Blood, 15 March 2003, Vol. 101, No. 6, pp. 2446-2446
CORRESPONDENCE
To the editor:
Severe skin reaction to imatinib in a case of
Philadelphia-positive acute lymphoblastic leukemia
STI571 (imatinib) is increasingly being used in the
treatment of different phases of chronic myeloid leukemia and
metastatic gastrointestinal stromal tumors.1,2
Philadelphia-positive acute lymphoblastic leukemia (Ph+ALL)
has a poor prognosis with the current treatment options.3 Allogenic stem cell transplantation is the only curative management option available to date, the long-term survival being 35% to 65%4 in first complete remission, and poorer in second
and third remissions. In a phase 2 trial with relapsed or refractory Ph+ALL, imatinib induced hematologic responses in 60% of
cases.5 In this journal, Rule et al6 recently
reported that imatinib treatment can be continued in patients with skin
eruptions by using concomitant short-term steroid therapy or by
reintroducing imatinib with gradual dose escalation. The present study
describes a case of Ph+ALL with a severe adverse cutaneous
reaction to imatinib, and its course upon reintroducing imatinib.
A 72-year-old white woman with Ph+ALL showed
hematologic response with induction therapy (vincristine,
daunorrubicine, cyclophosphamide, and prednisolone). Maintenance
therapy was started with mercaptopurine, after which imatinib was
continued at a dose of 400 mg/d. After 17 days of treatment, the
patient developed an erythematous maculopapular and mildly pruritic
rash, with erosive ulcers on the mouth. The rash affected the back,
abdomen, and upper and lower limbs. Some papules had a vesiculated
center whereas others were target lesions. A papule biopsy diagnosed
drug-induced erythema multiforme with folliculitis. Imatinib was
discontinued and prednisolone was introduced. The patient refused to
restart imatinib and continued with mercaptopurine alone. ALL relapsed
3 months later, followed by second complete remission with reinduction
chemotherapy. At this point the patient agreed to restart treatment
with imatinib. We decided to start with a low imatinib dose (100 mg/d)
associated to prednisolone (30 mg/d). There were no further recurrences
in skin eruption and presently, 30 days later, the dose is well
tolerated. As a result, the imatinib dosage has been increased
to 400 mg/d, with continuation of prednisolone at 10 mg/d.
Erythema multiforme is a severe adverse cutaneous reaction producing
important morbidity.7,8 In patients treated with imatinib,
7% to 21% suffer adverse cutaneous reactions.9 This incidence appears to be dose-dependent, and 5% of such reactions are
severe or life-threatening.9 In coincidence with
Rule et al,1 the present case shows that imatinib
can be reintroduced when it is associated to steroids over the
short-term, even in patients with severe adverse cutaneous reactions.
Blanca Sanchez-Gonzalez, Jose C. Pascual-Ramirez, Pascual Fernandez-Abellan, Isabel Belinchon-Romero, Concepcion Rivas, and Gloria Vegara-Aguilera
Correspondence: Blanca Sanchez-Gonzalez, Hospital
General Universitario, Hematology, Alicante, Spain;
e-mail: blsanch{at}yahoo.es
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