Acute vesiculobullous hand dermatitis and anagen effluvium in Ganoderma lucidum-induced aplastic crisis

Abstract

Dear Editor, A 66-year-old male patient presented to our department due to vesiculobullous skin lesions over the entire palms and soles that had rapidly progressed over three days. He was treated with topical corticosteroids and oral antihistamines at a private clinic; however, the skin lesions were refractory to the treatments, and the patient developed additional symptoms of fever and myalgia. His medical history revealed that he had been treated with daily olmesartan 20 mg and amlodipine 5 mg for hypertension, which had not been changed for over a year. During the previous two weeks, he had been ingesting Ganoderma lucidum, which his wife and son had also ingested. On physical examination, his body temperature was 38.4 °C, and extensive vesiculobullous lesions with sloughing epidermis were noted on the erythematous palms and soles (Fig. 1). In addition, diffuse alopecic patches over the entire scalp and a positive hair pull test with numerous anagen hairs were noted. Routine laboratory tests were performed, and a biopsy specimen was obtained from an erythematous, but nonvesiculobullous, hand lesion. Complete blood count revealed severe leucopenia of 190 cells/μL (normal range 4,000–10,800 cells/μL; neutrophils 13.6 %, lymphocytes 82.7 %, monocytes 1 %, eosinophils 1 %, and basophils 0.6 %), thrombocytopenia of 36,000 cells/μL (normal range 150,000–400,000 cells/μL), mild anemia of 12.2 g/dL (normal range 13.0–17.0 g/dL), and reticulocyte count of 0.98 % (normal range 0.5–2.31 %). Other laboratory tests were unremarkable. Skin biopsy of the palm revealed mildly infiltrated inflammatory cells adjacent to the dilated capillaries in the upper dermis (Fig. 2a, b). Further investigation for the evaluation of pancytopenia revealed nearly acellular marrow and panhypoplasia without remarkable abnormal cells or blasts (Fig. 2c, d). Klebsiella pneumoniae was isolated from a blood culture. Additional tests, including computed tomography, were performed to rule out Bazex acrokeratosis paraneoplastica. Although there were no remarkable findings suggestive of malignancy, pulmonary angioinvasive aspergillosis forming multifocal areas of lobular and subsegmental consolidation was detected. The patient was diagnosed with G. lucidum-induced aplastic crisis, and pancytopenia was treated with a transfusion of platelet concentrates and subcutaneous filgrastim injection. For the skin lesions of the palms and soles, topical corticosteroid and emollient creams were applied to alleviate the burning sensation. The patient was discharged after five weeks of systemic antifungal and antibacterial therapy, and his complete blood count was normalized at follow up. His hands and feet completely recovered and his scalp hair grew back completely. Routine laboratory tests were also performed for his wife and son, who had also been ingesting G. lucidum. His wife complained of fever and myalgia; however, no skin lesions of the palms or soles or hair loss were noted. Her body temperature was 39.0 °C and complete blood count revealed leucopenia of 830 cells/μL (neutrophils 4.2 %, lymphocytes 79.1 %, monocytes 0.7 %, eosinophils 8.8 %, and basophils 0.4 %), thrombocytopenia of 43,000 cells/μL, anemia of 8.8 g/dL, and reticulocyte count of 0.34 %. Other laboratory tests were unremarkable, with the exception of elevated liver enzyme levels with AST of 213 IU/L (normal range: M. J. Choi :D.-Y. Kim : S. B. Cho (*) Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea e-mail: drsbcho@gmail.com