quality of life and prevent further complications.