INTRODUCTION
Cutaneous side effects are relatively common in chemotherapy but vary in frequency and severity depending on the medication, dose, duration, pharmacokinetics, and pharmacodynamics. Gemcitabine, a pyrimidine nucleoside analogue, is a common oncologic agent used in the treatment of a variety of malignancies such as cancers of the head and neck, lung cancer, breast cancer, pancreatic cancer, non-Hodgkin lymphoma, and CTCL. Common adverse events include nausea, vomiting, and myelosuppression. Severe side effects such as hemolytic uremic syndrome and thrombotic thrombocytopenic purpura are uncommon. Herein we present an unusual case of widespread skin necrosis mimicking toxic epidermal necrolysis but lacking mucosal involvement in a patient receiving gemcitabine therapy for cutaneous T-cell lymphoma.
CASE REPORT
A 45-year-old woman with past medical history of Stage IIIA CTCL treated previously with topical nitrogen mustard, bexarotene, interferon alpha 2b, romidepsin, pembrolizumab, and brentuximab vedotin was admitted to a community hospital with erythroderma, skin erosions, and intermittent fever. Of note, the patient had not received systemic chemotherapy in the 8 weeks prior to this acute presentation. Upon admission, she was diagnosed with otitis externa and herpes simplex virus (HSV) of the face and was treated with vancomycin, meropenem, micafungin, and acyclovir, which resulted in defervescence. Six days later, the patient received her first dose of gemcitabine, which initially resulted in clearing of her skin. The patient received a second dose of intravenous gemcitabine 1000 mg/m2 one week later. Two days after the second dose of gemcitabine, she developed cytopenia-requiring filgrastim (Neupogen) and generalized full-thickness necrosis of the neck, trunk, and extremities without mucosal involvement (Figure 1A-C). Gemcitabine was discontinued and the patient was transferred to our facility for wound care and further treatment.Upon admission to our hospital, she was noted to be afebrile. Workup included basic metabolic panel and liver function tests, which were within normal limits. She was noted to be anemic with hemoglobin of 6.5 g/dL and was given a transfusion of 1 unit of packed red blood cells (PRBC). The patient’s albumin was 1.4 and nutrition was optimized. Other relevant laboratory data included a CD4/CD8 ratio of 1.26, Sezary count of 0%, and HTLV I/II were negative. She was placed on combination medical therapy with intravenous methylprednisolone 40 mg every 8 hours, intravenous acyclovir 10 mg/kg three times a day, intravenous vancomycin 1 g every 8 hours, and intravenous meropenem 1 g every 8 hours. Additionally, oral acitretin 25 mg was administered every other day and increased to 25 mg daily on day 19. Wound care included nonstick sheets, dressings with 0.5% silver nitrate and sterile water every 8 hours changed every 3-4 days with bedside monitored anesthesia care (MAC). The patient remained afebrile and blood cultures were negative, therefore antibiotic therapy was discontinued on hospital day five and acyclovir was changed from intravenous to oral. Repeat wound cultures were negative for HSV but were positive for candida parapsilosis and mixed gram-positive flora indicating normal skin flora contaminants.Histopathological examination of skin biopsies revealed residual cutaneous T-cell lymphoma with CD30-negative large cell transformation. The epidermis showed chemotherapy-related changes (Figure 2A-H). No viable epidermis was identified. Gram stain was negative for bacteria. HSV type 1 and type 2 immunostains were both negative.The patient’s skin continued to epithelialize and she was ultimately treated with extracorporeal photophoresis, two
