Table 1 Therapy and Rash Characteristics
Patient | Demographics at Time of Rash Onset | Therapy Sequence [(Days to Rash Onset (RO)] | Clinical Course | Lab Abnormalities | CTCAE Rash Grade (G), Characterization Location Initial Diagnosis | Histopathology | Confounding Variables | Current Survival Status |
|---|---|---|---|---|---|---|---|---|
1 | 54 year old Caucasian female | I/N ×1 - > N (Day − 315 to − 148) V/C (Day −12 to RO) | Hospitalized High grade fever Hypotension Oral mucositis | Hyponatremia Hypokalemia Elevated lactate (2.5XULN) Lymphocytopenia Elevated sIL-2R (20 X ULN) CRP 163 | G-4, Diffuse morbilliform eruption of trunk and extremities DRESS vs SJS vs drug reaction | Papillary dermal edema, slight basal layer vacuolization, superficial dermal perivascular lymphocytic infiltration and eosinophils | Started allopurinol 14 days prior to rash onset | Deceased |
2 | 60 year old Caucasian female | N (Day − 408 to −228) D/T (Day −214 to RO) | ICU High grade fever Hypotension AMS Lip swelling Difficulty swallowing | Transaminitis | G-4, Diffuse morbilliform eruption of trunk and extremities Drug reaction vs sepsis vs DRESS | Subepidermal vesicle formation with eosinophils; positive direct immunofluorescence with linear IgG and IgA at the basement membrane zone suggestive of bullous pemphigoid or linear IgA bullous dermatosis | On course of amoxicillin-clavulanic acid at rash onset | Alive |
3 | 54 year old Caucasian male | D/T (Day − 331 to − 143) N (Day − 122 to − 24) V/C (Day − 16 to RO) | Hospitalized High grade fever | Hyponatremia Elevated creatinine Lymphocytopenia | G-4, Diffuse targetoid lesions involving trunk, extremities and face SJS vs drug eruption (including DRESS) vs viral exanthem | Papillary dermal edema, slight basal layer vacuolization, superficial dermal perivascular lymphocytic infiltration and eosinophils | Symptoms of upper respiratory tract infection present immediately prior to rash onset | Deceased |
4 | 58 year old Caucasian female | N (Day − 344 to −43) V/C (Day −13 to RO) | Outpatient management | None | G-4 Diffuse morbilliform eruption of trunk and extremities Drug reaction | No biopsy performed | Started with full doses of V/C when had been instructed to start at a reduced dose of each | Deceased |
5 | 59 year old Caucasian female | V/C (Day −75 to −11) P (Day −6 to RO) | ICU High grade fever Hypotension Tachycardia | Elevated creatinine Transaminitis Hyperbilirubinemia CRP 200 | G-4 Diffuse morbilliform eruption of trunk and extremities Sepsis vs DRESS vs pembrolizumab induced reaction | Papillary dermal edema, slight basal layer vacuolization, superficial dermal perivascular lymphocytic infiltration and eosinophils; few plasma cells, neutrophils, and a rare focus of parakeratosis | Concern for sepsis from cellulitis (re-fevered after antibiotics narrowed) | Deceased |
6 | 58 year old Caucasian female | P (Day −56) V/C (Day −21 to RO) | Outpatient management | Transaminitis Lymphocytopenia CRP 159 | G-2 Discrete scattered erythematous edematous plaques on extremities Drug reaction vs Sweets Syndrome vs early SJS | Papillary dermal edema, slight basal layer vacuolization, superficial dermal perivascular lymphocytic infiltration and eosinophils | No apparent confounding variables | Alive |