Bullous fi xed drug eruption secondary to dietary supplement

Fixed drug eruption (FDE) is a cutaneous adverse drug reaction (CADR) due to type IV or delayed cell mediated hypersensitivity [1]. It is characterized by solitary or multiple oval or round lesions that may affect any part of the body. These lesions are commonly developed in trunk, lips, hands, and genital mucosa and presented as an erythematous patch which occurs after administration of an offending drug within hours and heals with residual hyperpigmentation and may recur on the same sites upon read ministration of the same causative agent.


INTRODUCTION
Fixed drug eruption (FDE) is a cutaneous adverse drug reaction (CADR) due to type IV or delayed cell mediated hypersensitivity [1]. It is characterized by solitary or multiple oval or round lesions that may affect any part of the body. These lesions are commonly developed in trunk, lips, hands, and genital mucosa and presented as an erythematous patch which occurs after administration of an offending drug within hours and heals with residual hyperpigmentation and may recur on the same sites upon read ministration of the same causative agent.
Antimicrobial, anti-inflammatory, and anti-convulsive agents are the most common causative drugs associated with FDE.
We report in our knowledge the first case of fixed bullous drug eruption secondary to dietary supplement.

CASE REPORT
A 16-year-old female with no particular medical history. She consulted the emergency department for a hysteria attack putted under D STRESS, 3 days later she showed erythematous itchy lesions on the trunk, back and thighs. She had no history of allergic disease or allergic reactions to drugs.
Dermatologic examination revealed erythematous plaques, partly disappearing at the vitropression of variable size, well defined with irregular contours sitting in chin, the trunk, back and the lower limbs (Figs. 1a -1d), with central blistering of those sitting in thigh and abdomen (Figs. 2a and 2b). The rest of the physical examination did not reveal any abnormalities.
After performing biopsy, the lesion was diagnosed as fixed drug eruption.
A pharmacovigilance investigation was conducted, and D stress was confirmed as the agent responsible for the bullous fixed drug eruption (FDE) in our patient.
Our patient was put on dermocorticoid with degression. The evolution was marked by a clear improvement of the lesions with a residual pigmentation after 1 month of treatment (Figs. 3a and 3b).

DISCUSSION
FDE is one of the most prevalent cutaneous drug induced reactions, and classically presents as a distinctly bordered erythematous lesion that periodically recurs at the same site after administration of a causative drug [1].
Till now pathogenesis of FDE is unknown but cell-mediated immunity, certain serum factors, and antibodies are some of the causative factors. Intraepidermal CD8+ T cells are thought to be responsible for cutaneous manifestations in FDE, producing large amounts of IFN-g. After drug reexposure, cutaneous lesions may occur because of prolonged expression of intercellular adhesion molecule-1 in basal keratinocytes by participation of CD8+ effector/memory T cells [4]. D-Stress is a dietary supplement against stress. It contains 120 mg of magnesium element as well as Taurine, Arginine and B vitamins, acting synergistically to physiologically adapt the body to any stress or fatiguew situation.
FDE is a clinical diagnosis and histological findings are usually supportive.
The initial treatment of FDE is discontinuation of the causative agent, after which lesions typically improve, leaving only hyperpigmented changes on previously affected areas [4].

CONCLUSION
To our knowledge, this is the first case reported in the literature of FDE secondary to dietary supplement use.