A 64-year-old woman presented with left axillary lymphadenopathy in December 2014. Metastatic infiltrating ductal carcinoma of the left breast and left axillary and pectoral lymph nodes was diagnosed. The tumor was clinical stage III T2N2, estrogen receptor negative, progesterone receptor negative, and HER2 overexpressed.\nShe began treatment in 2015 with triple therapy on February 24, March 17, and April 7: paclitaxel, pertuzumab, and trastuzumab. She also received monotherapy with paclitaxel on March 3, March 10, March 24, and March 31. Following her treatment on April 7, she developed eyelid ptosis and peripheral neuropathy with ataxia that was attributed to paclitaxel.\nMonotherapy with trastuzumab was resumed on May 9, 2015. On June 1, 2015, 3 days after receiving trastuzumab on May 29, 2015, she developed pruritus. She also noted a rash developing on her chest, abdomen, arms, and legs.\nCutaneous examination on June 3, 2015 showed erythematous, distinct and intermingled (in a lacy pattern), linear streaks on her arms (Figs. , ), chest, and abdomen (Fig. ). The morphology of the clinical lesions was a flagellate erythema. Similar linear streaks—both erythematous and hemorrhagic—were also noted on her legs (Figs. , ).\nA skin biopsy from her left arm showed basket-weave orthokeratosis overlying a spongiotic epidermis. There was edema in the dermis with a predominantly lymphocytic inflammatory infiltrate that is present around blood vessels in the papillary dermis. There was exocytosis of small lymphocytes into the overlying epidermis (Fig. ). The pathologic findings were those of a spongiotic dermatitis, compatible with a medication reaction.\nCorrelation of the clinical history, symptoms and findings in concert with the pathologic features observed established the diagnosis of drug-induced flagellate erythema. In this patient, the causative agent was trastuzumab.\nShe was treated systemically with prednisone (60 mg each morning for 3 days, followed by 40 mg each morning for 2 days and 20 mg in the morning for 1 day), and antihistamines for 2 weeks: Fexofenadine 180 mg each morning and diphenhydramine 25 mg each evening. Topical therapy was also initiated: Clobetasol propionate 0.05 % cream twice daily for 10 days and then once daily for 4 days.\nWithin 2 days, the itching had resolved and the skin eruption had nearly cleared. Follow-up examination after 2 weeks, on June 17, 2015, showed complete clearing of the flagellate erythema on her chest, abdomen, and arms. The erythematous hemorrhagic linear streaks on her distal legs were less prominent and asymptomatic.\nThe patient has subsequently had a left breast lumpectomy and complete lymph node dissection. There was no residual carcinoma in the breast and 26 lymph nodes were negative for malignancy. She has also received adjuvant radiation therapy.\nHer oncologist decided that she would need to receive treatment with trastuzumab, every 3 weeks, for 1 year. She has been receiving dexamethasone prior to each trastuzumab treatment to prevent recurrence of the adverse skin event. Neither pruritus nor flagellate erythema has occurred with the subsequent administration of trastuzumab.
A 53-year-old man presented with unstable angina due to the severe stenosis of the left anterior descending coronary artery and obtuse marginalis, although the right coronary artery was normal. Laboratory findings, including a complete blood count, erythrocyte sedimentation rate, and C reactive protein, were normal. Chest X-ray revealed no abnormal findings, and there was no valvular abnormality on preoperative echocardiography. The patient had no co-morbid disorders, but his left ventricular ejection fraction was reduced (40–45%).\nThe intraoperative course was uneventful. There were no findings of pericarditis. On physical examination, there was no respiratory distress, blood pressure was 130/80 mm Hg, heart rate was 80 beats per minute, respiratory rate was 23 per minute, the neck veins were not distended, and there was no ankle edema. Cardiovascular system examination showed regular first and second heart sounds with no gallop or murmur. The electrocardiogram (ECG) demonstrated a Q wave in the precordial leads. For temporary coronary artery occlusion, 4/0 Viline sutures and a Bulldog Clamp were used, and warm blood was employed to de air the graft. Temporary coronary artery occlusion was not prolonged, and the electrocardiogram and hemodynamic variables and objective data showed no signs of ischemia or contractile dysfunction. The operation was uneventful. No intra-coronary shunt was utilized.\nThe patient left the operating room without any inotropic support. Six hours later, however, he developed low cardiac output. At exploration, cardiac tamponade was excluded and flowmetry showed that the graft had adequate function. There were no findings as regards pericarditis, and the patient’s postoperative erythrocyte sedimentation rate, C-reactive protein, and cardiac enzymes were normal. A high dose of adrenalin and dobutamine was administered, and an intra-aortic balloon pump was used.\nIntraoperative transesophageal echocardiography demonstrated a depression in the left ventricular function due to an akinetic lateral left ventricular wall in the region of the obtuse marginalis. After hemodynamic stabilization, the patient left the Intensive Care Unit without an intra-aortic balloon pump and inotropic support. On the fifth postoperative day, a coronary angiogram demonstrated patent grafts and correct anastomotic sites ( & ). On the seventh postoperative day, the akinetic lateral wall of the left ventricle changed to dyskinesia. Finally, after hospital discharge on the thirtieth postoperative day, an echocardiogram showed a normal left ventricular function without regional wall motion abnormalities.