Gemcitabine associated pseudocellulitis: A missed diagnosis

Abstract

We report a case of a 51-year-old male with past medical history significant for cholangiocarcinoma presented with two weeks of worsening bilateral lower extremity swelling and erythema. Patient has been on active chemotherapy for his cholangiocarcinoma with Gemcitabine weekly infusions. Physical exam was significant for bilaterally petechial rash coalescing into ecchymoses over the dorsum of the feet, sparing soles and toes, which dissipated into thinning petechiae more proximally. On labs he did not have any leukocytosis, his platelet count was 50 × 10/µL and basic metabolic panel was benign. Patient was started on Vancomycin for presumed cellulitis. Lower extremity ultrasound Doppler ruled out deep venous thrombosis. Patient did have biopsies bilaterally on his legs, which showed hypersensitivity reaction consistent with the diagnosis of pseudocellulitis. His Vancomycin was discontinued and his symptoms improved. Our case further supports that pseudocellulitis is underrecognized and underreported, potentially leading to unnecessary antibiotic exposure and unnecessary diagnostic work-up as seen unfortunately in our patient. Unnecessary antibiotic exposure is increasing the risk for clostridium difficile and or antibiotic resistance, therefore awareness of this reaction is critical, as to avoid unnecessary antibiotics, and costly diagnostic workups.

Qingyihuaji formula reverses gemcitabine resistant human pancreatic cancer through regulate lncRNA AB209630/miR-373/EphB2-NANOG signals

“…GEM-based chemotherapy regimens have been widely used in clinic. GEM combined with capecitabine can improve the half-year survival rate and objective remission rate of patients [8]. It supports being the first line of advanced pancreatic cancer.…”

Gemcitabine-Induced Pseudocellulitis: A Case Report and Review of the Literature

“…Pseudocellulitis without prior radiation exposure is a rare, but increasingly recognized, side effect of gemcitabine [3][4][5]7,8,10,11,[19][20][21] . As in cellulitis, the patient typically presents with localized inflammation of the dermis and hypodermis, with the reaction typically beginning within 2 days of gemcitabine exposure 4 .…”

“…Although the cause of gemcitabine-induced pseudocellulitis is not fully understood, current hypotheses involve impaired lymphatic drainage leading to drug permeation into the interstitial fluid 9,10 . That mechanism might allow for the relatively lipophilic gemcitabine to accumulate in subcutaneous tissue, altering capillary permeability and, in turn, leading to a localized reaction 5,7 . In the present case, the patient first had positive ultrasound findings indicative of great saphenous vein thrombosis.…”

“…Dermatologic side effects have also been described, including a diffuse mild skin rash and radiation-dependent dermatitis 2 . As the use of gemcitabine increases, formerly rare reactions have been shown to occur with increased frequency, including several cases of localized cutaneous inflammation otherwise known as pseudocellulitis [3][4][5][6][7][8][9][10][11] .…”

Unilateral Pemetrexed-induced Pseudocellulitis Mimicking Bacterial Cellulitis

“…Interestingly, pseudocellulitis has also been reported in patients treated with gemcitabine, another chemotherapeutic agent that interferes with DNA synthesis. 10,11 Recognizing the potential for pemetrexedinduced pseudocellulitis or other drug hypersensitivity reactions to present unilaterally could limit unnecessary use of broad-spectrum antibiotics, and in some cases, including this one, may require adjusting a patient's cancer treatment regimen.…”