Acral Erythema associated with Irradiated Blood Transfusion in Myelodysplastic Syndrome: A Case Report

摘要

Acral erythema (AE) is a known chemotherapy-induced adverse cutaneous reaction that has been described in association with a number of different chemotherapeutic agents. The most common agents implicated in this reaction are cytarabine, doxorubicin, and fluorouracil. This disorder has also been described in association with graft versus host disease (GVHD) related to solid organ and bone marrow transplantation. An association with blood transfusion has only been described in transfusion- related GVHD. The skin reaction consists of painful intense macular erythema of palms and soles. It may be followed by blister formation and skin necrosis and usually heals uneventfully with desquamation of the skin. We describe a case of an 88 year old female with myelodysplastic syndrome (MDS) who presented with red, swollen and painful macular rash on both palms and soles after receiving leukocyte depleted, irradiated packed red blood cells 2 days prior. We found no description in the medical literature of AE to be associated with blood transfusion in the absence of GVHD. Introduction Acral erythema (AE), also known as hand-foot syndrome, palmo-planta erythrodyesthesia, and toxic erythema of palms and soles, was first reported by Zuehlk in 1974 in association with mitotane therapy [1]. Several chemotherapy-induced clinical and histologic changes of the area have been reported in the past decade because of new chemotherapeutic drugs, better recognition of histologic reaction patterns, and the prescription of higher dosages by oncologists. Since then, AE has been described as a side effect of many chemotherapeutic agents. Drugs implicated most commonly include doxorubicin [2], methotrexate [3], 5-flourouracil [4], cytosine arabinoside [5], and hydroxyurea [6]. A distinctive acral erythema has been depicted in patients with myelogenous leukemia, subsequent to blood transfusions and intensive chemotherapy with cytarabine [5]. Other reports have also linked AE to GVHD related to bone marrow and solid organ transplantation [7]. Prior association of AE association with blood transfusion was only described in the setting of transfusion related GVHD [8,9]. We report a case of AE associated with irradiated blood transfusion in the absence of GVHD. Case report An 88-year-old Caucasian female with a history of transfusion dependent myelodysplastic syndrome (MDS) of 8 months duration presented with red, swollen and painful intense macular erythema of the palms and soles. Since the diagnosis of MDS, the patient received 10 units of irradiated, leukocyte-depleted packed red cells with no complications or adverse events. Benadryl was routinely administered prior to transfusion to prevent transfusion reactions,. The patient had a history of coronary artery disease, and her angina was occasionally exacerbated with worsening of anemia. She was on extended release metoprolol, isosorbide dinitrate, and enteric coated aspirin for angina and hypertension. No new medications were started before this presentation and she had no known drug or food allergies. She was given 2 units of irradiated, leukocyte depleted, packed red blood cell transfusion two days prior to admission without premedication with benadryl to avoid sedation. After transfusion of the second unit, she developed fever, acral tingling, pruritis, burning sensation and pain followed by a rash only in the acral area (Figures 1 and 2). Physical examination revealed a temperature of 38.5?C, pulse 96 per minute, respiratory rate 18 per minute and blood pressure of 146/46 mm/Hg. Both palms were red, edematous, and tender with erythema extending up to the forearms. There was marked tenderness, erythema and edema of both feet, with turbid bullae on the soles. The skin lesions progressed to necrosis in some areas. The remainder of the physical examination was unremarkable, except for radiologically persistent (clinically not significant) bilateral lung infiltrates due to a recently treated bacterial pneumonia