Gemcitabine is a chemotherapeutic agent used for treatment of a variety of malignancies. It has been associated with multiple cutaneous reactions including rash, alopecia, and pruritus. Less commonly, gemcitabine has been associated with "pseudocellulitis," a noninfectious skin inflammatory reaction, which resembles cellulitis. The majority of cases reported in the literature are radiation recall reactions in which inflammation occurs in areas of previous radiation post drug treatment; however, there are also reports of pseudocellulitis occurring in areas of preexisting lymphedema. The pathophysiology of both of these reactions are still unknown, though it is theorized that areas of lymphedema may both increase concentration of gemcitabine and reduce its rate of metabolism leading to increased drug exposure time. In this study, we report a case of pseudocellulitis in a patient with chronic lower extremity lymphedema and a review of the current literature. By recognizing this side effect of gemcitabine, one can avoid unnecessary hospitalization and exposure to antibiotics.

BACKGROUND: Low molecular weight heparins (LMWHs) have been cautiously used in patients with chronic kidney disease (CKD) due to fear of accumulation. Dalteparin, however, has shown minimal tendency to accumulate in patients with CKD and may be safe to use in this patient population. OBJECTIVE: We compared the incidence of clinically significant bleeding in patients with CKD receiving therapeutic doses of dalteparin to that of patients with CKD receiving therapeutic doses of UFH. DESIGN: This was a retrospective cohort study. SUBJECTS: Inpatients with CKD (GFR<60 ml/min) who were treated with therapeutic dalteparin or UFH were included in the study MAIN MEASURES: Primary outcome was major bleeding within 10 days of anticoagulation, identified by ICD-9 code and confirmed by chart review. Demographic characteristics, laboratory values, comorbidities, prior bleeding history and inpatient medications were extracted for each admission from the electronic medical record. Logistic regression models were created to examine the association between choice of anticoagulant and bleeding rates, after adjustment for demographic and clinical characteristics. KEY RESULTS: Dalteparin-treated patients were significantly less likely to experience a major bleed than patients treated with UFH (1.14 % vs. 3.49 %, p<0.001). The reduced likelihood of bleeding associated with dalteparin treatment remained significant after adjustment for patient characteristics (HR 0.39, 95 % CI: 0.21-0.70, p < 0.0001). A stratified analysis for subgroups with GFR< 30 mL/min and with GFR between 30 and 60 mL/min showed that dalteparin was still associated with lower odds of bleeding compared to treatment with unfractionated heparin, but the difference was nonsignificant for GFR< 30 (HR 0.35,), even after adjustment (OR 0.37, 95 % CI: 0.11-1.22). CONCLUSION: In patients with CKD, treatment with therapeutic dose dalteparin was associated with lower rates of bleeding than treatment with unfractionated heparin. For patients with severe CKD (GFR< 30), dalteparin was shown to be at least as safe as unfractionated heparin.KEY WORDS: dalteparin; renal insufficiency; bleed; heparin.

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