A 35-year-old pregnant woman at 36 weeks of gestation with a 23 × 11-mm mass and multiple lymph nodes in the left axillary up to 23 × 10-mm involvement in ultrasonography was included in this study. After performing core needle biopsy, she had been diagnosed with invasive ductal carcinoma grade II in the upper outer quadrant of her left breast. Accordingly, this tumor was characterized as negative by immunohistochemistry for estrogen and progesterone receptors, but it resulted as positive for HER2 and Ki67 positive in >25% of tumor cells. The patient at 38 weeks of gestation delivered, and then the assessment for metastasis was done. Fortunately, no metastases were found, and her cancer stage was found to be II.\nThe patient included in this study received neoadjuvant chemotherapy with both adriamycin and cyclophosphamide 4 courses. Following the breast ultrasound, clear reductions were observed in the size of the mass and axilla lymph nodes. Thereafter, the patient received paclitaxel and AryoTrust (TH) for a 12-week duration, and then AryoTrust was continued once per 3 weeks. Of note, the generic name of the trastuzumab biosimilar used for the patient was AryoTrust. Afterward, left breast quadrectomy was done, showing no tumor residue, and left axillary sentinel lymph node excisional biopsy also resulted as negative (which is a very good response to neoadjuvant chemotherapy). After performing breast-conserving surgery, radiation therapy to the whole breast and regional lymphatics were considered. This technique contains tangential fields that is performed using the 3-dimensional conformal radiation therapy. The dose provided to the whole breast was between 45 and 50 Gy over 5–6 weeks (1.8–2 Gy tumor dose daily, 5 weekly fractions), with an additional boost dose or 10–16 GY in 2 Gy fractions to the tumor bed with the patient treated with 6-MV photons.\nThe overall treatment was well tolerated by the patient. After performing 5 cycles of AryoTrust (6 mg/kg every 3 weeks), she complained of swollen eyes and urticarial lesions. By conducting the physical examination, periorbital swelling and erythema (heliotrope rash) were revealed (Fig. ). An erythematous rash on the arms (Fig. ) and chest was also observed. Also, muscle strength of the lower limbs decreased (4/5), while it was normal in all upper limbs. The laboratory examination revealed moderately elevated serum muscle enzymes (a creatine phosphokinase value: 492 IU/L with a normal laboratory range of 38–176 IU/L;lactatedehydrogenase value: 510 IU/L with a normal laboratory range of 140–280 IU/L), but fluorescent antinuclear antibody, anti-double-stranded DNA, and antibodies to histidyl tRNA synthetase were negative. Skin lesion biopsy diagnosed papillary edema, epidermal spongiosis with few eosinophilic infiltrations, and a mild interstitial mucin deposition. Since the interval between radiotherapy and the onset of the symptoms was about 6 months and a recent screening for disease recurrence resulted as negative, the observed DM symptoms were attributed to trastuzumab. For this reason, the practitioner discontinued the use of trastuzumab. With Rheumatologic consult, prednisolone and hydroxychloroquine were started. Subsequently, the patient's symptoms improved, and 1 month later, she was free of any related symptom, and CPK was found in the normal range. In the first week, AryoTrust was started with 4 mg/kg, which was then followed by 2 mg/kg weekly for 3 weeks. Afterward, the dose of AryoTrust was increased to 6 mg/kg every 3 weeks. Fortunately, the patient had no complications.
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.