Febrile pleuropericarditis, a potentially life-threatening adverse event of balsalazide – case report and literature review of the side effects of 5-aminosalicylates

Abstract

Ulcerative colitis (UC) is an idiopathic chronic inflammatory disorder that affects the colonic mucosa. One class among the drugs used for its treatment is the 5-aminosalicylates (5-ASAs). While highly efficacious in treating mild-to-moderate UC, 5-ASAs are associated with rare but potentially life-threatening side effects such as pericarditis, myocarditis and pneumonitis. These adverse events appear to be caused by a hypersensitivity reaction and resolve after cessation of 5-ASA drugs. This article presents a case report of febrile pleuropericarditis in a UC patient treated with balsalazide, and provides a thorough literature review of the rare side effects of 5-ASAs, their incidence, clinical presentation, differential diagnosis and treatment. In conclusion, the clinicians should be aware that this type of adverse events to 5-ASA compounds can be easily overlooked but it has significant morbidity if not promptly diagnosed.

Keywords::

• 5-ASA
• balsalazide
• hypersensitivity reaction
• inflammatory bowel disease
• pleuropericarditis
• ulcerative colitis

Financial & competing interests disclosure

Funding support for this study was provided from the Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine and Gatorade fund at the University of Florida. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• 5-ASA compounds remain the first-line therapy in treatment of mild-to-moderate UC.

• 5-ASA can cause idiosyncratic reactions such as serositis, pneumonitis, myocarditis and lupus-like reaction.

• There is an overlap in clinical presentation of extra-intestinal manifestation in IBD and hypersensitivity reaction induced by 5-ASA derivatives.

• The diagnosis is mainly clinical and confirmed by resolution of the symptoms upon drug discontinuation.

• Early diagnosis of idiosyncratic reactions is important to avoid significant morbidity and potential mortality.

• Hypersensitivity reaction usually occurs within 2–4 weeks from the initiation of the drug but delayed onset, months to years, have been documented as well.

• Hypersensitivity to one of the 5-ASA derivatives usually precludes the use of other compounds from the same class.

Notes