Fingolimod
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Cutaneous warts and lymphopenia: 5 case reports In a case series, 5 patients [ages and sexes not stated] were described, who developed HPV associated squamous cell carcinoma, verruca vulgaris, mosaicism or verruca filiformis and lymphopenia during treatment with fingolimod [routes, dosages and indications not stated]. Case 1: The patient who was receiving fingolimod developed wart subtype squamous cell carcinoma at anal after 58 months of therapy initiation. At that time, the patient was found to have a lymphopenia with a lymphocyte count of 0.5–1.5 × 109 [unit not stated]. After the wart development, the patient’s therapy with fingolimod was discontinued and the patient was treated with fluorouracil, mitomycin and radiotherapy. However, the wart further progressed to metastatic malignancy. Case 2: The patient who was receiving fingolimod developed wart subtype verruca vulgaris at ankle after 17 months of therapy initiation. At that time, the patient was found to have a lymphopenia with a lymphocyte count of 0.2–0.4 × 109 [unit not stated]. Two months after wart presentation, fingolimod dosage was altered to second daily dosing and the patient was treated with imiquimod. Additionally, the patient underwent local excision and cryotherapy. This led to a reduction in the size of wart. Case 3: The patient who was receiving fingolimod developed wart subtype verruca vulgaris and mosaicism at feet after 20 months of therapy initiation. At that time, the patient was found to have a lymphopenia with a lymphocyte count of 0.5–1.1 × 109 [unit not stated]. After the wart development, the patient’s therapy with fingolimod was continued as previous. The patient additionally received imiquimod and underwent cryotherapy. Despite this, the patient had persistence of wart. Case 4: The patient who was receiving fingolimod developed wart subtype verruca filiformis at jaw after 49 months of therapy initiation. At that time, the patient was found to have a lymphopenia with a lymphocyte count of 1.0–1.2 × 109 [unit not stated]. Fourteen months after wart presentation, fingolimod dosage was altered to second daily dosing and the patient was treated with imiquimod. Additionally, the patient underwent cryotherapy. Six months after the dose reduction, wart resolved. Case 5: The patient who was receiving fingolimod developed wart subtype verruca vulgaris at finger after 51 months of therapy initiation. At that time, the patient was found to have a lymphopenia with a lymphocyte count of 0.3–0.5 × 109 [unit not stated]. Twenty-six months after wart presentation, fingolimod was discontinued. Four months after the discontinuation, wart resolved. Author comment: "These five cases of cutaneous warts suggest that impaired immune response to viruses associated with fingolimod therapy may result in increased risks of chronic HPV infection and the potential for associated malignancies". "S1P activity inhibition by fingolimod may result in reduced circulating lymphocyte numbers and impaired intrinsic cancer surveillance." Triplett J, et al. Warts
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