Mefloquine is currently recommended as first-line chemoprophylaxis for malaria in travelers to areas where chloroquine-resistant malaria is present. We describe a 62-year-old woman in otherwise good health who traveled to Tanzania and Kenya for 2 weeks in October 1994. She began receiving mefloquine, 250 mg/wk, 1 week before departure. She developed pruritic petechiae on her lower extremities after ingesting the fourth of six scheduled doses. She received the fifth dose before medical evaluation. Examination showed lower-extremity edema and petechiae and two erythematous papular lesions on the right lateral leg (Figure 1). Mefloquine therapy was discontinued. The patient also noted moderately severe myalgias and arthralgias. Examination of a skin biopsy specimen showed extensive leukocytoclasis in the superficial and deep dermis with perivascular fibrin deposition around the superficial vessels. Because of new skin lesions and severe constitutional symptoms, the patient was treated with methylprednisolone (an initial dose of 16 mg/d followed by tapered doses for 1 month). The patient's rash and systemic symptoms resolved with steroid treatment. The skin lesions, myalgias, and arthralgias have not recurred since methylprednisolone therapy was discontinued.

View larger version (151K): [in this window] [in a new window]   Figure 1. Lower-extremity edema, petechiae, and erythematous popular lesions on the right lateral leg that developed after the patient received mefloquine prophylaxis.

Mefloquine prophylaxis in travelers has become widely used since the late 1980s. Cutaneous reactions have been noted occasionally [1, 2], including a handful of severe cutaneous reactions such as the Stevens-Johnson syndrome [3]. Ours is only the second reported case of cutaneous vasculitis associated with mefloquine use. In the other case, cutaneous vasculitis was diagnosed clinically during mefloquine prophylaxis [4]. In our patient, a clear temporal association was seen between mefloquine therapy and the onset of vasculitis, slow resolution of vasculitis (consistent with the long elimination half-life), and the absence of recurrence after discontinuation of therapy. We believe that vasculitis should be included among the side effects of mefloquine and that patients who develop vasculitis while receiving mefloquine should discontinue therapy with the drug.