A 65-year-old retired male (Fitzpatrick phototype II) previously healthy except for a distant history of basal cell carcinoma presented to our dermatology clinic with a two-day duration of a rash. The lesions were first noticed on his chest, upper extremity and back []. The rash was extremely pruritic resulting in insomnia for the previous 2 nights which went unrelieved despite oral diphenhydramine. Also concerning to him and his wife was the whip like nature of the rash which was somewhat linear and run vertically right down his back in a manner unlikely to be produced by simple excoriation. In addition, he denied reaching for or scratching his back in any manner. Review of systems was negative, and he denied any recent history of travel, similarly sick contacts or recent outdoor contactants or change in body soaps or laundry detergents.\nHe denied any prior history of similar rashes and his past medical history was non-contributory. A detailed exposure history revealed the patient had eaten mushrooms 48 hours ago during dinner at a Chinese cuisine buffet. He admitted to ingesting great quantities of a medley of cooked and raw mushroom including the Shiitake mushroom variety.\nPhysical examination was striking with a truncal dominant but generalized rash in a centripetal distribution (). The lesions consisted of raised, relatively uniform erythematous papulovesicles arranged in linear arrangement. Close-up views [] confirmed the papulo-vesicular nature of the rash with multiple small papules grouped both along the breadth and length of each linear streak within an erythematous background.\nGiven the clinical history and presentation the diagnosis was consistent with a shiitake dermatitis. Flagellate patterns of eruption have also been noted in drug reactions particularly to bleomycin, peplomycin (a bleomycin derivative), docetaxel, adult-onset Still’s disease, and dermatomyositis [].\nThe patient was put on a mid-potency topical steroid (Triamcinolone 0.1% ointment applied to affected areas twice daily). The rash resolved within 1 week. It has been reported that shiitake dermatitis can also resolve spontaneously.
In April 2013, a 42-year-old male was diagnosed with stage IIIB testicular cancer in accordance with the American Joint Committee on Cancer Staing Classification () at the Kangwon National University Hospital (Chuncheon, Korea). The histology revealed non-seminomatous germ cell tumor (NSGCT) comprising seminoma (60%), yolk sac tumor (25%), embryonal carcinoma (10%) and teratoma (5%). Following orchiectomy, serum α-fetoprotein (αFP) levels were 20 ng/ml and lactate dehydrogenase (LDH) levels were 298 U/l (normal, <190 U/l). Computed tomography (CT) scanning showed pre- and para-aortic lymphadenopathy ≤3.6 cm. There was no medical history of note and, specifically, no history of dermatological disorders or allergy. The pateint’s pulmonary function test results were normal. The patient was commenced on bleomycin, etoposide and cisplatin chemotherapy, intravenously from May 20, 2013 in the outpatient clinic. Bleomycin (30 units) was scheduled to be administered on days 2, 9 and 16, while etoposide (100 mg/m2) and cisplatin (20 mg/m2) were administered for 5 days from day 1. Treatment was intended to be repeated every three weeks. After 10 days from the start of treatment, the patient subsequently developed a generalized pruritus and erythematous linear rash that was most prominent on the trunk and upper and lower extremities. The patient visited the emergency room (ER) and was given antihistamine. The patient then revisited the clinic for bleomycin treatment on day 16, and the rash in which the patient appeared to have been whipped over multiple body areas was observed. Physical examination showed the appearance of an erythematous popular rash on the whole body, with evidence of dermatographia (). There were no scales or lichenification, and the patient’s vital signs were normal. Laboratory tests at ER showed a white blood cell count of 3,800/mm3 (normal range, 3,800–10,000/mm3) (segmented neutrophils, 70%; lymphocytes, 24%; and eosinophils, 3%), hemoglobin levels of 13.7 g/dl (normal range, 13.3–16.5 g/dl), a platelet count of 313,000/mm3 (normal range, 140,000–400,000/mm3), serum LDH levels of 208 U/l (normal range, <190 U/l) and C-reactive protein levels of 5.35 mg/dl (normal range, <0.75 mg/dl). Prothrombin time and activated prothrombin time were 11.5 (normal range, 12.1–14.5 sec) and 36.7 sec (normal range, 31.0–43.7 sec), respectively.\nA skin biopsy of a right forearm lesion was taken. Bleomycin treatment on day 16 was cancelled. Pathological examination of the skin biopsy showed endothelial swelling and perivascular mononuclear cell infiltration present in the superficial and deep dermis (). The findings were considered to be consistent with a systemic hypersensitivity reaction. Given the patient’s clinical history and the gross appearance of the lesions, the diagnosis was most compatible with a severe bleomycin-induced flagellate erythema reaction. The patient was commenced on a short course of oral prednisolone, 20 mg daily, and antihistamine. The itching sensation was improved, but mild hyperpigmentation remained.\nConsequently, bleomycin was withheld from the treatment regimen. As the patient’s NSGCT was intermediate-risk, we recommended that the regimen should be changed to etoposide, ifosfamide and cisplatin. However, the patient refused to add ifosfamide following a discussion of the possible toxicities. Tumor markers, such as αFP and LDH levels, were normalized within 3 weeks of the first cycle of chemotherapy. Following a further three cycles of etoposide 100( mg/m2, days 1–5) and cisplatin (20 mg/m2, days 1–5), without bleomycin, every three weeks, no remnant mass was visible in the abdomen on positron emission tomography-CT.