Atypical Sweet syndrome: skin sinus tracts in an acutely febrile patient after lymphoma treatment: a case report, 2023.
"A 30-year-old male patient was admitted to our hospital for 8 days with redness and swelling of the abdominal wall and left arm. The patient had systemic anaplastic large cell lymphoma (sALCL). He had received immune-chemotherapy with a BV-CHP regimen, including brentuximab vedotin (BV, 1.8 mg/kg on day 1), cyclophosphamide (750 mg/m2 on day 1), doxorubicin (50 mg/m2 on day 1), and prednisone (100 mg on days 1–5) (4) for four cycles and achieved complete remission (CR) during the second cycle. Ten days after his last treatment, the patient received granulocyte colony-stimulating factor (G-CSF 300 μg for 2 days) injections in the abdomen wall and left arm due to agranulocytosis. Seventy-two hours after G-CSF injections, the patient developed rapidly expanding erythema and induration in the areas of administration. In addition, he also reported low-grade fever. At hospital admission, the size of the abdominal wall induration had reached 10×10 cm2."
- 30-year-old male patient.
- Redness and swelling of abdomen and left arm.
- Receiving chemotherapy for cancer - systemic anaplastic large cell lymphoma.
- Rapidly growing skin rash after granulocyte colony-stimulating factor (G-CSF 300 μg for 2 days) injections in the abdomen and left arm.
- Initially misdiagnosed as infection, but didn't respond to antibiotics.
- Skin rash developed into crater-like ulcer and abscess. The ulcer was a sinus tract ulcer or tunnelling ulcer. Normally, Sweet's syndrome doesn't affect the tissues below the dermal skin layer. In this case both fatty tissue and muscle were affected.
- Skin biopsy showed lots of neutrophils in the muscle and fatty tissue, but no lymphoma cells.
- PET and CT scan showed a negative result for lymphoma. Tumour recurrence and skin invasion ruled out.
- Patient diagnosed with drug-induced Sweet's syndrome or DISS (probably granulocyte colony-stimulating factor). Successfully treated with prednisone.
- DISS usually develops within 2 weeks after drug use. Repeated use of the same drug at the same site can cause DISS recurrence. G-CSF is currently thought to be the most common drug that induces DISS.
- The skin ulceration was localized, developing at the injection sites. This isn't consistent with brentuximab vedotin (BV)-induced skin lesions where the lesions are widespread. However, BV may have been a contributing factor. BV increases immune activity that can lead to hypersensitivity to G-CSF injection (immune system overreacts to G-CSF).
ADDITIONAL NOTE.
- Ulcerative Sweet's syndrome (SS) needs to be distinguished from pyoderma gangrenosum (PG). Both SS and PG are forms of neutrophilic dermatosis.
- In SS, white blood cell count, including granulocytes (particularly neutrophils) can be significantly increased.
- At the time of admission, the patient had some skin changes but no ulcers, and significantly increased white blood cells and granulocytes in peripheral blood.
- In PG, the time from skin change to ulcer is fast, while most SS lesions don't progress to ulcer.
- The patient’s skin in this case took 11 days to progress from local redness to ulceration.
- Unlike PG, skin did not form “wrinkled paper” changes after ulcers healing.
- PG mainly affects lower legs. SS more likely to affect upper body. ncbi.nlm.nih.gov/pmc/articl...
