Journal of the Louisiana State Medical Society
Toxic Erythema of Chemotherapy Following Leukemia Cutis
Nadine Kaskas, BS; Catherine DiGiorgio, MD; Bethaney Vincent, MD; Suneeta Walia, MD; Julie Mermilliod, MD
A 56-year-oldCaucasianmale newly diagnosedwith acutemyelogenous leukemia (AML)M3 presentedwith a six-week history of multiple painful erythematous nodules scattered on his trunk and extremities, previously treated as abscesses with incision and drainage plus oral trimethoprim-sulfamethoxazole without improve- ment. A punch biopsy was performed, and the histopathology and immunostaining profile were compatible with leukemia cutis secondary to AML. Induction chemotherapy for AML with cytarabine, etoposide, and mitoxantrone was initiated. Dermatology was reconsulted two weeks later for evaluation and treatment of a new eruption on both dorsal hands and wrists that began three days after starting induction chemotherapy. On physical exam, there were well-demarcated erythematous patches and plaques with mild induration on the hands, extending onto the distal forearms and sparing the dorsal metacarpalphalangeal joints and ventral wrists. Biopsy findings were consistent with toxic erythema of chemotherapy, likely secondary to cytarabine.
CASE PRESENTATION A 56-year-old Caucasian male newly diagnosed with acute myelogenous leukemia (AML) M3 presented with a six-week history of multiple painful erythematous nod- ules scattered on his trunk and extremities, previously treated as abscesses with incision and drainage plus oral trimethoprim-sulfamethoxazole without improvement. In addition to AML M3, the patient’s past medical history included schizophrenia and anxiety. He had no past surgery history and denied the use of alcohol, tobacco, and illicit drugs. Inpatient medications at the time of consultation included acetaminophen, allopurinol, ciprofloxacin, diphen- hydramine, fluconazole, fluoxetine, haloperidol, olanzapine, piperacillin-tazobactam, senna-docusate, and ondansetron. At the time of the initial consult to dermatology, physical exam revealed several scattered, non-tender, firm erythematous superficial and subcutaneous nodules. A 4 mm punch biopsy was performed on a nodule on the abdomen. Histopathology showed sheets of large, atypical mononuclear cells with slightly eccentric basophilic nuclei, single nucleoli, and scant cytoplasm. Numerous mitotic figures were identified. The tumor also focally assumed a leukemic infiltrative pattern (Figure 1). Immunohisto- chemistry revealed the dermal atypical lymphoproliferative infiltrate stained strongly and diffusely positive for CD43, CD45, myeloperoxidase, and C117. The tumor stained largely positive for CD68. Rare positive CD15 cells were noted in the infiltrate. CD56 and CD34 were negative. The
histopathology and staining profile were compatible with leukemia cutis secondary to AML. Induction chemotherapy for AML with cytarabine, etoposide, andmitoxantrone was initiated. Dermatology was reconsulted two weeks later for evaluation and treatment of a new eruption on both dorsal hands and wrists that began three days after starting induction chemotherapy. Discontinued medications at the time included senna-docusate; recently added medications included acyclovir, potassium phosphate, promethazine, vancomycin, and piperacillin-tazobactam. The patient re- ported the eruption began on his left hand as a red, scaly spot that progressed to include his wrists circumferentially and then his dorsal hands and fingers (Figure 2a). Though he reported occasional pruritus, he stated the eruption was not bothersome. On physical exam, there were well-demarcated ery- thematous patches and plaques with mild induration and scattered subcutaneous nodules on both dorsal wrists and hands, extending onto the distal forearms. The palms and soles were spared. The skin on the dorsal metacarpalphalan- geal, proximal interphalangeal, and distal interphalangeal joints was also spared (Figure 2b). A 4 mm punch biopsy was performed of a nodule on the left dorsal hand. His- topathology showed epidermal pseudo-epitheliomatous hyperplasia and dysmaturation with scattered dyskeratotic keratinocytes (Figure 3a). Prominent dilated, telangiectatic blood vessels were noted within the superficial dermis with an associated lymphohistiocytic inflammatory infiltrate. Extensive syringo-metaplasia was noted within the mid to
236 J La State Med Soc VOL 166 November/December 2014
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