Cyclophosphamide and Doxorubicin Induced Melanonychia: A Case Report

Abstract

A 67-year-old woman came with complaints of increasing breathlessness and nodular swelling in the axillary and cervical regions since three weeks. On examination, she had generalized lymphadenopathy and massive right pleural effusion. Lymph node biopsy revealed non Hodgkins lymphoma -follicular type. Breathlessness was relieved by thoracocentesis and no malignant cells were detected in pleural fluid. She was treated with the R-CHOP chemotherapy regimen. The patient was being given the following dosage; injection rituximab 525 mg, injection cyclophosphamide 1050 mg, injection doxorubicin 50 mg, injection vincristine 1.9 mg and dexamethasone 12 mg per cycle. Total six cycles of chemotherapy were given over a period of four months with an interval of three weeks between each cycle. Positron Emission Tomography (PET) scan done post chemotherapy showed near complete resolution of all the malignant lymph nodes. After the third cycle of chemotherapy patient started noticing diffuse blackish discoloration of her nails which progressed with subsequent chemotherapy. The discoloration pattern was uniform and involved all the nails of hands [Table/ Fig-1,2] and toes [Table/ Fig-3]. There was no associated skin or mucous membrane pigmentation. Interestingly, the blackish nail discoloration started to regress after the completion of chemotherapy. DISCUSSIONMelanonychia is described as the brown to black pigmentation of the nail. It may be due to stimulation and hyperplasia of nail matrix melanocytes, invasion of nail by melanin producing pathogens, subungual haemorrhage and also due to drugs [1][2][3][4][5]. We present a brief report on a patient with non Hodgkin lymphoma -follicular type who developed diffuse blackish discoloration of nails during six cycles of R-CHOP chemotherapy regimen. Drug induced melanonychia usually affects numerous nails and appears as multiple light brown to black longitudinal or transverse bands or diffuse nail discoloration [6]. These depends on the type of melanocytic activation; in case of clus ter activation they will be presented as single longitudinal pigmented bands while diffuse activation will result to discoloration of the whole nail [6,7]. A number of chemotherapeutic agents are associated with melanonychia like; bleomycin sulfate, cyclophosphamide, met hotrexate, dacarbazine, doxorubicin, etoposide, 5-fluorouracile, hy droxyurea, imatinib, mel phalan hydrochloride, daunorubicin hydrochloride, nitrogen mustard, nitrosourea, busulfan, and tegafur [3,6].Our patient was on cyclophosphamide and doxorubicin which precipitated the discoloration of the nails. Cyclophosphamide is an alkylating agent which acts by introducing an alkyl group to the DNA strand resulting in the DNA cross-linkage leading to disruption of DNA replication stopping cancer cells from growing. It also has immunosuppressant activity; it has cytotoxic effect on lymphocytes. There are many mechanism proposed for cyclophosphamide induced nail pigmentation like genetic predisposition, toxicity to the nail bed and matrix, focal...

Mixed Mammary Carcinosarcoma in Domesticated Asian Palm Civet (Paradoxurus hermaphroditus).

“…Moreover, the utilisation of cyclophosphamide and vincristine potentially inhibit the metastases during two months of the observed periods. Cyclophosphamide is the alkylating agent that able to bind the DNA and depress the DNA replication and mitosis (Prajapati et al, 2017), and vincristine binds the tubulin to inhibit cell's metaphase (Dong et al, 2016).…”

Onychoscopic Analysis of Cyclophosphamide-Induced Polydactylic Bluish-Gray Discoloration in a Case of Pemphigus Foliaceus

“…Drug-induced nail discoloration commonly presents with a polydactylic inclination [ 5 ]. Several mechanisms have been proposed to explain the occurrence of nail pigmentation induced by cyclophosphamide, including genetic predisposition, toxicity to the nail bed and matrix, focal activation of the melanocytic matrix, and photosensitization [ 6 ]. The pigmentation of nails, which manifests after a period of several weeks or months, exhibits a range of patterns, including diffuse, horizontal, or longitudinal streaks.…”

“…It is important to distinguish this discoloration from melanonychia (brownish-black pigmentation), which may be a sign of NAM. Therefore, performing a biopsy of melanonychia is advisable to ascertain whether it is attributable to melanoma or other underlying factors [ 6 ]. The prevalence of this condition is higher among older individuals and is primarily confined to a single digit, usually the thumbnail or great toenail [ 4 ].…”

Cancer Chemotherapy-associated Pigmentation of the Oral Mucosa

“…Treatment for pigmentation includes waiting for spontaneous resolution. Pigmentation of the skin and oral mucosa is generally considered likely to improve within a few months after discontinuation of the causative agent (11,15,(22)(23)(24). However, a case with improvement, but not resolution, of pigmentation in the oral mucosa after 18 months of follow-up has been reported (25).…”