Bleomycin-induced flagellate erythema in a patient with Hodgkin’s lymphoma – A case report and review of literature

Abstract

Bleomycin is a glycopeptide used as a chemotherapeutic agent for lymphomas, germ cell tumors, and pleurodesis of malignant pleural effusions. The pulmonary toxicity of bleomycin is well known while the cutaneous side effects are uncommon and varies from generalized hyperpigmentation, sclerodermoid changes, erythema multiformae, and gangrene to flagellate dermatosis. Here we report a characteristic but rare side effect of flagellate erythema, which developed secondary to bleomycin in a 27-year old woman with Hodgkin's lymphoma after two cycles of treatment with adriamycin, bleomycin, vinblastine, dacarbazine regimen. The rash subsided after discontinuation of bleomycin and treatment with steroids.

Antineoplastic therapy‐associated flagellate dermatoses

“…are credited with the initial description of bleomycin‐induced flagellate erythema in oncology patients . This unique reaction to bleomycin may be observed in patients with germ cell tumors or Hodgkin's lymphoma who are treated with 5–465 IU of the drug . The lesions are often pruritic and appear within less than 1 day to 9 weeks after initiating therapy …”

“…In addition to bleomycin, antineoplastic therapy‐induced flagellate dermatoses (presenting as erythema or dermatitis) have also been described in oncology patients who have received other agents (Table ) . Flagellate dermatitis was observed in several individuals who received intravenous peplomycin (a bleomycin analog) as part of combination chemotherapy for various neoplasms .…”

“…Most patients with bleomycin‐induced flagellate erythema stop the drug—especially if they develop severe rash; the man with bendamustine‐induced flagellate dermatitis discontinued treatment with rapid improvement of his symptoms and skin lesions . However, similar to Mendonca et al .…”

Unusual and interesting adverse cutaneous drug reactions

“…Flagellate erythema is a distinctive morphologic presentation of linear, whiplash-like pattern, red streaks on the skin which usually leaves residual postinflammatory hyperpigmentation behind. It has been described with antineoplastic agents including bleomycin[ 36 37 38 39 40 41 42 43 44 ] (most commonly), bendamustine,[ 45 ] docetaxel,[ 46 ] peplomycin,[ 47 ] and trastuzumab. [ 48 ] Other conditions which may lead to flagellate dermatoses include chikungunya fever, parvovirus B19 infection, hypereosinophilic syndrome, inflictions and abuse, phytophotodermatitis, paederus dermatitis, toxin-induced (mushroom, shiitake), and rheumatologic conditions (SLE, dermatomyositis, and adult-onset Still's disease).…”

Bleomycin-Induced Flagellate Dermatitis

“…3 Bleomycin-induced flagellate dermatitis has been seen in 8% to 20% of treated patients and is believed to be independent of route of delivery and dose, [1][2][3] with initial appearance varying from 2 hours after the first bleomycin dose to several weeks later after multiple administrations. 1,4,5 Flagellate dermatitis is often self-limited, but in severe cases the causal agent should be discontinued. 3…”