Cutaneous Vasculitis Induced by Osimertinib

Abstract

A 65-year-old female with T2aN3M1c stage ⅣB adenocarcinoma of the lung commenced osimertinib monotherapy 80 mg/day. Six weeks after the initiation of osimertinib, multiple palpable purpura with neither pain nor pruritus appeared on her legs (Fig. 1). She presented without fever, arthralgia, fatigue, or other symptoms associated with systemic vasculitis. She had no signs of connective tissue disease. Laboratory testing revealed a platelet count of 158,000/mL and serum immunoglobulin A was within the normal range. Antinuclear antibody, rheumatoid factor, cryoglobulin, proteinase-3 Figure 1. Multiple palpable purpura appeared on her legs.

Cutaneous leucocytoclastic vasculitis secondary to cabozantinib therapy for renal cell carcinoma

“…Onset of symptoms ranges from 14 to 240 days, and resolution of symptoms occur within 14–49 days. Interestingly, in several cases, rechallenge with reduced‐dose erlotinib and osimertinib did not induce further leucocytoclastic vasculitis 3,4 . However, recurrence of symptoms did occur in one case following rechallenge with gefitinib, 5 and likewise with cabozantinib in our case.…”

“…Interestingly, in several cases, rechallenge with reduced-dose erlotinib and osimertinib did not induce further leucocytoclastic vasculitis. 3,4 However, recurrence of symptoms did occur in one case following rechallenge with gefitinib, 5 and likewise with cabozantinib in our case. Notably, our patient has since been treated for > 4 months with axitinib, another TKI with a different kinase specificity, which has resulted in radiological response and no treatment-related toxicity.…”

The future of digital dermatology

“…Cases of drug rash sparing sites of tinea versicolor has been termed 'anatopic phenomenon'. 4 A case of drug reaction to trimethoprim, which showed sparing of active psoriatic lesions along with a peripheral rim of normal skin, was thought to be an area of subclinical psoriasis with mediators that inhibited the drug reaction. 5 This could be taken as an example of reverse isotopic response as the sparing phenomenon occurred when the primary dermatosis was still active.…”

“…5 This could be taken as an example of reverse isotopic response as the sparing phenomenon occurred when the primary dermatosis was still active. 4 We considered isotopic nonresponse in our case as the sunburn spared healed lesions of psoriasis, and there was also a peripheral halo of normal-appearing skin around each lesion, possibly corresponding to a WR. The reason for UV light-induced erythema sparing the WR was experimentally shown by Penneys et al to be due to the presence of a prostaglandin inhibitor within the WR.…”

“…1 Persistence of T regulatory cells and/or decrease in the number of Langerhans cells are possible mechanisms for the sparing phenomenon in HZ. 3,4 The pathomechanisms tend to differ based on the primary and secondary dermatoses involved in the sparing phenomenon. Cases of drug rash sparing sites of tinea versicolor has been termed 'anatopic phenomenon'.…”