A Case of Methotrexate-induced Bullous Acral Erythema: CASE REPORT
A 65-year-old man visited our hospital with a history of multiple palpable cervical lymph nodes for several months. The cervical lymph node biopsy was done and he was diagnosed as Non-Hodgkin’s lymphoma, diffuse large B-cell type, in November 2000. He was treated with combination chemotherapy comprising 6 cycles of CHOP regimen (epirubicin, cyclophosphamide, vincristine and pre- dnisolone) for six months, and had been in a tolerable state for 4 years without any cutaneous symptom or sign of tumor recurrence. However, the tumor recurred on the terminal ileum in October 2004. He was again treated with combination chemotherapy comprising 2 cycles of MACOB-B regimen (epirubicin and cyclophosphamide for the 1st cycle, vincristine and methotrexate for the 2nd cycle) for 2 weeks. 1 day after the completion of the 2nd MACOB-B chemotherapy including vincristine 1.4 mg/m2 and methotrexate 360 mg/m2, painful erythema and bullous lesions developed on his soles (Fig. 1). There was no abnormal finding on physical examination except a dehydrated tongue. Initial laboratory investigations showed WBC 1,100/mm3(seg: 28%), BUN/Cr 44.3/1.65 mg/dL. The 24 hour urine chemistry was examined for the calculation of creatinine clearance rate, 58.1 mL/ min. The methotrexate level of the serum was 0.04 ymol/L.
Fig. 1. Symmetrical, well-demarcated, painful erythema and bullous lesions on both soles.
A skin biopsy was completed on the lesion of the sole. The biopsy specimen showed epidermal necrosis, exocytosis, spongiosis, vacuolar degeneration of basal cell layer and subepidermal bulla with perivascular mononuclear cell infiltration in upper dermis (Fig. 2).
canadian drugstore online
Fig. 2. Epidermal necrosis, exocytosis, spongiosis, vacuolar degeneration of basal cell layer and sub- epidermal bulla with perivascular mononuclear cell infiltration in upper dermis (H&E, x 200).
The patient was placed on the topical therapy with high-potent corticosteroid ointments, his symptoms improved rapidly. Marked desquamation was observed in these lesions over the next 5 days, and the cutaneous lesions resolved completely. He completed 5 additional courses of MACOB-B without recurrence of the lesions. Apcalis Oral Jelly