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Drug-induced subacute cutaneous lupus erythematosus associated with docetaxel chemotherapy: a case report.

Wong NY, Parsons LM, Trotter MJ, Tsang RY - BMC Res Notes (2014)

Bottom Line: Drug-induced subacute cutaneous lupus erythematosus is an uncommon disorder associated with the use of pharmacological agents including systemic chemotherapy.We report a case of docetaxel-induced subacute cutaneous lupus erythematosus in a 60-year-old Caucasian female with Sjögren's syndrome diagnosed 2 months after receiving docetaxel as part of the adjuvant FEC-D (5-fluorouracil, epirubicin, cyclophosphamide, docetaxel) chemotherapy protocol for early stage breast cancer.Although the exact mechanisms behind the autoimmune response elicited by docetaxel are unclear, the involvement of anti-SSA/Ro antibodies has been implicated.

View Article: PubMed Central - PubMed

Affiliation: Department of Oncology, Division of Medical Oncology, University of Calgary, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, Alberta T2N 4N2, Canada. roger.tsang@albertahealthservices.ca.

ABSTRACT

Background: Drug-induced subacute cutaneous lupus erythematosus is an uncommon disorder associated with the use of pharmacological agents including systemic chemotherapy.

Case presentation: We report a case of docetaxel-induced subacute cutaneous lupus erythematosus in a 60-year-old Caucasian female with Sjögren's syndrome diagnosed 2 months after receiving docetaxel as part of the adjuvant FEC-D (5-fluorouracil, epirubicin, cyclophosphamide, docetaxel) chemotherapy protocol for early stage breast cancer. Although the exact mechanisms behind the autoimmune response elicited by docetaxel are unclear, the involvement of anti-SSA/Ro antibodies has been implicated.

Conclusion: This case highlights the symptom severity and clinical course of docetaxel-induced subacute cutaneous lupus erythematosus, and highlights the importance of recognizing this uncommon but potentially severe chemotherapy-associated cutaneous reaction.

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Related in: MedlinePlus

Photomicrographs of a skin biopsy. Photomicrographs show an interface dermatitis with associated mid-dermal peri-vascular lymphocytic inflammation (A: hematoxylin and eosin, 100X) and dermal mucin deposition (B: Hale’s colloidal iron, 100X).
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Fig2: Photomicrographs of a skin biopsy. Photomicrographs show an interface dermatitis with associated mid-dermal peri-vascular lymphocytic inflammation (A: hematoxylin and eosin, 100X) and dermal mucin deposition (B: Hale’s colloidal iron, 100X).

Mentions: A 60-year-old post-menopausal Caucasian woman with Stage IIB (T2 N1) invasive ductal carcinoma of the left breast commenced adjuvant chemotherapy with the FEC-D (5-fluorouracil, epirubicin, cyclophosphamide for 3 cycles, followed by docetaxel for 3 cycles) protocol with G-CSF support (peg-filgrastim) after undergoing breast-conserving surgery and axillary lymph node dissection. Her past medical history is significant for chronic benign neutropenia and Sjögren’s syndrome primarily manifested by dry eyes, myalgias, and arthralgias, without a pre-existing history of lupus or other connective tissue disorders. She reports no known drug allergies aside from a rash from adhesive tapes, and her medication profile consists of duloxetine, hydroxyquinine, and celecoxib. Two days following the administration of the first cycle of FEC chemotherapy, she developed an exanthema described as a mild erythematous maculopapular pruritic rash on her extensor forearms and anterior trunk, which was felt to be characteristic of a typical chemotherapy-associated rash, given its near complete resolution prior to her subsequent chemotherapy cycle. Nonetheless, the rash did recur with subsequent cycles of FEC chemotherapy, and the switchover to docetaxel after 3 cycles of FEC chemotherapy was delayed by 1 week to allow for its improvement with supportive measures including anti-histamines and a topical corticosteroid. The decision was then made to begin her docetaxel treatment with standard dexamethasone pre-medication. Shortly after the first cycle of docetaxel, however, she developed a moderately severe, erythematous desquamating rash initially located on her forearms and anterior trunk. The severity and extent of this rash differed from that seen with FEC. With the second cycle of docetaxel, despite the addition of a course of prednisone, the rash progressed to involve her scalp, cheeks, ears, neck, back, as well as membranes of the nose and vagina resulting in epistaxis and vaginal bleeding (Figure 1). This was associated with severe burning pains, and facial and peri-orbital edema. Due to the severity of her presentation, an urgent dermatology consultation was obtained, with a working diagnosis of Stevens – Johnson syndrome (Table 1). A biopsy was performed on her right forearm, and demonstrated an interface dermatitis with dermal mucin deposition (Figure 2). This pathology was consistent with a diagnosis of subacute cutaneous lupus erythematosus, which was felt to be most likely precipitated by the docetaxel exposure. Laboratory and serologic data revealed an ANA speckled pattern with a titre of 1/2560, high positive levels of anti-SSA/Ro 60 antigen at a value of 88 AU/mL (>81 AU/mL is high positive), moderately positive levels of anti-SSB/La at a value of 66 AU/mL (moderate range is 51-80 AU/mL), and elevated rheumatoid factor at 113 kU/L. A decision was made to discontinue chemotherapy after the second cycle of docetaxel, and following its discontinuation, the rash fully resolved after two months, with supportive measures including topical betamethasone cream. During her treatment course, no discernible worsening of her Sjögren’s syndrome was reported, which may have been underreported due to concurrent chemotherapy-related toxicities.Figure 1


Drug-induced subacute cutaneous lupus erythematosus associated with docetaxel chemotherapy: a case report.

Wong NY, Parsons LM, Trotter MJ, Tsang RY - BMC Res Notes (2014)

Photomicrographs of a skin biopsy. Photomicrographs show an interface dermatitis with associated mid-dermal peri-vascular lymphocytic inflammation (A: hematoxylin and eosin, 100X) and dermal mucin deposition (B: Hale’s colloidal iron, 100X).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4232622&req=5

Fig2: Photomicrographs of a skin biopsy. Photomicrographs show an interface dermatitis with associated mid-dermal peri-vascular lymphocytic inflammation (A: hematoxylin and eosin, 100X) and dermal mucin deposition (B: Hale’s colloidal iron, 100X).
Mentions: A 60-year-old post-menopausal Caucasian woman with Stage IIB (T2 N1) invasive ductal carcinoma of the left breast commenced adjuvant chemotherapy with the FEC-D (5-fluorouracil, epirubicin, cyclophosphamide for 3 cycles, followed by docetaxel for 3 cycles) protocol with G-CSF support (peg-filgrastim) after undergoing breast-conserving surgery and axillary lymph node dissection. Her past medical history is significant for chronic benign neutropenia and Sjögren’s syndrome primarily manifested by dry eyes, myalgias, and arthralgias, without a pre-existing history of lupus or other connective tissue disorders. She reports no known drug allergies aside from a rash from adhesive tapes, and her medication profile consists of duloxetine, hydroxyquinine, and celecoxib. Two days following the administration of the first cycle of FEC chemotherapy, she developed an exanthema described as a mild erythematous maculopapular pruritic rash on her extensor forearms and anterior trunk, which was felt to be characteristic of a typical chemotherapy-associated rash, given its near complete resolution prior to her subsequent chemotherapy cycle. Nonetheless, the rash did recur with subsequent cycles of FEC chemotherapy, and the switchover to docetaxel after 3 cycles of FEC chemotherapy was delayed by 1 week to allow for its improvement with supportive measures including anti-histamines and a topical corticosteroid. The decision was then made to begin her docetaxel treatment with standard dexamethasone pre-medication. Shortly after the first cycle of docetaxel, however, she developed a moderately severe, erythematous desquamating rash initially located on her forearms and anterior trunk. The severity and extent of this rash differed from that seen with FEC. With the second cycle of docetaxel, despite the addition of a course of prednisone, the rash progressed to involve her scalp, cheeks, ears, neck, back, as well as membranes of the nose and vagina resulting in epistaxis and vaginal bleeding (Figure 1). This was associated with severe burning pains, and facial and peri-orbital edema. Due to the severity of her presentation, an urgent dermatology consultation was obtained, with a working diagnosis of Stevens – Johnson syndrome (Table 1). A biopsy was performed on her right forearm, and demonstrated an interface dermatitis with dermal mucin deposition (Figure 2). This pathology was consistent with a diagnosis of subacute cutaneous lupus erythematosus, which was felt to be most likely precipitated by the docetaxel exposure. Laboratory and serologic data revealed an ANA speckled pattern with a titre of 1/2560, high positive levels of anti-SSA/Ro 60 antigen at a value of 88 AU/mL (>81 AU/mL is high positive), moderately positive levels of anti-SSB/La at a value of 66 AU/mL (moderate range is 51-80 AU/mL), and elevated rheumatoid factor at 113 kU/L. A decision was made to discontinue chemotherapy after the second cycle of docetaxel, and following its discontinuation, the rash fully resolved after two months, with supportive measures including topical betamethasone cream. During her treatment course, no discernible worsening of her Sjögren’s syndrome was reported, which may have been underreported due to concurrent chemotherapy-related toxicities.Figure 1

Bottom Line: Drug-induced subacute cutaneous lupus erythematosus is an uncommon disorder associated with the use of pharmacological agents including systemic chemotherapy.We report a case of docetaxel-induced subacute cutaneous lupus erythematosus in a 60-year-old Caucasian female with Sjögren's syndrome diagnosed 2 months after receiving docetaxel as part of the adjuvant FEC-D (5-fluorouracil, epirubicin, cyclophosphamide, docetaxel) chemotherapy protocol for early stage breast cancer.Although the exact mechanisms behind the autoimmune response elicited by docetaxel are unclear, the involvement of anti-SSA/Ro antibodies has been implicated.

View Article: PubMed Central - PubMed

Affiliation: Department of Oncology, Division of Medical Oncology, University of Calgary, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, Alberta T2N 4N2, Canada. roger.tsang@albertahealthservices.ca.

ABSTRACT

Background: Drug-induced subacute cutaneous lupus erythematosus is an uncommon disorder associated with the use of pharmacological agents including systemic chemotherapy.

Case presentation: We report a case of docetaxel-induced subacute cutaneous lupus erythematosus in a 60-year-old Caucasian female with Sjögren's syndrome diagnosed 2 months after receiving docetaxel as part of the adjuvant FEC-D (5-fluorouracil, epirubicin, cyclophosphamide, docetaxel) chemotherapy protocol for early stage breast cancer. Although the exact mechanisms behind the autoimmune response elicited by docetaxel are unclear, the involvement of anti-SSA/Ro antibodies has been implicated.

Conclusion: This case highlights the symptom severity and clinical course of docetaxel-induced subacute cutaneous lupus erythematosus, and highlights the importance of recognizing this uncommon but potentially severe chemotherapy-associated cutaneous reaction.

Show MeSH
Related in: MedlinePlus