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.
A 45-year-old woman was admitted to our heart center with severe mitral stenosis and left atrial clot. The patient gave a history of shortness of breath on minimal exertion for one week and no cerebral symptoms, including headache, dizziness, transient ischemic attacks, or strokes. She was found to be fully conscious, alert, and oriented with stable vital signs. Blood pressure was 110/80 mmHg, and diastolic murmur was audible over the mitral area. Physical examination revealed intact cranial nerves, motor power, and sensation. There was no evidence of vasculitis such as Osler’s nodes, Jane way pad, palmer erythema, or cyanosis of fingers. Blood investigation showed an erythrocyte sedimentation rate (ESR) of 4 mm with no leukocytosis and a white blood cell (WBC) of 10.000 mm3. The electrolytes and kidney and liver function were within normal limits. Chest X-ray showed prominence of the left cardiac border due to left atrial enlargement. Electrocardiography was indicative of no change, but two–dimensional echocardiography revealed a large bulky non-mobile thrombosis in the left atrium with severe mitral stenosis. The mitral valve area was 0.6 cm2, and the other cardiac valves were normal. Pre- and postoperative laboratory measurements included negative antinuclear antibodies and rheumatoid factor, and elevation of C4 & C3 components of complement; in addition, HBS Antigen (especially in polyarteritis nodosa) was negative.\nThe patient underwent open heart surgery via the ascending aorta and bicaval cannulation. The aorta was cross-clamped, and the heart was arrested with cold cardioplegia by achieving systemic hypothermia at 30 °C on the cardiopulmonary bypass. Intraoperatively, the stenotic mitral valve was found to have a bulky clot attached to the valve and wall of the left atrium. The diseased mitral valve and the clot were excised, and the left atrial cavity was irrigated with copious amounts of normal saline and a valve was thereafter implanted. The left ventricle was then filled completely with saline and blood and fully deaired. The patient was weaned successfully off cardiopulmonary bypass with inotropic support and transferred to the intensive care unit. After 6 hours, blood pressure dropped and central venous pressure elevated and the extremity became cool and cyanotic. Inotropic support was commenced with dobutamine and adrenaline (2 and 1 mic/kg/min, respectively). On the third postoperative day, the inotropic drugs were tapered and blood pressure stabilized. By this point, however, the cyanosis had changed to gangrene and on the 12th postoperative day the acral part of the extremity was amputated and the specimen was sent for histopathological examination. In the histopathological examination, there was only non-specific vasculitis with thrombosis. The patient did not regain full consciousness on the following morning and was found to be quadriplegic with non-voluntary movements of the four limbs and face. The eyes could move only on the vertical plane, with both pupils having become small and fixed. After 72 hours, she managed to respond to questions only by blinking or moving her eyes vertically. Brain MRI revealed multiple infarction of the brainstem. Prolonged ventilatory support was maintained and eventually a tracheostomy was performed to facilitate tracheobronchial suctioning and weaning. Acute renal failure with anemia was managed and the kidneys recovered completely. However, the patient remained in this locked-in state for 4 weeks with no neurological improvement despite all ventilatory, nutritional, and nursing support. She eventually expired from hepatic failure and generalized sepsis.