Paclitaxel, a microtubule-stabilizing anti-neoplastic agent that belongs to the family of taxanes, is used in the treatment of advanced and/or refractory lung, breast, head, neck and other epithelial cancers. Site-specific reactions, such as inflammation at injection sites or cellulitis after extravasation ( 1 ), have been reported. Adverse cutaneous reactions associated with paclitaxel treatment include bullous fixed drug eruption (2), erythema multiforme (3), pustular eruption (4), scleroderma-like cutaneous lesions (5), onycholysis (6), and acral erythema (one case) (7). Of note, acral erythema (erythrodysesthesia) has been reported with multi-drug chemotherapy protocols that included paclitaxel (8,9). We report here the first case of paclitaxel-induced neutrophilic adverse reaction with concomitant acral erythema, and highlight the mechanisms that may be involved. CASE REPORTA 77-year-old Caucasian woman undergoing chemotherapy for breast cancer presented with mildly sensitive skin lesions on the dorsal hands and painful lesions on the lower extremities. She had been treated with weekly intravenous paclitaxel for 3 months, and the skin lesions were noticed after the second cycle of the drug, flared after each subsequent dose of the medication. There was no history of fever or other systemic symptoms, and no prior trauma to the extremities. The treatment protocol involved premedication with diphenhydramine and ranitidine 3 h prior to receiving paclitaxel. Other medications during this period were alendronate sodium, levothyroxine, vitamin D and aspirin. The patient had been taking these medications for several years prior to paclitaxel exposure and continued taking them after the skin lesions resolved. Physical examination revealed erythematous, mildly edematous, tender papules and plaques on the dorsal hands ( Fig. la), palms, dorsal feet and soles, as well as multiple, tender, erythematous, dusky red or violaceous papules and plaques symmetrically on the lower extremities (Fig. lb).Biopsy specimens from the left leg demonstrated hyperkeratosis, acanthosis, spongiosis, dyskeratosis with occasional satellite cell necrosis, and a moderately dense predominantly neutrophilic infiltrate (Fig. 2). Stains for microorganisms (Gram and Giemsa) were negative. Complete blood cell count and differential, urinalysis, electrolytes, liver function tests, serum protein electrophoresis, hepatitis sérologies and autoantibody profile (antinuclear, SSA, SSB and anti-neutrophic cytoplasmic antibodies) were within normal limits. Treatment with clobetasol 0.05% cream was not helpful. The lesions on the legs resolved spontaneously over the course of several weeks after the last cycle of paclitaxel.
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