Pemetrexed induces frequent conjunctivitis, peripheral edema, and edema of the limbs. Female gender seems to be an independent risk for CAE. CAEs are frequently disabling and symptomatic treatment should be proposed.

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A 34-year-old Chinese man presented with necrosis of several fingertips and paresthesia of both legs, which had progressively developed during the previous 2 months. His medical history was non-contributory. He had smoked five cigarettes daily for 8 years, and he denied any drug misuse.On physical examination, the patient appeared healthy. His limbs were cyanotic, with pulpar necrosis of the second finger of the right hand, of the second and fourth fingers of the left hand (Fig. 1a), and of the fifth toe and external side of the left foot, with haemorrhagic splinters (Fig. 1b). Peripheral pulses were diminished, but the cardiovascular examination was otherwise unremarkable. Sensorimotor deficiency was found, mainly on the external side of the right leg. A lymph node (20 mm in size) was palpable in the left axilla.Laboratory investigations including full blood cell count found an eosinophil cell count of 3220 ⁄ mm 3 (normal < 500 ⁄ mm 3 ). Results of serum creatinine and liver function tests were normal, and serum IgE level was within normal range. Investigations for thrombophilia, antiphospholipid, anticardiolipin, anti-b2 glycoprotein 1, antinuclear and antineutrophil cytoplasmic antibodies, and cryoglobulin gave negative results. Parasitic infestations were excluded. On ultrasonography and angio-magnetic resonance imaging of the legs, diffuse narrowing of the left tibial arteries was seen. Echocardiography was normal. Computed tomography of the thorax, abdomen and pelvis did not reveal any abnormalities.On histopathological examination of a biopsy taken from the area of lymphadenopathy in the left axilla, follicular hyperplasia with reactive germinal centres was seen, with a dense interfollicular infiltrate made up of eosinophils and hyperplasia of high endothelial venules (postcapillary venous swellings), consistent with Kimura disease (KD) (Fig. 2a,b). Immunohistochemical analysis cell using B-and T-cell markers did not reveal any abnormality, and no clonal population was found.Electromyography was consistent with axonal mononeuritis multiplex of both legs. A neurological biopsy taken from the left external popliteal sciatic nerve displayed severe axonal neuropathy, but no eosinophils C P D Figure 1 Necrosis of (a) several finger tips, and (b) fifth toe and external side of the left foot.

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