A 70-year-old female patient without other relevant medical history was started on pemetrexed and carboplatin for mesothelioma after vitamin B12 and folic acid supplementation. The patient developed a rash on the anterior chest wall 7 days after the first cycle which persisted despite treatment with loratadine. Four days after the second cycle (14 days after the onset of the rash), the patient was admitted with widespread maculopapular eruptions treated with betamethasone valerate 0.1% cream along with cetirizine 10 mg twice daily. The patient’s additional symptoms were fever, pancytopenia, including neutropenia, seizures and confusion, pulmonary embolism, and nausea. Over the next few days, the rash continued to coalesce and spread. Forty days after the initial onset, 80% of the total body’s surface area (TBSA) was affected with beginning denudation (). Histology showed widespread epidermal necrosis with multiple dyskeratotic keratinocytes. A TEN-like reaction was diagnosed. Treatment with prednisone 50 mg daily to be weaned off by 10 mg every 7 days was initiated along with supportive measures. The patient could be discharged to the community in a stable condition 50 days after the initial rash. Chemotherapy was discontinued and palliative care was initiated due to the sADRs including the diagnosis of a TEN-like reaction.
A 42-year-old woman diagnosed with stage IV NSCLC (adenocarcinoma) was admitted to our hospital in August 2013 and given an AP regimen (pemetrexed 500 mg/m2 on day 1, cisplatin 75 mg/m2 on days 1 to 3, repeated every 3 weeks) as initial chemotherapy on August 2nd, 2013. She received folate, vitamin B12, and corticosteroids as recommended. Several days later, her EGFR genetic test results demonstrated an exon 19 mutation (L747-T751>P); thus, she started taking gefitinib (250 mg once daily) on August 15th. On August 23th, which was 21 days after AP chemotherapy and 8 days after gefitinib treatment, the patient suddenly developed a widespread eruption including acne-like rash on the face, erythema papules on the trunk and limbs, oral ulcer, and conjunctivitis ( and ), followed by a fever of 39°C. The rash gradually increased and aggravated, accompanied with blisters, pruritus, and ulceration. Twelve days after gefitinib treatment, the patient was hospitalized. Gefitinib was immediately stopped, and imipenem, amikacin, and fluconazole were administered intravenously as prophylaxis, and diphenhydramine and loratadine were given as an anti-allergy treatment. On the 13th day, the patient's condition deteriorated further with a fever of 42°C, fused mucocutaneous rash as well as diffuse vesicles and bullae ( and ), which coalesced and then sloughed, presenting a scalded appearance. A positive Nikolsky sign was present on her back and feet ( and ). After consulting dermatology doctors, the patient was diagnosed with TEN and transferred to the Dermatology Department at the Second Affiliated Hospital of Sun Yat-sen University for further treatment.\nRoutine laboratory testing showed a white blood cell (WBC) count of 6.26 × 109/L [reference value: (3.69-9.16) × 109/L], neutrophil (NEU) proportion of 73.1% (reference: 50%-70%), and C-reactive protein (CRP) level of 16.36 mg/L (reference: 0-8.2 mg/L); both the Mycoplasma pneumoniae IgM antibody and Mac strains were negative. No suspicious fungus was found in the oral swab examination, nor did bacteria grow in the skin secretion culture.\nImmunosuppressive treatment was started with 100 mg methylprednisolone (daily injection) for 9 days and intravenous immunoglobulin (20 g/day) for 5 days, followed by 10 g/day for 5 days, accompanied with imipenem and teicoplanin for anti-infection and other supportive treatment. This treatment led to a recurrence of the rash and the mucosal lesions, reepithelization of the denuded skin (), and improvement of the patient's general condition within 40 days. A chest computed tomography (CT) scan and brain magnetic resonance imaging (MRI) showed partial remission after treatment. The combination of AP and gefitinib was suspended; accordingly, the patient began treatment with icotinib (another EGFR-TKI made in China) after recovery, without exfoliative dermatitis or other similar toxicities. Stable disease was later achieved.