Drug-induced glove and stocking distribution rash: A rare
entity in the intensive care unit
Ajith P1, Anjishnujit
Bandyopadhyay1, Kajal Jain1,
Sunaakshi Puri1
1 Department of Anaesthesia and Intensive Care
Postgraduate Institute of Medical Education and Research
Chandigarh- 160012
India
Correspondence to- Dr. Anjishnujit Bandyopadhyay, docbando@gmail.com
Senior Resident, Department of Anaesthesia and Intensive Care
Postgraduate Institute of Medical Education and Research
Chandigarh- 160012
Conflict of Interest – none
Financial disclosures- none
Informed consent was obtained from family
Figure – 1
Word count – 426
A rash in the glove and stocking distribution is rare and was first
reported by Hamm and Feldman in their case series.1Till date there are more than 70 reports published in which the
causative agent was found to be a virus- most commonly parvovirus
B-19.2 On the other hand, drug causing glove and
stocking distribution rash is extremely rare. Other than rare cases of
Cotrimoxazole-associated stock and glove rash, acute adverse cutaneous
drug reactions manifesting as a glove and stocking reported in
literature is absent, to the best of our knowledge.3Written informed consent was obtained from family.
A 45-year old gentlemen admitted in our intensive care unit following
traumatic brain injury developed central line associated blood stream
infection for which culture based vancomycin was started. Within 30
minutes, following administration of first dose of vancomycin patient
developed an erythematous macular rash with a striking glove and
stocking distribution on all the four limbs sparing of face and trunk
(Figure 1). The development of the rash was also associated with
hypotension which was managed by fluid boluses. However, this episode
was not accompanied by fever, bronchospasm or shortness of breath.
Further administration of vancomycin was withheld and was replaced with
teicoplanin. The rash healed with desquamation over 4-5 days following
stoppage of the offending drug, with no long-term cutaneous sequelae.
Red-man reaction is the most common cutaneous adverse drug reaction
following vancomycin administration with an incidence of up to 47%.
Generally, it comprises of a pruritic erythematous rash over face, neck
and torso occurring within 1 hour of first vancomycin administration.
Hypotension and shortness of breath are also not
uncommon.4 The effects are generally relieved with
administration of antihistamines and supportive care. A rash in the
glove and stocking distribution is traditionally associated with viral
infection especially parvovirus B-19 although association with
cotrimoxazole has also been reported.2,3 In our case,
the patient had no evidence of any viral infection and vancomycin was
the only new drug added to the patient treatment. The rash developed
within 30 minutes of drug administration and was also associated with
hypotension, thereby showing a temporal causal association. Moreover,
the rash resolved after withdrawal of vancomycin.
Drug-induced cutaneous drug reactions are a frequent occurrence and are
reported as part of pharmacovigilance. To the best of our knowledge,
such an atypical cutaneous adverse reaction with vancomycin, probably a
variant of Red Man syndrome has not been reported in clinical literature
so far. It is important for clinicians – particularly intensivists, to
be aware and vigilant of this rare manifestation of vancomycin-induced
skin reaction.
References
- Harms M, Feldmann R, Saurat JH. Papular-purpuric “gloves and socks”
syndrome. J Am Acad Dermatol 1990; 23: 850–54.
- Feldmann R, Harms M, Saurat JH. Papular-purpuric ’gloves and socks’
syndrome: not only parvovirus B19. Dermatology. 1994; 188: 85-7
- van Rooijen MM, Brand CU, Ballmer-Weber BK, Yawalkar N, Hunziker TK.
Drug-induced papular-purpuric gloves and socks syndrome. Hautarzt
1999; 50: 280–83.
- Sivagnanam S, Deleu D. Red man syndrome. Crit Care. 2003; 7: 119-120.