Drugs as a Frequent Cause of Acute Rash in Patients after CD34+-Selected Peripheral Blood Stem Cell Transplantation

Abstract

Although histopathological differences have been reported between acute graft-versus-host disease (aGVHD) rash and non-aGVHD rash in CD34 +-selected peripheral blood stem cell transplantation (PBSCT) recipients, skin biopsy alone is usually insufficient to determine rash etiology. As such, distinguishing inflammatory non-aGVHD rashes, such as drug eruptions, from cutaneous aGVHD after CD34 +-selected PBSCT remains challenging and relies on clinical presentation. This study aimed to identify etiologies of skin rash in the first year after CD34 +-selected PBSCT and to assess whether laboratory serologic markers, transplant characteristics, and rash morphology and symptomatology aid in differentiation of cutaneous aGVHD rash versus non-aGVHD rash. We conducted a retrospective study of 243 adult patients who underwent CD34 +-selected PBSCT at Memorial Sloan Kettering Cancer Center between 2008 and 2011. Among this cohort of transplant recipients, only 43 patients (17.7%) developed cutaneous aGVHD. A total of 152 patients (63%) were identified with rash within 1 year after PBSCT. The proportion of patients who experienced peripheral eosinophilia was not different between those with an aGVHD versus non-aGVHD rash (P .90), nor when stratified by CD34 + selection method (Isolex, P = .70; CliniMACS, P .90). The proportion of patients with pruritus was also not different between those with an aGVHD rash versus non-aGVHD rash (P= .20), or when stratified by CD34 + selection modality (Isolex, P = .20; CliniMACS, P = .50). The most common cause of non-aGVHD rash among those with a clear etiology was drug (39% of Isolex; 26% of CliniMACS). Single drug culprits were identified in 51% of drug rashes. The most commonly reported offending agents included antibiotics, keratinocyte growth factor, chemotherapy, and recombinant glycosylated human IL-7.

Presence of Parvovirus B19 but Not Herpesvirus Genome in Acute Skin Rash after Allogeneic Stem Cell Transplantation Correlates with Outcome

“…We reported a rate of 79% of patients with exanthema. Klager et al [6] reported a rate of 62% (152 of 243 patients) of skin rashes of any causes, only 17.7% being due to GvHD after T-cell depleted ASCT. The incidence of GvHD in non-T-cell-depleted ASCT is 40–60%, and about 70% of these patients have skin involvement [49].…”

“…However, making a distinction between aGvHD of the skin and the competing diagnoses is difficult and mainly based on clinical findings, as no specific diagnostic markers for aGvHD are established [6]. The diagnostic value of skin histopathology is limited by the lack of specific diagnostic criteria [26].…”

“…In most cases, skin rash is the first symptom of aGvHD [4, 5]. However, skin rashes until day 100 after ASCT can have very different causes, such as viral infections, drug allergies, radiation dermatitis due to total body irradiation, or engraftment syndrome [6].…”

The Impact of Immunological Checkpoint Inhibitors and Targeted Therapy on Chronic Pruritus in Cancer Patients

“…Allo-hematopoietic stem-cell transplantation (HSCT) patients are subjected to composite drug protocols, augmenting the risk for pruritus [ 156 ]. A report evaluated the possible causes of skin alterations in the first year after CD34+-selected peripheral blood stem cell transplantation (PBSCT) [ 157 ]. A retrospective study evaluated 243 subjects who experienced CD34+-selected PBSCT.…”

“…Single drug culprits were recognized in 51% of rashes. The most frequently described drugs comprised chemotherapy, antibiotics, keratinocyte growth factor, and recombinant IL-7 [ 157 ].…”