Exfoliative dermatitis and multi system damage due to leflunomide

A 54-year-old woman with systemic lupus erythematosus and lupus nephritis (type Ⅳ) received methylprednisolone 40 mg once daily. She added up to take leflunomide 20 mg once daily because of her positive proteinuria. On day 8 of adding leflunomide, the patient developed high fever, diffuse oral ulcer, red rash (face, neck, both upper extremities, and chest and abdomen), furfuration and pruritus. Leflunomide was stopped after 7days continuing to take the medication. Laboratory tests on day 15 to 18 of adding leflunomide showed the following results: ESR 20 mm/1 h, Scr 258 μmol/L, ALT 66 U/L, AST 254 U/L, albumin 28.0 g/L, IgM 0.26 g/L, C4 0.16 g/L, C3 0.43 g/L, PLT 66×109/L, urine protein (+ + + ), urine occult blood (+ + + ). She was diagnosed as dermatitis exfoliativa, oral ulcer, acute kidney injury, acute liver injury, and thrombocytopenia. The patient received gargling by nystfungini tablet (2.5 million U) dissolved in 5% sodium bicarbonate solution, spraying by bovine basic fibroblast growth factor aerosol, IV infusions of methylprednisolone 40 mg, reduced glutathione 2.4 g, magnesium isoglycyrrhizinate 150 mg, and alprostadil 20 μg once daily. And inunction of betamethasone cream was done on the surface of erythra. On day 5 of treatment, her pain of oral ulcer was alleviated, the color of erythra at the skin of face, neck, upper limbs, chest and abdomen were appeared light and decrustation. There was no new erythra. Laboratory tests showed the following results: PLT 126×109/L, Scr 83 μmol/L, AST 68 U/L, ALT 153 U/L, albumin 27.0 g/L. On day 9 of treatment, her oral ulcer reccured. There were only a few rashes on her face and neck. Laboratory tests showed the following results: Scr 71 μmol/L, AST 26 U/L, ALT 75 U/L, albumin 27.0 g/L. Key words: Leflunomide; Dermatitis, exfoliative; Multi system damage