Time- and dose-limiting erysipeloid rash confined to areas of lymphedema following treatment with gemcitabine-a report of three cases

Abstract

Gemcitabine is a deoxycytidine analog with broad antitumor activity. Its main toxicities include myelosuppression, flu-like symptoms, bronchospasms and mild skin rash. We report three cases, in which the patients developed time- and dose-limiting erysipeloid skin reactions confined to areas of impaired lymphatic drainage after application of gemcitabine. Three patients with metastatic tumors (breast cancer, endometrial cancer and non-small cell lung cancer) received weekly infusions of gemcitabine (1000 mg/m2). All patients suffered from lymphedema of different origin and developed an erysipeloid erythema 40-48 h after chemotherapy within their preexisting lymphedema. Genuine erysipela was ruled out by laboratory tests and clinical observation. The skin reaction was repeatedly observed and faded after 14 days without specific treatment. Although the pathogenesis of the observed reaction is unclear, it is suspected that the skin symptoms were caused by gemcitabine or its metabolites. Gemcitabine is usually metabolized fast and excreted renally. In areas with impaired lymphatic drainage pharmakocinetics might be altered: inactivation happens slower and the drug might accumulate in the s.c. and cutaneous tissue, thus increasing local toxicity. Clinical judgement and biochemical parameters can help to tell apart genuine erysipela and the erysipeloid reaction.

Gemcitabine-associated scleroderma-like changes of the lower extremities

“…No scleroderma-like changes were noted, but no histology of the skin lesion was mentioned. 9 Various scleroderma-like conditions induced by chemotherapeutic drugs have been reported. 10 Progressive systemic scleroderma-like presentation including sclerodactyly with swelling; induration of the hands and forearms; tightening and thickening of the skin of hands, forearms, arms, thighs, legs, and feet; hyperpigmentation; and inconstant Raynaud phenomenom have been repeatedly reported with bleomycin 11 and more recently with uraciltegafur.…”

Chemotherapeutic agents and the skin: An update

“…245 In another case, localized erythematous plaques also resembling erysipelas developed over elbow and knee joints and recurred on subsequent cycles. 246 A case of gemcitabine-induced pseudolymphoma in a patient with NSCLC has been reported.…”

Gemcitabine-associated acute lipodermatosclerosislike eruption: An underrecognized phenomenon

“…Although side effects such as bone marrow suppression are well described, cutaneous side effects are less recognized. Certain gemcitabine-associated cutaneous reactions have been categorized under the umbrella terminology pseudocellulitis , including lipodermatosclerosislike and erysipeloid reactions, sclerodermalike changes, and radiation recall events 1, 2. Additionally, these reactions are often confused with other diagnoses, in particular, infectious cellulitis, which may subject patients to unnecessary treatment with antibiotics, hospitalizations, and interruption of chemotherapy.…”