Abstract
Sweet syndrome is a rare complication of azathioprine treatment with unelucidated clinical features. The purpose of this study was to investigate the clinical characteristics of azathioprine-induced Sweet syndrome (AISS) and provide a reference for diagnosis, treatment and prognosis. We collected relevant case reports of AISS by searching Chinese and English databases from 1960 to December 31, 2022, extracted the data and carried out a retrospective analysis. The median age of the 44 patients was 50 (range 9–89) years, and they included 32 males (72.7%). Fever (86.4%) and arthralgia (31.8%) were the most common clinical symptoms. The skin lesions were mainly pustules (54.5%), papules (40.9%), plaques (40.9%) and nodules (31.8%), which were mainly distributed on the extremities (54.5%), face (38.6%) and hands (36.4%). Laboratory examination revealed neutropenia (65.9%) as well as elevated C-reactive protein (63.6%) and erythrocyte sedimentation (40.9%) rates. Histopathology of the lesioned skin showed neutrophil infiltration (93.2%) and dermal edema (38.6%). Symptom relief was achieved at a median time of 7 days (range 2–28 days) after azathioprine discontinuation in all patients. Nine patients (20.5%) had skin lesions that recurred within 24 h after taking azathioprine again. Clinicians and pharmacists should grasp the regularity and characteristics of AISS and should not recommend the readministration of azathioprine, to avoid the recurrence of Sweet syndrome.
Similar content being viewed by others
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
Cohen PR. Sweet’s syndrome–a comprehensive review of an acute febrile neutrophilic dermatosis. Orphanet J Rare Dis. 2007;2:34.
Heath MS, Ortega-Loayza AG. Insights into the pathogenesis of sweet’s syndrome. Front Immunol. 2019;10:414.
Rochet NM, Chavan RN, Cappel MA, Wada DA, Gibson LE. Sweet syndrome: clinical presentation, associations, and response to treatment in 77 patients. J Am Acad Dermatol. 2013;69(4):557–64.
Patel AA, Swerlick RA, McCall CO. Azathioprine in dermatology: the past, the present, and the future. J Am Acad Dermatol. 2006;55(3):369–89.
Sheiko MA, Sundaram SS, Capocelli KE, Pan Z, McCoy AM, Mack CL. Outcomes in pediatric autoimmune hepatitis and significance of azathioprine metabolites. J Pediatr Gastroenterol Nutr. 2017;65(1):80–5.
Aljumah AA, Al Jarallah B, Albenmousa A, et al. The Saudi association for the study of liver diseases and transplantation clinical practice guidelines for management of autoimmune hepatitis. Saudi J Gastroenterol. 2018;24(7 Suppl):S1–20.
Riello L, Talbotec C, Garnier-Lengliné H, et al. Tolerance and efficacy of azathioprine in pediatric Crohn’s disease. Inflamm Bowel Dis. 2011;17(10):2138–43.
Bidinger JJ, Sky K, Battafarano DF, Henning JS. The cutaneous and systemic manifestations of azathioprine hypersensitivity syndrome. J Am Acad Dermatol. 2011;65(1):184–91.
Choonhakarn C, Chaowattanapanit S. Azathioprine-induced Sweet’s syndrome and published work review. J Dermatol. 2013;40(4):267–71.
Lemann M, Bouhnek Y, Kmieciak-Le Corguille M, et al. Treatment of Crohn’s disease with 6-mercaptopurine in patients intolerant to azathioprine. Gastroenterology. 1997;112:A1025.
McLeod HL, Krynetski EY, Relling MV, Evans WE. Genetic polymorphism of thiopurine methyltransferase and its clinical relevance for childhood acute lymphoblastic leukemia. Leukemia. 2000;14(4):567–72.
Mayo JM, Colmenarejo MB, Vaquerizo PJ, Gutierrez MV. Hypersensitivity reaction to azathioprine in a patient with ulcerative colitis. Inflamm Bowel Dis. 2004;10(5):700.
Cyrus N, Stavert R, Mason AR, Ko CJ, Choi JN. Neutrophilic dermatosis after azathioprine exposure. JAMA Dermatol. 2013;149(5):592–7.
Knowles SR, Gupta AK, Shear NH, Sauder D. Azathioprine hypersensitivity-like reactions-a case report and a review of the literature. Clin Exp Dermatol. 1995;20(4):353–6.
Ytting H, Vind I, Bang D, Munkholm P. Sweet’s syndrome–an extraintestinal manifestation in inflammatory bowel disease. Digestion. 2005;72(2–3):195–200.
Bajaj JS, Saeian K, Varma RR, et al. Increased rates of early adverse reaction to azathioprine in patients with Crohn’s disease compared to autoimmune hepatitis: a tertiary referral center experience. Am J Gastroenterol. 2005;100(5):1121–5.
Imhof L, Meier B, Frei P, et al. Severe sweet’s syndrome with elevated cutaneous interleukin-1β after azathioprine exposure: case report and review of the literature. Dermatology. 2015;230(4):293–8.
Strickland I, Rhodes LE, Flanagan BF, Friedmann PS. TNF-alpha and IL-8 are upregulated in the epidermis of normal human skin after UVB exposure: correlation with neutrophil accumulation and E-selectin expression. J Invest Dermatol. 1997;108(5):763–8.
Belhadjali H, Marguery MC, Lamant L, Giordano-Labadie F, Bazex J. Photosensitivity in Sweet’s syndrome: two cases that were photoinduced and photoaggravated. Br J Dermatol. 2003;149(3):675–7.
Marinaki AM, Ansari A, Duley JA, et al. Adverse drug reactions to azathioprine therapy are associated with polymorphism in the gene encoding inosine triphosphate pyrophosphatase (ITPase). Pharmacogenetics. 2004;14(3):181–7.
Cohen PR, Kurzrock R. Sweet’s syndrome: a neutrophilic dermatosis classically associated with acute onset and fever. Clin Dermatol. 2000;18:265–82.
Walker DC, Cohen PR. Trimethoprim-sulfamethoxazole-associated acute febrile neutrophilic dermatosis: case report and review of drug-induced Sweet’s syndrome. J Am Acad Dermatol. 1996;34(5 Pt 2):918–23.
Cohen PR, Kurzrock R. Sweet’s syndrome and cancer. Clin Dermatol. 1993;11:149–57.
Funding
This research was supported by Scientific Research Fund Project of Hunan University of Chinese Medicine (No. 2022XYLH004) and the Natural Science Foundation of Hunan Province (No. 2023JJ30847).
Author information
Authors and Affiliations
Contributions
ZF, CW, and CY: Conceptualization, Methodology, Software. ZF, YH, ZL, and CY: Data curation, Writing- Original draft preparation. CY and CW: Visualization, Investigation. ZF, CY and CW: Writing- Reviewing and Editing. All authors reviewed and approved the final version of the article.
Corresponding authors
Ethics declarations
Conflict of interest
The authors declare no conflict of interest.
Ethical approval
This study did not require an ethical board approval because the study was a retrospective study and did not involve sensitive personal information.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Fan, Z., He, Y., Sun, W. et al. Clinical characteristics, diagnosis and management of Sweet syndrome induced by azathioprine. Clin Exp Med 23, 3581–3587 (2023). https://doi.org/10.1007/s10238-023-01135-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10238-023-01135-9