Reactions 1704, p128 - 2 Jun 2018 Various toxicities: case report A 56-year-old man developed leukocytoclastic vasculitis, acute kidney injury, febrile neutropenia and thrombocytopenia during treatment with methotrexate and cytarabine [Ara-C; not all routes stated] for primary central nervous system lymphoma (PCNSL). The man, who was diagnosed with PCNSL, started receiving treatment with high dose methotrexate 3 g/m infused over a period of 24 hours on day 1 with folinic acid rescue therapy and high dose cytarabine 2 g/m twice daily on days 2 and 3, planned for 6 8 cycles of chemotherapy administered every three weeks. Initially, the treatment with methotrexate and cytarabine was well tolerated. After approximately 14 days, he developed grade 2 febrile neutropenia with absolute neutrophil count nadir of 300 cells/mm , grade 1 acute kidney injury, grade 2 thrombocytopenia with a platelet count nadir of 3 3 32000 × 10 /mm and a grade 3 rash, which involved violaceous plaque and mainly affected the lower limbs and genitals. Consequently, the man was hospitalised. He was treated with imipenem/cilastatin and filgrastim. After 48 hours, all blood cultures, infection markers and all other biologic tests for autoimmune vasculitis were negative. His thrombocytopenia resolved. A skin biopsy showed reactive small vessels in the upper dermis with the presence of a mild perivascular lymphocytic infiltrate and mild hyperplastic epidermis with a few apoptotic bodies. These findings were suggestive of leukocytoclastic vasculitis. At this time, his treatment with antibiotics and filgrastim was discontinued. On day 21, the lesions started improving spontaneously and completely resolved by day 28. nd For the 2 cycle of chemotherapy, the man received single- agent high dose methotrexate infused after a desensitisation protocol. Additionally, he received prednisolone, desloratadine and montelukast for five days, immediately before high dose methotrexate infusion. He received the nd 2 cycle and did not experienced any adverse events except for grade 2 acute kidney injury, that resolved with hydration. He received additional four cycle of high dose methotrexate every three weeks with the same desensitisation regimen and supportive care. High dose cytarabine was not restarted. Author comment: "[Leukocytoclastic vasculitis] is an uncommon side effect of cytotoxic drugs." "[High dose methotrexate] has been previously associated with [leukocytoclastic vasculitis]" "The combination of [high dose methotrexate] [high dose cytarabine] is an effective regimen for [primary central nervous system lymphoma] but is associated with severe toxicities." Hanna C, et al. Leukocytoclastic Vasculitis and Desensitization to High-dose Methotrexate in Primary Central Nervous System Lymphoma. Clinical Lymphoma, Myeloma & Leukemia 18: e197-e200, No. 5, May 2018. Available from: URL: http://doi.org/10.1016/j.clml.2018.03.008 - Lebanon 803323388 0114-9954/18/1704-0001/$14.95 Adis © 2018 Springer International Publishing AG. All rights reserved Reactions 2 Jun 2018 No. 1704
Reactions Weekly – Springer Journals
Published: Jun 2, 2018
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