Late onset toxic epidermal necrolysis induced by mogamulizumab, an anti‐CC chemokine receptor 4 antibody for the treatment of adult T‐cell leukaemia/lymphoma

Abstract

Late onset toxic epidermal necrolysis induced by mogamulizumab, an anti-CC chemokine receptor 4 antibody for the treatment of adult T-cell leukaemia/lymphomaTo the Editor Adult T-cell leukaemia/lymphoma (ATLL) is a rare type of highly aggressive peripheral T-cell malignancy induced by infection with human T-cell leukaemia virus type 1 (HTLV-1) [1]. Acute and lymphoma types of ATLL particularly display an aggressive clinical course with a poor outcome because of the resistance to conventional combination chemotherapies [2]. Mogamulizumab (MOG), a defucosylated humanized monoclonal antibody targeting CC chemokine receptor 4 (CCR4), has recently been launched for treatment of ATLL; almost all ATLL cells express CCR4 [3]. On the other hand, skin rashes have been reported as significant adverse effects of MOG [3]. It is often difficult to distinguish between a skin lesion caused by MOG and an ATLL lesion, and the detail characteristics, clinical course and treatment are still unclear, particularly in severe events including Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). Here, we report a case of TEN induced by MOG for the treatment of ATLL, which developed at a very late phase after the last infusion of MOG.A 77-year-old man was introduced to our hospital for general fatigue, palpitation and abnormal lymphocytes in peripheral blood. He was diagnosed as having acute type of ATLL by flow cytometry analysis and detection of HTLV-1 antibody. He received low-dose etoposide as an initial treatment; however, lung infiltration of ATLL cells was demonstrated by bronchoalveolar lavage and transbronchial lung biopsy 7 months after diagnosis. Because combination chemotherapies were considered to be a high risk for his general condition, MOG monotherapy was started for 8 months. Detail clinical course of the patient following the treatment of MOG was shown in Figure 1. At the initial infusion of MOG, an infusion reaction was diagnosed for the rapid development of respiratory failure, hyperthermia and systemic skin rash. Three courses of MOG monotherapy were given in combination with a steroid, and MOG was then discontinued owing to a grade 4 adverse effect of thrombocytopenia. He achieved complete remission in both peripheral blood and lung lesions after the therapy. Serum soluble interleukin-2 receptor levels were also significantly decreased from 6290 to 1190 U/ml. On day 5 after the last infusion of MOG, he developed systemic erythema. The skin lesions were improved by administration of 1 mg/kg of prednisolone; however, it was exacerbated again during the tapering of prednisolone. The results of a skin biopsy on day 30 after the last infusion of MOG were consistent with a drug eruption rather than an ATLL lesion. We increased the level prednisolone; however, the lesions continued to progress. On day 42 after the last infusion of MOG, a total of 25% of epidermal necrolysis and erosion, enanthema of the scrotum and systemic symptoms including fever had developed [ Figure 2(A) and (B)], leading to the diagnosis ...

Toxic epidermal necrolysis in adult T cell leukemia/lymphoma treated with mogamulizumab

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