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Palifermin-Associated Papular Eruption

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Palifermin-Associated Papular Eruption OBSERVATION Palifermin-Associated Papular Eruption Brett King, MD, PhD; Eleanor Knopp, MD; Anjela Galan, MD; Gerard Nuovo, MD; Robert Tigelaar, MD; Jennifer McNiff, MD Background: Palifermin is a recombinant human ke- mavirus. Immunohistochemical staining with antibod- ratinocyte growth factor that is used to reduce the du- ies to Ki-67 and cytokeratin 5/6 showed increased ke- ration and severity of oral mucositis in patients under- ratinocyte proliferation in lesional skin. going hematopoietic stem cell transplantation after myelotoxic therapy. Cutaneous adverse reactions asso- Conclusions: After treatment with palifermin, a papu- ciated with keratinocyte growth factor are reported to be lar eruption clinically resembling lichen planus or plane rash, pruritus, and erythema. warts, with histologic features of verruca plana, and in- tertriginous erythema may occur. In this case, neither Observations: After receiving palifermin following au- eruption required treatment, and spontaneous resolu- tologous hematopoietic stem cell transplantation and treat- tion was observed over days to weeks. Histopathologic ment with melphalan, a patient developed erythema and staining patterns of Ki-67 and cytokeratin 5/6 may be use- lichenoid papules that were distributed primarily in in- ful in identifying adverse reactions to palifermin therapy. tertriginous areas. A biopsy specimen of the papules showed a striking resemblance to verrucae, but in situ hybridization studies were negative for human papillo- Arch Dermatol. 2009;145(2):179-182 ERATINOCYTE GROWTH FAC- be “rash, pruritus, erythema, and paresthe- tor (KGF) is a member of sia.” The rash is not described further. the family of fibroblast A review of the literature since 2004 re- growth factors. While many vealed 3 case reports of cutaneous erup- fibroblast growth factors tions in the setting of palifermin treat- Kaffect the proliferation, migration, and/or dif- ment. The first case report describes ferentiation of a variety of different cell types, palmoplantar erythrodysesthesia (a reac- KGF acts specifically on epithelial cells in tion not uncommonly seen with high- a broad range of tissues, including skin, oral dose cytarabine therapy) in a patient af- mucosa, gastrointestinal tract, lung, and ter BEAM (carmustine, etoposide, genitourinary tract.1-3 Mucosal epithelial cell cytarabine, and melphalan) chemo- proliferation assessed by Ki-67 immuno- therapy, which includes low-dose cy- histochemical staining is increased in the tarabine. The authors hypothesized that setting of KGF exposure.4 Palifermin (re- enhanced epithelial proliferation due to combinant human KGF) is a truncated ver- palifermin therapy increased the suscep- sion of endogenous KGF that demon- tibility to cytarabine-induced palmoplan- strates similar biologic activities with tar erythrodysesthesia.6 In the second case increased stability. report, a “papulopustular (acne-like)” A phase 3 trial published in 2004 dem- eruption of the head and upper trunk was onstrated the efficacy and safety of pali- observed in a patient 11 days after treat- fermin therapy in reducing the duration ment with busulfan, cyclophosphamide, and severity of oral mucositis in patients and antithymocyte globulin and concur- undergoing autologous hematopoietic stem rent with the administration of palifer- cell transplantation after total-body irra- min.7 In a third report, a “mild rash pre- diation and high-dose chemotherapy.5 In sumed to be due to palifermin” therapy was Author Affiliations: that trial, palifermin was administered for reported in one patient (the features of the Department of Dermatology, 3 consecutive days before total-body irra- rash are not described), and a desquamat- Yale University School of diation and again for 3 consecutive days ing rash of the groin, axillae, and palmo- Medicine, New Haven, Connecticut (Drs King, Knopp, after transplantation. Cutaneous adverse plantar surfaces initially thought to be due Galan, Tigelaar, and McNiff); reactions, similar to those seen in phase 1 to palifermin therapy but later attributed and Department of Pathology, and 2 trials, occurred approximately 3 days to the use of etoposide was reported in an- Ohio State Medical Center, after the third dose of palifermin, lasted ap- other patient.8 Biopsy results were not Columbus (Dr Nuovo). proximately 3 days, and were reported to mentioned in any of these reports. (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 2), FEB 2009 WWW.ARCHDERMATOL.COM 179 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 polyangular, planar papules without scale primarily within A B and immediately peripheral to the intertriginous distribu- tion of the aforementioned erythema (Figure 1A) but also scattered on the trunk and all 4 extremities (sparing the palms and soles); and (3) confluent, white plaques on the tongue and remaining oral mucosa. He denied a history of a similar eruption or any other skin condition. There was no antecedent or concurrent fever, chills, diaphoresis, cough, nausea, vomiting, or diarrhea. At the time of the initial der- matology evaluation, a shave biopsy specimen was ob- tained from a papule on the left proximal thigh area. Two days later, by which time there had already been notice- able fading of the intertriginous erythema, a second shave biopsy specimen was obtained from a papule on the right upper inner arm area. Over the following week, without treatment, the intertriginous erythema resolved without des- quamation, and the lichenoid papules regressed (Figure 1B). Figure 1. Clinical appearance on initial evaluation revealed erythema and a papular eruption in a predominantly intertriginous distribution (A); 1 week later, the eruption was largely resolved (B). METHODS A After the patient gave informed consent, shave biopsy speci- mens were obtained from papules located on the left thigh and right arm. Tissue specimens were fixed in 10% buffered forma- lin, embedded in paraffin, and stained with hematoxylin-eosin according to standard procedures. Immunohistochemical stud- ies were performed with antibodies to Ki-67 (Dako Corp, Carpin- teria, California) (prediluted) and cytokeratin (CK) 5/6 (Dako Corp) (dilution 1:40). This latter antibody was selected based on reports that epidermal growth factors specifically induce activa- tion- and hyperproliferation-associated CKs 6 and 16,9 coupled with the lack of availability of monospecific antisera to CK 6 or B C 16. For controls, the tips of excisional specimens of 5 nevi and 5 verrucae from unrelated patients were used. In situ hybridization was performed using a previously pub- lished protocol10 to test for human papillomavirus (HPV) types 1, 2, 5, 6, 8, 11, 16, 18, 30, 31, 33, 35, 39, 42, 43, 44, 45, 51, 52, 56, 57, 58, 68, and 70 as well as other “novel” types (an HPV detected that is related to but distinct from those included in the probe cocktail). Control specimens included plantar warts, Figure 2. Skin biopsy specimen of an early lesion. A, Hematoxylin-eosin verruca vulgaris, warts of epidermodysplasia verruciformis, con- staining shows papillated epidermal hyperplasia, hypergranulosis, and dyloma acuminata, and cervical low- and high-grade squa- laminated hyperkeratosis (original magnification ϫ40). B, Immunostaining mous intraepithelial lesions. with Ki-67, a proliferation marker, shows dramatically increased labeling of basilar and suprabasilar keratinocytes (original magnification ϫ40). C, Immunostaining with cytokeratin 5/6 shows activation of the entire basal RESULTS layer and stratum spinulosum (original magnification ϫ40). HISTOPATHOLOGIC FINDINGS REPORT OF A CASE Histologic examination of the specimen of the papule A 70-year-old man with multiple myeloma whose disease from the left thigh showed a discrete area of papillated was progressing despite previous treatment with melpha- epidermal hyperplasia, hypergranulosis, and laminated lan, thalidomide, bortezomib, lenalidomide, and cyclo- hyperorthokeratosis with slight inward bowing of the phosphamide was hospitalized for autologous peripheral lateral rete ridges (Figure 2A). Notably, koilocytes blood stem cell transplantation. After 2 days of treatment and parakeratotis were absent. Histologic examination with melphalan and decadron, he underwent infusion of of the specimen of the papule from the right inner arm peripheral blood stem cells and started daily intravenous area obtained 2 days later showed a gradual transition palifermin therapy for 3 consecutive days. Three days af- from normal epidermis to digitated epidermal hyper- ter peripheral blood stem cell transplantation and 1 day af- plasia, hypergranulosis, and compact hyperorthokera- ter completing a course of palifermin, he was noted to have tosis (data not shown). The lesion lacked sharp cir- 3 morphologically distinct oral mucosal and cutaneous erup- cumscription, koilocytosis, and parakeratosis. tions: (1) asymptomatic blanching erythema of the neck Additional testing for HPV and markers of cellular and inframammary folds, axillae (Figure 1A), groin, back, proliferation were performed to further assess the pos- and buttocks; (2) numerous 2- to 6-mm, pink to purple, sibility of verruca. (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 2), FEB 2009 WWW.ARCHDERMATOL.COM 180 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 SPECIAL STUDIES of epidermal hyperplasia, Figure 2B) and normal con- trols mirrors what is observed in oral mucosa after pali-
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