Scratch dermatitis

Abstract: Dear Editor, Scratch dermatitis, or flagellate erythema, is characterized by linear erythematous/hyperpigmented streaks, and can be caused by shiitake mushroom, bleomycin, dermatomyositis and Still’s disease. Engraftment syndrome (ES) presents with pyrexia, maculopapular eruption and edema during neutrophil recovery following hematopoietic stem cell transplantation. Here, we describe a case with scratch dermatitis encountered as a clinical manifestation of ES. A 44-year-old Japanese woman was referred to us with a 2day history of distinct scratch marks due to severe pruritus 18 days after unrelated allogeneic bone marrow transplantation (BMT) from an unrelated donor to treat blast crisis of chronic myeloid leukemia. Human leukocyte antigens between patient and donor were matched at eight of eight loci serologically, and seven of eight loci by DNA typing (mismatch for DRB1). The patient denied having eaten shiitake mushrooms recently. Neither bleomycin nor peplomycin had been administrated. Physical examination showed severe pruritus and erythematous streaks on the trunk on post-BMT day 18 (Fig. 1a). Maculopapular eruptions appeared on the trunk and extremities on day 19 (Fig. 1b). No diarrhea or jaundice was observed. Bodyweight was 56.0 kg, 57.2 kg and 56.2 kg on day 16, 18–21 and 22, respectively. Maximum daily axillary temperature was 37.9°C on day 16, 39.5°C on day 17, 39.1°C on day 18, 39.5°C on day 19 and 38.0°C on day 20. Neutrophil counts were 400/lL on day 16, 1300/lL on day 18 and 3500/lL on day 19. Aspartate transaminase and alanine transaminase concentrations were 173 IU/mL and 340 IU/mL, respectively, on day 18. Histopathological examination of the streaks on the

Abstract: 1 A 73-year-old woman without any pertinent history was admitted to the hospital due to remittent fever with erythema. She showed itching and linearly arranged erythema on the chest, back, and abdomen [Figure 1a and b]. As she had been taking daily cefditoren pivoxil for the 4 days before her admission, she was diagnosed as having drug-related scratch dermatitis, and the antibiotic treatment was stopped. Her fever remained. Laboratory data showed elevated levels of white blood cells (14,800/μl, normal range 4000–7000) and liver enzymes such as aspartate aminotransferase (AST) 138 IU/L (normal range 5–40), alanine aminotransferase 97 IU/L (normal range 5–35), and ferritin (17469.5 ng/mL, normal range 5–152). A blood culture was negative for bacteria. A computed tomography examination revealed mild mediastinal lymphadenopathy of the cervicum to the abdomen. Biopsies of mediastinal lymph node, bone marrow, and skin were performed, and all were negative for the infiltration of lymphoma cells or any malignancy. As the patient’s fever and erythema remained, a biopsy of the skin erythema was performed [Figure 1c and d]. The histopathological diagnosis was non-specific interface dermatitis. As infection and malignancy were denied, she was finally diagnosed as having adult Still’s disease (ASD) based on the high ferritin level.[1-3] Prednisolone (1 mg/kg/day) was administered, and her fever and erythema disappeared within 1 week. The prednisolone was gradually tapered, and the patient has maintained in complete remission.