Overexpression of suppressor of cytokine signalling-5 augments eosinophilic airway inflammation in mice

BACKGROUND

Enhanced expression of the suppressor of cytokine signalling (SOCS)-5 might be of therapeutic benefit for T-helper type 2 (Th2) dominant diseases, as its expression is reported to result in a reduction of Th2 differentiation in vitro due to the inhibition of IL-4 signalling.

OBJECTIVE

To investigate the regulatory role of SOCS-5 in vivo, we explored the phenotype of an experimental asthma model developed in SOCS-5 transgenic (Tg) mice.

METHODS

The SOCS-5 Tg mice or wild-type (WT) mice were sensitized and repeatedly challenged with ovalbumin (OVA). We examined bronchoalveolar lavage fluid (BALF), lung specimens, and airway hyperresponsiveness (AHR) to methacholine.

RESULTS

The production of IFN-gamma by CD4(+) T cells from unprimed SOCS-5 Tg mice was significantly increased in comparison with unprimed wild-type mice, indicating that SOCS-5 Tg mice have a Th1-polarizing condition under natural conditions. However, in an asthma model, significantly more eosinophils in the airways and higher levels of IL-5 and IL-13 in BALF were observed in the SOCS-5 Tg than the wild-type mice. AHR in the asthma model of SOCS-5 Tg was also more enhanced than that of wild-type mice. OVA-stimulated CD4(+) T cells from the primed SOCS-5 Tg mice produced significantly more IL-5 and IL-13 than CD4(+) T cells from wild-type mice.

CONCLUSION

Our results demonstrate that the overexpression of SOCS-5 does not inhibit Th2 response, but rather augments the phenotype of the asthma model in vivo. This finding throws into question the therapeutic utility of using enhancement of SOCS-5 expression for Th2-dominant disease.

A randomized trial of intrapericardial (ip) bleomycin (BLM) after drainage for management of malignant pericardial effusion (MPE) in lung cancer patients (pts): Report of a Japan Clinical Oncology Group trial (JCOG 9811)

7710

Background: This trial was aimed to evaluate the safety and efficacy of ip BLM instillation as compared to pericardial drainage alone in pts with MPE. Methods: Pts ≤ 75 y.o. with pathologically documented lung cancer, who had received pericardial drainage for clinical MPE within 72 hours of the enrollment, were eligible. Pts with chemo-naïve small cell cancer, major organ failure, or severe co-morbidity were excluded. Signed consent form was obtained. Pts were randomized to either Arm A: observation alone after drainage, or Arm B: ip BLM of 15mg, followed by additional ip BLM 10mg q48hours. Drainage tube was removed when daily drainage was ≤20mL; the protocol therapy was judged as primary failure, with no regulations on post-therapy, if this criteria could not be met after 7 days from enrollment. MPE was followed at 1,2,4,6 and 12 months by echocardiography. The primary endpoint was survival with MPE control (effusion failure-free survival, EFFS) at 2 months, assumed to be 60% vs. 30%. The trial was designed to provide 80% power with 5% one-sided alpha, with 80 cases. Results: From Aug./99 to Jan./06, 80 pts were enrolled, with 79 eligible. M:F=51:29, median age 60 y.o. (range: 39–75), 75 nonsmall histology, 53 with prior chemotherapy, and 20 with prior radiotherapy. Median drainage volume was 600 mL (range: 130–1930). Cytology of the effusion was positive in 58/76 examined. EFFS ( table ) tended to favor Arm B, with hazard ratio of 0.64 (one-sided p=0.030 by logrank test, 95% C.I. 0.40–1.03). No additional acute toxicities or complications were observed for Arm B. There were 2 cases with late constrictive complications in Arm B, but none was severe. The median survival was 79 days (A) and 119 days (B) (not significant). Conclusions: Although the difference of EFFS at 2 months was not statistically significant, BLM ip after pericardial drainage appears to be safe and effective in allover for management of MPE.

No significant financial relationships to disclose.

[Table: see text]

A phase I/II, pharmacokinetic (PK) and pharmacogenomic (PG) study of weekly irinotecan (CPT-11) therapy for elderly patients with advanced non-small cell lung cancer

2539

Background: CPT-11 is commonly used to treat lung cancer, but there is little evidence about its efficacy in elderly patients. The aim of this study was to determine the recommended dose (RD) of CPT-11 for weekly administration to elderly patients, and to assess its efficacy and safety. In addition, a PK and PG study was performed to investigate the influence on the clinical outcome. Methods: CPT-11 was infused intravenously on Days 1 and 8 (every 21 days). In the phase I study, the dosage of CPT-11 was escalated from 60 (Level 1) to 80 (Level 2) and 100 mg/m2 (Level 3). PK of CPT-11 and SN-38, and UGT1A1 polymorphism were analyzed during the first treatment cycle in the phase II study. Results: In the phase I study, 12 patients were enrolled (level 1/2/3=6/3/3) and the RD was determined to be 100 mg/m2. The 37 patients in phase II had the following characteristics: male/female=25/12, median age=77 (71–88), IIIB/IV=10/27, PS 0/1=12/25. The overall response rate and the disease control rate (PR+SD) was 8% and 73%, respectively. The median survival time was 441 days and the 1-year survival rate was 54.0%. Grade 3/4 neutropenia and diarrhea occurred in 27% and 8%, respectively. The AUCs for both CPT-11 and SN-38 were significantly correlated with neutropenia (P=0.0095, P=0.0004). Both the UGT1A1*6 and UGT1A1*28 genotypes were significantly correlated with the AUC ratio, leukopenia, and neutropenia ( Table ). Conclusion: CPT-11 monotherapy is considered to be effective for non-small cell lung cancer in elderly patients because good survival with tolerable adverse events were achieved. The UGT1A1*6 and UGT1A1*28 genotypes might both influence the toxicity of irinotecan in Asians.

[Table: see text]

[Table: see text]

Randomized controlled trial comparing docetaxel (D)-cisplatin (P) combination with D alone in elderly patients (pts) with advanced non-small cell lung cancer (NSCLC): JCOG0207

7629

Background: Platinum-based chemotherapy is currently recommended as the standard approach for pts with advanced NSCLC. However prospective clinical trials specifically designed for elderly pts demonstrating the P benefit are still lacking. Therefore, we conducted a phase III trial to determine whether the addition of P to single agent-chemotherapy for elderly NSCLC pts could improve survival. Methods: Eligibility criteria included; chemotherapy-naive; stage III/IV NSCLC; age=70 and PS 0–1. Pts were randomized to receive either DP or D with minimization method balancing site, age (=74/=75) and stage (III/IV), and both regimens were given every 4 weeks. DP comprised D (20 mg/m2) and P (25 mg/m2) iv on days 1, 8, 15. D comprised D (25 mg/m2) iv on the same schedule. Primary endpoint was overall survival (OS). The planned sample size was 115 pts in each arm to provide 80% power to detect 0.667 hazard ratio for DP to D in OS and 2.5% one-sided alpha. Results: Between Apr 2003 and Apr 2006, 126 pts were randomized (D/DP: 63/63). The second planned interim analysis was performed on 112 assessable pts (D/DP:56/56, median age 76, =74/=75: 39/61%, male/female: 77/23%, PS 0/1: 39/61%, III/IV: 30/70%). Maturity of information, defined proportion of interim events to the planned events, was 26% (=49/191). As the one-sided p-value(p=0.00515) of the stratified log-rank test by age and stage was not lower than the critical value for the interim analysis, the formal criterion for stopping the trial failed to meet. However the Data and Safety Monitoring Board recommended study termination and disclosure of the results based on the strong interaction (two-sided p=0.077, hazard ratios [95% C.I.] for =74/=75: 0.23 [0.09–0.62]/0.72 [0.35- 1.49]) that DP may be beneficial for subgroup of age between 70- 74. Major Grade 3–4 toxicities were (%D/DP): neutropenia 4.9/13.1, anemia 1.6/16.4, anorexia 8.3/24.2, infection 11.7/8.1, pneumonitis 1.7/1.6. TRD occurred in 1 pt in DP arm. Conclusions: The interpretation of study results is limited due to early stopping and resultant loss of statistical power. But these data indicated that =74 young elderly have no more need to evaluate tolerability and efficacy of P.

No significant financial relationships to disclose.

Endoscopic treatment for superficial squamous cell carcinoma in the head and neck region (HNSCC)

16542

Background: The HNSCC are usually diagnosed at advanced stage, therefore, the prognosis is dismal. Recently we can find the superficial HNSCC by using high-resolution and magnifying endoscopy. We expect to get a good prognosis by the endscopic treatment (EMRC: Endoscopic Mucosal Resection by Cap-method/ELPS: Endoscopic Laryngo-Pharyngeal Surgery) for the superficial HNSCC. The purpose of this study is to examine the usefulness and effectiveness of endoscopic treatment for the superficial HNSCC. Methods: The superficial HNSCC means that the depth of cancer invasion is within the subepithelial layer. When we diagnose superficial HNSCC with no lymphnode metastasis, the endoscopic treatment (EMRC/ELPS) becomes the first line treatment under general-anesthesia. For those treatment cases, We examine the method of treatment, complication, pathological diagnosis and prognsis. Result: We have 130 patients (201 lesions) of the superficial HNSCC from Jan 2000 to Jan 2007. The endoscopic treatment cases were 92 (142 lesions), 87 male and 5 female, ranging in age from 40 to 86 years. Of the 92 patients, 56 (60.9%) had been treated by EMRC, 36 (39.1%) had been treated by ELPS. EMRC is good for small lesion (less than 10 mm in diameter). ELPS is suitable for large lesion. In EMRC case, a wound pain was often slight after the operation, and patient could leave the hospital in 4–5POD. In ELPS case, a wound pain was stronger than EMRC, and needed more hospital days. Major complication was not recognized both in EMRC and ELPS. Of 142 lesions which clinical assessments of the depth of cancer invasion were ep (epithelial layer) or sep (subepithlial layer), 140 lesions (98.6%) were histopathologically ep or sep. Two lesions (1.4%) were mp (proper muscular layer). Of the 92 patients, 83 are alive, 9 had been dead. There was no lymphnode metastasis, distant metastasis and local recurrent case. Forty patients of 3 years observation were accrued from Jan 2000 to Dec 2003. Of the 40 patients, 33 were alive, 7 were dead. No HNSCC patients died. The cause specific 3 years survival rate is 100%. Conclusion: The result of our trial indicated the usefulness of endoscopic treatment for superficial HNSCC and the effectiveness for improving the prognosis of HNSCC

No significant financial relationships to disclose.

Randomised phase III trial of carboplatin plus etoposide vs split doses of cisplatin plus etoposide in elderly or poor-risk patients with extensive disease small-cell lung cancer: JCOG 9702

We compared the efficacy and the safety of a carboplatin plus etoposide regimen (CE) vs split doses of cisplatin plus etoposide (SPE) in elderly or poor-risk patients with extensive disease small-cell lung cancer (ED-SCLC). Eligibility criteria included: untreated ED-SCLC; age ⩾70 and performance status 0–2, or age <70 and PS 3. The CE arm received carboplatin area under the curve of five intravenously (IV) on day 1 and etoposide 80 mg m⁻² IV on days 1–3. The SPE arm received cisplatin 25 mg m⁻² IV on days 1–3 and etoposide 80 mg m⁻² IV on days 1–3. Both regimens were given with granulocyte colony-stimulating factor support in a 21–28 day cycle for four courses. A total of 220 patients were randomised. Median age was 74 years and 74% had a PS of 0 or 1. Major grade 3–4 toxicities were (%CE/%SPE): leucopenia 54/51, neutropenia 95/90, thrombocytopenia 56/16, infection 7/6. There was no significant difference (CE/SPE) in the response rate (73/73%) and overall survival (median 10.6/9.9 mo; P=0.54). Palliation scores were very similar between the arms. Although the SPE regimen is still considered to be the standard treatment in elderly or poor-risk patients with ED-SCLC, the CE regimen can be an alternative for this population considering the risk–benefit balance.

Differential expression of the glycosylated forms of MUC1 during lung development

Human MUC1 mucin is a high-molecular weight transmembrane glycoprotein expressed on the apical surface of the simple epithelia of many different tissues. Previous investigations suggest the involvement of MUC1 in epithelial cytodifferentiation and glandular morphogenesis. However, the role of MUC1 in the development of the fetal respiratory tracts has so far been poorly investigated. To obtain more information on the roles of MUC1 during fetal lung development, we examined the expression and distribution of MUC1 by immunohistochemical staining of postmortem lung specimens from fetuses and neonates of various gestational ages. Three monoclonal antibodies, HMFG1, HMFG2, and anti-KL-6, which bind different glycosylation variants, were used. Each monoclonal antibody has been shown to recognize heavily-glycosylated MUC1, sparsely-glycosylated MUC1, and sialylated carbohydrate side chains of MUC1, respectively. At 13 weeks of gestation, the terminal respiratory tracts were diffusely stained with HFMG1 and anti-KL-6. Sparsely-glycosylated MUC1, as recognized by HMFG2, was detected only in the distal portions of the terminal bronchioles that divided into respiratory bronchioles. As such development continued, MUC1, recognized by HMFG1 and anti-KL-6, was detected throughout the bronchioles and terminal sacs, although HMFG1 immunoreactivity decreased in intensity towards the terminal sacs. Sparsely-glycosylated MUC1, as recognized by HMFG2, was mainly observed in the terminal portions. In the adult lungs, both the alveolar spaces and the respiratory bronchioles stained with HFMG1 and anti-KL-6. However, the distribution of sparsely-glycosylated MUC1 was limited in the alveolar epithelial cells. Our investigation demonstrated that variants of MUC1 were expressed in the fetal respiratory tracts as early as 13 weeks of gestation, and its expression persisted even after lung maturation. The precise roles of MUC1 were not determined in the present study; however, different glycosylation variants of MUC1 may be associated with the development of different regions of the terminal respiratory tract.

Total body irradiation and granulocyte colony-stimulating factor-combined high-dose cytarabine as a conditioning regimen in allogeneic hematopoietic stem cell transplantation for advanced myelodysplastic syndrome: a single-institute experience

In this study, we retrospectively evaluated the efficacy and safety of total body irradiation (TBI) and granulocyte colony-stimulating factor (G-CSF)-combined high-dose cytarabine as a conditioning regimen for allogeneic hematopoietic stem cell transplantation (HSCT) in patients with advanced myelodysplastic syndrome (MDS). We evaluated 22 patients with advanced MDS, including refractory anemia with excess blasts (RAEB; n=10), RAEB in transformation (n=2), acute myelogenous leukemia transformed from MDS (n=6) and chronic myelomonocytic leukemia (n=4). The conditioning regimen consisted of 12 Gy of TBI and high-dose cytarabine (3 g/m(2)) every 12 h for 4 days, and the cytarabine was combined with continuous administration of G-CSF. The stem cell sources were bone marrow or peripheral blood stem cells from human leukocyte antigen (HLA)-identical siblings (n=12) and bone marrow from HLA serologically matched unrelated donors (n=10). Three patients experienced disease relapse, two of whom died of disease progression. Of 22 patients, 16 are currently alive and disease-free. The 5-year estimated overall survival, disease-free survival, relapse and non-relapse mortality rates are 76.7, 72.2, 16.6 and 14.1%, respectively. These results suggest that G-CSF-combined high-dose cytarabine could be a promising component of the conditioning regimen of allogeneic HSCT for advanced MDS, providing a low incidence of both relapse and treatment-related mortality.

Type I IFN-mediated enhancement of anti-leukemic cytotoxicity of gammadelta T cells expanded from peripheral blood cells by stimulation with zoledronate

BACKGROUND

In order to establish efficient gammadelta T-cell based tumor immunotherapy, we explored a method to enhance the cytotoxicity of gammadelta T cells against leukemia cells by stimulating gammadelta T cells with type I IFN.

METHODS

Gammadelta T cells were expanded from normal PBMC by culturing with zoledronate and a low concentration of IL-2 for 2 weeks. For the activation of gammadelta T cells, gammadelta T cells were cultured with type I IFN (HLBI, IFN-alpha2b and IFN-beta) for 1-3 days. The cytotoxicity of HLBI-activated gammadelta T cells against leukemia cell lines and fresh leukemia cells was evaluated by 51Cr-release assay.

RESULTS

Gammadelta T cells, which were expanded and purified with magnetic beads using an anti-gammadelta TCR MAb, were demonstrated to be cytotoxic against leukemia cell lines of both lymphoid and myeloid origin and fresh myeloid leukemia cells. By culturing expanded gammadelta T cells with type I IFN, the expression of the activation marker CD69 was increased and the cytometric bead array showed an elevated production of IFN-gamma by gammadelta T cells. In addition, the cytotoxicity of gammadelta T cells against leukemia cells was definitely enhanced by culturing gammadelta T cells with HLBI.

DISCUSSION

The present study has demonstrated that type I IFN could enhance the anti-leukemic cytotoxicity of expanded gammadelta T cells, which implies that in vitro bisphosphonate (such as zoledronate)-expanded and type I IFN-activated gammadelta T cells could be applied to immunotherapy for hematologic malignancies such as leukemia and lymphoma.

Phase II study of amrubicin, a new active drug in refractory or relapsed small-cell lung cancer (SCLC): Thoracic Oncology Research Group Trial 0301

7060

Background: Amrubicin, a totally synthetic 9-aminoanthracycline, is a topoisomerase II inhibitor. The response rate to amrubicin at 45 mg/m2 on days 1–3 in chemotherapy-naive patients with extensive stage SCLC was 75.8% on an intent-to-treat analysis, with major dose-limiting toxicities of neutropenia, anemia, thrombocytopenia, and anorexia. The very high activity of amrubicin as a single agent in this disease led us to carry out the phase II trial reported here, which was designed to determine the antitumor activity and toxicity of amrubicin in previously treated pts with SCLC. Methods: Pts with cytologically or histologically proven SCLC who were previously treated with at least one platinum-based chemotherapy and ECOG PS 0–2 were eligible. They received amrubicin 40mg/m2 intravenously on days 1–3 every 3 weeks. The primary end-point was the response rate, which determined the sample size of 44 pts in the sensitive cases and 15 pts in the refractory cases, respectively. Secondary objectives were to determine the progression-free survival, overall survival, and 1-year survival rate. Results: In total, 60 pts consisting of 44 sensitive cases and 16 refractory cases with median age 67 years (range 52–79) and 46 out of 60 male were enrolled. The median treatment cycles were 4 (1–8). Grade 3/4 hematological toxicity per patient (pt) was neutropenia (83%), thrombocytopenia (20%) and anemia (33%). Febrile neutropenia was observed in 3 pts. Grade 3/4 non-hematological toxicity per pt was pneumonia (3%), anorexia (15%), low Na levels (8.3%), pneumonitis (1.7%) and cerebral hemorrhage (1.7%). No treatment-related death was observed. The overall response rates were 52% (95% CI: 37–68) in the sensitive cases, and 50% (95% CI: 25–75) in the refractory cases. The progression-free survival, overall survival and 1-year survival in the sensitive cases and the refractory cases were 4.0 and 3.2 months, 11.7 and 10.9 months and 48.2 and 37.8%, respectively. Conclusions: Amrubicin has a significant activity in SCLC, particularly in pts refractory to prior chemotherapy, with predictable and manageable toxicities. Further studies to evaluate the survival benefit of amrubicin in this setting are warranted.

No significant financial relationships to disclose.

Dose intensive chemotherapy (Cx) in advanced thymoma: Initial report of Japan Clinical Oncology Group trials (JCOG 9605 and 9606)

7080

Background: Thymoma is considered to be sensitive to Cx. Dose intensive Cx might well be suitable for such tumors, especially in combination with local therapy. Objectives of the trials were to evaluate the safety and efficacy of the dose intensive CODE (cisplatin[C]- vincristine[O]- doxorubicin[D]- etoposide[E]) Cx in thymoma. The primary endpoint was progression-free survival time (PFS). Methods: Patients (pts) with 15–70 years of age with histologically documented Cx-naïve thymoma with stage IVa/IVb disease (JCOG 9605) or unresectable stage III disease (JCOG 9606) were eligible. Tumors of other histology, such as thymic carcinoma, carcinoid or lymphoma were excluded; pts were to have ample organ function and ECOG PS of 0–2. Myasthenia was allowed. Signed consent form was obtained. Pts received CODE Cx of 9 weeks (w): C 25 mg/m2 Cx day 1 on each w1–9; O 1mg/m2 d1 on w1,2,4,6,8; D 40 mg/m2 d1 and E 80 mg/m2 d1,2,3 on w 1,3,5,7,9. Cx courses were supported by GCSF. Steroids were used only for antiemesis. Those with stage III disease (JCOG 9606) went on to surgery, if judged to be resectable, and post-operative radiotherapy (RT) of 48Gy; those with unresectable disease received 60Gy RT. Results: From Jul./97 to Apr./05, 53 pts were entered to the studies. Five were found ineligible because of different histology. Pt characteristics and response to the Cx were summarized in the table . Toxicity of the Cx was mainly hematologic and generally well tolerated, with no toxic death; 70% of the pts completed planned 9 weeks. Thirteen pts in JCOG 9606 (stage III) received thoracotomy; tumor was resected in 11 pts, completely in 9 (39% of enrolled pts). Pathologic CR was observed in 3. The median PFS was 9.5m for stage IV and 4.5 y for stage III diseases. Overall survival at 2 & 5 yrs were 82% & 57% for stage IV and 96% & 77% for stage III pts. Conclusions: Short-course, dose intensive Cx was active against thymoma. Although it does not seem to bring long PFS in stage IV pts, it could improve resectability in limited disease.

[Table: see text]

No significant financial relationships to disclose.

Adoptive transfer of T-helper cell type 1 clones attenuates an asthmatic phenotype in mice

T-helper cell type 1 (Th1) cells have been postulated to have a significant role in protective immunity against allergic diseases. However, recent studies using polarised Th1 cells showed conflicting effects on both airway responsiveness and eosinophilic inflammation in a mouse asthma model. The current study explored the effects of adoptive transfer of established Th1 clones on a murine model of atopic asthma. Mice (BALB/c) were sensitised with ovalbumin (OVA) and challenged with aerosolised OVA (5%, 20 min) for 5 days. Just before starting the first challenge, Th1 clones (5x10(6) x body(-1)) or PBS alone were injected via the tail vein. After assessment of airway responsiveness to methacholine, bronchoalveolar lavage fluid (BALF) was obtained. Histological examination, including morphometric analysis, measurement of cytokines in the BALF and Northern blotting of lung chemokines, was also performed. Adoptive transfer of Th1 clones showed a significantly increased total number of cells, whereas significantly decreased eosinophils were found in the BALF, when compared with mice with injection of vehicle alone or splenic mononuclear cells. Administration of Th1 clones significantly decreased the infiltration of eosinophils but increased mononuclear cells in the peribronchial area. Goblet cell hyperplasia and peribronchial fibrosis were also suppressed by Th1 clones. The transfer of Th1 cells significantly decreased airway responsiveness. Th1 injection significantly increased interferon gamma in the BALF, but significantly decreased interleukin (IL)-5 and IL-13. Eotaxin mRNA was predominantly expressed in the lungs of asthma model mice, whereas RANTES (regulated on activation, normal T-cell expressed and secreted) predominates in such mice with Th1 transfer. In conclusion, results suggest that the adoptive transfer of T-helper cell type 1 clones can suppress both lung eosinophilia and airway responsiveness, but increase noneosinophilic inflammation in a mouse model of asthma.

Predominant presence of Streptococcus anginosus in the saliva of alcoholics

Chronic alcohol consumption is known to be a major risk factor for cancers of the upper aerodigestive tract. The incidence of esophageal cancer (4.4%) in alcoholics is reported to be much higher than that in the Japanese population as a whole (0.0001%). This suggests the presence of specific factors in chronic alcohol consumption-related carcinogenesis. Recently, data showing a significant correlation between Streptococcus anginosus and carcinogenesis in the upper aerodigestive tract have been reported. In this study, the ratio of S. anginosus to oral bacteria in the saliva of 38 alcoholic patients was investigated to determine if there is an association between alcoholic patients and S. anginosus infection. The level of S. anginosus in the saliva from 22 healthy people, 41 esophageal cancer patients, 32 gastritis patients, and 24 periodontitis patients was also investigated and compared to the level in alcoholic patients. In the saliva from esophageal cancer patients, the level of S. anginosus was not significantly different from that of healthy people. The levels of S. anginosus in periodontitis and gastritis patients were also similar. In alcoholics, however, there was an extremely high level of S. anginosus, suggesting that they, rather than healthy people and general esophageal cancer patients, have a high risk for S. anginosus infection.

Multiple fixed drug eruption due to drug combination

We report the case of a multiple fixed drug eruption (FDE) after taking 1 g of PL and 100 mg of levofloxacin (Cravit) at the same time. Patch tests with PL alone, levofloxacin alone and the combination of PL and levofloxacin were all negative on the involved and uninvolved sites. Lymphocytic stimulation tests were also negative for PL alone, levofloxacin alone and the combination of PL and levofloxacin. Oral provocation tests with PL alone or levofloxacin alone produced no reactivation. However, we could provoke multiple erythematous plaques on the involved areas by taking a 1/10th dose of the combination of PL and levofloxacin at the same time. Drug eruption due to a drug combination appears to be very rare. This is the first case of multiple FDE caused by taking PL-levofloxacin combination.