Do not prescribe ibuprofen in patientswith systemic Lupus erythematosus (SLE) because it can cause ibuprofen-induced aseptic meningitis
Do not prescribe ibuprofen in patientswith systemic Lupus erythematosus (SLE) because it can cause ibuprofen-induced aseptic meningitis: Excerpt from Avoiding Common Pediatric Errors
Author:
Johann Peterson, MD
What to Do - Make a Decision
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in
many rheumatologic diseases, including SLE. Despite their common use
and over-the-counter status, they are a potential cause of adverse reactions
and should be prescribed with caution.
Aseptic meningitis refers to the clinical picture of meningeal inflammation (stiff neck, headache, fever, photophobia, Kernig and Brudzinski signs)
and pleocytosis of the cerebrospinal fluid (CSF), but without an infectious
agent identified in theCSF.Itis, therefore,a diagnosisof exclusion,andmost
cases will require empiric antibiotic coverage while cultures and viral studies are pending. With the development of sensitive viral assays, many cases
that previously would have been classified as aseptic meningitis are probably
now being diagnosed as viral meningitis. Enteroviral infections (coxsackievirus, echovirus, polio) are a common cause of viral meningitis in children.
Mumps and California virus are also possible. Localized infections, such as
an epidural abscess, cranial osteomyelitis, and sinusitis, can cause meningeal
inflammation, mimicking aseptic meningitis. And other infectious agents,
such as mycobacteria, malaria and other parasites, fungi, spirochetes, and
Rickettsiae, can cause meningitis and may not be identified with the usual
CSF testing.
There are a number of recognized causes of aseptic meningitis, including drug reactions, autoimmune diseases, meningeal involvement with
tumors, Borrelia burgdorferi infection (Lyme disease), and the acute retroviral syndrome. Ibuprofen is the most common medication responsible for
drug-induced aseptic meningitis, and the risk appears to be greater among
patients with SLE or other autoimmune diseases. Other NSAIDs have
been implicated, as well as trimethoprim with or without sulfamethoxazole,
cephalosporins and other antibiotics, intravenous immunoglobulin (IVIG),
and other agents. Not surprisingly, a number of intrathecal medications and
contrast agents have also been responsible. NSAID-induced aseptic meningitiscanoccurafteronlyonedose,andtypicallyoccursshortlyafteringestion
of ibuprofen, but it can be delayed until after 2 years of regular use. Some patients have suffered multiple episodes until the relationship was recognized.
In most cases, patients can be successfully treated with another NSAID, but
there are some reports of patients who developed aseptic meningitis with
multiple different NSAIDs.
There is insufficient published data to estimate a quantitative risk of
aseptic meningitis in healthy patients or in patients with rheumatologic disease. In one recent literature review, 39% of published cases were in patients
withSLE.Inpatientswithlupus,avoidingibuprofenasafirst-lineagentmay
be useful. Screening for autoimmune disease in otherwise-healthy patients
who develop NSAID meningitis may also be important.
Clinically, most patients have a typical meningitis syndrome, although
some have encephalitic features including focal neurologic deficits, Babinski
sign,syndromeofinappropriatesecretionofantidiuretichormone(SIADH),
sensorineuralhearingloss,andevencoma.Therearenoreportsofpermanent
neurologic sequelae. The CSF findings usually include pleocytosis (9–5,000
white blood cells [WBCs]/”L), which is often mostly neutrophils, but occasionally monocytes or eosinophils predominate. Protein is often elevated,
but CSF glucose is usually normal. No CSF findings have been shown to
reliably exclude bacterial meningitis. Symptoms may resolve rapidly (1–2
days) after stopping ibuprofen, but CSF abnormalities may last longer. Factors that may help distinguish Lyme meningitis from aseptic meningitis of
another cause are a more subacute course, and longer duration of headache,
history of facial weakness or cranial neuropathy, and, of course, the erythema
migrans rash.
Suggested Readings
Eppes SC, Nelson DK, Lewis LL, Klein JD. Characterization of Lyme meningitis and com
parison with viral meningitis in children. Pediatrics. 1999;103(5 Pt 1):957–960.
JollesS,SewellWA, Leighton C. Drug-induced aseptic meningitis:diagnosis and management.
Drug Saf. 2000;22(3):215–226.
RodriguezSC,OlguŽinAM,MirallesCP,etal.CharacteristicsofmeningitiscausedbyIbuprofen:
report of 2 cases with recurrent episodes and review of the literature. Medicine (Baltimore).
2006;85(4):214–220.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Lupus
More Medical Textbooks Online about Lupus
Review other book chapters online related to Lupus:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
|
|
More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
|
|
» Next page: Lupus Erythematosus (The 5-Minute Pediatric Consult)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
