Letter to the editor about Maculopapular Rash after Penicillin Injection in a Patient with Confirmed Infectious Mononucleosis
Mostafa Shahabi Nejad1, Shayan Shahabi Nejad2, Naser Shahabi Nejad3
1 MS Student of Health Services Management, School of Public Health, Baqiyattallah University of Medical Sciences, Tehran, Iran.
2 Medical Sciences Researcher, Kerman, Iran.
3 Infectious Disease Specialist in Private Clinic, Kerman, Iran.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Mr. Shahabi Nejad Mostafa, Iran, Tehran, Vanak sq, Mollasadra Ave. Sheikhe Bahaei Ave., Baqiyattallah University of Medical Sciences, Faculty of Public Health. E-mail : mostafa.sh.n2212@gmail.com.
Dear Editor
We read your journals and other journals that have reported maculopapular rash developed in patients with Infectious Mononucleosis (IM) after taking antibiotics, such as Ampicillin, Amoxicillin, Minocycline, Azithromycin and Clindamycin [1,2]. But we want to explain another antibiotic which is Penicillin that caused maculopapular rash in an 18-year-old female with confirmed infectious mononucleosis. To our knowledge, there is no reported case in the literature about penicillin induced rash in infectious mononucleosis. The skin rashes developed about a week after the administration of antibiotics and usually have improved up to three months later [3]. Infectious mononucleosis is caused by Epstein-Barr Virus & kissing is the main way of transmitting the primary EBV infection. For this reason it is sometimes called “kissing disease” [4]. The laboratory tests to diagnose this disease are IgM, IgG, PCR (Polymease Chain Reaction) and widely by Monospot Test [5].
The patient that we were talking about developed rashes two days after she had received penicillin. At first we thought that the rashes can be the result of drug sensitivity. But after studying the lab results and clinical symptoms Infectious mononucleosis was confirmed. We used the Naranjo ADR (Adverse Drug Reaction) possible score [Table/Fig-1].
The Naranjo adverse drug reaction score
| BCC subtype | Yes | No | Do not know | Score |
|---|
| 1. Are there previous conclusivereports on this reaction? | +1 | 0 | 0 | 0 |
| 2. Did the adverse event occurafter the suspected drugwas administered? | +2 | -1 | 0 | +2 |
| 3. Did the adverse reaction improve whenthe drug was discontinued or a specificantagonist was administered? | +1 | 0 | 0 | +1 |
| 4. Did the adverse reaction reappear whenthe drug was readministered? | +2 | -1 | 0 | 0 |
| 5. Are there alternative causes(other than the drug) that could haveon their own caused the reaction? | -1 | +2 | 0 | -1 |
| 6. Did the reaction reappear whena placebo was given? | -1 | +1 | 0 | +1 |
| 7. Was the drug detected in the blood(or other fluids) in concentrationsknown to be toxic? | +1 | 0 | 0 | 0 |
| 8. Was the reaction more severe whenthe dose was increased or less severewhen the dose was decreased? | +1 | 0 | 0 | 0 |
| 9. Did the patient have a similar reactionto the same or similar drugs inany previous exposure? | +1 | 0 | 0 | 0 |
| 10. Was the adverse event confirmedby any objective evidence? | +1 | 0 | 0 | +1 |
| Total | | | | +4 |
The mechanism of rash appearance in patients with infectious mononucleosis is not clearly understood. It seems that in some cases, rash development is a non-immunological response. One theory is that, the skin rash may be due to immune response as a result of the EBV presence or because of changes in pharmaceutical metabolism caused by the disease [2]. It is believed that, the immune response due to presence of the virus, is the main cause of skin rash during concurrent treatment with antibiotics. Finally, it is recommended penicillin skin test be performed, if penicillin injection is mandatory in future.
Sincerely.
[1]. Onodi-Nagy K, Kinyo A, Meszes A, Garaczi E, Kemeny L, Bata-Csorg Z, Amoxicillin rash in patients with infectious mononucleosis: evidence of true drug sensitization Allergy, Asthma & Clinical Immunology 2015 11(1):1-4. [Google Scholar]
[2]. Banerjee I, Mondal S, Sen S, Tripathi SK, Banerjee G, Azithromycin-induced Rash in a patient of infectious mononucleosis–a case report with review of literature Journal of clinical and diagnostic research: JCDR 2014 8(8):HD01-2. [Google Scholar]
[3]. Chovel-Sella A, Ben Tov A, Lahav E, Mor O, Rudich H, Paret G, Incidence of rash after amoxicillin treatment in children with infectious mononucleosis Pediatrics 2013 131(5):e1424-27. [Google Scholar]
[4]. Babaria SS, Taneja PK, Dalal B, Shah R, Infectious Mononucleosis: a case Report GCSMC J Med Sci 2013 2(2):49-51. [Google Scholar]
[5]. Luzuriaga K, Sullivan JL, Infectious mononucleosis New England Journal of Medicine 2010 362(21):1993-2000. [Google Scholar]