1
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Becker SL, Kody S, Fett NM, Hines A, Alavi A, Ortega-Loayza AG. Approach to the Atypical Wound. Am J Clin Dermatol 2024; 25:559-584. [PMID: 38744780 DOI: 10.1007/s40257-024-00865-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
The heterogeneity of atypical wounds can present diagnostic and therapeutic challenges; however, as the prevalence of atypical wounds grows worldwide, prompt and accurate management is increasingly an essential skill for dermatologists. Addressing the underlying cause of an atypical wound is critical for successful outcomes. An integrated approach with a focus on pain management and patient engagement is recommended to facilitate enduring wound closure. Advances in treatment, in addition to further research and clinical training, are necessary to address the expanding burden of atypical wounds.
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Affiliation(s)
- Sarah L Becker
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Shannon Kody
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Nicole M Fett
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | | | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA.
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2
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Pham JP, Flora A, Frew JW. Understanding multi-kinase inhibitor-associated cutaneous ulcers may provide molecular insights into the aetiology of pyoderma gangrenosum: A comment on Jeon et al. Australas J Dermatol 2024; 65:e81-e84. [PMID: 38337172 DOI: 10.1111/ajd.14221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/17/2023] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Affiliation(s)
- James P Pham
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Laboratory of Translational Cutaneous Medicine, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine and Health, Sydney, New South Wales, Australia
| | - Akshay Flora
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Laboratory of Translational Cutaneous Medicine, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine and Health, Sydney, New South Wales, Australia
| | - John W Frew
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Laboratory of Translational Cutaneous Medicine, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine and Health, Sydney, New South Wales, Australia
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3
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Kanzaki M, Honda A, Sawai Y, Suda K, Suda A, Kawachi Y. Lenvatinib-induced pyoderma gangrenosum in a patient with hepatocellular carcinoma: A case report. J Dermatol 2024; 51:e31-e32. [PMID: 37438964 DOI: 10.1111/1346-8138.16896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/14/2023]
Affiliation(s)
- Mirei Kanzaki
- Department of Dermatology, Tokyo Medical University Ibaraki Medical Center, Ami, Japan
| | - Akira Honda
- Joint Research Center, Tokyo Medical University Ibaraki Medical Center, Ami, Japan
- Division of Gastroenterology and Hepatology, Tokyo Medical University Ibaraki Medical Center, Ami, Japan
| | - Yasumasa Sawai
- Department of Dermatology, Tokyo Medical University Ibaraki Medical Center, Ami, Japan
| | - Kiyoka Suda
- Department of Dermatology, Tokyo Medical University Ibaraki Medical Center, Ami, Japan
| | - Ayumi Suda
- Department of Dermatology, Tokyo Medical University Ibaraki Medical Center, Ami, Japan
| | - Yasuhiro Kawachi
- Department of Dermatology, Tokyo Medical University Ibaraki Medical Center, Ami, Japan
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4
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Ishikawa M, Yamamoto T. Neutrophil extracellular traps formation in the lesional skin of various types of pyoderma gangrenosum. Exp Dermatol 2023; 32:2029-2033. [PMID: 37596809 DOI: 10.1111/exd.14913] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/21/2023] [Accepted: 08/06/2023] [Indexed: 08/20/2023]
Abstract
Pyoderma gangrenosum (PG) is a chronic neutrophilic disorder characterized by recurrent painful ulcers. Aseptic inflammation by neutrophils plays an essential role, and neutrophil extracellular traps (NETs) formation can contribute to the pathogenesis of PG. Seventy-five patients were diagnosed as having PG in our department, among which 58 ulcerative, 4 bullous, 3 pustular and 10 vegetative type. We examined the 20 skin biopsy specimens (11 ulcerative, 3 bullous, 2 pustular and 4 vegetative type), and local NETs formation in various types of PG was compared among each type. The biopsied specimens were double labelled for myeloperoxidase, citrullinated histone H3. Immunofluorescent images indicated that the histopathologic location and depth of NETs formation in PG varied by the clinical subtypes. In ulcerative PG, NETs formation was observed in the upper to deep dermis. In bullous PG, NETs formation was mainly observed in the epidermis. Pustular type showed NETs formation in the epidermis near the pustules, and in vegetative type, showed NETs formation mainly in the upper dermis. These results indicate that NETting neutrophils play an important role in the pathogenesis of various forms of PG, although the location and depth of NETs formation in the skin lesion of PG differ depending on each type. Further studies are necessary to examine what factors identify different clinical features of PG.
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Affiliation(s)
- Masato Ishikawa
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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5
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Yamamoto T, Yamasaki K, Yamanaka K, Komine M, Kawakami T, Yamamoto O, Kanekura T, Higuchi T, Takahashi T, Matsushima Y, Kikuchi N. Clinical guidance of pyoderma gangrenosum 2022. J Dermatol 2023; 50:e253-e275. [PMID: 37311717 DOI: 10.1111/1346-8138.16845] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 06/15/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare, neutrophilic skin disease. For the purpose of accurate diagnosis and proper treatment of PG, the Japanese clinical practice guidance for PG developed by the Japanese Dermatological Association was published in 2022. In this guidance, clinical aspects, pathogenesis, current therapies, and clinical questions on PG are described from the viewpoints of current knowledge and evidence-based medicine. Here, the English version of the Japanese clinical practice guidelines for PG is presented and is intended to be widely referred to in the clinical examination and treatment of PG.
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6
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Dissemond J, Marzano AV, Hampton PJ, Ortega-Loayza AG. Pyoderma Gangrenosum: Treatment Options. Drugs 2023; 83:1255-1267. [PMID: 37610614 PMCID: PMC10511384 DOI: 10.1007/s40265-023-01931-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 08/24/2023]
Abstract
Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. Although the exact pathogenesis is not yet fully understood, various auto-inflammatory phenomena with increased neutrophil granulocyte activity have been demonstrated. Despite the limited understanding of the pathogenesis, it is no longer a diagnosis of exclusion, as it can now be made on the basis of validated scoring systems. However, therapy remains a major multidisciplinary challenge. Various immunosuppressive and immunomodulatory therapies are available for the treatment of affected patients. In addition, concomitant topical pharmacologic therapy, wound management and pain control should always be addressed. Corticosteroids and/or cyclosporine remain the systemic therapeutics of choice for most patients. However, in recent years, there has been an increasing number of studies on the positive effects of biologic therapies such as inhibitors of tumour necrosis factor-α; interleukin-1, interleukin-17, interleukin-23 or complement factor C5a. Biologics have now become the drug of choice in certain scenarios, particularly in patients with underlying inflammatory comorbidities, and are increasingly used at an early stage in the disease rather than in therapy refractory patients.
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Affiliation(s)
- Joachim Dissemond
- Department of Dermatology, Venerology and Allergology, University of Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Angelo V Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Philip J Hampton
- Department of Dermatology, Newcastle Dermatology, Newcastle Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science, University, Portland, OR, USA
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7
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Kim HS, Kwon JE, Park YJ. Atezolizumab Plus Bevacizumab-induced Recalcitrant Pyoderma Gangrenosum Treated with Baricitinib: A Case Report. Acta Derm Venereol 2023; 103:adv9646. [PMID: 37526292 PMCID: PMC10413870 DOI: 10.2340/actadv.v103.9646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/20/2023] [Indexed: 08/02/2023] Open
Abstract
Abstract is missing (Short communication)
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Affiliation(s)
- Han Seul Kim
- Department of Dermatology, Ajou University School of Medicine, Suwon, Korea
| | - Ji Eun Kwon
- Department of Pathology, Ajou University School of Medicine, Suwon, Korea
| | - Young Joon Park
- Department of Dermatology, Ajou University School of Medicine, Suwon, Korea.
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8
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Romagnuolo M, Moltrasio C, Iannone C, Gattinara M, Cambiaghi S, Marzano AV. Pyoderma gangrenosum following anti-TNF therapy in chronic recurrent multifocal osteomyelitis: drug reaction or cutaneous manifestation of the disease? A critical review on the topic with an emblematic case report. Front Med (Lausanne) 2023; 10:1197273. [PMID: 37324147 PMCID: PMC10264797 DOI: 10.3389/fmed.2023.1197273] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoinflammatory disease, clinically characterized by chronic and recurrent episodes of osteoarticular inflammation, that generally presents in children and adolescents. From a dermatological point-of-view, CMRO can be associated with skin rashes mainly including psoriasis, palmoplantar pustulosis and acne. Pyoderma gangrenosum (PG) is a rare immune-mediated inflammatory skin disease classified within the spectrum of neutrophilic dermatoses that, in some cases, has been reported as cutaneous manifestation in CMRO patients. This paper presents a 16-year female patient diagnosed with CMRO, who presented PG lesions located on the lower leg, that arose after the administration of the tumour necrosis factor (TNF)-α inhibitor adalimumab. Cases of PG have been reported in patients being treated with certain medications, including TNF-α antagonists, leading to classified them in a setting aptly termed "drug-induced PG." In this paper, we discuss the co-occurrence of PG and CRMO, in the light of recent evidence on the pathogenesis of both diseases and giving ample space to a literature review on drug induced PG. In our case, it is plausible that PG could be considered a cutaneous manifestation of CRMO, although the mechanisms underlying this intriguingly relationship remain to be fully unraveled.
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Affiliation(s)
- Maurizio Romagnuolo
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Chiara Moltrasio
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Iannone
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
| | - Maurizio Gattinara
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy
| | - Stefano Cambiaghi
- Pediatric Dermatology Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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9
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Aromolo IF, Maronese CA, Moltrasio C, Boggio F, Violetti SA, Avallone G, Morini N, Carrera CG, Genovese G, Marzano AV. Genetic findings in a patient with paradoxical pyoderma gangrenosum induced by brodalumab. Clin Exp Dermatol 2023; 48:293-295. [PMID: 36763724 DOI: 10.1093/ced/llac117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 11/30/2022] [Accepted: 12/05/2022] [Indexed: 01/22/2023]
Abstract
We describe a patient with psoriasis who developed pyoderma gangrenosum while on treatment with brodalumab, an anti-interleukin (IL)-17 receptor monoclonal antibody. Genetic analyses revealed heterozygous polymorphisms within the promoter region of the IL-6 (promoter polymorphism –174 G/C) and IL-10 genes (promoter polymorphism –1082 A/G).
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Affiliation(s)
- Italo Francesco Aromolo
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Carlo Alberto Maronese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Chiara Moltrasio
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Francesca Boggio
- Pathology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Alberti Violetti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Gianluca Avallone
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Department of Medical Sciences, Dermatology Clinic, University of Turin, Turin, Italy
| | - Nicole Morini
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Carlo Giovanni Carrera
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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10
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Chen B, Li W, Qu B. Practical aspects of the diagnosis and management of pyoderma gangrenosum. Front Med (Lausanne) 2023; 10:1134939. [PMID: 36865058 PMCID: PMC9971223 DOI: 10.3389/fmed.2023.1134939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare autoinflammatory ulcerative neutrophilic skin disease. Its clinical presentation is a rapidly progressing painful skin ulcer with ill-defined borders and surrounding erythema. The pathogenesis of PG is complex and not fully understood. Clinically, patients with PG often have various systemic diseases, the most common being inflammatory bowel disease (IBD) and arthritis. Due to the lack of specific biological markers, diagnosing PG remains difficult, which easily resulting in misdiagnosis. Some validated diagnostic criteria have been applied in clinical practice that facilitate its diagnosis. The treatment of PG currently consists mainly of immunosuppressive and immunomodulatory agents, especially biological agents, which have bright prospects for PG therapy. After the systemic inflammatory response is controlled, the problem of wounds becomes the main contradiction in PG treatment. Surgery is not controversial for PG, increasing evidence shows that with adequate systemic treatment, the benefits of reconstructive surgery for patients are increasing.
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Affiliation(s)
| | - Wei Li
- Department of Burns, Sichuan Academy of Medical Sciences and Sichuan People’s Hospital, Chengdu, China
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11
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Akyol Ş, Tüfekçi Ö, Baysal B, Yılmaz Ş, Ören H. Abscess-like skin and lung lesions in a patient with acute lymphoblastic leukemia: Pyoderma gangrenosum. Pediatr Blood Cancer 2022; 69:e29655. [PMID: 35278042 DOI: 10.1002/pbc.29655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/19/2022] [Accepted: 02/27/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Şefika Akyol
- Department of Pediatric Hematology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Özlem Tüfekçi
- Department of Pediatric Hematology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Birsen Baysal
- Department of Pediatric Hematology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Şebnem Yılmaz
- Department of Pediatric Hematology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Hale Ören
- Department of Pediatric Hematology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
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12
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Kao AS, King AD, Daveluy S. Successful Treatment of Cabozantinib-induced Pyoderma Gangrenosum with Ixekizumab Therapy: A Case Report. Dermatol Ther 2022; 35:e15716. [PMID: 35837805 DOI: 10.1111/dth.15716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 06/03/2022] [Accepted: 07/13/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Andrew S Kao
- Wayne State University School of Medicine, Detroit, MI
| | - Andrew D King
- Department of Dermatology, Wayne State University School of Medicine, Detroit, MI
| | - Steven Daveluy
- Department of Dermatology, Wayne State University School of Medicine, Detroit, MI
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13
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Yamamoto T. Skin Manifestation Induced by Immune Checkpoint Inhibitors. Clin Cosmet Investig Dermatol 2022; 15:829-841. [PMID: 35592732 PMCID: PMC9112343 DOI: 10.2147/ccid.s364243] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/21/2022] [Indexed: 11/23/2022]
Abstract
In accordance with recent therapeutic progress of immune checkpoint inhibitors for certain cancers, various disorders are induced as immune-related adverse events (irAEs) affecting the skin, gut, thyroid gland, lung, and liver. Among such irAEs, mucocutaneous manifestation is the most common. Cutaneous manifestations are categorized into several groups, ie, inflammatory reactions, immunobullous reactions, alterations of epidermal keratinocytes, and alterations of epidermal melanocytes; however, there are additionally various cutaneous toxicities, unclassified into those groups. Blocking of programmed cell death 1 (PD-1)/programmed cell death ligand 1(PDL1) can lead to the induction of autoimmune reaction, via activation of cytotoxic T cells, inhibition of regulatory T cell function, and alteration of cytokine balance. Similarly, blockade of cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) reduces the suppressive function of regulatory T cells. Due to those mechanisms, various autoimmune conditions can be induced, in addition to nonspecific drug eruptions. Dermatologists should be aware of various types of those mucocutaneous manifestations, either common or rare, as well as the management of such conditions. Herein, various mucocutaneous manifestations of irAEs and cases involving Japanese patients have been described, based on a single institute's experience.
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Affiliation(s)
- Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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14
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Weiss EH, Ko CJ, Leung TH, Micheletti RG, Mostaghimi A, Ramachandran SM, Rosenbach M, Nelson CA. Neutrophilic Dermatoses: a Clinical Update. CURRENT DERMATOLOGY REPORTS 2022; 11:89-102. [PMID: 35310367 PMCID: PMC8924564 DOI: 10.1007/s13671-022-00355-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/13/2022]
Abstract
Purpose of Review Neutrophilic dermatoses are defined by the presence of a sterile neutrophilic infiltrate on histopathology. This review focuses on the pathogenesis, epidemiology, clinicopathological features, diagnosis, and management of four disorders: Sweet syndrome, pyoderma gangrenosum, Behçet syndrome, and neutrophilic eccrine hidradenitis. Recent Findings Recent studies have provided insight into the complex pathogenesis of neutrophilic dermatoses. Evidence supports an intricate interplay of abnormal neutrophil function and inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic predisposition. Summary Neutrophilic dermatoses have diverse cutaneous and extracutaneous manifestations and may be associated with significant morbidity and mortality. Common underlying associations include infectious, inflammatory, and neoplastic disorders, as well as drug reactions. Emerging diagnostic and therapeutic frameworks identify an expanding role for biologic and targeted anti-inflammatory therapies.
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15
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Nasseh J, Abi Rached H, Dumitru I, Staumont-Sallé D, Dezoteux F. Pyoderma gangrenosum developing in a patient treated with dupilumab. JAAD Case Rep 2022; 20:58-60. [PMID: 35097179 PMCID: PMC8783112 DOI: 10.1016/j.jdcr.2021.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jessica Nasseh
- Service de Dermatologie, Centre Hospitalier Universitaire de Lille, Lille, France
- Correspondence to: Jessica Nasseh, MD, Centre Hospitalier Universitaire de Lille, Dermatology, 136 Rue du Faubourg de Roubaix, Lille 59000, France.
| | - Henry Abi Rached
- Service de Dermatologie, Centre Hospitalier Universitaire de Lille and INSERM U1189 - Laser Assisted Therapies and Immunotherapies for Oncology, Université de Lille, Lille, France
| | - Ioana Dumitru
- Institut de Pathologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Delphine Staumont-Sallé
- Service de Dermatologie, Centre Hospitalier Universitaire de Lille and INSERM U1286 - Institute for Translational Research in Inflammation, Université de Lille, Lille, France
| | - Frédéric Dezoteux
- Service de Dermatologie, Centre Hospitalier Universitaire de Lille and INSERM U1286 - Institute for Translational Research in Inflammation, Université de Lille, Lille, France
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16
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Khoshnam-Rad N, Gheymati A, Jahangard-Rafsanjani Z. Tyrosine kinase inhibitors-associated pyoderma gangrenosum, a systematic review of published case reports. Anticancer Drugs 2022; 33:e1-e8. [PMID: 34282745 DOI: 10.1097/cad.0000000000001140] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pyoderma gangrenosum is a rare ulcerative dermatosis. It may be caused by some drugs, including small molecule tyrosine kinase inhibitors (TKIs). The aim of this study was to evaluate the reported evidence of pyoderma gangrenosum associated with the use of these drugs. A systematic electronic literature search of PubMed and Embase was conducted. In these databases, search terms describing pyoderma gangrenosum were combined with TKIs. Fifteen case reports (eight cases associated with sunitinib, two with imatinib, two with ibrutinib, one with gefitinib, one with pazopanib, and one with dabrafenib and trametinib) were identified over the 14 years. The average Naranjo score of these cases is 6.6, which indicates a probable adverse drug reaction. Pyoderma gangrenosum is a probable and reversible drug reaction associated with some TKIs. Detailed medical history can help to prompt diagnosis of drug-induced pyoderma gangrenosum. Clinicians should be aware of TKI-associated pyoderma gangrenosum when caring for the skin of oncologic patients undergoing therapy with kinase inhibitors.
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Affiliation(s)
| | - Azin Gheymati
- Department of Clinical Pharmacy, Faculty of Pharmacy
| | - Zahra Jahangard-Rafsanjani
- Department of Clinical Pharmacy, Faculty of Pharmacy
- Breast Disease Research Center (BDRC), Tehran University of Medical Sciences, Tehran, Iran, Tehran, Iran
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17
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Faraci AG, Genovese G, Ferrucci S, Marzano AV. Imatinib-induced pyoderma gangrenosum in a patient with chronic myeloid leukemia. Indian J Dermatol Venereol Leprol 2021; 87:704-706. [PMID: 34114414 DOI: 10.25259/ijdvl_1158_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/01/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Andrea Giuseppe Faraci
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Genovese
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Silvia Ferrucci
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Angelo Valerio Marzano
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Miyagawa A, Adachi T, Takamiyagi S, Arakawa H, Matsushita M, Inazumi T. First case of lenvatinib-induced pyoderma gangrenosum: Possible management with dose reduction. J Dermatol 2021; 48:e221-e222. [PMID: 33651422 DOI: 10.1111/1346-8138.15829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/04/2021] [Accepted: 02/12/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Akihiro Miyagawa
- Department of Dermatology, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Takeya Adachi
- Department of Dermatology, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan.,Department of Medical Regulatory Science, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Saeko Takamiyagi
- Department of Dermatology, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Hiroki Arakawa
- Department of Dermatology, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Misako Matsushita
- Department of Gastroenterology, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Toyoko Inazumi
- Department of Dermatology, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
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Haber R, Dib N, El Gemayel M, Makhlouf M. Paradoxical neutrophilic dermatosis induced by biologics and immunosuppressive drugs: A systematic review. J Am Acad Dermatol 2021; 85:1048-1049. [PMID: 33607180 DOI: 10.1016/j.jaad.2021.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/05/2021] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Roger Haber
- Department of Dermatology, Saint George Hospital University Medical Center, Beirut, Lebanon; Faculty of Medicine, Balamand University, El-Koura, Lebanon.
| | - Nicole Dib
- Department of Dermatology, Saint George Hospital University Medical Center, Beirut, Lebanon; Faculty of Medicine, Balamand University, El-Koura, Lebanon
| | - Maria El Gemayel
- Department of Gastroenterology, Hotel-Dieu de France Hospital, Beirut, Lebanon; Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Milissa Makhlouf
- Department of Dermatology, Saint George Hospital University Medical Center, Beirut, Lebanon; Faculty of Medicine, Balamand University, El-Koura, Lebanon
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Tunçez Akyürek F, Akyurek M, Zekey E, Can I, Saylam Kurtipek G. Pyoderma gangrenosum with thymoma and myasthenia gravis: A case report. J Cosmet Dermatol 2020; 20:943-946. [PMID: 32920928 DOI: 10.1111/jocd.13717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 08/13/2020] [Accepted: 09/03/2020] [Indexed: 11/27/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis which is characterized by painful, necrotic ulcer with violaceous border that heals with cribriform scar. Although the etiopathogenesis of PG is not known exactly, it can be triggered by many factors such as genetics, autoimmune, pathergy phenomenon, drugs, and paraneoplastic. It is frequently associated with autoimmune pathogenesis such as inflammatory bowel disease and rheumatologic disease. It can also be associated with hematological or solid organ malignancies, and then, it is called paraneoplastic PG. The association of PG with myasthenia gravis and thymoma has not been previously reported. In our case, these three diseases with a common paraneoplastic pathogenesis were seen together and the coexistence of the three diseases is rare. Treatment of PG should be decided according to the severity, spread of the lesions, concomitant disease, medical condition, and tolerance of the patient. The purpose of treatment is to control the lesions and related diseases for a long time with minimal side effects. Mycophenolate mofetil treatment was used safely and successfully for both generalized MG and PG in our case.
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Affiliation(s)
- Fatma Tunçez Akyürek
- Department of Dermatology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Mehmet Akyurek
- Department of Dermatology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Emre Zekey
- Department of Dermatology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Ismail Can
- Department of Dermatology, Faculty of Medicine, Selcuk University, Konya, Turkey
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Katsuo K, Honda T, Kaku Y, Nishitani-Isa M, Honda Y, Yasumi T, Kabashima K. Pyoderma gangrenosum associated with chronic recurrent multifocal osteomyelitis as a possible paradoxical reaction to anti-tumor necrosis factor-α therapy. J Dermatol 2020; 47:e283-e284. [PMID: 32515066 DOI: 10.1111/1346-8138.15417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kosuke Katsuo
- Departments of, Department of, Dermatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tetsuya Honda
- Departments of, Department of, Dermatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yo Kaku
- Departments of, Department of, Dermatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Yoshitaka Honda
- Department of, Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Yasumi
- Department of, Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenji Kabashima
- Departments of, Department of, Dermatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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22
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Chong VH. Pyoderma gangrenosum, infection or both. QJM 2020; 113:591-592. [PMID: 32294200 DOI: 10.1093/qjmed/hcaa126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- V H Chong
- Department of Medicine, PMMPHAMB Hospital, Jalan Sungai Basong, Tutong, Brunei Darussalam
- Department of Medicine, RIPAS Hospital, Bandar Seri Begawan, Brunei Darussalam
- Institute of Health Sciences, PAPRSB, Universiti Brunei Darussalam, Bandar Seri Begawan, Brunei Darussalam
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23
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Hobbs MM, Ortega-Loayza AG. Pyoderma gangrenosum: From historical perspectives to emerging investigations. Int Wound J 2020; 17:1255-1265. [PMID: 32378319 DOI: 10.1111/iwj.13389] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 01/01/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare disease of unknown aetiology, first described over a century ago. Initially thought to have an infectious cause, and now primarily considered an autoinflammatory condition, PG continues to be poorly understood, commonly misdiagnosed, and difficult to treat. In this review, we discuss the journey of our understanding of PG to date, including first descriptions, challenges with diagnosis, presumed pathogenesis, and treatments used. We highlight major historical landmarks and their importance, explain the rationale behind current investigations, note outstanding gaps in knowledge, and explore the future directions of PG research. We summarise what we have known, what we are working on knowing, and what we have yet to explore about PG, illustrating overall trends to invigorate future research.
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Affiliation(s)
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon, USA
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24
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Ellis SR, Vierra AT, Millsop JW, Lacouture ME, Kiuru M. Dermatologic toxicities to immune checkpoint inhibitor therapy: A review of histopathologic features. J Am Acad Dermatol 2020; 83:1130-1143. [PMID: 32360716 DOI: 10.1016/j.jaad.2020.04.105] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 04/03/2020] [Accepted: 04/20/2020] [Indexed: 02/08/2023]
Abstract
Antineoplastic agents that use the immune system have revolutionized cancer treatment. Specifically, implementation of immune checkpoint inhibitors, monoclonal antibodies that block cytotoxic T-lymphocyte-associated antigen-4, programmed cell death protein 1, or programmed cell death ligand 1 show improved and sustained responses in patients with cancer. However, these agents are associated with a plethora of adverse events, many manifesting in the skin. As the clinical application of cancer immunotherapies expands, understanding the clinical and histopathologic features of associated cutaneous toxicities becomes increasingly important to dermatologists, oncologists, and pathologists to ensure timely diagnosis and appropriate care. This review discusses cutaneous reactions to immune checkpoint inhibitors, focusing on histopathologic features.
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Affiliation(s)
- Samantha R Ellis
- Department of Dermatology, University of California, Davis, Sacramento, California; PotozkinMD Skincare Center, Danville, California
| | - Aren T Vierra
- Department of Dermatology, University of California, Davis, Sacramento, California
| | - Jillian W Millsop
- Department of Dermatology, Vacaville Medical Center, The Permanente Medical Group, Vacaville, California
| | - Mario E Lacouture
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maija Kiuru
- Department of Dermatology, University of California, Davis, Sacramento, California; Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, California.
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Gatti M, Antonazzo IC, Diemberger I, De Ponti F, Raschi E. Adverse events with sacubitril/valsartan in the real world: emerging signals to target preventive strategies from the FDA adverse event reporting system. Eur J Prev Cardiol 2020; 28:983-989. [DOI: 10.1177/2047487320915663] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/08/2020] [Indexed: 12/28/2022]
Abstract
Abstract
Aims
The aim of this study was to characterise clinical priority of adverse events with sacubitril/valsartan for targeting preventive measures.
Methods
We used the US Food and Drug Administration adverse event reporting system (worldwide pharmacovigilance database) to compare adverse events recording sacubitril/valsartan as suspect with other cardiovascular drugs. Disproportionality analyses were performed by calculating the reporting odds ratios, deemed significant when the lower limit of the 95% confidence interval was greater than 1. Clinical priority was assigned to adverse events with significant disproportionality by scoring (range 0–10 points) five features (number of events, magnitude of the lower limit of the 95% confidence interval, mortality frequency, important/designated medical event, biological plausibility).
Results
Sacubitril/valsartan was recorded in 20,021 reports, with 178 adverse events associated with significant disproportionality: 71.9%, 25.9% and 2.2% were classified as weak, moderate and strong clinical priorities, respectively. Increased reporting emerged for several cardiovascular adverse events, including ‘renal failure’ (N = 388; lower limit of the 95% confidence interval 2.26), ‘hyperkalaemia’ (314; 2.42) and ‘angioedema’ (309; 1.56). Sudden cardiac death (priority score 9 points) was the only designated medical event with strong clinical priority. Notably, sudden cardiac death occurred early after sacubitril/valsartan administration (average onset 124 days), with concomitant drugs known for pro-arrhythmic potential (e.g. amiodarone, escitalopram, mirtazapine, loop diuretics) in 26.2% of records.
Conclusion
The increased cardiovascular reporting of sacubitril/valsartan in the real world was largely predictable from pre-approval evidence, underlying disease and likely patients’ comorbidities. The unexpected reporting of sudden cardiac death occurred well before the complete development of positive electrical remodelling induced by sacubitril/valsartan, and calls for stringent clinical monitoring (to reduce the pro-arrhythmic burden related to co-medications), and further investigation on appropriate combination with other preventive measures.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | | | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, University of Bologna, Italy
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Welborn ME, Kubicki SL, Patel AB. Pyoderma Gangrenosum Following Initiation of Immune Checkpoint Inhibitor Therapy. ACTA ACUST UNITED AC 2020. [DOI: 10.4103/jipo.jipo_11_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Abstract
Pyoderma gangrenosum (PG) is an ulcerating neutrophilic dermatosis that is often associated with the underlying systemic disease. For example, PG is often a common presenting symptom in patients with hematologic malignancies, most commonly myelodysplastic syndrome (MDS). Here, we present the case of a patient who developed PG and a lichenoid drug eruption after the initiation of ipilimumab and nivolumab immune checkpoint inhibitor (ICPI) therapy. Lichenoid drug eruptions are well known to be associated with ICPI therapy, particularly nivolumab. However, only one case of PG has been reported in association with ipilimumab and no cases have ever been reported with nivolumab. Awareness that PG can be associated with ICPI therapy in patients with MDS can allow physicians to be better prepared to help in early recognition and early treatment to prevent the spread of disease.
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Affiliation(s)
| | - Shelby L Kubicki
- Department of Dermatology, University of Texas McGovern Medical School
| | - Anisha B Patel
- Department of Dermatology, University of Texas McGovern Medical School
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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27
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Abstract
Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis that presents with painful, sterile ulcers. Drug-induced PG is a rare condition; propylthiouracil, granulocyte colony-stimulating factor, and sunitinib are drugs that have been implicated to date. This article presents a case of PG associated with sunitinib.
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Noronha M, Arora S, Pai K, Sathish Pai B, Jindal A. A case of pyoderma gangrenosum induced by insulin. Int Wound J 2019; 16:1239-1242. [PMID: 31353778 DOI: 10.1111/iwj.13170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 07/07/2019] [Indexed: 12/31/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare auto-inflammatory, neutrophilic, ulcerative disorder characterised by acutely painful, rapidly spreading, sterile ulcers over the trunk and lower limbs. The pathogenic mechansim of PG is under constant evolution and drugs are emerging to be a an important trigger. In the literature, 52 cases of drug-induced PG have been documented, of which cocaine laced with levamisole has shown most direct association, with a mean Naranjo score of 9. Other drugs probably associated with PG are isotretinoin, sunitinib, and propylthiouracil. We describe a case of a 59-year-old male who had multiple well-defined ulcers with a violaceous, undermined edge limited to the site of subcutaneous injection of insulin. Histopathological examination showed psoriasiform hyperplasia in the epidermis, with abundant infiltration of neutrophils in the dermis, consistent with the clinical diagnosis of PG. As per the modified Naranjo algorithm, the patient's total score was 7, indicating insulin to be the probable causative agent in our case. So, compiling temporal localisation of lesions to the site of administration of insulin and clinical, histopathological, and Naranjo score evidence all prompt the diagnosis of PG. Insulin stimulates the release of matrix-metalloproteinases 9 which acts as endopeptidases and also results in the chemotaxis of neutrophils, causing ulcer formation. This is the first case reporting PG triggered by insulin.
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Affiliation(s)
- Malcom Noronha
- Department of dermatology, venereology and leprosy, Kasturba Medical college, Manipal Academy of Higher Education, Manipal, India
| | - Sukriti Arora
- Department of dermatology, venereology and leprosy, Kasturba Medical college, Manipal Academy of Higher Education, Manipal, India
| | - Kantilatha Pai
- Department of dermatology, venereology and leprosy, Kasturba Medical college, Manipal Academy of Higher Education, Manipal, India
| | - B Sathish Pai
- Department of dermatology, venereology and leprosy, Kasturba Medical college, Manipal Academy of Higher Education, Manipal, India
| | - Anuradha Jindal
- Department of dermatology, venereology and leprosy, Kasturba Medical college, Manipal Academy of Higher Education, Manipal, India
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30
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Grávalos C, Sanmartín O, Gúrpide A, España A, Majem M, Suh Oh HJ, Aragón I, Segura S, Beato C, Botella R. Clinical management of cutaneous adverse events in patients on targeted anticancer therapies and immunotherapies: a national consensus statement by the Spanish Academy of Dermatology and Venereology and the Spanish Society of Medical Oncology. Clin Transl Oncol 2018; 21:556-571. [PMID: 30284232 DOI: 10.1007/s12094-018-1953-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/11/2018] [Indexed: 12/17/2022]
Abstract
Progress in the understanding of many tumors has enabled the development of new therapies, such as those targeted at specific molecules involved in cell growth (targeted therapies) or intended to modulate the immune system (immunotherapy). However, along with the clinical benefit provided by these new treatments, new adverse effects have also appeared. Dermatological toxicities such as papulopustular eruptions, xerosis, and pruritus are common with EGFR inhibitors. Other adverse effects have also been described with PDGFR, BCR-ABL, and MAPK tyrosine kinase inhibitors, antiangiogenic drugs, and inhibitors at immune checkpoints such as CTLA-4 and PD-1/PD-L1. Onset of these adverse effects often causes dose reductions and/or delays in administering the prescribed therapy, which can affect patient survival and quality of life. It is, therefore, important to prevent the occurrence of these adverse effects, or to treat unavoidable ones as soon as possible. This requires cooperation between medical oncologists and dermatologists. This article reviews the various dermatological toxicities associated with targeted therapies and immunotherapies, along with their diagnosis and therapeutic management.
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Affiliation(s)
- C Grávalos
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Avenida de Córdoba km 5.4, 28041, Madrid, Spain.
| | - O Sanmartín
- Dermatology Department, Instituto Valenciano de Oncología, Valencia, Spain
| | - A Gúrpide
- Medical Oncology Department, Clínica Universitaria de Navarra, Pamplona, Spain
| | - A España
- Dermatology Department, Clínica Universitaria de Navarra, Pamplona, Spain
| | - M Majem
- Medical Oncology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - H J Suh Oh
- Dermatology Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - I Aragón
- Medical Oncology Department, Complejo Hospitalario Universitario de Huelva, Huelva, Spain
| | - S Segura
- Dermatology Department, Hospital del Mar, Barcelona, Spain
| | - C Beato
- Medical Oncology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - R Botella
- Dermatology Service, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
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31
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McKenzie F, Arthur M, Ortega-Loayza AG. Pyoderma Gangrenosum: What Do We Know Now? CURRENT DERMATOLOGY REPORTS 2018. [DOI: 10.1007/s13671-018-0224-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Jockenhöfer F, Wollina U, Salva KA, Benson S, Dissemond J. The PARACELSUS score: a novel diagnostic tool for pyoderma gangrenosum. Br J Dermatol 2018; 180:615-620. [PMID: 29388188 DOI: 10.1111/bjd.16401] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The lack of objective diagnostic criteria renders pyoderma gangrenosum (PG) a diagnosis of exclusion. The diagnostic approaches proposed to date have not been systematically evaluated. Thus, PG remains a challenging and frequently misdiagnosed disorder. OBJECTIVES To develop and assess a comprehensive, yet clinically practicable, sensitive diagnostic scoring system for PG. METHODS Clinical history and images of a total of 60 participants with previously confirmed PG located on the lower extremity and a control cohort of 50 patients with venous leg ulcers were retrospectively evaluated by expert teams at two tertiary dermatological centres specializing in wound care using a newly developed diagnostic scoring system composed of 10 criteria. RESULTS The three major diagnostic criteria are rapidly progressing disease, assessment of relevant differential diagnoses and a reddish-violaceous wound border (prevalent in 98% of patients with PG). Minor criteria (evident in 61-95% of patients with PG) include amelioration by immunosuppressant drugs, characteristically irregular shape of ulceration, extreme pain > 4/10 on a visual analogue scale and localization of lesion at the site of the trauma. Three additional criteria (observed in up to 60% of patients with PG) encompass suppurative inflammation in histopathology, undermined wound borders and systemic disease associated. A total score value of 10 points or higher indicates a high likelihood of PG and differentiates PG from venous leg ulcers. The initial letters of the above-listed criteria form the acronym PARACELSUS. CONCLUSIONS The PARACELSUS score represents a novel, easily implementable, effective and sensitive diagnostic tool for PG.
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Affiliation(s)
- F Jockenhöfer
- Department of Dermatology, Venereology and Allergology, University Hospital of Essen, Germany
| | - U Wollina
- Department of Dermatology and Allergology, Academic Teaching Hospital Dresden, Germany
| | - K A Salva
- Department of Dermatology, Venereology and Allergology, University Hospital of Essen, Germany
| | - S Benson
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital of Essen, Germany
| | - J Dissemond
- Department of Dermatology, Venereology and Allergology, University Hospital of Essen, Germany
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Abstract
INTRODUCTION Pyoderma gangrenosum (PG) is a complex neutrophilic dermatosis that can occur as an idiopathic disease, in association with systemic conditions such as inflammatory bowel disease, as part of an inherited inflammatory syndrome. It can be challenging to treat, as it occurs in a wide variety of clinical settings and there is a lack of a standardized treatment approach. The main limitations to treatment have been an incomplete understanding of the pathogenesis. However, recent advances have been made in understanding the pathogenesis of this condition, and PG is now considered an autoinflammatory disease process. Areas covered: This review discusses the newest studies that further define our understanding of this disease and the relevant literature on treatment options for pyoderma gangrenosum. Expert commentary: The presence of abnormal neutrophils and T-cells lead to immune dysregulation, leading to lesions of PG. Increased levels of inflammatory mediators including IL-1β, IL-8, IL-17, and TNF-α contribute to the development of the disease but there are still several unknown factors, including the trigger for immune dysregulation and additional contributory components of the immune system. We provide our approach to the management of PG lesions, which involves a multi-faceted approach including wound care, topical therapy, and systemic medications in most cases.
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Affiliation(s)
- Christine Ahn
- a Department of Dermatology , Wake Forest School of Medicine , Winston Salem , North Carolina , USA
| | - Deborah Negus
- a Department of Dermatology , Wake Forest School of Medicine , Winston Salem , North Carolina , USA
| | - William Huang
- a Department of Dermatology , Wake Forest School of Medicine , Winston Salem , North Carolina , USA
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Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that may be caused by an adverse drug reaction. We discuss the clinical presentation and outcomes of 52 cases of drug-induced PG reported to date in the literature. We conducted our literature search for case reports of drug-induced PG using keywords on PubMed and Medical Subject Heading (MeSH) terms on MEDLINE and EMBASE. To assess the probability that each case of PG was related to drug therapy, we used the Naranjo criteria. We identified 44 studies in the literature, with a total of 52 cases of drug-induced PG. The mean Naranjo score for cocaine-induced PG (n = 13) was 9.4, indicating a definite adverse drug reaction, while the mean Naranjo scores for isotretinoin (n = 5), propylthiouracil (n = 5), and sunitinib (n = 5) were 6.2, 6.8, and 7.4, respectively, indicating probable adverse drug reactions. Drugs should be considered as a possible triggering event whenever PG is diagnosed, and clinicians should particularly consider this in patients taking isotretinoin, propylthiouracil, or sunitinib, as well as in patients with a history of cocaine use.
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Affiliation(s)
- Jane Y Wang
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lars E French
- Department of Dermatology, Zürich University Hospital, Zurich, Switzerland
| | - Neil H Shear
- Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Dermatology, Women's College Hospital, University of Toronto, 76 Grenville St, 5th Floor, Toronto, ON, M5S 1B2, Canada
| | | | - Afsaneh Alavi
- York Dermatology Centre, Toronto, ON, Canada.
- Division of Dermatology, Women's College Hospital, University of Toronto, 76 Grenville St, 5th Floor, Toronto, ON, M5S 1B2, Canada.
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35
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Ortega-Loayza AG, Nugent WH, Lucero OM, Washington SL, Nunley JR, Walsh SW. Dysregulation of inflammatory gene expression in lesional and nonlesional skin of patients with pyoderma gangrenosum. Br J Dermatol 2017; 178:e35-e36. [PMID: 28734003 DOI: 10.1111/bjd.15837] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- A G Ortega-Loayza
- Department of Dermatology, Center for Health and Healing, Oregon Health and Science University, Portland, OR, 97230, U.S.A.,Department of Dermatology, Virginia Commonwealth University, Richmond, VA, 23298, U.S.A
| | - W H Nugent
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, VA, 23298, U.S.A
| | - O M Lucero
- Department of Dermatology, Center for Health and Healing, Oregon Health and Science University, Portland, OR, 97230, U.S.A
| | - S L Washington
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, VA, 23298, U.S.A
| | - J R Nunley
- Department of Dermatology, Virginia Commonwealth University, Richmond, VA, 23298, U.S.A
| | - S W Walsh
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, VA, 23298, U.S.A
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36
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Skalkou A, Manoli SM, Sachinidis A, Ntouros V, Petidis K, Pagkopoulou E, Vakirlis E, Pyrpasopoulou A, Dimitroulas T. Pyoderma gangrenosum and pyogenic arthritis presenting as severe sepsis in a rheumatoid arthritis patient treated with golimumab. Rheumatol Int 2017; 38:161-167. [PMID: 29075910 DOI: 10.1007/s00296-017-3861-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/19/2017] [Indexed: 01/27/2023]
Abstract
Rheumatoid arthritis is a systemic autoimmune disease resulting in joint destruction and deformities, but also associated with extraarticular and systemic manifestations. The later devastating conditions, such as the development of rheumatoid vasculitis, are more frequently encountered in seropositive patients and their incidence has been attenuated after the introduction of biologic disease modifying drugs, such as anti-tumor necrosis factor alpha (TNFa) agents, which generally have considerably contributed to the better control and long-term outcomes of the disease. Interestingly, autoimmune syndromes may, rarely, present in patients without a positive history after the initiation of treatment. We present a rare case of a woman with seronegative rheumatoid arthritis who developed pyoderma gangrenosum whistle on treatment with golimumab, a fully humanized anti TNFa antibody. The recording of this as well as analogous paradoxical autoimmune syndromes in association with the individual patient characteristics will render treating physicians aware of potential adverse reactions and assist in the understanding of the cytokine driven pathophysiological mechanisms underlying these disorders.
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Affiliation(s)
- Anastasia Skalkou
- 2nd Propedeutic Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sofia-Magdalini Manoli
- 1st Department of Dermatology, Hospital for Skin and Venereal Diseases, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandros Sachinidis
- 2nd Propedeutic Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios Ntouros
- 2nd Propedeutic Department of Surgery, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Petidis
- 2nd Propedeutic Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Pagkopoulou
- 4th Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Str, 54642, Thessaloniki, Greece
| | - Efstratios Vakirlis
- 1st Department of Dermatology, Hospital for Skin and Venereal Diseases, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athina Pyrpasopoulou
- 2nd Propedeutic Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Dimitroulas
- 4th Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Str, 54642, Thessaloniki, Greece.
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Sehgal R, Resnick JM, Al-Hilli A, Mehta N, Conway T, Stratman EJ. Nasal septal and mucosal disease associated with pyoderma gangrenosum in a cocaine user. JAAD Case Rep 2017; 3:284-287. [PMID: 28702496 PMCID: PMC5484981 DOI: 10.1016/j.jdcr.2017.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Rahul Sehgal
- Department of Rheumatology, Marshfield Clinic Health System, Marshfield, Wisconsin
- Correspondence to: Rahul Sehgal, MD, Department of Rheumatology, Marshfield Clinic, 1000 N Oak Avenue, Marshfield, WI.Department of RheumatologyMarshfield Clinic1000 N Oak AvenueMarshfieldWI
| | - Jeffrey M. Resnick
- Department of Pathology, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Ali Al-Hilli
- Department of Internal Medicine, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Namrata Mehta
- Department of Family Practice, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Tyler Conway
- Department of Dermatology, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Erik J. Stratman
- Department of Dermatology, Marshfield Clinic Health System, Marshfield, Wisconsin
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38
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Alavi A, French LE, Davis MD, Brassard A, Kirsner RS. Pyoderma Gangrenosum: An Update on Pathophysiology, Diagnosis and Treatment. Am J Clin Dermatol 2017; 18:355-372. [PMID: 28224502 DOI: 10.1007/s40257-017-0251-7] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic disorder with prototypical clinical presentations. Its pathophysiology is complex and not fully explained. Recent information regarding the genetic basis of PG and the role of auto-inflammation provides a better understanding of the disease and new therapeutic targets. PG equally affects patients of both sexes and of any age. Uncontrolled cutaneous neutrophilic inflammation is the cornerstone in a genetically predisposed individual. Multimodality management is often required to reduce inflammation, optimize wound healing, and treat underlying disease. A gold standard for the management of PG does not exist and high-level evidence is limited. Multiple factors must be taken into account when deciding on the optimum treatment for individual patients: location, number and size of lesion/ulceration(s), extracutaneous involvement, presence of associated disease, cost, and side effects of treatment, as well as patient comorbidities and preferences. Refractory and rapidly progressive cases require early initiation of systemic therapy. Newer targeted therapies represent a promising pathway for the management of PG, and the main focus of this review is the management and evidence supporting the role of new targeted therapies in PG.
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Mogle BT, Seabury RW, Jennings S, Cwikla GM. Severe neutrophilic dermatosis following submental deoxycholic acid administration. Clin Toxicol (Phila) 2017; 55:681. [PMID: 28394637 DOI: 10.1080/15563650.2017.1306071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Bryan T Mogle
- a Department of Pharmacy , Upstate University Hospital , Syracuse , NY USA
| | - Robert W Seabury
- a Department of Pharmacy , Upstate University Hospital , Syracuse , NY USA
| | - Shane Jennings
- b Department of Emergency Medicine , Upstate University Hospital , Syracuse , NY , USA
| | - Gregory M Cwikla
- a Department of Pharmacy , Upstate University Hospital , Syracuse , NY USA
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