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OtherClinical Image
Open Access

Non-pruritic linear rash in a patient with metastatic cancer

Clinical Presentation

Ali Hassan, Amna Alsaihati, Haitham Alaithan and Salman Aljubran
Saudi Medical Journal January 2020, 41 (1) 102-103; DOI: https://doi.org/10.15537/smj.2020.1.24762
Ali Hassan
From the Department of Internal Medicine (Hassan, Alsaihati, Alaithan), King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Kingdom of Saudi Arabia and from the Department of Allergy and Immunology (Aljubran), University of Missouri-Kansas City, School of Medicine, Kansas City, United States of America
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Amna Alsaihati
From the Department of Internal Medicine (Hassan, Alsaihati, Alaithan), King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Kingdom of Saudi Arabia and from the Department of Allergy and Immunology (Aljubran), University of Missouri-Kansas City, School of Medicine, Kansas City, United States of America
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Haitham Alaithan
From the Department of Internal Medicine (Hassan, Alsaihati, Alaithan), King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Kingdom of Saudi Arabia and from the Department of Allergy and Immunology (Aljubran), University of Missouri-Kansas City, School of Medicine, Kansas City, United States of America
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  • For correspondence: [email protected]
Salman Aljubran
From the Department of Internal Medicine (Hassan, Alsaihati, Alaithan), King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Kingdom of Saudi Arabia and from the Department of Allergy and Immunology (Aljubran), University of Missouri-Kansas City, School of Medicine, Kansas City, United States of America
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Notice: Authors are encouraged to submit quizzes for possible publication in the Journal. These may be in any specialty, and should approximately follow the format used here (maximum of 2 figures). Please address any submissions to: Editor, Saudi Medical Journal, Prince Sultan Military Medical City, PO Box 7897, Riyadh 11159, Kingdom of Saudi Arabia. Tel. +966 (11) 4777714 Ext. 42844.

A 27-year-old male patient presented with generalized painless, non-pruritic skin rash. He had been diagnosed with metastatic germ cell tumor, for which he had undergone the first chemotherapy cycle consisting of cisplatin, etoposide, and bleomycin, one week prior to presentation. He had no history of alopecia and demonstrated no changes in the appearance of his nails, oral ulcers, or joint swelling. Moreover, he did not report any lifestyle change or travel or recent intake of mushroom. Physical examination revealed a rash involving the trunk and extremities, appearing as linear brown streaks with no erythema or excoriation marks (Figure 1).

Figure 1
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Figure 1

Multiple, brown patches in a linear configuration on A) the chest B) the back, and C) the lower limbs.

Question

What is the most likely diagnosis?

A. Contact dermatitis

B. Dermatitis artefecta

C. Flagellate hyperpigmentation

D. Shiitake dermatitis

Answer

C. Flagellate hyperpigmentation

Discussion

Based on the clinical presentation, a diagnosis of bleomycin-induced flagellate dermatitis was made. The patient required no treatment as he was completely asymptomatic, and the rash had started fading spontaneously. However, it flared up during the chemotherapy cycles. Given the classic appearance of the rash, biopsy was not needed.

Bleomycin, a glycopeptide, is an anti-neoplastic antibiotic that is generally used to treat various malignancies and to achieve chemical pleurodesis.1 The pulmonary adverse effects of bleomycin are well-established; however, its cutaneous manifestations are somewhat uncommon and vary among patients. Flagellate hyperpigmentation constitutes a unique cutaneous adverse effect of bleomycin, which has been reported to have an incidence of up to 10%; however, severe and widespread dissemination of the rash is rare.1 It is noteworthy that most cases of flagellate hyperpigmentation are associated with pruritus.2 However, it may also present as completely asymptomatic, as in our case.

Low bleomycin hydrolase levels in the skin and lungs are implicated as the basis of complications in these tissues. Moreover, minor skin trauma (namely from scratching) results in local bleomycin accumulation by increasing the cutaneous blood flow.1 Rash associated with shiitake dermatitis, which might be observed after ingesting raw or undercooked shiitake mushrooms, present with similar features.3 However, in the present case, the patient had no history of recent intake of shiitake mushrooms. Thus, this rare case of extensive non-pruritic rash following bleomycin administration was diagnosed as bleomycin-induced flagellate dermatitis based on the clinical characteristics.

Learning points

i) Flagellate hyperpigmentation constitutes a unique cutaneous adverse effect of bleomycin.ii) Although most cases of flagellate hyperpigmentation are associated with pruritus, it may also present as completely asymptomatic

  • Copyright: © Saudi Medical Journal

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

References

  1. ↵
    1. Mota GD,
    2. Penna AMD,
    3. Soares RC,
    4. Baiocchi OCG
    (2014) Bleomycin-induced flagellate dermatitis. Rev Bras Hematol Hemoter 36:297–299.
    OpenUrl
  2. ↵
    1. Yamamoto T
    (2006) Bleomycin and the skin. Br J Dermatol 155:869–875.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Santos N,
    2. Silva PM,
    3. São Bráz MA
    (2018) A case of flagellate dermatitis after ingestion of shiitake mushrooms. Allergy Clin Immunol Pract 6:647–648.
    OpenUrl
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Saudi Medical Journal: 41 (1)
Saudi Medical Journal
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1 Jan 2020
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Non-pruritic linear rash in a patient with metastatic cancer
Ali Hassan, Amna Alsaihati, Haitham Alaithan, Salman Aljubran
Saudi Medical Journal Jan 2020, 41 (1) 102-103; DOI: 10.15537/smj.2020.1.24762

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Non-pruritic linear rash in a patient with metastatic cancer
Ali Hassan, Amna Alsaihati, Haitham Alaithan, Salman Aljubran
Saudi Medical Journal Jan 2020, 41 (1) 102-103; DOI: 10.15537/smj.2020.1.24762
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© 2025 Saudi Medical Journal Saudi Medical Journal is copyright under the Berne Convention and the International Copyright Convention.  Saudi Medical Journal is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work. Electronic ISSN 1658-3175. Print ISSN 0379-5284.

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