engleski

Vemurafenib-induced hypersensitivity reaction during therapy for metastatic melanoma

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, severe, drug-induced hypersensitivity reaction that includes skin eruption, eosinophilia, atypical lymphocytosis, lymphadenopathy and internal organ involvement. It is characterized by a latency period of two to eight weeks and a prolonged course with frequent relapses, despite the discontinuation of the offending drug. We herein present a case of a systemic hypersensitivity reaction to BRAF inhibitor vemurafenib, that displayed some but not all features of DRESS. A 34-year old woman presented with a widespread morbilliform skin rash with follicular accentuation and mild facial erythema and edema one week following the initial administration of vemurafenib for metastatic melanoma. The skin lesions were accompanied by fever (up to 38°C), significantly elevated values of liver enzymes and C- reactive protein and slight, transient eosinophilia. Due to suspected DRESS, vemurafenib was withdrawn and the patient was treated with systemic and topical glucocorticoids. After three weeks, there was significant improvement of the skin rash, along with normalization of liver enzymes' and CRP values. Given the unavailability of other treatment options, vemurafenib was reintroduced albeit at a lower dose, while the patient was still on prednisone. Gradually, the vemurafenib dose was increased and prednisone was successfully tapered. The patient developed only a mild erythema of the face and neck, along with a slight and transient elevation of liver enzymes. Throughout the course of treatment with vemurafenib, the patient’s skin condition continued to wax and wane and each subsequent bout was successfully treated with local therapy. A skin biopsy and patch test were not performed in our patient, however, based on a retrospective analysis of the patient’s laboratory reports and the representative skin eruption, a diagnosis of DRESS was likely. Since the patient did not meet all of the RegiSCAR criteria, we conclude that the patient experienced a "mini- DRESS" reaction to vemurafenib. DRESS or DRESS-like reactions must be recognized promptly due to possible acute life-threatening complications as well as subsequent development of autoimmune disorders. However, this case indicates that vemurafenib does not necessarily induce fully developed DRESS and that the anti-cancer treatment may even be continued without severe complications, to ensure the best possible prognosis for the patient.

vemurafenib, drug-induced hypersensitivity reaction, DRESS

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