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CLINICAL IMAGES OPEN ACCESS

Unusual serpentine supravenous hyperpigmentation during chemotherapy treatment

Houda Mouzount, Sihame Lkhouyaali, Saber Boutayeb, Hassan Errihani

CASE REPORT

A 54­year­old female patient diagnosed for inoperable colic adenocarcinoma with multiple liver metastases in January 2011. She was treated by first line fluorouracil and irinotecan­based chemotherapy in combination with bevacizumab. After three cycles of chemotherapy, a good response to treatment were observed and the patient did not show cutaneous toxicity, the treatment was continued. Two days after the seventh cycle, the patient noticed for the first time asymptomatic pigmentation retracing venous streak of right and left arms, from forearms to shoulders. Clinical examination revealed serpiginous hyperpigmented streaks along the course of the superficial veins (Figure 1 A). There were no apparent leakages of medical agents in Figure 1: Serpentine supravenous hyperpigmentation of arms surrounding skin and no other mucocutaneous and forearms (A) One day after fluorouracil infusion. (B) After abnormalities. No history of extravasation or phlebitis two weeks. preceded the hyperpigmentation. No history of extravasation or phlebitis preceded the hyperpigmentation. For this patient, the chemotherapy was suspended and no other treatment was added. After two weeks, we noticed remarkable reduction in DISCUSSION hyperpigmented lesions. (Figure 1B) Fluorouracil was replaced by capecitabine. Two months later, this Serpentine supravenous hyperpigmentation was first complication was completely resolved. described in 1976 by Hrushesky as an uncommon side effect of intraveinous fluorouracil [1]. Other chemotherapeutic agents, such as vinorelbine, fotemustine, and docetaxel, have also been found to Houda Mouzount1 , Sihame Lkhouyaali1 , Saber cause serpentine supravenous hyperpigmentation [2]. Boutayeb1 , Hassan Errihani1 In a recent study, skin hyperpigmentation occurred in Affiliations: 1 MD, National institute of oncology, 26% of patients treated by fluorouracil. However, linear Department of Medical Oncology, Rabat, Morocco. hyperpigmented streaks over the arm veins used for Corresponding Author: Houda Mouzount, National injections without previous erythematous changes have institute of Oncology, department of medical Oncology, rarely been reported [3]. Its exact mechanism of Rabat, Morocco 1 01 00; Ph: +21 2 666336474; Email: pigment induction is unknown [4]. Some hypotheses [email protected] suggest that these cytotoxic drugs cause loss of endothelial integrity. This would permit the leakage of agent from the vessel to the overlying epidermis where Received: 29 February 201 2 it interferes with melanogenesis thus resulting in Accepted: 21 July 201 2 Published: 01 April 201 3 hyperpigmentation [2, 4]. No specific treatment is recommended. Pigmentation promptly subsides once the offending drug is stopped [4].

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 4, April 201 3. ISSN – [0976-31 98] IJCRI 201 3;4(4):241 –242. Mouzount et al. 242 www.ijcasereportsandimages.com

CONCLUSION Hassan Errihani – Analysis and interpretation of data, Revising it critically for important intellectual content, Serpentine supravenous hyperpigmentation can be Final approval of the version to be published prevented by avoiding peripheral infusion of some chemotherapy agents, especially fluorouracil, by using Guarantor permanent central­infusion catheter or suggesting oral The corresponding author is the guarantor of chemotherapy if possible. submission.

********* Conflict of Interest Authors declare no conflict of interest. Mouzount H, Lkhouyaali S, Boutayeb S, Errihani H. Unusual serpentine supravenous hyperpigmentation Copyright during chemotherapy treatment. International Journal © Houda Mouzount et al. 2013; This article is of Case Reports and Images; 2013(4):241–242. distributed under the terms of Creative Commons Attribution 3.0 License which permits unrestricted use, ********* distribution and reproduction in any means provided the original authors and original publisher are properly doi:10.5348/ijcri­2013­04­303­CI­12 credited. (Please see www.ijcasereportsandimages.com/ copyright­policy.php for more information.)

********* REFERENCES

Acknowledgements 1. Hrushesky WJ. Letter: Serpentine supravenous We aknowledge Professor Youssef Bakri for his critical fluorouracil hyperpigmentation. JAMA review. 1976;236(2):138. 2. Rao R, Balachandran C. Serpentine supravenous pigmentation. A rare vasculo­cutaneous effect Author Contributions induced by systemic 5­fluorouracil. Indian J Houda Mouzount – Substantial contributions to Dermatol Venereol Leprol 2010;76(6):714–5. conception and design, Acquisition of data, Analysis and 3. Yun­Hsuan Ouyang, Chia­Yu Chu, Shu­Ling Hu. interpretation of data, Drafting the article, Revising it Linear Hyperpigmentation of the Left Hand critically for important intellectual content, Final Following Chemotherapy. Dermatol Sinica approval of the version to be published 2004:262–3. Sihame Lkhouyaali – Analysis and interpretation of 4. Chan CC, Lin SJ. Images in clinical medicine. data, Revising it critically for important intellectual Serpentine supravenous hyperpigmentation. N Engl content, Final approval of the version to be published J Med 2010;29:363(5):e8. Saber Boutayeb – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published

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IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 4, April 201 3. ISSN – [0976-31 98]