Furosemide Induced Bullous Pemphigoid Associated with Antihistone Antibodies

Matthew F. Helm, BS, Lin Lin, MD, PhD, Peter Santalucia, MD, Brummitte Dale Wilson, MD, RW Plunkett, PhD, Raminder Grover, MD


An 81 year old man developed tense blisters on his abdomen and thighs several months after starting oral furosemide. Routine histologic studies revealed subepidermal bullae filled with eosinophils and neutrophils typical of bullous pemphigoid.  Direct immunofluoresence studies revealed weak linear deposits of IgG and trace C3 along the dermal-epidermal junction along with a striking in vivo ANA reaction. ELISA studies to BP180 and BP230 antigens were negative although a low titer of IgG4 was noted in the blister roof on 1M NaCl split skin.  A homogenous pattern of ANA on Hep2 cells was detected at a titer of > 5120.  Antibodies to histone were very high when detected with ELISA.  The clinical and pathologic findings are consistent with drug induced bullous pemphigoid.  The associated  drug induced lupus erythematosus-like immunopathologic findings are unusual and illustrate the broad range of changes that may occur.  Furosemide induced bullous pemphigoid and the significance of antihistone antibodies in drug induced autoimmune disease will be reviewed. 


bullous pemhigoid, drug reaction, furosemide, antihistone antibodies, antinuclear antibodies

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