Toxic epidermal necrolysis following thalidomide and dexamethasone treatment for multiple myeloma: a case report

Abstract

Dear Editor, Toxic epidermal necrolysis (TEN) is a life-threatening idiosyncratic adverse drug reaction characterized by fullthickness epidermal necrosis and eventual development of subepidermal bullae [1, 2]. Carbamazapine, phenytoin, and allopurinol are frequent causes of TEN in Asia [1]. Although thalidomide has been suggested as a cause of TEN, to the best of our knowledge, only two cases had been reported worldwide [3, 4]. We present the case of a 65-year-old male patient who was initially diagnosed with Immunoglobulin G-κ (IgG-κ) multiple myeloma stage IIIA, and had been treated with combination chemotherapies including a VAD (vincristine, doxorubicin, and dexamethasone) regimen as well as an MP (melphalan and prednisone) regimen. About 3 years after finishing MP treatment, the patient presented with bone pain and a serum monoclonal protein level of 4,170 mg/dl. We initiated treatment with 200 mg thalidomide per day for 12 days and 40 mg dexamethasone per day for 4 days, and the dose of thalidomide was then increased to 400 mg per day. Eleven days after the boost, the patient’s course was complicated by the development of sloughing from the periorbital and perioral regions. Three days after the onset of the initial event, the patient was admitted to the emergency department with fever, dysphagia, and itching. The same day, oral mucositis, angioedema of lips and eyebrow, and diffuse erythematous to purpuric patches and plaques appeared on the face, neck, trunk, and extremities. On the third day of hospitalization, a skin biopsy showed subepidermal bullous change with an infiltration of lymphocytes and polymorphonuclear cells in the epidermis which suggested TEN (Fig. 1). On the fifth day, the clinical course was complicated by the worsening rash over the entire trunk, and the patient was started on 400 mg/kg intravenous immunoglobulin (IV-Globulin S®, Green Cross Inc., Korea) per day for five consecutive days. In addition, the patient was intensively treated as a burn patient. On the sixth day, focal skin detachment was noticed and, after 2 days, was followed by generalized detachment from the face to the lower extremities. The patient’s severity-ofillness score for TEN (SCORTEN) was 4 with an expected W. K. Eo : S. H. Cheon : S. H. Lee : J. S. Jeong Integrative Cancer Center, Kyung Hee University, East-West Neo Medical Center, Seoul, South Korea