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.
The patient was a 68-year-old woman with a medical history of postoperative treatment of NSCLC with bone metastasis 1 year 8 mo before presentation.\nA review of the patient’s medical history revealed nothing significant other than lung cancer and hypertension.\nA review of the patient’s medical history revealed nothing significant other than lung cancer and hypertension.\nThe patient had no significant personal or family history.\nThe patient presented with multiple erythematous papules mainly on the face and thigh on day 74. Seventy-eight days later, the patient developed several oral blisters and scattered erythema papules that rapidly developed into mucosal erosion and systemic epidermal abscission including the skin on the face and back (Figure ). The large area of exfoliation involved 30% of the body surface area. Nikolsky’s sign was positive. Despite the severity of the disease, the patient’s general condition is acceptable.\nRoutine laboratory examination revealed normal alanine aminotransferase (ALT 22 U/L, normal limits 13-69 U/L). Laboratory markers of systemic involvement indicated anemia, leucopenia, hypoalbuminemia, and hyponatremia. More importantly, there was no short-term drug or diet exposure before the outbreak. In addition, the interval between the first administration of AZD-9291 and the onset of disease was consistent with hypersensitivity latency. Bacterial cultures of blood, urine, and blisters revealed no evidence of bacterial infection. A drug lymphocyte-stimulation test was positive for AZD-9291, with a stimulation index of 2.6. As the above information was indicative enough, and the patient refused to have a pathological examination, biopsy was not performed.\nChest computed tomography (CT) showed pulmonary lesions in posterior segment of right upper lobe, and peripheral lung cancer with multiple pulmonary metastases. Multiple metastases of the thoracic vertebrae, sternum, and ribs were considered (Figure and ), which were similar to previous CT images (Figure and ). Follow-up was recommended.