Acute Mucocutaneous Methotrexate Toxicity Associated With Interface Dermatitis and Numerous Eosinophils

Ferguson, Nkanyezi N.; Asarch, Adam; VanBeek, Marta; Swick, Brian L.

doi:10.1097/dad.0b013e31827b7674

Cited by 9 publications

(6 citation statements)

References 13 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Our case is distinguished by the occurrence of perivascular and interstitial lymphocytic infiltrate with numerous eosinophils. This finding was also reported by Ferguson et al 4 and Fridlington et al 12. Pathologists must be aware of these histopathological changes since they can mislead the diagnosis towards an inflammatory condition rather than a toxic skin reaction, deferring treatment.…”

Section: Discussionsupporting

confidence: 89%

“…Other contributing factors include renal insufficiency, folic acid deficiency, infection and other concomitant use of medications, such as cyclosporine, penicillin, trimethoprim-sulfamethoxazole and phenytoin 4. In our patient, two possible mechanisms can be proposed for the development of erosions and ulcerations: first, the methotrexate overdosage, evidenced by the accidental daily intake and second, renal dysfunction which results in elevated methotrexate levels due to reduced renal clearance.…”

Section: Discussionmentioning

confidence: 83%

“…A rare skin finding of methotrexate toxicity is painful erosions, where histological examination contributes to the diagnosis. The pathological changes related to acute mucocutaneous methotrexate toxicity (AMMT) range from pauci-inflammatory erosions with dyskeratotic keratinocytes to interface dermatitis and rarely eosinophils 4. Tissue eosinophilia is not a classic finding in AMMT.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Acute mucocutaneous methotrexate toxicity with marked tissue eosinophilia

et al. 2018

View full text Add to dashboard Cite

Methotrexate toxicity in mucocutaneous areas is usually not associated with tissue eosinophilia. We describe a case of acute methotrexate-induced mucocutaneous erosions with interface dermatitis and eosinophils. A 76-year-old African-American woman with a history of bullous pemphigoid on methotrexate therapy presented with lower extremity cellulitis, developing oral and cutaneous erosions during hospitalization after daily dosage of methotrexate. Shallow circular cutaneous erosions were found on chest, abdomen and limbs. Laboratory results showed pancytopaenia and elevated liver function tests. Skin biopsy revealed irregular acanthotic epidermis with interface dermatitis, individual dyskeratotic cells and superficial perivascular lymphocytic infiltrate with numerous eosinophils. Methotrexate was stopped and leucovorin was administered, leading to improvement. The histopathological changes in acute mucocutaneous toxicity range from pauci-inflammatory erosions with dyskeratotic keratinocytes to interface dermatitis and infrequently seen eosinophils. This case exemplifies that interface dermatitis with a marked eosinophilic infiltrate can be found in the setting of acute mucocutaneous methotrexate toxicity.

show abstract

Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 83%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Acute mucocutaneous methotrexate toxicity with marked tissue eosinophilia

et al. 2018

View full text Add to dashboard Cite

show abstract

“…For instance, methotrexate has been linked to interface dermatitis with a dense eosinophilic infiltrate in addition to the more commonly reported manifestation of mucocutaneous erosions [78]. While the typical rash associated with sirolimus and temsirolimus is characterized by a non-specific neutrophilic infiltrate, a variant eczematoid eruption with eosinophilic spongiosis has also been reported [79,80].…”

Section: Other Skin and Soft Tissue Reactions Maculopapular Exanthemamentioning

confidence: 97%

Eosinophilic Drug Allergy

Kuruvilla

Khan

2015

Clinic Rev Allerg Immunol

View full text Add to dashboard Cite

While peripheral or tissue eosinophilia may certainly characterize drug eruptions, this feature is hardly pathognomonic for a medication-induced etiology. While delayed drug hypersensitivity reactions with prominent eosinophilic recruitment have been typically classified as type IVb reactions, their pathophysiology is now known to be more complex. Eosinophilic drug reactions have a diversity of presentations and may be benign and self-limited to severe and life-threatening. The extent of clinical involvement is also heterogeneous, ranging from isolated peripheral eosinophilia or single organ involvement (most often the skin and lung) to systemic disease affecting multiple organs, classically exemplified by drug-reaction with eosinophilia and systemic symptoms (DRESS). The spectrum of implicated medications in the causation of DRESS is ever expanding, and multiple factors including drug metabolites, specific HLA alleles, herpes viruses, and immune system activation have been implicated in pathogenesis. Due to this complex interplay of various factors, diagnostic workup in terms of skin and laboratory testing has not been validated. Similarly, the lack of controlled trials limits treatment options. This review also describes other localized as well as systemic manifestations of eosinophilic disease induced by various medication classes, including their individual pathophysiology, diagnosis, and management. Given the multitude of clinical patterns associated with eosinophilic drug allergy, the diagnosis can be challenging. Considerable deficits in our knowledge of these presentations remain, but the potential for severe reactions should be borne in mind in order to facilitate diagnosis and institute appropriate management.

show abstract

“…The idea for developing this case was based upon a case report involving medication toxicity as described in the dermatology literature. 5…”

Section: Introductionmentioning

confidence: 99%

Drug Toxicity in Kidney Disease: A Standardized Patient Case for Clerkship Students

Karpa

Difelice

2016

MedEdPORTAL

View full text Add to dashboard Cite

Introduction A disconnect appears to exist for medical students between learning drug facts in a basic science context and applying those facts in a clinical context when they begin working with authentic patients. In patients with kidney dysfunction, dosages of medications that are renally eliminated often need to be adjusted, due to potentially toxic accumulation in the body. To gain insight into the thought processes and gaps underlying student thinking, we developed this standardized patient (SP) case featuring a patient with drug-related renal dysfunction. Methods This activity was conducted in a simulation center, in a setting reminiscent of an emergency department. It took place over 2 days, with all 23 third-year medical students at our regional campus. After reporting to the simulation center at their assigned time, students completed four different medication scenarios. This specific case involved two parts. The first part, an SP-student encounter, was allotted 15 minutes, followed by 1 minute to walk to a computer station. For the second part, writing a SOAP (subjective, objective, assessment, and plan) note, 15 minutes were allotted. This was followed by 3 minutes for the SP to provide student feedback and 1 minute to rotate to the next station. In total, 35 minutes were allotted for each student to complete the case. Results All third-year medical students at our regional campus completed this activity at the midpoint of their academic year. Students were well prepared to gather necessary background information from the standardized patient. However, few made the connection between the patient's symptoms and the way in which her medications were contributing. Nor did they recommend an appropriate course of action for medications that required adjustment. Discussion From this activity, we gained insight into the student thought process with regard to medication management and have been able to develop new ways of revisiting basic science concepts in clinically relevant contexts to help bridge the gap between the basic and clinical components of pharmacology education.

show abstract

Acute Mucocutaneous Methotrexate Toxicity Associated With Interface Dermatitis and Numerous Eosinophils

Cited by 9 publications

References 13 publications

Acute mucocutaneous methotrexate toxicity with marked tissue eosinophilia

Acute mucocutaneous methotrexate toxicity with marked tissue eosinophilia

Eosinophilic Drug Allergy

Drug Toxicity in Kidney Disease: A Standardized Patient Case for Clerkship Students

Contact Info

Product

Resources

About