Case Presentation: Discussion45-year-old male with history of HIV on Antiretroviral and treated syphilis presented with painful oral lesions and difficulty swallowing which started several days after being placed on Nitazoxanide, Doxycycline, Levaquin, and Omeprazole for diagnosis of Helicobacter Pylori via Endoscopy done for diarrhea. He was given fluconazole for presumed thrush during ER visit. His lesions worsened so he stopped all medications and presented again to ER where he was seen by dermatology. On exam, tongue with bright red slightly edematous appearance with tooth indentation marks, superficial erosions and scattered white, non-adherent exudate were noticed. Lower mucosal lip had more superficial erosions with mild crusting. Noted penile foreskin with shiny red thin edematous plaque, Right scrotum with poorly demarcated red patch, and anus with edema and focal superficial erosions. His Vital signs were stable. Labs were unrevealing except for RPR titer of 1:32 which was lower than 1:64 showing response to treatment. Test for chlamydia, gonorrhea, trichomonas, and herpes simplex virus were all negative. Mononucleosis screen and strep throat negative. Drug Hypersensitivity Reaction from Nitazoxanide, Doxycycline, Levaquin, and Omeprazole was suspected based on the timing of the oral lesions but Omeprazole thought to be the most likely culprit. Pt was discharged on dexamethasone swish and spit twice a day along with hydrocortisone 2.5% ointment for the affected areas of the penis/scrotum/anus.
Discussion: The prevalence of cutaneous reactions to Proton Pump Inhibitors (PPIs) varies ranges from 3-20 per 100,000 of the treated population. Most of the reactions are immunological and can manifest as either an immediate or delayed-type hypersensitivity reaction (HSR). Omeprazole, lansoprazole and esomeprazole are the most common PPIs involved. It is postulated that the sulfur moiety in Benzimidazole, an agent commonly used in PPIs, is the offending agent. PPI HSR can have several clinical manifestations ranging from benign localized dermatoses such as fixed drug eruptions and lichen planus to more life threatening conditions such as drug eruption with eosinophilia and systemic symptoms (DRESS) and toxic epidermal necrolysis (TEN). The temporal relation of PPI and dermatologic manifestation can range from days to years so high clinical suspicion should be maintained. Skin biopsy and serological studies can help elucidate etiology and treatment usually includes removing the suspected drug along with other supportive measures.
Conclusions: This case highlights a unique example of a Drug Hypersensitivity Reaction to omeprazole when used in a treatment course for H. Pylori. One should consider any new dermatologic condition to be caused by a PPI especially when a strong temporal association seems to be present. PPIs are not as benign medication as traditionally thought.
