An Unusual Presentation of Cutaneous Bullous Lupus

Drug-induced lupus erythematosus (DILE) is an autoimmune reaction that results in symptoms of polyarthralgia, fever, and cutaneous lesions and other manifestations. Several drugs have been documented to cause this disease, including procainamide, isoniazid, methyldopa, penicillamine, and hydralazine. Systemic lupus erythematosus (SLE) manifestations often occur after the patient has been taking the drug without complications for months to years. Hydralazine, an oral antihypertensive drug, is a well-known cause of DILE; however, clinical presentation is generally limited to classic SLE symptoms such as malar or discoid rash and polyarthralgia. In this case, we will discuss a 75-year-old female patient with actively bleeding oral, nasal, and conjunctival ulcers of unknown origin, eventually found to have bullous lupus erythematosus while on hydralazine for several years. Bullous lupus erythematosus is a rare cutaneous manifestation of SLE that presents with blister-type lesions in patients with a history of SLE. Histologically, bullous lupus erythematosus is characterized by marked epidermal and dermal inflammation, and an inflammatory infiltrate that consists primarily of neutrophils at the base of the bullae. Although hydralazine has been implicated in DILE, it is very rarely noted to have a bullous lupus erythematosus presentation. Given the acuity of patient's presentation and resolution with cessation of hydralazine, it was concluded that hydralazine was the main contributing factor for this patient's multiple hemorrhagic bullous lupus erythematosus lesions.