Hyperpigmentation after bleomycin therapy. Ultrastructural study

Bleomycin-induced flagellate dermatitis

Flagellate dermatitis shows very characteristic lesions: linear erythema or hyperpigmentation in various areas of the skin. It is a side effect of bleomycin, an immunosupressive drug used for several types of cancers. All physicians must be aware of this disease so they can make a rapid diagnosis and interrupt the causative agent. Our patient presented during chemotherapy for a Hodgkin's lymphoma pruritic, erythematous lesions on the lower limbs and the back diagnosed as flagellate dermatitis due to bleomycin.

Diffuse hyperpigmentation of the skin: a clinicopathologic approach to diagnosis

There are multiple causes of diffuse hyperpigmentation of the skin (DHP) and determination of the exact etiology can sometimes be difficult. A systematic classification based on both clinical and pathological findings that should aid the clinician who is confronted with this situation is presented in this article. The skin diseases that cause DHP are classified based on the pigment characteristics (melanin, non-melanin), pigment distribution (epidermal, epidermal-dermal, dermal) and density of melanocytes (normal, increased). The intent of this review is to provide a "histopathological tool" that increases diagnostic accuracy in the evaluation of a patient with DHP.

Blue vitiligo

The progression of vitiligo and postinflammatory hyperpigmentation simultaneously in a patient with AIDS led to the appearance of a blue color on much of the patient's skin. The blue coloration subsequently resolved with follicular repigmentation typical of resolving vitiligo. We believe this is the first reported case of "blue vitiligo."

The cutaneous histopathology of chemotherapeutic reactions

The histological diagnosis of chemotherapy-induced cutaneous reactions is a difficult problem for the dermatopathologist. The initial effort should be directed towards obtaining as much clinical history as possible since the provided information is often incomplete and clinical correlation is usually required. The biopsy should be examined in a systematic fashion to assess the presence of damage to specific cutaneous structures. A recommended approach is to initially examine the epidermis and then proceed to hair follicles, eccrine sweat glands, vessels and dermis. The degree and pattern of damage will usually indicate whether or not a cytotoxic reaction is present. The intensity, pattern, and components of the inflammatory response should be assessed since they provide clues to whether a hypersensitivity reaction or immunomodulating chemotherapeutic reaction is present. In addition to the possibility of a chemotherapeutic reaction, the dermatopathologist must also consider the possibility of an infection since the host is usually immunocompromised and must also exclude the presence of a residual malignancy. After examination of the biopsy specimen and determination of the pathologic process or precesses, the observed findings should be correlated with the clinical history before rendering an interpretation.

Bleomycin-induced flagellate erythema

A 56-year-old woman who developed widespread pruritus and flagellate erythema after attempted pleuredesis with bleomycin is described. The raised linear lesions of flagellate erythema could not be reproduced by scratching, and histopathological examination revealed a lymphocytic vasculitis. The rash faded spontaneously over several weeks to leave streaks of post-inflammatory melanoderma which remained for 6 months. The role of scratching and dermographism in the pathogenesis of the bleomycin-specific eruption is discussed.

Mitochondrial DNA damage by bleomycin

We have modified a specific and sensitive method of detecting different forms of mitochondrial DNA (mtDNA) and utilized it to study bleomycin (BLM)-induced mtDNA damage. Intact, nicked circular, and linear forms of mtDNA were separated by gel electrophoresis, detected by Southern blot hybridization, and characterized by size markers and alkali treatment. DNA from BLM-treated mitochondria from liver, lung, and L1210 tumors were all equally sensitive to damage by BLM. The extent of BLM-induced mtDNA damage was dependent on experimental conditions. In vitro incubation of isolated mitochondria with BLM showed that 100 microM BLM caused complete conversion of intact to nicked and linear forms. Scission of mtDNA was more extensive if mitochondria were lysed in the presence of BLM than after several washings to remove the drug from the incubation media. Isolated mtDNA was extremely sensitive to BLM such that 10 nM BLM caused loss of intact form. The extent of mtDNA damage by BLM was decreased by the addition of EDTA.

Flagellate pigmentation from intrapleural bleomycin. A light microscopy and electron microscopy study

A case is presented of a 65-year-old white man with left pleural mesothelioma treated with a single intrapleural instillation of bleomycin for cavitary sclerosis. One month later the patient developed pigmented flagellate streaks on his arms and chest wall. To our knowledge, this is the first case in the literature showing these typical pigmentary changes in which a single small dose of bleomycin acted as an intrapleural sclerosing agent.

Bleomycin-induced fatal hyperpyrexia

Bleomycin is a frequently used antitumor agent with adverse effects usually involving the lungs, skin, and bone marrow. An acute hyperpyrexic reaction has also been noted with this agent, usually after the initial injection. Thus a test dose is recommended before therapy is begun. A case of fulminant hyperpyrexia and death in a patient with lymphoma who had previously received multiple courses of bleomycin without prior hyperpyrexia is reported. Fever was associated with the patient's lymphoma and may have effectively reduced the patient's "margin" for tolerating the additional drug-induced pyrexia. It is suggested that attempts be made to lower fevers before therapy with this agent is initiated.

The histopathology and ultrastructure of liver disease in erythropoietic protoporphyria

The light, polarization and electron microscopic changes in the liver of four cases of erythropoietic protoporphyria (EPP) are described. In one of these cases liver involvement resulted in death, whereas in the other three there were no symptoms of referable to hepatic disease. In two cases hepatic pigment was readily visible on light and polarization microscopy and corresponded to characteristic crystalline aggregates seen ultrastructurally. Pronounced micronodular cirrhosis and cholestasis were present in the fatal case, while in the other only mild periportal fibrosis and mononuclear inflammatory cell infiltrate occurred. The third and fourth cases showed no evidence of hepatic involvement on light microscopy. Electron microscopy, however, revealed characteristic crystal-containing vacuoles indicative of protoporphyrin deposition. The need for early detection of the hepatic lesion is emphasized.