Dermatomyositis-like reaction induced by chemotherapeutical agents

Case 1 A 34-year-old-man diagnosed of chronic myeloid leukemia Ph positive in chronic phase achieved hematological complete response after 19 months of hydroxyurea treatment (1.5 g/day). The patient was then admitted to the hospital for an allogenic bone marrow transplantation from an identic Human Leucocyte Antigen (HLA) donor. Conditioning was achieved with busulfan (1 mg/kg/6 h) and cyclophosphamide (60 mg/kg/day). Cyclosporine and methotrexate on short course (days +1, +6, +11) were used to prevent graft-vs.-host disease and acylovir was given as prophylaxis of cytomegalovirus infection. On day +22 he developed bilateral, pruritic, erythema of the palms and erythematous lesions on dorsa of finger joints (Fig. 1) and elbows. No periungual erythema was present. There was no evidence of muscle weakness. Lesions disappeared spontaneously in eight days. Laboratory findings were within normal range. Two histological studies taken from palm and elbow showed hyperkeratosis, focal degeneration of the basal cell layer with scattered necrotic keratinocytes and perivascular chronic infiltrate. Figure 1. Erythema over the interphalangeal joints (case 1) Download figure to PowerPoint Case 2 A 44-year-old woman on partial remission after chemotherapeutic treatment of a follicular lymphoma stage IVb was admitted to the hospital to undergo peripheral stem cell transplant. Myeloablation and immunosuppression were attained with total body irradiation and cyclophosphamide (4080 mg/24 h). On day +5 after infusion she complained of nonpruritic erythema over eyelids and palpebral edema. A few days later she developed peribucal erythema, erythematous plaques on interdigital folds and painful palmar erythema. Physical examination revealed scaly symmetric erythema over eyelids and erythematous, well defined plaques on interdigital folds, over the interphalangeal joints and elbows (Fig. 2). Periungual and palmar erythema was also present. No muscle weakness was evidenced and laboratory studies including muscle enzymes, antinuclear antibodies, Jo-1, Mi-2 and SRP were normal or negative. Skin biopsies from right elbow and right palm showed similar features: hyperkeratosis, vacuolar degeneration of the basal cell layer and chronic perivascular infiltrate (Fig. 3). Figure 2. Erythematous plaque on the elbow (case 2) Download figure to PowerPoint Figure 3. Vacuolar degeneration of the basal cell layer and perivascular infiltrates Download figure to PowerPoint Case 3 A 27-year-old woman diagnosed of acute lymphoblastic leukemia (M4) was admitted to the hospital to undergo chemotherapeutical treatment of a second relapse after peripheral stem cell transplant two years before. High doses of etoposide (5460 mg) were administered for 4 days. The last day of the chemotherapeutic treatment she referred non pruritic erythema over eyelids, cheeks and forehead. On physical examination we could appreciate palpebral edema and symmetric, macular, violaceous, erythema over cheeks, eyelids and forehead (Fig. 4). Erythematous, painful plaques on elbows and forearms were also present. No nailfold abnormalities swere observed. Lesions disappeared spontaneously in a few days leaving slight hyperpigmentation. She had no muscular weakness and laboratory findings including muscle enzymes were within normal ranges. Histological studies from left elbow were consistent with a vacuolar interface dermatitis. Figure 4. Erythema over the eyelids and palpebral edema (case 3) Download figure to PowerPoint