Pyrazinamide-Induced Exfoliative Dermatitis in a Patient on Hemodialysis: A Rare Complication

A 60-year-old male patient on maintenance hemodialysis was started on antituberculosis therapy with isoniazid, rifampin, ethambutol, and pyrazinamide for pulmonary tuberculosis. After 4 weeks of therapy, he developed pruritic lesions in the extremities followed by exfoliation. The lesions progressively spread over the entire body. Lesions resolved after withdrawal of antituberculosis medications and administration of oral corticosteroids and antihistamines. After 2 weeks antituberculosis drugs were rechallenged one at a time. Administration of oral pyrazinamide resulted in reappearance of symptoms (pruritis and erythema) within 48 hours. Pyrazinamide was substituted with ofloxacin while other three drugs were restarted without any side effects. The case illustrates a rare but potentially dangerous complication of pyrazinamide therapy. 1. Background Cutaneous adverse drug reactions (CADR) are often encountered with first-line antituberculosis therapy (ATT). Exfoliative dermatitis is a dangerous form of CADR which needs immediate withdrawl of all the four drugs. In a hemodialysis patient with active pulmonary tuberculosis, early withdrawl followed by prompt rechallenging to identify the causative agent and then to achieve cure of pulmonary tuberculosis is an interesting therapeutic challenge. 2. Case History and Hospital Course A 60-year male with three-week history of low-grade fever, weight loss, and sputum positive tuberculosis was started on thrice weekly antituberculosis therapy with isoniazid, rifampin, ethambutol, and pyrazinamide. He was on maintenance hemodialysis thrice a week (duration 5 hours) since 8 years and his routine medications included antihypertensives (amlodipine 10？mg per day, metoprolol 50？mg per day), erythropoietin, iron, folic acid, and phosphate-binding agents (calcium acetate). There was no change in prescription since last 6 months. ATT was administered in dosage of 150？mg of isoniazid, 450？mg of rifampicin, 400？mg of ethambutol, and 1000？mg of pyrazinamide. All drugs were given thrice a week, 24 hours prior to next dialysis. At the start of ATT his liver function tests (total bilirubin 0.6？mg/dL (0.1–1.3？mg/dL), direct bilirubin 0.4？mg/dL (0–0.5？mg/dL), total protein 5.9？g/dL (6–8.4？g/dL), albumin 3.8？g/dL (3.5–5.5？g/dL), SGOT 16？IU/l (5–40？IU/L), SGPT 18？IU/l (5–40？IU/L), alkaline phosphatase 24？U/L (35–150？U/L), LDH 120？IU/L (85–450？IU/L), uric acid 6？mg/dL (3.9–8.9？mg/dL), calcium 9.4？mg/dL (9–11？mg/dL), and inorganic phosphorus 4.3？mg/dL (2.5–4.5？mg/dL) were within normal limits. HBsAg, HIV, and anti-HCV antibody ELISA