Service de Dermatologie, Hôpital Bichat, Paris.
BACKGROUND: Prescriptions of tamoxifen can be expected to increase over the next few years, particularly for primary prevention of breast cancer. We report a case of a delayed tamoxifen-induced skin reaction. CASE REPORT: A 50-year-old woman was hospitalized for a diffuse maculopapulous eruption which developed four months after beginning a tamoxifen regimen instituted to prevent recurrence of breast cancer after surgery, chemotherapy and radiotherapy. The eruption resolved rapidly after withdrawal of tamoxifen. The same skin reaction occurred 9 hours after rechallenge with tamoxifen. Patch tests performed later with Nolvadex tablets crushed in vaseline were negative. DISCUSSION: Tamoxifen-induced skin reactions are uncommon. The likelihood that tamoxifen was the cause in this case was very high (C3S3 = I4, B2). The late onset (4 months) in this case is remarkable and misled us to look for another cause which could not be found. Challenge with tamoxifen confirmed its causal role. Once again, negative patch tests were found in this type of skin reaction.
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Service de Dermatologie, Hôpital Bichat-Claude Bernard, Paris, France.
Service de Dermatologie, Centre Hospitalier Bichat Claude Bernard, Assistance Publique des Hôpitaux de Paris, 46, rue Henri Huchard, 75018 Paris, France.
INTRODUCTION: Diagnosis of retroperitoneal fibrosis is generally delayed and revealed by various non-specific signs. We report the case of an isolated lymphedema of the lower limb revealing retroperitoneal fibrosis complicating a metastatic squamous cell carcinoma.CASE REPORT: In an 83-year-old women, a lymphedema appeared that remained isolated for several months before being associated with alteration in general health. Morphological examinations showed bilateral compression of the urinary excretory tracts and led to the diagnosis of retroperitoneal fibrosis. Histological examination of a sub-clavicular adenopathy that had evolved over 9 months, confirmed the diagnosis of a metastatic squamous cell carcinoma of pulmonary cancer. DISCUSSION: Retroperitoneal fibrosis is an exceptional etiology that must be recognized in isolated lymphadomas of the lower limbs. In view of the possible tumoral origin of retroperitoneal fibrosis, any evocative sign accompanying the lymphedema must be searched for.
Bullous pemphigoid in a leg affected with hemiparesia: a possible relation of neurological diseases with bullous pemphigoid?
Department of Dermatology, Bichat-Claude-Bernard Hospital, 46, rue Henri-Huchard 75018 Paris, France.
We report a typical case of bullous pemphigoid (BP) associated with a neurological disorder and study a possible link between neurological disorders and BP. An 84-year-old hemiplegic woman presented with unilateral BP on the hemiparetic side. BP was confirmed by histological and immunofluorescence data. The medical records of the previous 46 consecutive patients with BP were retrospectively analyzed (average age: 79; median age: 85). Thirty of the 46 patients with BP had neurological disorders. These disorders included dementia, epilepsy, multiple sclerosis, cerebral stroke, Parkinson's disease, gonadotropic adenoma, trembling, dyskinesia, lumbar spinal stenosis. In a control group of the 46 consecutive oldest patients (older than 71; average age: 82,5; median age: 80) with another skin disease referred during the previous two-year-period to our one-day-unit only, 13 patients had a neurological disorder. This study demonstrates that there is a high prevalence of neurological disorders in patients with BP (p = 0.0004). A prospective case control study with neurological examination and psychometrical evaluation is warranted to confirm these data. We speculate that neuroautoimmunity associated with the aging process or neurological disorders may be involved in pemphigoid development via an autoimmune response against dystonin which shares homology with bullous pemphigoid antigen 1. Bullous pemphigoid could be considered to be a marker of neurological disorder.
Association of human herpesvirus 6 infection with drug reaction with eosinophilia and systemic symptoms.
Dermatology Department, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018 Paris, France. email@example.com
BACKGROUND There is a current debate regarding the association of human herpesvirus 6 (HHV-6) infection and drug reaction with eosinophilia and systemic symptoms (DRESS). METHODS Seven consecutive patients hospitalized with DRESS were enrolled in a prospective study to evaluate evidence of active HHV-6 infection. OBSERVATIONS The imputable drugs were carbamazepine (5 patients), ibuprofen (1 patient), and sulfasalazine (1 patient). All patients were seropositive for anti-HHV-6 IgG antibodies. Anti-HHV-6 IgM antibodies were detected in 4 of the 7 patients with a seroconversion in 2 patients. Neither anti-cytomegalovirus nor anti-Epstein-Barr virus early antigen IgM antibody was detected. Human herpesvirus 6 genome was not detected by polymerase chain reaction in the first serum sample of all patients. It was weakly detected in skin lesions in the last patient tested by polymerase chain reaction but was not found in uninvolved skin. CONCLUSIONS The results suggest an association between HHV-6 active infection (primo-infection or reactivation) and severe DRESS. Absence of anti-cytomegalovirus or anti-Epstein-Barr virus early antigen IgM antibodies argues against a nonspecific viral reactivation. Human herpesvirus 6 infection may play a role in the development of DRESS in susceptible patients. Some drugs with reactive metabolites could favor reactivation and propagation of HHV-6.
Service de Dermatologie, Hôpital Bichat, 46, rue Henri-Huchard, 75877 Paris Cedex 18.
BACKGROUND Clinical manifestations of primary parvovirus B19 infection vary greatly. Epidermal megalerythema is the most common feature. We report a particular form resembling a drug-induced hypersensitivity reaction. CASE REPORT A 19-year-old man had a scarlatiniform eruption associated with multiple node enlargement, elevated liver enzymes and a abnormal white cell count with mononucleosis and lymphopenia, similar to that observed in hypersensitivity reactions. Seroconversion and positive PCR search for viral DNA established the diagnosis of primary parvovirus B19 infection. The spontaneous course was favorable with no recurrence at one month. DISCUSSION The clinical features and laboratory findings in this case of parvovirus B19 infection closely resembled drug-induced hypersensitivity syndrome. The role of viral agents in the development of hypersensitivity reactions have been suggested. It is important to look for viral infections in clinical presentations mimicking drug-induced hypersensitivity.
Service de Dermatologie, Hôpital Bichat, 75877 Paris Cedex 18.
OBJECTIVES We report four cases of eczema induced by alpha interferon in atopic patients treated for chronic hepatitis C. CASE REPORTS Eczema developed in 4 patients with certain (3 cases) or possible (1 case) atopy treated by subcutaneous injections of alpha interferon for hepatitis C virus infections. Delay to onset was 3 weeks to 6 months. Interferon was highly likely the causal agent: lesions started at site of interferon injection, followed the rhythm of interferon injections (three cases), disappeared at interferon withdrawal. In two patients, the lesions diffused to other sites. Both Introna and Roféron were used. Three patients also took ribavirine. The possible role of a contact factor (antiseptic.) was ruled out. Skin tests (patch tests, prick tests, intradermal reactions) were negative for interferon alpha and for a standard battery. DISCUSSION The role of interferon in the induction of skin diseases or its influence on the course of certain dermatoses is well known. In atopic patients, interferon might induce eczema via an immunomodulator rather than an allergic mechanism since skin tests (performed in one patient) were negative. This observation is similar to that in psoriasis induced by interferon in predisposed subjects who develop skin lesions at injection sites which sometimes diffuse to distant localizations. The role of other factors (hepatitis C virus infection, ribavirine) remains unknown; they might participate in this mechanism by aggravating skin dryness.
Department of Dermatology, Hôpital Bichat, 75018 Paris, France. firstname.lastname@example.org
Octreotide has proven to be effective for the treatment of intestinal dysmotility in patients with scleroderma in short-term administration. We report a global improvement of scleroderma manifestations under long-term administration of octreotide. A 53-year-old black woman was diagnosed with a four-year history of progressive and severe systemic scleroderma, with diffuse skin sclerosis, myositic involvement, impaired carbon monoxide transfer factor (57% of the predicted normal value and severe digestive involvement with pseudo-obstruction and bacterial overgrowth into the intestinal lumen). After one month of octreotide (75 mug/d), oral feeding was restarted and weight gain of 6.5 kg was achieved. After 8 months of treatment, normal weight was obtained and skin induration was spectacularly reduced and pigmentation returned to a normal state. Dyspnea disappeared and physical activity was quite normal. Octreotide effects on intestinal transit are unclear and may be secondary to immunomodulation or neurotransmission effects. Extradigestive effects of octreotide in scleroderma have not been studied. This report suggests that long-term administration of octreotide may be beneficial in the treatment of patients with systemic scleroderma. Long-term trials are required to confirm these preliminary results.
Service de Dermatologie, Hôpital Bichat, Paris.
BACKGROUND: Trichosporon beigelii, causal agent of white piedra can cause disseminated infection in immunodepressed subjects. Systemic infections due to this pathogen have been reported mainly in neutropenic patients and rarely in AIDS patients. CASE REPORT: A 36-year-old HIV+ man from Senegal was hospitalized for fever and meningoencephalitis associated with skin lesions. T. beigelii was isolated from skin biopsies and cerebrospinal fluid cultures. The patients was treated with amphotericin B with regression of the skin lesions. The diagnosis of disseminated T. beigelii infection was retained. DISCUSSION: Disseminated T. beigelii infections are known to occur in immunodepressed subjects, especially in case of neutropenia. In our patient, the presence of two proven localizations (meninges and skin) and the favorable outcome with amphotericin B favored disseminated infection. The good response to treatment can probably be explained by the absence of neutropenia. Skin lesions are frequent, usually occurring as disseminated papulae or purpural nodules. Pathology examination and skin biopsy culture can provide rapid diagnosis allowing appropriate treatment.
Human herpesvirus 6 infection associated with anticonvulsant hypersensitivity syndrome and reactive haemophagocytic syndrome.
V Descamps, F Bouscarat, S Laglenne, E Aslangul, B Veber, D Descamps, J L Saraux, M J Grange, M Grossin, E Navratil, B Crickx, S Belaich
Service de dermatologie, Hôpital Bichat, Paris, France.
Viral infections are thought to play a part in some cutaneous drug reactions. Human herpesvirus 6 (HHV6), which is the agent of exanthema subitum (sixth disease), has never been implicated in a drug reaction. We report a patient with severe phenobarbital-induced anticonvulsant hypersensitivity syndrome in whom a fulminant haemophagocytic syndrome was associated with HHV6 infection. We discuss the possible role of HHV6 in this reactive condition.
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Paulo Morais, Teresa Baudrier, Alberto Mota, Ana Paula Cunha, Susana Cadinha, Ana Margarida Barros, Filomena Azevedo
Department of Dermatovenereology, Hospital S. João, E.P.E., Porto, Portugal. email@example.com
A 56-year-old white woman developed a distinctive skin eruption over her mammary, lumbosacral, and pubic areas 2 weeks after the start of esomeprazole therapy for dyspeptic symptoms. Skin biopsy disclosed a spongiotic dermatitis with predominantly lymphocytic dermal infiltrate. Treatment with a tapering dose of corticosteroid and withdrawal of the suspected drug led to a rapid resolution of the eruption without residual dyschromia. Patch testing with esomeprazole 2% in petrolatum was negative at 48 and 72 hours but became positive on day 6. Oral-controlled provocation test induced the reappearance of the lesions over the mammary areas, confirming the putative involvement of this drug. Therefore, the patient was diagnosed as having a nonpigmented fixed drug eruption associated with esomeprazole. This compound is a proton-pump inhibitor developed as the S-isomer of omeprazole to improve its pharmacokinetic properties. Reports of cutaneous reactions to proton-pump inhibitors are quite common, but reports of such reactions to esomeprazole are rare, which demonstrates the need for higher clinical awareness and knowledge of reactions to these drugs.
Noboru Yahara, Hiroto Hayashi, Takumi Furuya, Toshihiro Saeki, Hideto Hayashi, Yuka Inoue, Hideo Yanai, Noriko Ishigaki
Department of Surgery, Kanmon Medical Center.
A 58-year-old man of unresectable gastric cancer was treated with S-1 (120 mg/body/day) after gastrojejunostomy. After 5 courses of orally administration of S-1 for 4 weeks and withdrawal for 2 weeks, partial response (PR) was obtained clinically and distal gastrectomy was performed. The histological diagnosis showed no residue of carcinoma with both HE and immunohistochemical staining. The patient has been in good health and no recurrence has occurred for about 4 years and 4 months after resection.
Dept. of Sugery, Hirosaki University School of Medicine.
We report a woman in her 30s who developed a right breast tumor 10 years after undergoing mastectomy for invasive ductal carcinoma of the left breast. She underwent modified radical mastectomy for the right breast cancer, which was diagnosed histologically as invasive ductal carcinoma with metastasis to the axillary lymph nodes. Because of the risk of recurrence, she received postoperative systemic adjunctive chemotherapy using CMF, but this had to be withdrawn because of liver toxicity. The patient therefore received hormonal therapy with goserelin and tamoxifen for 24 months. During this period, however, she became menopausal, necessitating withdrawal of the goserelin. After a disease-free interval of 34 months, liver metastasis appeared, and so tamoxifen was changed to exemestane. After 3 months, the metastasis showed a marked response, and this has been subsequently maintained for 48 months. Because the patient's menstrual cycle then returned, goserelin was restarted after consultation with a gynecologist. This case illustrates that exemestane and goserelin combination therapy is effective for recurrent breast cancer.
Service de dermatologie, hôpital Ambroise-Paré, Assistance publique–Hôpitaux de Paris, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France.
BACKGROUND: Fluindione is an oral anticoagulant belonging to the vitamin K antagonist class. Although fluindione is very widely prescribed in France, few cases of cutaneous drug reactions have been reported. Below we describe a case of acute generalised exanthematous pustulosis due to fluindione as confirmed by patch-testing. PATIENTS AND METHODS: A 70-year-old woman was hospitalised for diffuse erythematous and pustular rash 48hours after initiation of fluindione treatment for cardiac arrhythmia. A diagnosis of fluindione-induced acute generalised exanthematous pustulosis was made. After withdrawal of fluindione, the eruption cleared up within eight days. Warfarin was then used without skin reaction. Subsequent patch-tests were positive for fluindione. DISCUSSION: These signs were consistent with fluindione-induced acute generalised exanthematous pustulosis. A causative role of fluindione is very likely in view of the rapid onset after initiation, improvement after withdrawal and positive patch tests. Skin patch-testing, which is easily performed, can be extremely helpful in determining a causal relationship with medication.
J Dermatol. 2007 Oct ;34 (10):696-8 17908140
Department of Dermatology, School of Medicine, Fukushima Medical University, Fukushima City, Fukushima Prefecture, Japan. firstname.lastname@example.org
We present the case of a patient who developed deformities of the fingernails and reddish nodules on the nail beds after administration of propylthiouracil (PTU) for 6 months to treat Grave's disease. Histological examination of the lesion revealed a lichenoid tissue reaction. After withdrawal of PTU, she noticed an improvement in the eruption and the growth of the nails. No recurrence of the eruption was detected after the withdrawal of PTU. Thus, we strongly suggest that this was a rare case of PTU-induced lichenoid drug eruption of nail.
Klinische Pharmakologie & Toxikologie, regionales Pharmacovigilance-Zentrum, Universitätsspital, Basel. email@example.com
We report the case of an 18-year-old woman with arthralgia and swelling of distal joints at hands and feet, photosensitive reaction, butterfly rash, fatigue, tachypnea and unspecific cardiac pain three months after beginning a treatment with minocycline for acne. Recurrence of symptoms at a higher intensity occurred within hours of reexposition with minocycline. The antinuclear antibody test was positive. After withdrawal of minocycline, the symptoms improved and minocycline-induced lupus was diagnosed. In the Swissmedic and WHO adverse drug reaction databases 267 other cases of possible minocycline-induced lupus were identified. Typical clinical and laboratory features are arthralgia, arthritis, myalgia, increased transaminases and/or jaundice, unspecific symptoms like fatigue and fever, skin disorders and positive antinuclear antibodies.
Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, USA. firstname.lastname@example.org
CONTEXT Radiation recall has been described in the context of gemcitabine chemotherapy. However, this phenomenon has been largely limited to skin. CASE REPORT We hereby report a case of radiation recall dermatitis and myositis occurring on gemcitabine monotherapy, five months after completing chemoradiation for locally advanced pancreatic cancer. Radiation recall resolved spontaneously with withdrawal of gemcitabine. CONCLUSIONS This is the second case report that describes gemcitabine-induced radiation recall in rectus abdominus muscles after gemcitabine-based radiation therapy. Given the wide use of gemcitabine following chemoradiation for pancreatic cancer, providers should be aware of this potential complication.
Department of Dermatology, Hedi Chaker Hospital, Sfax, Tunisia. email@example.com
Erysipelas is a bacterial hypodermal cellulitis usually associated with Streptococcal infection. Erysipelas of the upper limbs in women treated for breast cancer is relatively rare. We undertook a 10-year retrospective study identifying 26 cases of erysipelas of the upper limb following treatment for breast cancer; we describe the clinical, therapeutic, and evolutionary aspects. The age of our patients ranged from 37 to 80 years with a mean age of 53. All patients had a breast surgery and lymphadenectomy. Fifteen patients had chemotherapy and 23 had radiotherapy. The erysipelas appeared with an average of 5.23 years after cancer treatment (3 months to 15 years) and was recurrent in nine cases. Lymphedema occurred in eighteen patients. The first signs were fever and shivering in 25 patients. The clinical aspect was an inflammatory plaque. The physical findings of erysipelas included a raised edge (6 cases), blisters (1 case), purpura (1 case), and cellulitis (1 case). The portal of entry was not found in eleven patients. The upper limb was affected in all cases. Involvement of the axillary folds or the chest was observed in eight cases. Treatment with penicillin was undertaken for all patients; the length of treatment varied from 11 to 26 days. Lympadenectomy and radiotherapy in breast cancer may lead to lymphedema, which can be evident or sometimes discrete. Those patients who developed erysipelas in our series usually fared well with treatment, but many had recurrences attributed to persistent lymphedema. It was also of note that for many patients in this series, the portal of entry was not identified.
Department of Medical Oncology, University Medical Center, P.O. Box 30001, 9700 RB Groningen, The Netherlands.
OBJECTIVES A literature search was conducted to gather information concerning the pathophysiologic mechanisms leading to hot flushes, their prevalence and severity in breast cancer patients, their influence on quality of life, and the best therapeutic option. METHODS Relevant studies in English were selected from Medline. RESULTS AND CONCLUSION Pathophysiologic mechanisms leading to hot flushes are poorly understood. Estrogen withdrawal is considered to have a central role. Also, serotonin and norepinephrine seem to be involved in hot flush induction. Menopause induced by chemotherapy or ovarian ablation, is accompanied by an abrupt decrease in estrogen level, causing vasomotor symptoms. Hot flushes are also a side effect of tamoxifen and aromatase inhibitors. Quality of life in breast cancer patients may be negatively influenced by hot flushes, and therefore, adequate treatment is important. Currently, of the several non-hormonal options, the selective serotonin-reuptake inhibitor (SSRI) venlafaxine is the most effective in breast cancer patients. However, studies on interaction between SSRIs and tamoxifen may influence future recommendations.
Results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion of 5 years' adjuvant treatment for breast cancer.
A Howell, J Cuzick, M Baum, A Buzdar, M Dowsett, J F Forbes, G Hoctin-Boes, J Houghton, G Y Locker, J S Tobias
Christie Hospital, Manchester, UK. firstname.lastname@example.org
The standard adjuvant endocrine treatment for postmenopausal women with hormone-receptor-positive localised breast cancer is 5 years of tamoxifen, but recurrences and side-effects restrict its usefulness. The aromatase inhibitor anastrozole was compared with tamoxifen for 5 years in 9366 postmenopausal women with localised breast cancer. After a median follow-up of 68 months, anastrozole significantly prolonged disease-free survival (575 events with anastrozole vs 651 with tamoxifen, hazard ratio 0.87, 95% CI 0.78-0.97, p=0.01) and time-to-recurrence (402 vs 498, 0.79, 0.70-0.90, p=0.0005), and significantly reduced distant metastases (324 vs 375, 0.86, 0.74-0.99, p=0.04) and contralateral breast cancers (35 vs 59, 42% reduction, 12-62, p=0.01). Almost all patients have completed their scheduled treatment, and fewer withdrawals occurred with anastrozole than with tamoxifen. Anastrozole was also associated with fewer side-effects than tamoxifen, especially gynaecological problems and vascular events, but arthralgia and fractures were increased. Anastrozole should be the preferred initial treatment for postmenopausal women with localised hormone-receptor-positive breast cancer.