DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY

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Justin Hoover
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1 Focus Session U020: Case-based Challenges in Pediatric Dermatology Hospital Consults DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Raegan D. Hunt, MD, PhD Assistant Professor of Dermatology & Pediatrics Chief, Pediatric Dermatology Texas Children s Hospital Baylor College of Medicine Raegan Hunt, MD, PhD Focus Session U020: Case-based Challenges in Pediatric Dermatology Hospital Consults DISCLOSURES Pfizer: Advisory Board Consulting Fee Objectives Diagnose pediatric skin eruptions in the hospital setting Determine when laboratory testing or skin biopsy may be helpful in management of hospitalized pediatric patients Case 4-month-old healthy child Blistering x 2 days Previously with 1 localized blister on shin about 3 weeks ago, diagnosed as impetigo No FMHx blistering disorders What is your next step? 1. Panic 2. Google 3. Phone a friend 4. Skin biopsy No pregnancy complications 1

2 What is your next step? What diagnosis do you suspect? 1. Panic 2. Google 3. Phone a friend 4. Skin biopsy 1. Mastocytosis 2. Linear IgA disease 3. Stevens Johnson syndrome 4. Thermal burn 5. Infantile bullous pemphigoid What diagnosis do you suspect? Bullous Mastocytosis 1. Mastocytosis 2. Linear IgA disease 3. Stevens Johnson syndrome 4. Thermal burn 5. Infantile bullous pemphigoid Bullous mastocytosis: Form of Diffuse Cutaneous Mastocytosis Mast cell infiltration of skin Thick and leathery skin ( peau d orange skin appearance) Plaques and nodules Bullae can be the first presentation Suspected etiology of bullae: serine protease release from mast cells Cutaneous Mastocytosis: Revised Consensus Classification 2016 Characteristics of typical adulthood-onset and typical childhood-onset mastocytosis Diffuse cutaneous mastocytosis Diffuse skin thickening and erythema Pronounced dermatographism Bullae in some infants ( bullous mastocytosis ) Adult onset morphology Maculopapular cutaneous mastocytosis Polymorphic (urticaria pigmentosa) Monomorphic Classic pediatric onset morphology Cutaneous mastocytoma No longer recommended: telangiectasia macularis eruptiva perstans (TMEP) Hartmann, et al. J Allergy Clin Immunol Jan;137(1):35-45 ISM: Indolent Systemic Mastocytosis Diffuse cutaneous mastocytosis Hartmann, et al. J Allergy Clin Immunol Jan;137(1):

3 Laboratory Work Up Pediatric Mastocytosis: screening for systemic disease CBC/Diff- within normal limits LFTs- within normal limits Tryptase 283 mcg/ L (range < 10.9 mcg/l) Bone marrow biopsy no abnormal mast cell proliferation C-KIT mutation analysis- negative Carter, et al. J Allergy Clin Immunol December ; 136(6): e1-3 Cohort of 105 children: Most children experienced major or complete disease resolution (57%) Partial improvement was observed among remaining children Enlargement of liver or spleen (hepatosplenomegaly): strong indicator of systemic disease Carter, et al. J Allergy Clin Immunol December ; 136(6): e1-3 Antihistamines: around the clock Cetirizine (H1 antihistamine) Ranitidine (H2 antihistamine) Treatment Mastokids.org: Magic Masto Lotion Interval viral illness with thrombocytopenia: Increased blistering Hemorrhagic appearance to bullae Breakthough: diphenhydramine as needed for flushing/itch Good skin moisturization Topical corticosteroids: triamcinolone 0.1% oint Magic Masto Lotion Summary: Pediatric Mastocytosis Revised cutaneous mastocytosis nomenclature (2016): Diffuse cutaneous mastocytosis Maculopapular cutaneous mastocytosis Polymorphic (urticaria pigmentosa) Monomorphic Cutaneous mastocytoma No longer recommended category: telangiectasia macularis eruptiva perstans (TMEP) Case Among children with cutaneous mastocytosis Organomegaly appears to be the most sensitive predictor of systemic disease Antihistamines (H1&H2) +/- topical corticosteroids or masgic mastolotion helpful Prognosis good with most children improving over time 3

4 16 year -old girl with history of ALL and refractory seizure disorder Skin eruption x 2 days Fever 38.4 C (101 F) Non-productive cough Cervical lymphadenopathy Facial and hand edema Medication History Divalproex sodium (depakote) 5 weeks before rash Added lamotrigine (lamictal) 4 weeks before rash Labs Eosinophils 12% AST 118 ALT 74 Free T ( ng/l), TSH within normal limits Cr within normal limits UA within normal limits Which additional laboratory finding may help with diagnosis? Which additional laboratory finding may help with diagnosis? 1. Atypical lymphocytosis 2. Thrombocytosis 3. Elevated divalproex sodium serum level 4. Serum PCR positive for HHV 5 5. Positive EBV IgM titers 1. Atypical lymphocytosis 2. Thrombocytosis 3. Elevated divalproex sodium serum level 4. Serum PCR positive for HHV 5 5. Positive EBV IgM titers Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)/ Drug-Induced Hypersensitivity Syndrome (DIHS) Manifests 2 to 6 weeks after the initiation of offending drug 10% Mortality rate Fever Skin eruption most often morbilliform can demonstrate microvesicles Lymphadenopathy Edema of face and hands Eosinophilia Atypical lymphocytosis Hepatitis/Transaminitis- up to 50% Pulmonary infiltrates Nephritis Myocarditis This 15-year-old girl taking lamotrigine x 4 weeks for bipolar disorder has fever to 101 F, morbiliform eruption, the lip findings shown, and a 1 cm superficial erosion on the vulvar mucosa. Labs: ALT 68, AST % eosinophils Which condition are you most concerned about? 1. Stevens-Johnson Syndrome 2. Toxic Epidermal Necrolysis 3. Erythema Multiforme 4. DRESS/drug-induced hypersensitivity syndrome 4

5 This 15-year-old girl taking lamotrigine x 4 weeks for bipolar disorder has fever to 101 F, morbiliform eruption, the lip findings shown, and a 1 cm superficial erosion on the vulvar mucosa. Labs: ALT 68, AST % eosinophils Which condition are you most concerned about? Mucosal involvement in DRESS Estimated to occur in 50% of DRESS cases Milder than TEN/SJS spectrum Conjunctival injection Mild mucosal ulcerations Ben m rad M, et al. Medicine (Baltimore) May;88(3): Stevens-Johnson Syndrome 2. Toxic Epidermal Necrolysis 3. Erythema Multiforme 4. DRESS/drug-induced hypersensitivity syndrome DRESS Stevens-Johnson syndrome Mucosal involvement in DRESS Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) DRESS Stevens-Johnson syndrome Evaluation CBC/diff Liver function tests Creatinine Urinalysis Baseline thyroid function studies Treatment Discontinue offending medication! Oral corticosteroids with 3-6 week taper if reaction severe Monitoring Thyroid function tests- 2 to 3 months after Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Common Culprit Medications Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Aromatic Anticonvulsants Antibiotics Other Phenytoin Carbamazepine Phenobarbitone Lamotrigine Sulfonamides Minocycline Nitrofurantoin Terbinafine Dapsone Allopurinol Cross reactivity between anticonvulsant medications may be as high as 75% If DRESS occurs with aromatic anticonvulsant, avoid the other aromatic anticonvulsants Phenytoin (Dilantin) Carbamazepine (Tegretol) Phenobarbitone (Phenobarbital) Lamotrigine (Lamictal) 5

6 Anticonvulsant hypersensitivity syndrome/dress Among patients taking lamotrigine: Rate of serious rashes - 0.1% Of patients with anticonvulsant hypersensitivity (DRESS) syndrome to lamotrigine, 60% also taking valproic acid derivative Co-administration of valproic acid derivative triples the half-life of lamotigrene Rahman M, Haider N. Am J Psychiatry May 2005; 162:1021 Started divalproex sodium (depakote) - 5 weeks before rash Added lamotrigine (lamictal) - 4 weeks before rash Black Box warning Serious Rash serious rashes requiring hospitalization and D/C tx incl. Stevens-Johnson syndrome, rare cases of toxic epidermal necrolysis, and rash-related deaths; incidence w/ adjunctive epilepsy tx 0.8% in 2-16 yo and 0.3% in adults; bipolar and other mood disorder incidence 0.08% as initial monotherapy and 0.13% as adjunctive tx; age is only risk factor identified as predictive for risk of rash occurrence or severity; other risk factors may incl. concurrent valproic acid derivative or exceeding initial lamotrigine dose or dose escalation recommendations; most lifethreatening rashes occur in the first 2-8wk of tx w/ isolated cases after prolonged tx; though benign rashes may also occur D/C tx at 1st sign of rash unless clearly not drug related; D/C tx may not prevent rash from becoming life-threatening or permanently disabling or disfiguring Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Associated with reactivation of human herpesvirus (HHV) HHV 6 HHV 7 HHV 6 positive DRESS is associated with a more severe course and longer hospital length of stay (LOS) LOS (11.5 days vs. 5 days, P = 0.039) Number of febrile days (12.5 days vs. 3 days, P = 0.032) Hara H, et al. Dermatology 2005; 211: Seishima M, et al. Br J Dermatol 2006 Aug; 155(2): Ahluwalia J, et al. Br J Dermatol Apr;172(4): Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Reported autoimmune sequelae Autoimmune thyroiditis Type 1 diabetes mellitus Vitiligo Alopecia areata Systemic lupus erythematosus In a study of 145 adult patients with DRESS/DIHS, the most common autoimmune sequelae were Autoimmune thyroiditis (4.8%) Type 1 diabetes mellitus (3.4%), sometimes fulminant within 1-2 months Kano, et al. J Dermatol Mar;42(3): Serious drug reaction 10% mortality Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Summary Clinical presentation Fever Lymphadenopathy Facial/hand swelling Erythematous skin eruption May have mild mucosal involvement Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Summary In acute phase, may affect multiple organ systems Liver Lungs Kidneys Heart In subacute phase (~2-3 months after resolution), may affect Thyroid Risk of autoimmune sequelae 6

7 Case Erythematous patches and petechiae in Neck fold Bilateral inguinal folds Infantile seborrheic dermatitis like symptoms have not improved with treatment in this 18-month old child. Biopsy will likely show what on histopathology? Infantile seborrheic dermatitis like symptoms have not improved with treatment in this 18-month old child. Biopsy will likely show what on histopathology? 1. Reniform cells staining positive for CD20 2. Reniform cells staining positive for CK Birbrick granules 4. Spongiotic dermatits 5. Leukocytoclastic vasculitis 1. Reniform cells staining positive for CD20 2. Reniform cells staining positive for CK Birbrick granules 4. Spongiotic dermatitis 5. Leukocytoclastic vasculitis EM: LCH -- Birbrick granules Langerhans Cell Histiocytosis (LCH) Skin findings occur in 50% of children with LCH Skin-only LCH in 10% of children Most often seborrheic dermatitis -like or diaper eruption Resistant to treatment Warning sign: petechiae in intertiginous areas Self-healing congenital reticulohistiocytosis (Hashimoto Pritzker disease)--- cannot be predicted reliably Young babies with skin findings of LCH must be followed ~ 50% will progress to multisystem disease Weitzman and Egeler. Current Opinion in Pediatrics 2008, 20:23 2 7

8 Mimic: Infantile seborrheic dermatitis Summary: Langerhans Cell Histiocytosis (LCH) in young children Skin findings occur in 50% of children with LCH Skin-only LCH disease in 10% of children Often seborrheic dermatitis -like or diaper eruption Resistant to treatment Warning sign: petechiae in intertiginous areas Self-healing congenital reticulohistiocytosis (Hashimoto Pritzker disease)--- cannot be predicted reliably Young babies with skin findings of LCH must be followed ~ 50% will progress to multisystem disease Weitzman and Egeler. Current Opinion in Pediatrics 2008, 20: year-old-boy with relapsed stage 2 Burkitt's lymphoma hospitalized for chemotherapy Painful groin eruption Case Erythema appeared the morning after patient cleaned genital area with a chlorhexidine gluconate 4% wipe No itch Worsening despite topical nystatin cream Advancing tender border Afebrile, absolute neutrophil count 233 What is your next step? What is your next step? 1. Take careful history for contact allergens 2. Fungal/yeast culture 3. Bacterial skin culture 4. Start patient empirically on IV antibiotic and IV antifungal 5. Take careful history for recent chemotherapy agents 1. Take careful history for contact allergens 2. Fungal/yeast culture 3. Bacterial skin culture 4. Start patient empirically on IV antibiotic and IV antifungal 5. Take careful history for recent chemotherapy agents 8

9 Oncology and urology team started treating patient with IV clindamycin and IV fluconazole Fungal/yeast skin culture- negative Bacterial skin culture- negative Blood cultures- negative Skin exposures Limited to hibiclens wipes, nystatin, zinc oxide Relapsed Burkitt s lymphoma: TAT ANHL01P1 group C COP-R Day 0 - cyclophosphamide 537 mg (300 mg/m2) day 0 - vincristine 1.8 mg (1 mg/m2) day 0 - prednisone 54 mg BID, day 0-6 COMRAP1 Day 8 - rituximab 670 mg (375 mg/m2) Day -2 and 0 - vincristine 2 mg (2 mg/m2) day 0 - cyclophosphamide 450 mg (250 mg/m2) day high dose methotrexate mg (8g/m2) day 0 NOTE: had delayed clearance - doxorubicin 107 mg (60 mg/m2) day 1 - prednisone 54 mg BID, day 0-4 with taper over 3 days - pegfilgrastim 6 mg day 6 - Intrathecal therapy: methotrexate, cytarabine, hydrocortisone Toxic Erythema of Chemotherapy Clinical features Erythematous patches or edematous plaques Most frequently: hands, feet, intertriginous zones, scrotum Less commonly: elbows, knees, neck, and ears Dusky hue, petechiae, and/or sterile bullae may be seen in the affected areas of erythema Scattered papules may be seen at the periphery of the lesions Timing of onset 2 days to 3 weeks after chemotherapy administered Symptoms Pain, burning, paresthesia, or tenderness, more often than pruritus Spontaneous resolution without specific therapy Heals with desquamation Possible recurrence if the same or higher dose is administered Bolognia JL, et al. J Am Acad Dermatol Sep;59(3):524-9 TL Parker, et al. Bone Marrow Transplantation (2013) 48, TL Parker, et al. Bone Marrow Transplantation (2013) 48, KA Webber, et al. Arch Dermatol. 2007;143(1):67-71 Toxic Erythema of Chemotherapy Toxic erythema of chemotherapy (TEC) Histological findings Vacuolar degeneration of the basal layer Necrotic keratinocytes Dysmaturation of keratinocytes Dermal edema Eccrine squamous syringometaplasia and/or eccrine hidradenitis TH McCalmont, J Cutan Pathol 2013: 40: Mirjana Ziemer and Maja Mockenhaupt (2011). Severe Drug-Induced Skin Reactions: Clinical Pattern,Diagnostics and Therapy, Skin Biopsy - Perspectives, Dr. Uday Khopkar (Ed.) TL Parker, et al. Bone Marrow Transplantation (2013) 48, Eccrine squamous syringometaplasia Palmoplantar erythrodysesthesia Acral erythema Hand-foot syndrome Neutrophilic eccrine hidradenitis Pseudocellulitis Ara-C ears Intertriginous eruption of chemotherapy C. Sivaramamoorthy, et al. Med J Aust 2009; 191 (1): 40 GL Anesi, et al. Journal of Clinical Oncology, Vol 30, No 16 (June 1), 2012: p e146 9

Chemotherapeutic agents associated with TEC Toxic Erythema of Chemotherapy: Treatment More commonly associated: Cytarabine (arac)

associated: Bleomycin Busulfan Carmustine, lomustine Cisplatin, carboplatin Clofarabine Cyclophosphamide, ifosfamide Etoposide

Thiotepa Vinorelbine Supportive Cool compresses Bland emollients Topical corticosteroids Topical antibiotics for erosions Limited

10 Chemotherapeutic agents associated with TEC Toxic Erythema of Chemotherapy: Treatment More commonly associated: Cytarabine (arac) Anthracyclines (doxorubicin) 5-Fluorouracil Capecitabine (5-FU prodrug) Taxanes (docetaxel > paclitaxel) Methotrexate Less commonly associated: Bleomycin Busulfan Carmustine, lomustine Cisplatin, carboplatin Clofarabine Cyclophosphamide, ifosfamide Etoposide Gemcitabine Hydroxyurea Melphalan 6-Mercaptopurine Mitoxantrone Receptor tyrosine kinase inhibitors (imatinib, sunitinib) Tegafur Thiotepa Vinorelbine Supportive Cool compresses Bland emollients Topical corticosteroids Topical antibiotics for erosions Limited data for: local hypothermia, systemic corticosteroids, oral vitamin B6 ( mg once daily), oral vitamin E (300 mg once daily) Bolognia JL, et al. J Am Acad Dermatol Sep;59(3):524-9 Summary: Toxic Erythema of Chemotherapy Toxic phenomenon Not immune mediated Self-limited THANK YOU Frequently misdiagnosed as Allergic drug reaction Allergic contact dermatitis Graft versus host disease Cutaneous infections 10

Pediatric Dermatology

Pediatric Dermatology --------- Emergencies & Urgencies Nicholas V. Nguyen, M.D. Director, Pediatric Dermatology Disclosures In the past 12 months, I have had the following financial relationships with