Pathogenetic associations of anti-ribosomal P protein antibody titres and their subclasses in patients with systemic lupus erythematosus

OBJECTIVES

We evaluated the association between anti-ribosomal P antibody (anti-RibP) titres and disease activity in Japanese SLE patients.

METHODS

Eighty patients admitted and treated in Niigata University Hospital for new-onset or flare-up of SLE were included in this retrospective cross-sectional study. Clinical data were obtained from medical records at admission. The anti-RibP index, and cytokine and tryptophan metabolite levels were determined by ELISA.

RESULTS

Of the 80 SLE patients, 30 had anti-RibP. Anti-RibP presence was associated with a greater prevalence of skin rash and more severe inflammatory responses, demonstrated by higher inflammatory cytokine levels, hypocomplementemia, and accelerated tryptophan metabolism, in younger patients. The serum anti-RibP index was correlated with age at diagnosis, clinical indicators, initial prednisolone dose, and cytokines and tryptophan metabolite levels in univariate analysis. Multivariate analysis showed that the anti-RibP index was independently associated with the initial prednisolone dose and the prevalence of skin rash. The anti-RibP IgGs were mainly the IgG2 and IgG3 subclasses, and anti-RibP IgG3 was associated with hypocomplementemia, higher DAS, accelerated kynurenine pathway activity, and higher proinflammatory cytokine production. The coexistence of anti-dsDNA IgG and anti-RibP IgG2 or IgG3 accompanied higher IL-10 and IFN-α2 levels; furthermore, anti-RibP IgG3 coexistence with anti-dsDNA antibody contributed to the requirement for higher initial prednisolone doses and accelerated kynurenine pathway activity.

CONCLUSION

Anti-RibP was associated with clinical manifestations and parameters in SLE, and its index might be a useful indicator of disease severity. Anti-RibP IgG3 was the IgG subclass most strongly associated with the pathogenesis of SLE.

A case report of Hyper-IgD syndrome in a 5-year-old girl with recurrent fever, skin rash, and arthralgia; novel MVK mutation (C.298G>A)

Key Clinical Message

This case highlights the potential for later-onset Hyper-IgD syndrome (HIDS) even beyond infancy. Clinicians evaluating children with recurrent fever, skin rash, and arthralgia should consider HIDS in the differential diagnosis, regardless of age. Early suspicion and genetic testing can lead to a timely diagnosis and targeted therapy with Anakinra, significantly improving patient outcomes.

Abstract

Hyper-IgD syndrome (HIDS) is a rare autosomal recessive autoinflammatory disorder characterized by recurrent episodes of fever, lymphadenopathy, arthralgia, diarrhea, abdominal pain, and skin rash. In this case report, we present a 5-year-old girl from Tajikistan with a mutation in the mevalonate kinase (MVK) gene, which is consistent with a diagnosis of HIDS. The clinical symptoms of the patient are described, along with immunological, hematological, and biochemical findings collected from the evaluation in the rheumatology clinic. Additionally, whole-exome sequencing revealed a heterozygous missense variation in exon 4 of the MVK gene. The diagnosis of HIDS in this case occurred at a later age than typically observed, emphasizing the importance of considering this condition even in older patients. This report highlights the broad clinical phenotype of MVK and the need for increased awareness among healthcare professionals regarding its clinical presentation and management.

Icodextrin-induced acute generalized exanthematous pustulosis in a patient with peritoneal dialysis

Icodextrin has been widely prescribed for peritoneal dialysis (PD) patients with inadequate ultrafiltration, but icodextrin induced acute generalized exanthematous pustulosis (AGEP) has been not well recognized in clinical practice. We described a young-aged female with IgA nephropathy and end stage kidney disease under continuous automated peritoneal dialysis. She developed skin erythema with exfoliation over the groin 7th day after initiation of icodextrin based PD dialysate. Initially, her scaling skin lesion with pinhead-sized pustules affected the bilateral inguinal folds, and then it extended to general trunk accompanied by pruritus. She was admitted because of deterioration of skin lesion on 14th day of icodextrin exposure. She was afebrile and physical examination was notable for widespread erythematous papules with pruritus extending over her groins and trunk. Pertinent laboratory examination showed leukocytosis of 18 970 cells/μL with neutrophile count of 17 642 cells/μL (92.3%), and c-reactive-protein: 3.39 mg/dL. Skin biopsy revealed multifocal sub corneal abscess with papillary dermal edema, and upper-dermal neutrophilia with perivascular accentuation, consistent with the diagnosis of AGEP. After discontinuation of PD, she underwent temporary high-flux haemodialysis with treatment of steroid and antihistamine. Her dermatologic lesion resolved without any skin sequalae completely within 4 days, and she underwent icodextrin-free peritoneal dialysis at 17th day. This case highlighted the fact that icodextrin-induced AGEP should be early recognized to avoid inappropriate management.

Real-world prostate-specific antigen response and progression to castration-resistant prostate cancer among men with metastatic castration-sensitive prostate cancer treated with apalutamide: a multi-institutional study in the Chu-shikoku Japan Urological Consortium

BACKGROUND

Japanese men receiving apalutamide often experience skin-adverse events (AEs), possibly requiring treatment interruption or dose reduction. However, concerns have arisen regarding the impact of these adjustments on the efficacy of apalutamide. Our study evaluated the efficacy, safety, and persistence of apalutamide in men with metastatic castration-sensitive prostate cancer (mCSPC).

METHODS

We retrospectively reviewed the medical records of 108 men with mCSPC from 14 Japanese institutions. The primary outcomes were the efficacy of apalutamide: prostate-specific antigen (PSA) response (50%, 90% and < 0.2 decline) and progression to castration-resistant prostate cancer (CRPC). The secondary outcomes were the skin-AE and compliance of apalutamide.

RESULTS

PSA50%, PSA90% and PSA < 0.2 declines were observed in 89.8, 84.3 and 65.7%, and the median time to CRPC progression was not reached. PSA < 0.2 decline and an initial full dose of apalutamide were significantly associated with a longer time to CRPC. The most common AE was skin-AE (50.9%), and there was no association between the occurrence of skin-AE and the time to CRPC (P = 0.72). The median apalutamide persistence was 29 months, which was longer in the initial full dose recipients than in the reduced dose recipients. The dosage is reduced in about 60% of patients within the first year of treatment in the initial full dose recipients.

CONCLUSIONS

Our findings indicate the effectiveness of apalutamide in Japanese men with mCSPC, despite a substantial portion requiring dose reduction within a year among the initial full dose recipients.

Hypothyroidism Due to Seaweed Overconsumption

Hypothyroidism presents various symptoms, ranging from commonly observed signs, such as fatigue, cold sensation, and constipation, to rare features, such as rash and pancytopenia, resembling certain rheumatological and hematological diseases. Chronic, excessive iodine consumption causes primary hypothyroidism. However, when iodine overconsumption becomes a regular part of daily dietary habits, it becomes difficult for patients to associate their symptoms with daily iodine consumption. Therefore, clinicians cannot obtain information on excessive iodine intake from the patient. Here, we present a case of hypothyroidism that was subsequently identified as caused by excessive dairy seaweed consumption for health purposes. This case report highlights the importance of a detailed dietary history in patients diagnosed with primary hypothyroidism without thyroid autoantibodies.

Time-Course Changes in Lamotrigine Concentration after Addition of Valproate and the Safety and Long-Term Tolerability of Lamotrigine-Valproate Combination Therapy

The aim of this study was to evaluate the time-course changes in lamotrigine (LTG) concentration after addition of valproate (VPA) and the safety and tolerability of the combination therapy. We reviewed our therapeutic drug monitoring (TDM) database and found 345 patients on LTG who received add-on therapy with VPA. VPA had been added at least 12 weeks after patients finished stepwise LTG titration. Also, we retrospectively evaluated the LTG concentration after addition of VPA and the safety and long-term tolerability of LTG-VPA combination therapy. Plasma LTG concentration increased more than 1.5-fold within 15 d of addition of VPA and reached a peak at 30 d. The rate of increase in LTG concentration occurred in a VPA concentration-dependent manner. During the first 120 d after addition of VPA, adverse events were reported by 58 patients (16.8%), but no patient developed cutaneous reactions. Kaplan-Meier analysis showed estimated retention rates for LTG-VPA combination therapy of 74.5% at 5 years. At 5 years, the mean concentration of LTG was 11.1 µg/mL (43.3 µmol/L). Because addition of VPA leads to a marked increase in LTG concentration over a short period, TDM for LTG should be performed at the earliest from 14 d after starting VPA. At 120 d after starting VPA therapy, the higher LTG concentration due to addition of VPA is not associated with an increased risk of cutaneous reactions. Although LTG-VPA combination therapy increases LTG concentration, it is well tolerated and has a high long-term retention rate.

Cutaneous Adverse Drug Reactions: Regional Experience of a Global Challenge

BACKGROUND

Adverse drug reactions (ADR) are considered any harmful and unintended side effects associated with the use of a drug at the usual therapeutic dose, in which skin is involved in most cases. Therefore, the availability of epidemiological information on reactions, reaction patterns, and their causative drugs can be helpful in timely diagnosis and necessary measures, such as caution in prescribing causative drugs to prevent these types of reactions.

METHODS

In this retrospective descriptive study, the archived files of patients with dermatoses due to ADR referred to Taleghani University Hospital, Urmia, Iran, during 2015-2020 were studied. Patterns and frequency of skin reactions, demographic data, and the frequency of chronic comorbidities were identified.

RESULTS

A total of 50 patients with drug-induced skin rash were found, of which 14 were male (28%) and 36 were female (72%). Skin rashes were most frequently found in patients aged 31-40 years. In 76% of patients, there was at least one chronic underlying disease. The most common reaction pattern was maculopapular rash (44%), and the most common causative drugs were antiepileptic drugs (34%) and antibiotics (22%). Mortality was found in 4 cases, which was due to antibiotics and antiepileptic drugs that caused toxic SJS/TEN and erythroderma. The hospital stays were highest in SJS and lowest in a maculopapular rash.

CONCLUSION

Knowledge about the epidemiology and the frequency of adverse drug reactions may be helpful in increasing the awareness of physicians for correct and rational drug prescriptions, which can reduce unnecessary hospital referrals and treatment costs.

Atypical cutaneous presentation of AOSD with persistent itchy urticaria: A case report

RATIONALE

Adult-onset Still's disease (AOSD) is a rare multisystem disorder considered a complex autoinflammatory syndrome. The clinical and biological features of AOSD typically include a high fever with arthritic symptoms, evanescent skin rash, sore throat, striking neutrophilic leukocytosis, hyperferritinemia, and abnormal liver function. The typical rash and fever are important diagnostic clues for AOSD. Here, we report a case of atypical rash manifesting as persistent itchy urticaria.

PATIENT CONCERNS

A 57-year-old female presented with a 6-day history of fever. During her hospital stay, she progressively developed rashes that were not associated with fever, primarily distributed on her back and the distal extremities, and associated with pronounced itching. The rash was initially suspected to be urticaria; however, the patient exhibited a poor response to antihistamines. After malignancies and other rheumatic diseases were excluded, the diagnosis leaned towards AOSD based on diagnostic criteria. The patient's fever was well controlled with the initiation of glucocorticoids, and no further rashes were observed.

DIAGNOSES

Although the patient exhibited atypical rashes, after ruling out malignancies and other rheumatic diseases, she met 2 major and 3 minor criteria. Based on Yamaguchi's criteria, the patient was diagnosed with AOSD.

INTERVENTIONS

Initially, the patient was administered an intravenous infusion of methylprednisolone at 40 mg once daily. This was later transitioned to oral administration with gradual dose reduction.

OUTCOMES

Follow-up at 1 year showed no recurrence of the rash, with a stable condition and no relapse.

LESSONS

This case provides valuable insights for the early diagnosis of AOSD, emphasizing the importance of considering this diagnosis even when presenting with atypical skin rash.

The Effect of Topical Vitamin K1 on the Treatment of Cetuximab-Induced Skin Rashes in Metastatic Colorectal Cancer Patients

Background

Considering the prevalence of cetuximab-induced rashes in colorectal cancer patients and its impact on patient's quality of life and treatment, this study aimed at investigating the effect of topical vitamin K1 on the treatment of skin rashes in metastatic colorectal cancer patients treated with cetuximab.

Materials and Methods

This randomized, controlled, triple-blind, clinical trial was conducted on 49 metastatic colorectal cancer patients who were candidates for cetuximab treatment and referred to Omid Hospital in Isfahan during 2021-2022. Vitamin K1 cream with a concentration of 0.1% in the intervention group (n = 25) and placebo cream in the control group (n = 24) were prescribed twice a day (in the morning and before bedtime) for eight weeks. The rash grade was recorded based on common terminology criteria for adverse events-4 (CTCAE-4) criteria before the intervention and in the fourth and eighth weeks during the intervention.

Results

During the intervention, skin rash grades in the fourth and eighth weeks with the means of 1.00 ± 0.64 and 0.84 ± 0.55, respectively, were significantly lower in the intervention group, as compared with the control group with the means of 1.42 ± 0.65 and 1.25 ± 0.68, respectively (P value < 0.05). Moreover, the severity of skin rashes decreased significantly in the intervention group over time during eight weeks (P value < 0.05); however, its decrease was not significant in the control group (P value > 0.05).

Conclusion

Topical vitamin K1 cream had a significant effect on reducing the severity of cetuximab-induced skin rashes over eight weeks of treatment.

Acute Respiratory Distress Syndrome due to Monkeypox Virus

We report the first case of monkeypox virus (MPXV) associated acute respiratory distress syndrome (ARDS). A 34-year-old French woman with no medical history was admitted to the intensive care unit (ICU) for fever, altered mental status, hypotension and hypoxaemia. She presented with a diffuse skin rash with vesiculopustular lesions involving the four limbs and perineal ulcers with a skin swab positive for MPXV. On day 2, the patient presented moderate ARDS requiring invasive mechanical ventilation. She also had pleural empyema due to Streptococcus pyogenes. MPXV PCR was positive in the bronchoalveolar lavage, the pleural effusion and the blood. The patient was treated with tecovirimat. Despite the treatment, she had persistent viraemia for at least ten days. The patient condition rapidly improved; she was weaned from mechanical ventilation on day 18 despite the persistence of radiological lung opacities. She fully recovered and was discharged home on day 38 after admission.

LEARNING POINTS

This is the first case of monkeypox virus associated ARDS in a young woman with no medical historyBiological follow-up showed disseminated MPXV and persistent viraemiaTecovirimat was well tolerated.

Ciguatera Toxin Syndrome from Amberjack Ingestion as a Cause of Chronic Dermatitis with Episodic Erythema

Bioaccumulation of naturally produced ciguatoxin (CTX), such as that in ciguatera poisoning, continues to be a subject of great interest. In this condition, CTX is ingested by subtropical and tropical reef fish. Humans consume the fish species, and CTX is absorbed through the gastrointestinal tract and binds voltage-gated sodium channels on nerve terminals to cause neurological, gastrointestinal, cardiac, and rare dermatological clinical manifestations. In this present case, we discuss a 65-year-old female who presented with acute loose bowel movements and generalized pruritus of her anterior chest wall, abdomen, and bilateral upper and lower extremities 48 hours after consumption of amberjack fish. The patient was treated with intravenous corticosteroids and epinephrine and discharged with an oral corticosteroid taper. After appropriate treatment protocol, the patient continued to have pruritus with a burning sensation in her extremities with a rare skin dermatitis. Subsequent treatment included topical corticosteroids and moisturizing lotion to create a skin barrier, fexofenadine for pruritus control, and gabapentin and amitriptyline for paresthesia. This case demonstrates the need for continued research and patient education into the broad clinical manifestations that present as life-altering ciguatera poisoning.

Anti-tumour necrosis factor-induced skin rashes in inflammatory bowel disease: a systematic review and evidence-based management algorithm

BACKGROUND

Anti-tumour necrosis factor alpha (anti-TNF) agents are a highly effective treatment for inflammatory bowel disease (IBD). Skin lesions, including psoriasiform, eczematous and lupoid eruptions, may paradoxically result from anti-TNF use and cause significant morbidity leading to discontinuation of therapy. There are no consensus guidelines on the management of these lesions.

AIMS

This systematic review considers the existing evidence regarding cutaneous complications of anti-TNF therapy in IBD and the development of an algorithm for management.

METHODS

A systematic review was performed by searching Medline (Pubmed) and Embase for articles published from inception to January 2021. The following search terms were used 'anti-tumour necrosis factor alpha', 'infliximab', 'adalimumab', 'certolizumab', 'golimumab', 'inflammatory bowel disease', 'Crohn disease', 'Ulcerative colitis', 'psoriasis', 'psoriasiform', 'dermatitis', 'lupus', 'skin lesion' and 'skin rash'. Reference lists of relevant studies were reviewed to identify additional suitable studies.

RESULTS

Thirty-four studies were included in the review. Eczema can generally be managed with topical agents and the anti-TNF can be continued, while the development of lupus requires immediate cessation of the anti-TNF and consideration of alternative immunomodulators. Management of psoriasis and psoriasiform lesions may follow a step-wise algorithm where topical treatments will be trialled in less severe cases, with recourse to an alternative anti-TNF or a switch to an alternative class of biological agent.

CONCLUSION

Assessment of anti-TNF skin lesions should be performed in conjunction with a dermatologist and rheumatologist in complex cases. High-quality prospective studies are needed to clarify the validity of these algorithms in the future.

Development of Erythema Nodosum After Olaparib Treatment in a Patient With Recurrent Breast Cancer and BRCA2 Mutation: A Case Report

BRCA1 and 2 mutations are known to be associated with breast cancer, and olaparib, a poly (adenosine diphosphate-ribose) polymerase (PARP) inhibitor, has been shown to be effective in cells carrying these mutations in some studies. Erythema nodosum (EN), which is one adverse event of olaparib and is discussed in this paper, is considered to be a very rare condition. A 69-year-old female patient underwent left breast conservative surgery with axillary lymph node dissection for left invasive ductal breast cancer (stage IIB). Her family history included a sister who developed ovarian cancer at age 63. Five years postoperatively, systemic metastases were discovered in the lung, bone, hilar, and poststernal lymph nodes. The surgically removed metastatic lung nodule was diagnosed as an estrogen receptor (ER)-positive, progesterone receptor (PgR)-negative, and human epidermal growth factor receptor 2 (HER2)-negative metastatic adenocarcinoma of breast cancer origin. And germline mutations of BRCA1/2 were assessed using BRACAnalysis CDx® (Myriad Genetics, Salt Lake City, UT, USA), and BRCA2 1241 delC was identified as a deleterious mutation. Oral administration of olaparib was started. On day 4 of this treatment, numerous erythematous plaques characterized by intense tenderness and infiltration appeared on the extensor surfaces of the bilateral lower legs. On the basis of the clinical findings, the lesions were diagnosed as EN. Oral prednisolone was started at the same time as olaparib discontinuation, and the EN lesions disappeared in one week. EN is an inflammatory lesion characterized by tender subcutaneous induration with a flushed surface, predominantly on the bilateral lower legs. EN occurring after olaparib administration is considered to be very rare. This article describes such a case and reviews the relevant literature.

Disseminated Gonococcal Infection With Dermatitis-Arthritis Syndrome

Gonorrhea is a sexually transmitted infection caused by gram-negative diplococci, Neisseria gonorrhoeae. Disseminated gonorrhea is diagnosed infrequently, partly due to low suspicion at the time of presentation, and at times, due to overlapping symptoms associated with non-infectious conditions like systemic lupus erythematosus (SLE). In this article, we present a 42-year-old sexually active female with knee pain and swelling, fever, and rash. Knee aspirate showed the presence of monosodium urate crystals, and the synovial culture grew gram-negative diplococci, requiring multiple joint washouts. The urine nucleic acid amplification test (NAAT) was indeterminate. She was treated with high-dose intravenous ceftriaxone for one week post-joint washout with rapid improvement in her condition and resolution of the rash.

Acute Exfoliative Dermatitis/Erythroderma Secondary to Gliclazide

Erythroderma is a general term used to describe severe, intense skin inflammation. The condition is also known as exfoliative dermatitis when it is associated with exfoliation. Erythroderma has many causes, such as adverse drug eruption, dermatitis, psoriasis, pityriasis rubra pilaris, immunobullous disease, cutaneous T-cell lymphoma (Sézary syndrome), underlying systemic malignancy, graft versus host disease, and HIV infection. Many medications can cause erythroderma, including antibiotics, antiepileptics, angiotensin-converting enzyme (ACE) inhibitors, and sulfonamides. Here, we report a rare case of erythroderma secondary to gliclazide, an oral antidiabetic. This presentation is rare, as we found only one case report of gliclazide causing erythroderma in the literature. Erythroderma is considered a medical emergency requiring immediate diagnosis and prompt management; therefore, early intervention should start on suspicion without waiting for dermatologist confirmation, as this will significantly reduce the mortality and morbidity of this potentially life-threatening emergency.

Clinical Profile, Risk Factors and Complications of Paediatric Herpes Zoster Ophthalmicus-A Case Series

To study the clinical profile, risk factors and complications of paediatric Herpes zoster ophthalmicus (HZO). Case records of clinically diagnosed paediatric HZO over the past five years period were collected. An analysis was done with the existing data to determine the patient's clinical presentation, risk factors and treatment outcomes. Among seven children (three males and four females), two were less than ten years. Risk factors like previous history of chickenpox were present in one patient and immunosuppression in another. Child with immunosuppression also had h/o viral encephalitis three days before the onset of HZO. While two patients presented with disciform keratitis and three with anterior uveitis, the remaining did not have anterior segment involvement. Six out of seven patients retained 6/6 visual acuity at one month follow-up. Paediatric HZO is prevalent even in immunocompetent children without any identifiable risk factor. It generally has a good prognosis with minimum residual complications.

Case report: Post-streptococcal pustulosis after subcutaneous injection of secukinumab

An acute diffuse pustular eruption occurred in a patient after secukinumab injection and then the clinical presentation has been related to streptococcus infection after it has been isolated from throat swabs. Pustulosisacuta generalisata was definitively diagnosed. Antibiotic treatment had a poor effect, but the response to glucocorticoids was better.

Stevens-Johnson Syndrome in Adult Patient Secondary to COVID-19 Infection: Case Report

COVID-19 is a global pandemic caused by a novel zoonotic RNA virus named SARS-CoV-2. Various cutaneous manifestations associated with COVID-19 have been described, including urticarial rash, confluent erythematous rash, papulovesicular exanthem, chilblain-like acral pattern, livedo reticularis, and purpuric vasculitis pattern. Here, we are presenting a case of a 45-year-old male with mucocutaneous features of Stevens-Johnson syndrome.

Case report: marfan syndrome (MFS) mimicking cutaneous vasculitis

Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder caused by variants in the extracellular microfibril fibrillin (FBN1) gene. Here we report an FBN1 variant in a child with an unusual skin rash mimicking cutaneous vasculitis, and mild aortic root dilatation. The case was complicated by lack of typical skeletal MFS phenotype; and severe needle phobia preventing any blood testing for workup of suspected vasculitis. Therefore inflammatory markers, autoantibody profile and general hematology/biochemistry results were unknown. Diagnosis of MFS was made via genetic testing of a saliva sample alone using a next-generation sequencing (NGS) targeted gene panel designed to screen for monogenic forms of vasculitis and noninflammatory vasculopathic mimics. This revealed the patient was heterozygous for a pathogenic frameshift variant in FBN1; NM_000138, c.1211delC, p.(Pro404Hisfs*44), predicted to cause premature protein truncation leading to loss of function. The variant has not been detected in control populations and has previously been detected in individuals with MFS. This rapid diagnosis significantly impacted the patient management: avoidance of invasive investigations; avoidance of unnecessary immunosuppression; facilitating genetic counselling of the index case and family; and directly informing lifelong monitoring and ongoing treatment for aortic root involvement from MFS. This case further emphasizes the diagnostic utility of NGS early in the diagnostic workup of paediatric patients referred with suspected vasculitis, and we emphasize that MFS can present with cutaneous vasculitic-like features in the absence of the typical Marfanoid skeletal phenotype.

Skin rash associated with combined cytotoxic chemotherapy and immunotherapy for cancer: A retrospective single-center case series

In recent years, the development of combination therapies with immune checkpoint inhibitors (ICIs) and cytotoxic anticancer drugs has radically changed the management of diverse malignancies and significantly improved patient outcomes. Several clinical trials have shown that skin rash caused by combination therapy with ICIs and cytotoxic drugs may be more frequent and severe than that developing after administration of ICIs alone or cytotoxic drug monotherapy. However, most reports provide little information on severity, treatment, post-diagnosis course, and recurrence of rashes on drug rechallenges. We aimed to describe the experience of skin rashes developing within 2 weeks from the first administration of combination therapy with ICIs and cytotoxic drugs in 11 patients visiting our dermatology department. This study included seven men and four women, and the patients' median age was 52 years. The primary disease was non-small-cell lung cancer in eight patients, cervical cancer in two patients, and esophageal cancer in one patient. Nine patients had a maculopapular rash and two patients developed erythema multiforme-like eruptions. The skin rash was often accompanied by extracutaneous symptoms, such as fever (n = 9), mucositis (n = 4), and liver dysfunction (n = 2). In all cases, the symptoms improved with topical steroid therapy alone, with no patients exhibiting severe symptoms requiring systemic steroids or immunosuppressive agents. In addition, when the causative drugs were re-administered after recovery from the rash, only two patients relapsed with accompanying systemic symptoms, and all patients except one were able to continue treatment using the same drug regimen. Although it was suggested that the rash caused by the combination therapy of ICIs and cytotoxic drugs may be more prominent than that caused by each agent alone, comprehensive judgment, including histopathological examination, may indicate the feasibility of continuing the treatment regimen for cancer.

Infectious Proctitis due to Human Mpox

We describe 2 cases of infectious proctitis secondary to human monkeypox in patients presenting with rectal pain. These cases highlight the importance of multidisciplinary management of monkeypox and in expanding case definitions and enabling clinical recognition in patients presenting without skin rash.

Adult-onset still's disease and budd-chiari syndrome: A case report

Adult onset still's disease (AOSD) is a rare autoinflammatory disease displaying with a wide range of non-specific symptoms and budd-chiari syndrome (BCS) is an uncommon disorder characterized by obstruction of hepatic venous outflow. We present the case of a young patient who presented with persistent fever, sore throat, elbow, hand fingers and knees arthralgia with abdominal pain. The patient's symptoms had started 7 days before the referral. Imaging and laboratory data led to the diagnosis of BCS in the context of AOSD. The patient treated with corticosteroid in combination of warfarin with favorable outcome and complete improvement of signs and symptoms. We came to this conclusion AOSD complicated with BCS is a rare but potentially life-threatening entity. Clinicians should be aware of this complication.

Comparison of Plasma Metabolites From Patients With Non-Small Cell Lung Cancer by Erlotinib Treatment and Skin Rash

Erlotinib is a necessary anticancer treatment for non-small cell lung cancer (NSCLC) patients yet it causes severe side effects such as skin rash. In this study, researchers compared the untargeted compound profiles before and after erlotinib administration to observe changes in blood metabolites in NSCLC patients. The levels of 1005 substances changed after taking erlotinib. The levels of 306 and 699 metabolites were found to have increased and decreased, respectively. We found 5539 substances with peak area differences based on the presence of skin rash. Carbohydrate, amino acid, and vitamin metabolic pathways were altered in response to the onset of erlotinib-induced skin rash. Finally, this study proposed using plasma metabolites to identify biomarker(s) induced by erlotinib, as well as target molecule(s), for the treatment of dermatological toxic effects.

Atypical exanthem with acral involvement in adult patients associated with human herpesvirus 7 active replication: A case series

An "atypical exanthem" (AE) is an eruptive skin eruption that differs in morphology and etiology from classical exanthems and is often a reason for urgent medical evaluation. The most frequent cause of AEs is a viral infection, but an accurate etiology cannot be established basing on the sole clinical features. Human herpesviruses (HHV) have been often suspected as etiologic agents or cofactors in atypical rashes. We performed a retrospective analysis of adult patients presenting an atypical exanthem associated with HHV-7 active replication in our center. The charts of patients were reviewed and the demographic, clinical and laboratory data collected. Nine patients (six males and three females) were included in the study, with a mean age of 43 years for men and of 26 years for women. All patients presented active HHV-7 replication in plasma during the rash, which turned negative after the exanthem resolved. The exanthem displayed a maculopapular pattern involving the trunk, limbs and, notably, the acral regions, in six patients. In three cases the exanthem was confined to only the acral sites. In most cases, there was no fever and the inflammatory indices remained unchanged. Antihistamines, topical and systemic corticosteroids were used as treatment, with excellent symptom control. We propose adding skin manifestation associated with HHV-7 to the concept of atypical exanthems, in particular those localized to the acral regions.

Persistent alteration of the skin microbiome in patients with skin rash after receiving EGFR inhibitor treatment

The pathological mechanism responsible for EGFR inhibitor (EGFRI)-induced skin rash remains unclear. Recent studies reveal associations between skin dysbiosis and skin inflammatory diseases. This study aimed to examine whether skin dysbiosis is associated with EGFRI-induced skin rash. Bacterial swabs were taken from the forehead of 17 cancer patients at baseline and at several time points after EGFRIs initiation, as well as from 20 healthy controls. The skin microbiome was analysed using 16S rRNA sequencing. The severity of the skin rash was assessed using the rash grade. Skin surface parameters (pH, water capacitance, and sebum level) were also measured. Compared with baseline, the abundance of Cutibacterium acnes decreased in 13 of 15 cases, and that of Staphylococcus aureus, Corynebacterium spp., Staphylococcus epidermidis or Proteobacteria increased in 13 of 15 cases after EGFRIs initiation. Skin pH increased significantly in parallel with a decrease in water capacitance after EGFRI initiation. Also, the composition of the skin microbiome of patients with severe rash was significantly different from that of healthy controls. In addition, the skin dysbiosis did not return to baseline during EGFRIs treatment for >1 year. These longitudinal observations indicate that skin dysbiosis is associated with development of skin rash.

Skin rash caused by EGFR-TKI could be treated successfully by Pien Tze Huang Unguentum Compositum: a case report

Epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) plays an important role in cancer therapy. However, EGFR is highly expressed in the skin and gives rise to one of the most concerning issues for the EGFR-TKI treatment, namely skin toxicity. Antibiotics and corticosteroids are usually used to treat the EGFR inhibitor-associated skin rash, with prominent side effects over long-time use. Pien Tze Huang (PZH) Unguentum Compositum is a traditional product for external application which is made of traditional Chinese medicine and oil base. Herein, we reported the case of a 50-year-old man who presented with skin rash on the face, head, and back induced by an EGFR-TKI named erlotinib. By using PZH Unguentum Compositum, we observed that the skin rash was mitigated and eventually disappeared. This case report suggests that PZH Unguentum Compositum may be an effective therapy in treating skin rash caused by EGFR-TKI with fewer side effects.

Monkeypox Disease: An Emerging Public Health Concern in the Shadow of COVID-19 Pandemic: An Update

The last few decades have witnessed an appalling rise in several emerging and re-emerging viral and zoonotic outbreaks. Such outbreaks are a lesson to learn from and seek insight into better disease monitoring and surveillance, thus preventing future outbreaks. Monkeypox, a viral zoonotic illness caused by the monkeypox virus, may no longer be endemic to the tropical rainforests of Central and West Africa. However, the current monkeypox outbreak in nonendemic countries is most likely due to failure to curb the disease dissemination in endemic African regions despite decades of constant outbreaks. The clinical manifestations are typified by a prodromal phase (fever, myalgia, malaise, and lymphadenopathy) followed by maculopapular or vesicular, or pustular cutaneous eruptions that eventually form encrustations and peel off. Children and the elderly, pregnant females, and individuals living with comorbidities (diabetes, HIV/AIDS, and lymphoproliferative ailments) are at a high risk of severe disease. Monkeypox is a self-limiting disorder, but its complications and pandemic potential signify its immense public health relevance. The recent ongoing monkeypox outbreak in nonendemic nations areas was identified with increased propensity in men who have sex with men (MSMs) with no travel history to endemic regions, emphasizing the changing trends in disease transmission. This review article provides an updated overview of the monkeypox disease taxonomy, pathogenesis, transmission, epidemiology, clinical and oral features, diagnostic aids, differential diagnosis, preventive aspects, and treatment protocol.

Case Report: Cannabidiol-Induced Skin Rash: A Case Series and Key Recommendations

Cannabidiol (CBD) is a non-psychotomimetic constituent of the Cannabis plant, with potential therapeutic properties for many physical and neuropsychiatric conditions. Isolated CBD has been suggested to have favorable safety and tolerability. Although CBD-related rash is described, few case reports are well documented in the literature, and usually, CBD was used concomitantly with other medications. Thus, we report four women who presented a skin rash after ongoing CBD use. Other causes of these skin rashes were ruled out after conducting an extensive viral and serological detection panel, and three patients had their lesions biopsied. Two patients were re-exposed to the vehicle (MCT) without developing a new skin rash. Therefore, clinicians must be aware of this potential adverse effect of CBD use.

Skin Manifestation Induced by Immune Checkpoint Inhibitors

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.

Comparison of perianal skin barrier function with moisturizer application in Japanese full-term newborns

BACKGROUND/OBJECTIVES

Some full-term newborns present with erythema and irritation of the buttocks and perianal area as early as the first 4 days of their lives. The effect of moisturizers in protecting this vulnerable skin has not been rigorously studied. This study aimed to clarify whether there is a difference in perianal skin barrier function with and without moisturizer application in the first month of life.

METHODS

Comparative investigation of 118 full-term newborns was performed, and they were allocated to intervention (n = 63) and control groups (n = 55). The intervention group received moisturizer application to the perianal area, and the control group received care without application of moisturizer to the perianal area from the first day of life until the 1-month visit. Transepidermal water loss (TEWL), stratum corneum hydration (SCH), and skin surface pH in the perianal area were measured as the indicators of skin barrier function on days 1 and 5 after birth and at the 1-month visit.

RESULTS

At the 1-month visit, TEWL was significantly decreased (intervention, 19.4 g/m² /h; control, 25.8 g/m² /h; p = .00) and SCH was significantly increased (intervention, 58.8 arbitrary units (a.u.); control, 46.5 a.u.; p = .00) in newborns using perianal moisturizer. The skin surface pH was not significantly different.

CONCLUSIONS

The use of moisturizer was effective in protecting the skin barrier function of the perianal skin. Further investigations are needed to determine the effect on the frequency and extent of rashes in the perianal area.

Allergic Skin Rash Caused by Iguratimod: A Report of Two Cases

Iguratimod has been used in the treatment of rheumatoid arthritis and Sjogren's syndrome (SS). Herein, we report two cases of skin allergic reactions caused by iguratimod in our hospital. Case 1 was a woman with SS who developed diffuse pruritus erythema after three weeks of combination therapy of hydroxychloroquine (HCQ) and iguratimod. When the patient was again prescribed iguratimod after the rash subsided, the pruritus erythema reappeared. Case 2 was a 23-year-old girl treated with prednisone, HCQ, and mycophenolate mofetil for systemic lupus erythematosus and SS. In the follow-up treatment, mycophenolate mofetil was replaced by iguratimod. On the 20th day of treatment, a pruritic erythematous maculopapular rash appeared. To the best of our knowledge, this is the first study to report the characteristics of an allergic rash caused by iguratimod. It is better to administer HCQ and iguratimod successively rather than simultaneously to a patient.

[Systemic Inflammatory Response in a Young Woman]

Systemic Inflammatory Response in a Young Woman Abstract. A 21-year-old patient with fever attacks, arthralgias, salmon-colored skin rash, neutrophilic leukocytosis, elevated CRP, ferritin, ASAT and ALAT was diagnosed with the rare systemic autoinflammatory disease, called adult Still disease, after having excluded other possible causes. An initial treatment with non steroidal anti-inflammatory drugs (NSAID) and prednisolone was not sufficiently effective, consecutively the therapy was escalated with the IL-6 antagonist tocilizumab. This immunosuppressive therapy resulted in fairly well controlled symptoms.

Selective Immune Modulating Activities of Viscum album and Its Components; A Possibility of Therapeutics on Skin Rash Induced by EGFR Inhibitors

Viscum album var. coloratum (Kom.) Ohwi is a traditional herbal medicine used in East Asia to treat hypertension, skeletal muscle disorders, and cancer. The inhibitory effects of Viscum album (VA) extract on chemokines and its therapeutic potential in erlotinib-induced skin rash were investigated in this study. ELISA was used to measure the levels of chemokines, MCP-1 and RANTES, which are thought to be mediators of erlotinib-induced skin rash in RAW264.7 cells. Western blot analysis was used to look into the activation of signaling pathways like AKT, MAPK, and EGF. In order to investigate the active compounds in VA extract, solvent fractionation and preparative HPLC were performed sequentially. VA extract significantly reduced the production of TNF-α, MCP-1, and RANTES but not IL-1. Furthermore, macrophage transmigration was inhibited without causing cell toxicity. VA extract had no effect on the phosphorylation of EGF receptors stimulated by EGF or suppressed by erlotinib in both A549, a non-small cell lung cancer cells, and Hacat, a human skin keratinocyte. The isolated viscumneoside III and viscumneoside V from VA extract significantly suppressed the expression of MCP-1, according to activity guided fractionation with organic solvent fractionation and preparative HPLC. These findings suggest that VA extract and its active compounds, viscumneoside III and viscumneoside V, regulate MCP-1 production and may have the potential to suppress erlotinib-induced skin toxicity by modulating macrophage activity without neutralizing anti-cancer efficacy.

A case of primary varicella meningoencephalitis in the absence of cutaneous lesions in a 4-month-old infant

Primary varicella infection has typical cutaneous lesions which aid in clinical diagnosis. Infants with transplacental transfer of varicella antibody can have varied cutaneous lesions. We report a 4-month-old infant with primary varicella meningoencephalitis without cutaneous lesions whose mother had no history of varicella during antenatal or post-natal period. Diagnosis was made possible by CSF DNA PCR. Infants with encephalitis pose diagnostic challenge to clinicians in resource limited settings. Varicella encephalitis is one such aetiology for which definitive therapy with Acyclovir is available. CSF PCR is the definitive and cost-effective test for the diagnosis varicella encephalitis. In children with meningoencephalitis it is prudent to add Acyclovir empirically pending CSF viral PCR results.

The Third Wave of the COVID-19 Arrived in Afghanistan: A Severe Case with Skin Manifestation

The COVID-19 is an ongoing global pandemic that has put the world in a devastating situation. The virus is able to attack multiple body systems and cause a variety of clinical problems ranging from asymptomatic to critical cases. Although young individuals are more likely to suffer milder forms of the disease, critical cases also might happen. Recent literature has revealed that, along with other clinical symptoms, skin manifestations have also progressively grown. In Afghanistan where COVID-19 has entered into a third wave, many people do not take the initial mild symptoms seriously to prevent further spreading in the community. We report symptoms of skin rash, fatigue, muscle pain, dry cough and fever at the onset of the disease, followed by rapid lung damage in a 23-year-old young adult, who did not have any preexisting risk factors. This case highlights the importance of urgent skin assessment of the COVID-19 patient complaining of any skin symptoms.

Preceding bortezomib administration for a certain period reduces the risk of lenalidomide-induced skin rash

WHAT IS KNOWN AND OBJECTIVE

It was previously reported that the incidence of lenalidomide (LEN)-induced skin rash is reduced by administration of bortezomib (BOR) prior to LEN administration in patients with multiple myeloma (MM). Therefore, we investigated whether LEN-induced skin rash is affected by the duration of BOR administration and the dosing interval between BOR and LEN administration.

METHOD

A retrospective investigation was conducted among MM patients who received BOR treatment prior to LEN treatment in Eiju General Hospital from May 2010 to December 2020. We investigated whether the BOR administration duration and interval duration from the completion of BOR administration to the initial LEN administration affect the development of LEN-induced skin rash.

RESULT AND DISCUSSION

Twenty-eight of the 81 patients exhibited LEN-induced skin rash (34.6%). The administered duration, but not the interval, was significantly longer in the group without skin rash. Cut-off values were set for the duration of administration and interval, which were 35 days and 30 days, respectively. Multivariate analysis was performed on patients which are administered duration of more than 35 days and intervals of less than 30 days, and those who are not applicable. A significant difference was observed in the incidence of skin rash for each factor.

WHAT IS NEW AND CONCLUSION

The risk of reduced LEN-induced skin rash is affected not only by the presence of prior BOR administration, but also by the duration of BOR and the interval from the completion of BOR to the initial LEN administration.

Dermato-Pathologic Clues To Diagnosis Of Adult Onset Still Disease: A Case Report

Adult-onset Still's disease (AOSD) is a rare systemic inflammatory condition classically consists of high spikes of fever, morbilliform evanescent skin rash, arthritis, neutrophilic leukocytosis, and multiple organ involvement. However, atypical form of skin rashes has been described with few specific clinical and histopathological patterns that can help in making the diagnosis. A 25-year-old female presented with high spikes of fever, severe debilitating arthritis of peripheral joints, and dusky erythematous flagellate rashes over trunk and proximal limbs. Skin punch biopsy from the cutaneous lesion revealed dyskeratotic keratinocytes in upper epidermis and stratum corneum along with acute inflammatory infiltrate in the dermis: a finding that recently has been found to be constantly associated with this specific pattern of rash of AOSD. The presence of necrotic keratinocytes in upper epidermis and a dermal infiltrate of neutrophils along with characteristic clinical scenario may facilitate earlier diagnosis of AOSD.

Apalutamide-associated skin rash in patients with prostate cancer: Histological evaluation by skin biopsy

INTRODUCTION

Apalutamide-associated skin rash is a more common adverse event in the Japanese population than in the global population. However, its mechanism remains elusive, and limited histopathological information hampers further understanding.

CASE PRESENTATION

Case 1: a 71-year-old man with metastatic castration-sensitive prostate cancer developed a skin rash after 70 days of apalutamide treatment. Case 2: a 71-year-old man with non-metastatic castration-resistant prostate cancer developed a skin rash after 71 days of apalutamide treatment. In both cases, the skin rash presented as a slightly exudative erythema. The histology showed spongiosis of the epidermis and perivascular and interstitial infiltration of lymphocytes and eosinophils in the upper dermis without necrotic keratinocytes.

CONCLUSION

Apalutamide-induced skin rashes can involve an eczematous reaction clinically and histologically.

Blister beetle dermatitis with mirror lesions in a cluster of travellers from Kenya

After returning from Kenya, a 20-year-old Caucasian girl presented with multiple itching and burning erythematous skin lesions in her limbs, which progressively evolved to pustulous linear lesions, some of them with mirror distribution. Toxic ‘dermatitis linearis’ due to Paederus spp. was confirmed by the identification of rove beetles.

A Disfiguring Rash

Patients with rheumatologic conditions can have complex dermatologic manifestations. In addition, immunosuppressing treatment for autoimmune disorders can also increase incidence of infectious complications. Skin conditions in rheumatologic patients present particular challenges and this case highlights a rare infectious complication.

Simple desensitization protocol for multiple myeloma patients with lenalidomide-induced skin rash: Case series

WHAT IS KNOWN AND OBJECTIVE

Skin rash is one of the typical side effects of lenalidomide (LEN) treatment. Desensitization therapies have been reported to be effective in patients with severe skin rash caused by LEN. However, they have proved impractical due to the complexity of the protocols.

CASE SUMMARIES

We present 5 patients who developed severe LEN-induced skin rash. The five patients received our simple, slow desensitization protocol, and all were re-administered LEN with no adverse reaction.

WHAT IS NEW AND CONCLUSION

Our simpler and slow desensitization protocol, which desensitizes the patients without reducing the effect of LEN, includes drug holidays, similar to the usual LEN dosing schedule, and moreover is recommended as a treatment option especially for elderly patients with no housemate to help with medical management.

A new rapid titration protocol for lamotrigine that reduces the risk of skin rash

Objective

Lamotrigine is one of the most widely used antiepileptic drugs, but it has a critical issue of a skin rash if the starting dose is too high or the escalation rate is too rapid. We investigated the efficacy and safety of a novel and rapid titration protocol for lamotrigine that takes only 11 days to reach a daily dose of 200 mg.

Methods

We prospectively enrolled 33 adult patients (age 18‐85) who were diagnosed with epilepsy and started lamotrigine administration for the first time at a single tertiary hospital. Our new protocol starts with a subthreshold dose of the drug and then administers a stepwise‐incremental dose until reaching the full therapeutic dose within 11 days.

Results

Of 29 patients analyzed, only two (6.9%) experienced idiosyncratic skin rash before the first follow‐up visit at 2 weeks (±3 days). In addition, a therapeutic concentration was reached in more than 75% of studied patients after 2 weeks of lamotrigine administration.

Significance

These findings demonstrate the value of the novel tolerance induction protocol for lamotrigine, which could widen the available application of lamotrigine in various situations. However, this study is a preliminary study limited by a small number of patients and its nonrandomized and open‐label design, so the current protocol needs more rigorous clinical evaluations before the application to the real clinical setting.

[Establishment of animal models of epidermal growth factor receptor inhibitor-related rashes]

OBJECTIVE

To establish animal models epidermal growth factor receptor inhibitor-related skin rashes using cetuximab, gefitinib or erlotinib.

OBJECTIVE

Female SCID mice were randomly divided into blank control group and high-, moderate-, and low-dose cetuximab groups. The mice in control group received intraperitoneal injection of saline, and those in the 3 cetuximab groups were injected with 80, 40, and 20 mg/kg cetuximab (3 times a week for 4 weeks), respectively. The general skin appearance and skin pathologies of the mice were observed. Female BN rats were randomly divided into blank group, ovalbumin group, gefitinib group and erlotinib group, and in the latter 3 groups, the rats were given ovalbumin (1 mg), gefitinib (37.5 mg/kg), and erlotinib (23.5 mg/kg) by lavage once daily for 45 days, respectively. Skin pathologies of the rats were observed, and serum levels of TNF-α, IL-6 and other inflammatory factors were detected using ELISA.

OBJECTIVE

Intraperitoneal injection of cetuximab did not induce typical skin rashes, scabs or obvious skin inflammation in the mice. In female BN rats, lavage of gefitinib caused obvious skin rashes, scabs and exudation, and obvious inflammatory cell infiltration, keratinosis, spinous layer release and epidermal thickening were observed in the skin. No obvious skin inflammation were observed in the rats in the control, ovalbumin or erlotinib groups. While IgE (P=0.061) and TNF-α concentrations (P=0.057) did not differ significantly among the groups, serum levels of IL-6 was significantly higher in gefitinib group than in the blank control group (P=0.016) but similar between erlotinib group and the blank group (P=0.910).

OBJECTIVE

Intraperitoneal injection of cetuximab can not induce epidermal growth factor receptor inhibitor-related skin rashes in SCID mice. Lavage of gefitinib, but not erlotinib, can be used to establish models of epidermal growth factor receptor inhibitor-related rashes in BN rats.

Early Diagnosis of Stevens-Johnson Syndrome in the Dental Clinic Setting

Stevens-Johnson syndrome (SJS) is a life-threatening acute and fatal dermatological disease. It can present with many variations and rapidly worsens in a short period of time. Early diagnosis and management play an important role in stopping SJS from progression. Various drugs such as antibiotics, anticonvulsants and non-steroidal anti-inflammatory drugs can trigger the disease as an adverse effect. Oral and dental manifestation of SJS is uncommon. However, dentists should be clinically oriented towards signs and symptoms of the disease, both oral and systemic. We present a case of a 37-year-old male with no past medical history who presented to the dental emergency clinic complaining of dysphagia and burning sensation in the mouth. On oral examination, oral rash and blisters were observed. In addition, a bilateral forearm erythematous, non-blanching painful rash with some blisters was found after antibiotic administration three days earlier. The antibiotic was stopped and the patient was started on topical betamethasone for 14 days, topical chlorhexidine for 10 days, and oral nystatin suspension 100,000 units. A complete resolution of the oral and systemic manifestation was seen without the need for hospital admission.

"Skin rashes" and immunotherapy in melanoma: distinct dermatologic adverse events and implications for therapeutic management

Immune checkpoint inhibitors have shown efficacy in the treatment of different cancers by stimulating the antitumoral activity of the patient’s immune system, representing a major breakthrough in the field of cancer therapy. Monoclonal antibodies including anti-cytotoxic T-lymphocyte–associated protein 4, anti–programmed cell death protein 1 and its ligand inhibitors have been approved for advanced melanoma among other solid cancers. Although immunotherapy demonstrated a good safety profile, a new spectrum of multisystemic immune-related adverse events has been recently reported due to their use. Cutaneous reactions represent one of the leading adverse events, often reported in literature as “skin rash”, and rarely further characterized in distinct dermatologic entities. Herein we describe the distinctive cutaneous rashes occurring during immunotherapies for advanced melanoma, discussing implications in the treatment management.

Toxic epidermal necrolysis syndrome induced by tigecycline: a case report

A 56-year-old man diagnosed with non-Hodgkin’s lymphoma underwent autologous bone marrow transplantation. He was subsequently admitted to the hospital with fever, and his symptoms were initially controlled by multiple antibiotics, including tigecycline. He then developed a generalized body rash that improved after treatment with anti-allergy drugs and steroids. Furthermore, tigecycline treatment for a second time resulted in a severe skin reaction with systemic symptoms, suggesting toxic epidermal necrolysis syndrome (TEN). The patient was shown to have the slow-metabolizing cytochrome P450 2C19 allele, denoted CYP2C19*2. He was transferred to a laminar flow ward and given strict mucosal care, together with corticosteroids and intravenous immunoglobulin. He recovered after 3 weeks of treatment. Tigecycline-induced Stevens–Johnson syndrome (SJS)/TEN has rarely been reported in the Chinese population. However, our experience suggests that Asians are more likely to have adverse reactions to drugs metabolized by the cytochrome P450 enzyme. Early identification of drug reactions and immediate cessation of the suspected drug is essential. Additionally, a combined therapy scheme and a clean laminar flow environment may improve the cure rate of SJS/TEN.

COVID-19 in a case with Kikuchi-Fujimoto disease

The accurate diagnosis of Kikuchi-Fujimoto disease can protect children from unnecessary diagnostic procedures and treatments. Also, the co-occurrence of rare diseases with other diseases can improve or worsen the symptoms of the patients.