Acute generalized exanthematous pustulosis associated with STI571 in a patient with chronic myeloid leukemia

Drug Triggers and Clinic of Acute Generalized Exanthematous Pustulosis (AGEP): A Literature Case Series of 297 Patients

Acute generalized exanthematous pustulosis (AGEP) is a rare skin reaction, commonly caused by drugs. Available evidence mostly relies on small studies or case reports. We collected published AGEP case reports and, subsequently, described the patient characteristics, suspect and concomitant drugs, time to onset, disease management, and clinical prognosis. This study included 297 AGEP patients (64.3% women) obtained from 250 published case reports or case series with individual patient data. AGEP affected patients of all ages, but the majority of patients (88.2%) were ≥25 years old. The most frequently reported suspect drugs were anti-infectives for systemic use (36.5%), particularly antibacterials for systemic use (31.0%), and especially beta-lactam antibacterials (18.3%) and macrolides (4.3%). Other frequent suspect drugs were antineoplastics (12.2%), and anti-inflammatory/anti-rheumatic products (5.2%) plus hydroxychloroquine (12.8%). Mean time to onset was 9.1 days (standard deviation SD 13.94). Some patients developed fever (64.3%) and systemic involvement (18.9%), and most patients (76.4%) received pharmacological treatment for AGEP. Seven patients died, although five of them were already critically ill prior to AGEP. In conclusion, antibiotics remain the most common suspected cause of AGEP. While case mortality rate may be up to 2.5%, disentangling the role of AGEP on the fatal outcome from the role of the preexisting health conditions remains challenging.

IL-31, itch and hematological malignancies

Pruritus is one of the most common symptoms experienced by neoplastic patients. The pathogenesis of neoplastic itch is complex and multifactorial and could be due to an unbalanced production of humoral mediators by altered immune effector cells. IL-31 is a pro-inflammatory cytokine produced by CD4 + T helper cells. The aim of this review was to evaluate the role of this Th2 cytokine and its receptor IL-31RA, in the onset of neoplastic pruritus. We analysed scientific literature looking for the most relevant original articles linking IL-31to itch in oncologic diseases. Interleukin-31 seems to be a main itch mediator in several hematologic disease such as Cutaneous T cells lymphomas. In these patients IL-31 was positively linked to itch level, and IL-31 matched with disease stage. IL-31 seems to play an important role in the signalling pathway involved in pruritus, but it is also suggested to play a proinflammatory and immunomodulatory role which could play a part in the progression of the neoplastic disease. Further studies will be fundamental in facing pruritus in oncologic patients, since this problem compromise their quality of life worsening an already critic picture.

Potentially life‑threatening severe cutaneous adverse reactions associated with tyrosine kinase inhibitors (Review)

Tyrosine kinase inhibitors (TKIs) have emerged as a new frontier of cancer therapy. These agents include inhibitors of epidermal growth factor receptor (EGFR), human epidermal growth factor receptor 2 (HER2), BRAF, mitogen‑activated protein kinase kinase (also referred to as MEK), bcr‑abl, c‑KIT, platelet‑derived growth factor (PDGFR), fibroblast growth factor receptor (FGFR), anaplastic lymphoma kinase (ALK) and vascular endothelial growth factor (VEGF). Along with the evolving applications of TKIs, there has been an increased recognition of the breadth of potential cutaneous toxicities to these agents. In this review, we provide an overview of potentially life‑threatening severe cutaneous adverse reactions (SCARs) that may occur during therapy with TKIs. These toxicities include Stevens‑Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP).

Pyoderma gangrenosum-like necrotizing panniculitis associated with Imatinib: A case report

Imatinib mesylate is a small tyrosine kinase inhibitor that targets BCR-ABL, ckit and platelet-derived growth factor receptor. It is prescribed by hematologists for chronic myeloid leukemia and acute lymphoblastic leukemia and by oncologists for Gastrointestinal Stromal Tumors (GIST). Cutaneous reactions to Imatinib are common but their incidence and severity widely varies between patients. A self-limited skin rash is the most common adverse effect but there have been reported cases of patients with maculopapular rash, pigmentary changes, superficial edema and rarer and clinically distinctive features such as lichenoid reactions or psoriasis. We here describe for the first time a case of pyoderma gangrenosum-like necrotizing panniculitis, a rare dermatological condition, after initiating therapy with Imatinib.

Cutaneous manifestations in chronic myeloid leukemia in chronic phase treated with imatinib

OBJECTIVE

The aim of this study was to see the patterns of skin changes in chronic myeloid leukemia (CML) in chronic phase treated with different doses of imatinib.

METHODS

This cross-sectional study was conducted in the Oncology Department of Jinnah Hospital, Lahore, over a period of 6 months. Patients aged 7-70 years diagnosed either by fluorescence in situ hybridization (FISH) for BCR-ABL or cytogenetics for Philadelphia (Ph) chromosomes and consuming different doses of imatinib for the treatment of CML were randomly selected. Skin manifestations were analyzed and recorded on a predesigned proforma by a dermatologist.

RESULTS

A total of 132 patients were enrolled; 65 male (49.24%) and 67 female (50.75%). Periorbital edema was found in 48.5% of cases, and hyperpigmentaion and melasma were found in 76.5% of cases. Pruritus was diagnosed in 6.8% of cases, alopecia in 5.3% of cases, and photosensitivity in 43.9% of cases.

CONCLUSIONS

It was concluded that imatinib is associated with many adverse cutaneous side effects which should be overcome or reduced by either decreasing the duration of treatment with imatinib or switching to other treatment options.

Severe cutaneous adverse reactions induced by targeted anticancer therapies and immunotherapies

With the increasing use of targeted anticancer drugs and immunotherapies, there have been a substantial number of reports concerning life-threatening severe cutaneous adverse reactions (SCARs), including Stevens–Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug rash with eosinophilia and systemic symptoms, drug-induced hypersensitivity syndrome, and acute generalized exanthematous pustulosis. Although the potential risks and characteristics for targeted anticancer agent- and immunotherapy-induced SCAR were not well understood, these serious adverse reactions usually result in morbidity and sequela. As a treatment guideline for this devastating condition is still unavailable, prompt withdrawal of causative drugs is believed to be a priority of patient management. In this review, we outline distinct types of SCARs caused by targeted anticancer therapies and immunotherapies. Also, we discuss the clinical course, latency, concomitant medication, tolerability of rechallenge or alternatives, tumor response, and mortality associated with these devastating conditions. Imatinib, vemurafenib, and rituximab were the top three offending medications that most commonly caused SJS/TEN, while EGFR inhibitors were the group of drugs that most frequently induced SJS/TEN. For drug rash with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome and acute generalized exanthematous pustulosis, imatinib was also the most common offending drug. Additionally, we delineated 10 SCAR cases related to innovative immunotherapies, including PD1 and CTLA4 inhibitors. There was a wide range of latency periods: 5.5–91 days (median). Only eight of 16 reported patients with SCAR showed clinical responses. Targeted anticancer drugs and immunotherapies can lead to lethal SCAR (14 deceased patients were identified as suffering from SJS/TEN). The mortality rate of TEN was high: up to 52.4%. The information compiled herein will serve as a solid foundation to formulate ideas for early recognition of SCAR and to discontinue offending drugs for better management.

Possible Role of Interleukin-31/33 Axis in Imatinib Mesylate-Associated Skin Toxicity

Imatinib mesylate is a small-molecule tyrosine kinase inhibitor (TKi) designed to target c-ABL and BCR-ABL, approved for the treatment of chronic myeloid leukemia and gastrointestinal stromal tumors. Adverse cutaneous reactions induced by imatinib are frequent, generally moderate, and dose-dependent. The aim of this work was to investigate the possible contribution of interleukin (IL)-33 and IL-31, cytokines involved in disorders associated with itching, in the pathogenesis of pruritus in a patient undergoing imatinib mesylate treatment. His IL-31 and IL-33 serum levels were significantly higher than in the control group (respectively 96.6 pg/mL vs. 7.623±7.681 pg/mL and 27.566 pg/mL vs. 6.170±7.060 pg/mL). In light of these findings, imatinib mesylate-related symptoms of dermatologic toxicities might be related to the release of IL-31 and IL-33. In particular, it is supposable that TKi usage could cause keratinocyte injury, the release of IL-33, and the consequent interaction with its receptor on mast cells that induces the secretion of several factors capable of causing skin manifestations, including IL-31, a known pruritus-inducing cytokine. This report, to the best of our knowledge, is the first work describing the possible involvement of the IL-31/IL-33 axis in the pathogenesis of skin side effects related to imatinib mesylate treatment.

Clinical and histopathologic analysis of 46 cases of cutaneous adverse reactions to imatinib

BACKGROUND

Although many cases of cutaneous adverse reactions to imatinib have been reported, their clinical and histopathologic characteristics are not well documented.

OBJECTIVES

The present study investigated clinical and histopathologic characteristics of cutaneous adverse reactions to imatinib.

METHODS

This retrospective study referred to 46 patients who experienced cutaneous adverse reactions to imatinib. Clinical data including age, sex, skin lesion morphology, underlying disorders, and imatinib treatment parameters (duration of imatinib medication, initial dose, and treatment modifications at the time of the study) were collected. Histopathologic data were available for all patients.

RESULTS

Cutaneous adverse reactions to imatinib developed at 1-24 weeks (median onset: 8 weeks) after imatinib administration. The severity of the reaction was categorized as grade 1 in 22%, grade 2 in 41%, and grade 3 in 37% of patients. Onset was earlier in high-severity reactions than in low-severity reactions. The severity of the reaction was dependent on imatinib dose. Grade 3 reactions were noted in nine of 16 (56%) patients administered "high-dose" (600 mg/d) imatinib. Spongiosis (78% of patients) and papillary dermal edema (83% of patients) were common histopathologic findings in the epidermis and dermis, respectively. Lymphohistiocytes were more predominant than eosinophils in dermal inflammatory infiltration. Histopathologic findings did not differ according to dose of imatinib or severity of the reaction.

CONCLUSIONS

Although the clinical features of cutaneous adverse reactions to imatinib depend on imatinib dose and the severity of the reaction, histopathologic findings are not associated with these clinical variables.

Cutaneous adverse effects of targeted therapies: Part I: Inhibitors of the cellular membrane

There has been a rapid emergence of numerous targeted agents in the oncology community in the last decade. This exciting paradigm shift in drug development lends promise for the future of individualized medicine. Given the pace of development and clinical deployment of targeted agents with novel mechanisms of action, dermatology providers may not be familiar with the full spectrum of associated skin-related toxicities. Cutaneous adverse effects are among the most frequently observed toxicities with many targeted agents, and their intensity can be dose-limiting or lead to therapy discontinuation. In light of the often life-saving nature of emerging oncotherapeutics, it is critical that dermatologists both understand the mechanisms and recognize clinical signs and symptoms of such toxicities in order to provide effective clinical management. Part I of this continuing medical education article will review in detail the potential skin-related adverse sequelae, the frequency of occurrence, and the implications associated with on- and off-target cutaneous toxicities of inhibitors acting at the cell membrane level, chiefly inhibitors of epidermal growth factor receptor, KIT, and BCR-ABL, angiogenesis, and multikinase inhibitors.

Adverse skin effects of imatinib, a tyrosine kinase inhibitor

Imatinib mesylate is a tyrosine kinase inhibitor that targets the BCR-ABL, c-kit, and PDGF (platelet-derived growth factor) receptors. Imatinib is mainly indicated for chronic myeloid leukemia and gastrointestinal stromal tumors but is also prescribed by dermatologists for dermatofibrosarcoma protuberans, systemic sclerosis, and systemic mastocytosis, among other conditions. Most adverse effects are mild or moderate and therapy is generally well tolerated. Adverse skin effects are very common and include nonspecific manifestations such as edema and maculopapular rashes or eruptions of diverse types (lichenoid or psoriasiform lesions, acute generalized exanthematic pustulosis, Stevens-Johnson syndrome, and more). Identifying and properly treating these reactions can help optimize adherence to treatment and improve the prognosis of the underlying disease.

Imatinib, dasatinib and nilotinib: a review of adverse cutaneous reactions with emphasis on our clinical experience

In the last years, several tyrosine kinase inhibitors (TKIs) have been developed and approved for human cancer treatment. Imatinib mesylate was the first of this novel family of drugs that target cancer-specific molecules and signalling pathways. The appearance of imatinib resistances led to the introduction of second-generation TKIs with higher potency and selectivity, such as dasatinib and nilotinib. However, the range of activity of these agents is not simply directed at tumour cells. Patients and their clinicians are indeed frequently confronted with the cutaneous side-effects associated with the employ of these drugs, which represent the most common non-hematological adverse reactions. For this reason, a systematic dermatological survey of patients receiving these therapies is highly important, and an early and appropriate dermatological treatment is required. In this review, we analyse the clinical and pathological characteristics of the most commonly reported adverse skin events associated with first- and second-generation tyrosine kinase inhibitors, with a particular emphasis on our clinical experience.

Lapatinib-induced acute generalized exanthematous pustulosis

Acute generalized exanthematous pustulosis (AGEP) is a pustular eruption, mainly drug induced often accompanied by fever and neutrophilic leukocytosis presenting as scarlatiniform erythema over the flexures evolving into numerous tiny non follicular pustules. We present a case report of a 56-year old woman, who had undergone mastectomy, treated with lapatinib for metastatic disease, and who presented with multiple erythematous papules and plaques with peripheral pustules. She also developed painful pyogenic granuloma-like lesions over the pulp of toe and over the proximal nail folds.All the lesions subsided following withdrawal of lapatinib. Although AGEP has been reported with imatinib (a multikinase inhibitor), there have been no reports of serious reactions with lapatinib, an EGFR inhibitor. This case could represent the first case report of AGEP to the EGFR inhibitor, lapatinib.

Adverse cutaneous reactions secondary to tyrosine kinase inhibitors including imatinib mesylate, nilotinib, and dasatinib

Imatinib mesylate is the first of a novel group of drugs that specifically target protein tyrosine kinases, which are central to the pathogenesis of human cancer. It has been approved for the treatment of chronic myeloid leukemia and gastrointestinal stromal tumor and has been found efficacious in other neoplastic diseases. Nilotinib and dasatinib, a second-generation of tyrosine kinase inhibitors (TKIs), were developed in response to findings of emerging imatinib resistance or intolerance to the drug. Cutaneous reactions are the most common nonhematologic side effect of these drugs, and their management is challenging especially in the absence of alternative anticancer agents. The present review focuses on the clinical characteristics and the hypothesized molecular pathogenesis of these first- and second-generation TKIs' cutaneous side effects, and approaches to their treatment. The wide range of adverse effects clarifies the difficulty in designing a truly antitumoral TKI.

Pityriasis rosea-like Drug Eruption Induced by Imatinib Mesylate (Gleevec™)

Imatinib mesylate (Gleevec™, STI571), a selective inhibitor of BCR-ABL, c-Kit, and platelet-derived factor receptor, has been used to treat chronic myelogenous leukemia (CML) and gastrointestinal stromal tumors. Although its use has been associated with various adverse cutaneous reactions, pityriasis rosea-like drug eruptions are rare. Here, we report a case of pityriasis rosea-like drug eruption that developed following the administration of imatinib mesylate to treat CML.

Serious skin reaction associated with imatinib in a patient with chronic myeloid leukemia

Imatinib mesylate (STI 571) is one of the fundamental chemotherapeutic agents used in the treatment of the chronic, accelerated and blastic phases of chronic myelocytic leukemia (CML), gastrointestinal stromal tumors and Philadelphia chromosome-positive acute lymphoblastic leukemia. It selectively inhibits receptor tyrosine kinases. Its effects limit the use of this drug. We present a case with a serious skin reaction requiring the discontinuation of the drug and that developed in relation to imatinib therapy. Six months prior, a 61-year-old male patient presenting to the hematology polyclinic with complaints of weight loss and sweating was hospitalized due to high leukocyte value. As a result of the hemogram, biochemistry analyses, peripheral blood smear examination, bone marrow aspiration evaluation, cytogenetic examination using FISH and PCR that were performed, CML was diagnosed. Additionally, to exclude myelofibrosis, we examined a bone marrow biopsy. Imatinib mesylate was started at 400 mg/day orally. In the fourth month of treatment, the patient complained of itching and a skin rash. Although the drug dose was reduced (300 mg/day), his complaints gradually increased. The skin biopsy result was superficial perivascular dermatitis. Imatinib was discontinued, and the patient was started on corticosteroid. The lesions disappeared completely. A month later, the patient was restarted on imatinib mesylate. However, the lesions recurred more prominently. His itching increased. The patient was considered intolerant to imatinib mesylate, and a second-generation tyrosine kinase inhibitor, dasatinib 100 mg/day, was started orally. The follow-up and treatment continues for the patient, who has been taking dasatinib 100 mg/day for the last two months without any skin finding or complaints. Imatinib mesylate-induced skin reactions are associated with the pharmacologic effect of the drug rather than hypersensitivity to the drug. Skin reactions are frequently observed, and this side effect is dose dependent. However, the interesting aspect of our case was that despite dose reduction, skin findings gradually increased, and eventually the drug had to be discontinued.

BCR-ABL kinase is dead; long live the CML stem cell

Chronic myeloid leukemia (CML) is a hematopoietic disease characterized by expansion of myeloid blood cells. It is caused by the t(9;22) chromosomal translocation that results in the expression of the fusion tyrosine kinase BCR-ABL. Tyrosine kinase inhibitor (TKI) therapy has led to long-term remissions, but patients remain BCR-ABL+. There is agreement that TKIs do not kill CML stem cells; however, it is controversial whether this is because of a lack of BCR-ABL kinase inhibition in CML stem cells or because CML stem cells do not require BCR-ABL for survival. In this issue of the JCI, Corbin and colleagues provide definitive evidence that BCR-ABL is kinase active in CML stem cells and that TKIs inhibit this kinase activity without affecting CML stem cell survival. Rather, CML stem cells revert to a normal dependence on cytokines for survival and proliferation. These results demonstrate that the CML stem cell is not BCR-ABL addicted and have important implications for developing curative therapeutic approaches to CML.

Acute generalized exanthematous pustulosis in a patient after stem cell transplantation

BACKGROUND

a severe generalized pustular eruption occurred several months after allogeneic hematopoietic stem cell transplantation for multiple myeloma in a patient being treated with antibiotics for respiratory infection. Neither he nor his donor had a history of psoriasis.

METHODS

the patient was treated with drug withdrawal and administration of cyclosporine and methylprednisolone without improvement; later, acitretin and methylprednisolone were used successfully. The eruption slowly subsided, and therapy was discontinued. Four months later, the patient experienced a recurrent severe pustular eruption associated with fever and leukocytosis, and the same treatment was used successfully again.

RESULTS AND CONCLUSION

the patient has not experienced relapses in the ensuing 3 years. Acute generalized exanthematous pustulosis is a rare cutaneous adverse reaction triggered most commonly by drugs with a tendency to resolve spontaneously. The surprisingly prolonged, refractory, and relapsing course of the eruption in our patient might be due to the immune alteration and the polypharmacologic therapy after stem cell transplantation.

Acne rosacea associated imatinib mesylate in a gastrointestinal stromal tumor patient

Tyrosine kinase inhibitors (TKIs) are targeted treatments for various cancers. Skin toxicities are one of the most common nonhematological side-effects of TKIs. We report an imatinib mesylate (IM) induced hyperpigmented acne rosacea (AR) and sunitinib-induced palmar hyperkeratosis in the case with gastrointestinal stromal tumor. AR was arisen due to the discontinuation of IM. To the best of our knowledge, this kind of cutaneous side-effect with IM has not been documented previously.

Oral lichenoid eruption secondary to imatinib (Glivec®)

BACKGROUND

Oral lichenoid drug eruption (OLE) is a self-restricted inflammatory condition usually secondary to a variety of drugs and dental materials (mercury, gold), and rarely to immunomodulators and new antineoplastic agents such as imatinib mesylate (Glivec). OLE clinical features are reminiscent of lichen planus and include symmetric and asymptomatic, erythematous, reticulated and painful ulcerated plaques. Histological examination reveals perivascular lymphocytic infiltrate and the presence of eosinophils that obscures the dermal-epidermal junction, with acanthosis and mild hyperkeratosis.

METHODS

A 62-year-old man was treated with Glivec for metastatic gastrointestinal stromal tumour (GIST).

RESULTS

The patient presented with grey-violaceous plaques on both cheek mucosal surfaces and the lateral sides of the tongue and labial mucosa, with a reticular pattern resembling oral lichen planus. These lesions appeared approximately 1 year after therapy and partially subsided in about 10 weeks, to clear after topical corticosteroids and oral omeprazole. The diagnosis of OLE induced by imatinib was confirmed by histological biopsy evaluation; immunohistochemical analysis revealed intense immunoreactivity with only cytokeratins 5/6 and 14 in the epithelium of affected mucosa. All laboratory investigations proved asiderotic anaemia but excluded infectious causes.

CONCLUSION

It is believed that this patient developed imatinib-induced OLE; this relationship with therapy rather than the underlying disease rules out a paraneoplastic reaction, and negative immunofluorescence excluded autoimmune dermatosis. In addition, we propose that these lesions are correlated with abnormal expression of some cytokeratins directly caused by this drug.

Acute generalized exanthematous pustulosis induced by bleomycin and confirmed by patch testing

Acute generalized exanthematous pustulosis is a potentially severe disease caused by drugs in about 90% of cases. To the best of our knowledge, acute generalized exanthematous pustulosis following use of bleomycin has not been previously reported. Here we report a case of acute generalized exanthematous pustulosis induced by bleomycin, which was confirmed by patch testing.

[Imatinib-induced DRESS]

BACKGROUND

Imatinib (Glivec) is a tyrosine kinase inhibitor used to treat certain cases of leukaemia. We report a case of a drug-induced reaction with eosinophilia and systemic symptoms (DRESS) caused by imatinib.

CASE-REPORT

A 77-year-old woman with a chronic myeloid leukaemia was treated with imatinib and allopurinol. Nineteen days after the start of treatment, the patient presented fever with a generalized polymorphous rash associated with oral erosions, facial oedema, diffuse lymphadenopathy and blood hypereosinophilia. Histological analysis of skin biopsy specimens suggested a drug-induced reaction. The outcome was favourable two weeks after discontinuation of treatment. Three months later, imatinib was reintroduced because of progression of the patient's chronic myeloid leukaemia, and recurrence of the skin rash and fever was observed within 12 hours.

DISCUSSION

Allopurinol was stopped definitively because of its more frequent imputability. Imatinib was reintroduced after considering the benefit-risk ratio and in full knowledge of the existence of cutaneous reactions to imatinib, despite there being only one recent report of DRESS following treatment with imatinib. According to the causality criteria of Bégaud et al. regarding imatinib, inherent causality of the drug in our patient was initially possible (I2) and appeared likely (I3) after the rechallenge test. This case clearly illustrates that imatinib is a potential cause of DRESS.

Chemotherapeutic agents and the skin: An update

Chemotherapeutic agents give rise to numerous well described adverse effects that may affect the skin, hair, mucous membranes, or nails. The mucocutaneous effects of longstanding agents have been extensively studied and reviewed. Over the last 2 decades, a number of new molecular entities for the treatment of cancer have been approved by the United States Food and Drug Administration (FDA). This article reviews the cutaneous toxicity patterns of these agents. It also reviews one drug that has not received FDA approval but is in use outside the United States and is important dermatologically. Particular emphasis is placed on the novel signal transduction inhibitors as well as on newer literature pertaining to previously described reactions.

LEARNING OBJECTIVES

At the completion of this learning activity, participants should able to list the newer chemotherapeutic agents that possess significant mucocutaneous side effects and describe the range of reactions that are seen with each drug. In addition, they should be able to formulate appropriate management strategies for these reactions.

Cutaneous reactions related to systemic immunomodulators and targeted therapeutics

The arrival of targeted therapeutics into the oncology clinic, while enthusiastically anticipated, introduced the oncologist to dermatologic events that can pose challenging management issues. The dermatologic effects of these targeted agents appear to be more frequent than those with cytotoxic therapy and are not uniform; that is, different agents have distinct dermatologic toxicities. Interestingly, dermatologic toxicity may correlate with antitumor activity with some of these targeted agents. The correlation of rash with response and survival in particular mandates the development of effective and appropriate management strategies. The nature and challenges of the dermatologic events observed to date with epidermal growth factor receptor inhibitors, multikinase inhibitors, proteosome inhibitors, BCR-ABL tyrosine kinase inhibitors, and immunomodulatory drugs will be addressed in this review.

Emerging Safety Issues with Imatinib and Other Abl Tyrosine Kinase Inhibitors

Imatinib and other Abl tyrosine kinase inhibitors (TKIs), such as dasatinib and nilotinib, have significantly improved the outcome of patients with chronic myeloid leukemia. Imatinib and dasatinib are currently Food and Drug Administration (FDA) approved, and nilotinib is expected to gain FDA approval soon. In addition, several other Abl TKIs are being evaluated in various clinical trials. Imatinib has also shown efficacy in the therapy of gastrointestinal stromal tumors, Philadelphia chromosome-positive acute lymphocytic leukemia and hypereosinophilic syndrome. Because of their efficacy, more patients will receive Abl TKIs for a longer period of time. Imatinib was FDA approved after a short follow-up because of its exceptional efficacy and safety profile. The most common adverse events reported included fluid retention, fatigue, diarrhea, and muscle cramps. With longer follow-up, issues related to the long-term use of imatinib have been discussed. Our aim is to review the emerging safety issues of Abl TKIs after a longer follow-up.

Desensitization to imatinib in patients with leukemia

BACKGROUND

Imatinib mesylate is a tyrosine kinase inhibitor used for the treatment of chronic myeloid leukemia and hypereosinophilic syndrome. Imatinib is associated with a variety of adverse cutaneous reactions, including urticaria, maculopapular exanthem, generalized exanthematous pustulosis, exfoliative dermatitis, and Stevens-Johnson syndrome.

OBJECTIVE

To evaluate the safety and efficacy of oral desensitization by administering incremental dosages of imatinib mesylate to patients with leukemia who have had rashes associated with prior exposure.

METHODS

Ten patients with leukemia and imatinib-associated recurrent rash underwent a 4-hour outpatient oral desensitization procedure. Beginning with 10 ng, we administered oral imatinib elixir in increasing dosages every 15 minutes. Patient outcomes were monitored by a return clinic visit and by telephone follow-up for a median of approximately 3 years.

RESULTS

No episodes of anaphylaxis or serious adverse effects occurred during or immediately after desensitization. Four patients (all with urticaria) had no recurrence of rash after desensitization, and 4 had recurrent rash that resolved after temporary glucocorticosteroid and antihistamine administration. Two patients developed a recurrent rash 5 hours and several days after the procedure and were unable to resume therapy.

CONCLUSION

This oral desensitization protocol appears to help some leukemic patients with recurrent rash tolerate imatinib mesylate, thus permitting continuation of this life-prolonging therapy. These findings suggest that some adverse cutaneous reactions to imatinib may be due to a hypersensitivity mechanism rather than a pharmacologic effect.

DRESS (Drug reaction with eosinophilia and systemic symptoms) après traitement par imatinib (Glivec)

BACKGROUND

Imatinib (Gleevec) is a tyrosine kinase inhibitor used to treat chronic myeloid leukemia. We describe a case of drug reaction with eosinophilia and systemic symptoms (DRESS) after institution of treatment with imatinib.

PATIENT AND METHODS

A 78-year-old woman was treated with low-dose imatinib for chronic myeloid leukemia since November 2003. A macular and pruritic eruption appeared on the patient's trunk after 7 weeks of treatment and gradually worsened. After 1 month, she was admitted for generalized skin eruption with fever and diffuse lymphadenopathy. Laboratory data showed hypereosinophilia and blood cultures positive for Staphylococcus aureus. Imatinib was stopped and replaced with hydroxyurea (Hydrea). Improved clinical and laboratory results were seen with antibiotics and topical steroids.

DISCUSSION

To our knowledge, this is the first case of DRESS following treatment with imatinib. Cutaneous reactions to imatinib are frequent and are usually mild, comprising maculopapular eruption, pruritus and facial edema. Few cases of serious skin reactions have been reported until now. Several authors suggest that the prevalence and severity of cutaneous manifestations are related to a pharmacologic effect of imatinib. Our observation cannot rule out an underlying immunologic mechanism. Septicemia may also play a part in the development of DRESS.

Dermatologic toxicity of chemotherapeutic agents

Due to its high metabolic rate, skin represents one of the major target organs of chemotherapy-associated toxicity. Reactions range from common, nonspecific exanthematous eruptions to rare but distinctive cutaneous lesions that may not become apparent until a drug transitions from clinical trials to widespread oncologic use. The challenge of the physician is to recognize reaction patterns that reflect a drug reaction, identify a likely causative drug, and determine whether the reaction is a dose-limiting toxicity. This review will focus on the cutaneous side effects of the newer classes of chemotherapy drugs, including targeted monoclonal antibody therapy and small molecule inhibitors.

Vitiligo-like lesions and diffuse lightening of the skin in a pediatric patient treated with imatinib mesylate: a noninvasive colorimetric assessment

Imatinib mesylate is a drug that has been recently approved for the treatment for chronic myeloid leukemia. It acts as a potent and selective inhibitor of BCR-ABL tyrosine kinase. It also inhibits both c-kit and platelet-derived growth factor receptor tyrosine kinases. Hypopigmentation of the skin in patients receiving this drug has been recently reported. We report a 17-year-old Caucasian patient affected by chronic myeloid leukemia in therapy with imatinib mesylate who developed hypopigmented vitiligo-like patches and generalized lightening of the skin. In order to evaluate the lightening observed clinically, we measured the progressive skin color hypopigmentation by using a colorimeter over several months. The colorimetric evaluation confirmed the generalized and gradual lightening of patient's skin over treatment with imatinib mesylate. We believe that this is the first reported instance of vitiligo-like lesions in a pediatric patient treated with imatinib mesylate, and the second in a Caucasian patient.

Severe Pustular Eruption Associated with Imatinib and Voriconazole in a Patient with Chronic Myeloid Leukemia

Imatinib is a specific and potent inhibitor of the BCR-ABL tyrosine kinase. Several clinical trials have demonstrated the efficacy of imatinib in chronic myeloid leukemia. Adverse cutaneous reactions induced by imatinib are frequent and may be dose related. We report a case of an unusual pustular eruption in a patient with chronic myeloid leukemia, who received high doses imatinib for blast crisis and later voriconazole for invasive pulmonary aspergillosis. At the time of his skin eruption, elevated plasma levels of imatinib were recorded. Imatinib is primarily metabolized by the cytochrome CYP3A4. Voriconazole is a cytochrome CYP3A4 inhibitor and can lead to high plasma levels of imatinib. This case suggests that severe drug reactions to imatinib may be related not only to imatinib doses, but also to elevated plasma drug levels resulting from pharmacokinetic interactions. The monitoring of imatinib plasma levels may be of help for identifying patients at risk for severe toxicity.

Pityriasis rosea–like eruption during treatment with imatinib mesylate: Description of 3 cases

Imatinib mesylate (IM) represents the first-line treatment for chronic myeloid leukemia (CML). We hereby relate 3 cases of an IM-induced pityriasis rosea (PR)-like cutaneous eruption. Patients developed an erythematous, slightly pruritic, macular skin eruption, with many lesions having a peripheral collarette of desquamation, confined to the trunk, limbs, and arms with a vaguely dermatomal diffusion. The histologic findings suggested a reactive process to the drug. Full dermatological recovery was obtained after IM discontinuation, but lesions reappeared upon restoring therapy, suggesting the drug-related nature of the rash. To our knowledge this is the first reported PR-like cutaneous eruption to IM.

Immunohistochemical characterization of cutaneous drug eruptions by STI571

BACKGROUND

STI571, a selective BCR-ABL tyrosine kinase inhibitor, is a promising new drug for chronic myelogenous leukemia (CML). However, the drug has been reported to be associated with adverse cutaneous drug eruptions with high frequency.

OBJECTIVE

In this study, the characteristics of the cutaneous drug eruptions by STI571 were investigated.

METHODS

The clinical records of 10 patients diagnosed with drug eruption by STI571 were reviewed. We obtained 10 skin biopsy specimens from patients with drug eruption by STI571, 6 from the antibiotics-induced drug eruption group, and 5 from normal skin (control). Immunohistochemical analysis was performed to detect CD4, CD8, CD56, IL-18, IL-1beta and ICAM-1 expression in the cutaneous drug eruption.

RESULTS

Seven out of 10 patients had maculopapular exanthema, 2/10 erythema multiforme, 1/10 urticaria. We analyzed the composition of T-lymphocyte subsets from the infiltrates at the STI571-induced drug eruption site in eight patients. Unlike other drug eruptions, the increase in the CD8 expression was statistically significant, especially in the dermoepidermal junction and the upper dermis (P < 0.01). The enhanced expression of IL-18 and IL-1beta was observed as well. In contrast, ICAM-1 was either weakly positive or negative.

CONCLUSION

Drug eruption caused by STI571 was mostly expressed as a maculopapular exanthema. The histopathological findings were similar in drug eruption by antibiotics or STI571. Unlike the drug eruptions caused by antibiotics, where the expression of CD4 was dominant, CD8 was dominant in drug eruptions by STI571. The expression of IL-18 and IL-1beta was increased in both groups. This elevation of IL-18 and IL-1beta may assist in understanding the pathogenesis of cutaneous drug eruption.

Interferon-gamma-dependent in vitro model for the putative keratin 17 autoimmune loop in psoriasis: exploration of pharmaco- and gene-therapeutic effects

In 1999, A.S. Gudmundsdottir et al. have envisaged an epitope on keratin 17 (K17) as a putative psoriasis major autoantigen recognized by T cells. In a HaCaT keratinocyte model, we now demonstrate that IFN-gamma and to a less extent also TNF-alpha and TGF-alpha are able to induce K17 protein expression, in contrast to IL-1alpha, IL-1beta, IL-6, IL-8 and IL-18. This supports our hypothesis of an existing proinflammatory cytokine/K17 autoimmune loop as a presumptive positive feedback mechanism driving psoriasis etiopathogenesis. K17 overexpression was now found to also coincide with suppression of keratinocyte proliferation, e.g. induced by NF-kappa B inhibitors (Bay 11-7082 and Bay 11-7085), and thereby correlated hyperapoptosis to be encountered in psoriatic epidermis. Acitretin as an established antipsoriatic drug and the tyrosine kinase inhibitor imatinib decreased, whereas hydrocortisone as well as dexamethasone increased the IFN-gamma-induced K17 overexpression. The latter might be another mechanism explaining the well-known rebound phenomena after abrupt withdrawal of corticosteroids in psoriasis treatment. Finally, we defined a K17-directed and effective antisense oligodesoxynucleotide which may hold promise for future gene-therapeutic approaches in psoriasis.

Acute generalized exanthematic pustulosis: a case and an overview of side effects affecting the skin caused by celecoxib and other COX-2 inhibitors reported so far

A 55-year-old woman who was treated for periarthritis humeroscapularis with celecoxib (Celebrex) developed a generalized pustular exanthema on the head and upper trunk, accompanied by fever, leukocytosis and increased erythrocyte sedimentation rate. The histological findings were subcorneal pustules, necrotic keratinocytes, edema in the upper dermis and polymorphic perivascular infiltrates. Four days after stopping celecoxib, the pustules disappeared without any treatment. Four weeks after disappearance of the skin lesions, celecoxib demonstrated a positive lymphocyte stimulation test. In this article, we present to our knowledge the first case of acute generalized exanthematic pustulosis caused by celecoxib, and we give an overview of the side effects affecting the skin caused by celecoxib and other cyclooxygenase type 2 inhibitors reported so far.

Indications for imatinib mesylate therapy and clinical management

Imatinib mesylate (Gleevec), Glivec, formerly STI571; Novartis Pharma AG; Basel, Switzerland) is a rationally-designed, molecularly-specific oral anticancer agent that selectively inhibits several protein tyrosine kinases central to the pathogenesis of human cancer. It has demonstrated remarkable clinical efficacy in patients with chronic myeloid leukemia and malignant gastrointestinal stromal tumors. Treatment with imatinib is generally well tolerated, and the risk for severe adverse effects is low. Adverse effects most commonly include mild-to-moderate edema, nausea and vomiting, diarrhea, muscle cramps, and cutaneous reactions. Hepatic transaminase level elevations and myelosuppression occur less frequently and resolve with interruption of imatinib therapy. In general, the incidence and severity of adverse effects tend to correlate with imatinib dose and, in chronic myeloid leukemia patients, the phase of disease; but, patient age and other factors are also associated with some types of reactions. With prompt and appropriate intervention, adverse effects in imatinib-treated patients have proven to be manageable across the spectrum of severity, and they seldom require permanent cessation of therapy. Dose reduction is not usually necessary, and reduction to subtherapeutic levels is not recommended.

Toxidermie lichénoïde à l’imatinib (Glivec®)

INTRODUCTION

Imatinib (Glivec) is a new therapeutic molecule used for the treatment of chronic myeloid leukemia. Cutaneous side effects with this treatment are common but lichenoid drug eruption is exceptional. We report the first case with profuse cutaneous lichen.

CASE REPORT

A 52 year-old woman presented with a 5-year history of chronic myeloid leukemia. The different chemotherapies had failed (persisting polyadenopathies and splenomegalia). She was treated with imatinib (400 mg/day). Two months after the beginning of this treatment a disseminated cutaneous eruption appeared on the trunk, legs, arms and face without mucosal involvement and composed of dark purple, prurigenous, papules suggestive of lichen planus. The cutaneous biopsy confirmed the diagnosis of lichen planus. Suspension of the drug led to the complete regression of the eruption, without any other local treatment, within 2 months. Reintroduction of the drug led to the recurrence of the lesions.

DISCUSSION

Cutaneous reactions to imatinib are common and occur in 11 to 67 p. 100 of patients depending on the series. More severe cutaneous reactions have been described: exfoliating dermatites, generalized pustulosis, epidermal necrolysis. The aspect of profuse lichenoid eruption of the skin and the correlation with cutaneous lesions clinically and histologically evocative of lichen planus has not been described other than an isolated buccal involvement in a 72 year-old woman. In our patient, study of the imputability criteria is in favor of imatinib's responsibility.

Chronic myelogenous leukemia: elements of conventional chemotherapy and an overview of autografting in the treatment of the chronic phase

Chronic myelogenous leukemia (CML) consists of a clonal malignancy that arises from a pluripotent hematopoietic stem call. In most cases, neoplastic cells are characterized by the formation of a shortened chromosome 22 called the Philadelphia chromosome. It results from a reciprocal translocation between long arms of chromosomes 9 and 22. A rearranged gene (bcr-abl) is the consequence of this translocation, and it may be considered as the first step toward leukemic transformation. Conventional chemotherapy of CML in the chronic phase is unable to suppress the Ph+ leukemic clone. The treatment with the IFNalpha may induce an overall cytogenetic response rate of 40-50% of patients. Autografting for patients with CML in chronic phase may induce a 53% overall cytogenetic response rate with a duration of disease-free time and survival from the autograft ranging, respectively, from 4 to 24 mo and from 8 to 40 mo.

Skin reactions related to treatment with anticytokines, membrane receptor inhibitors and monoclonal antibodies

Therapeutic monoclonal antibodies, soluble cytokines and receptors to cytokines, and inhibitors of tyrosine kinase, are currently used in an ever increasing number of patients with neoplastic and inflammatory disorders. Their cutaneous side effects are not always well known by physicians in charge of these new biotherapies. However, these side effects seem to be relatively frequent and may seriously disturb the patients or even represent a life-threatening event. Accordingly, it appears necessary for dermatologists and physicians using these therapies to be aware of the varied patterns of skin complications they may cause, in order to manage the treatment in the safest and most comfortable way for the patients.