High-Dose Methotrexate-Induced Bullous Variant of Acral Erythema

Abstract

Waltzer and Flowers 1 have identified a chemotherapy-induced bullous variant of acral erythema that is always associated with cytarabine, given alone or in combination with other agents. We report a case of bullous acral erythema occurring after the administration of high-dose methotrexate to an adolescent patient. Report of a Case. A 13-year-old girl was treated with methotrexate for chondroblastic osteogenic sarcoma of the left humerus at a dose of 12 g/m 2 (14 g per cycle). Each cycle was given at 1-week intervals. Within 24 hours following the seventh cycle, a symmetrical, edematous, painful, red, violaceous erythema developed on the balls of the feet and the fleshy part of the toes. A slight redness was noted on the palms of the hands. Over a 72-hour period, the plantar erythema became covered with large bullae, especially on the pressure points ( Figure 1 ). Simultaneously, diffuse macular lesions, which were purpuric and necrotic