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Delayed hypersensitivity reactions and cross sensitisation: case report A 70-year-old woman developed delayed hypersensitivity characterised by maculopapular rash and eosinophilia following treatment with lenalidomide for polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome. Subsequently, she developed delayed hypersensitivity characterised by maculopapular rash secondary to cross-sensitisation following treatment with pomalidomide for POEMS syndrome [routes not stated]. The woman, who had hypertension and autoimmune thyroiditis, developed distal paraesthesia of the upper and lower limbs in March 2015. Her medical history was significant for hyperprolactinaemia secondary to metoclopramide. Subsequent investigation was consistent with chronic demyelinating inflammatory polyradiculoneuritis (CIDP). She was treated with polyclonal immune globulin which proved unfavourable. Subsequently, she was diagnosed with POEMS syndrome. She started receiving lenalidomide 25 mg/day on day 1–day 21. She had been receiving various concomitant medications. However, six days after the initiation of lenalidomide, she developed cutaneous grade 3 maculopapular rash with moderate eosinophilia. She did not have fever and renal or hepatic involvement. The woman’s lenalidomide therapy was interrupted. She was treated with betamethasone. Thereafter, her rash and eosinophilia completely resolved. Therefore, a month later, lenalidomide was re-initiated at a lower dose of 15 mg/day, along with prednisone. However, she again developed grade 3 rash without eosinophilia. Lenalidomide therapy was interrupted. She was treated with betamethasone and prednisone therapy was tapered. Two weeks later, her rash completely resolved. Due to severity of the rash, desensitisation with lenalidomide was not attempted. Lenalidomide was permanently discontinued. Six weeks later, she started receiving pomalidomide 4 mg/day and dexamethasone. Two days after the initiation of pomalidomide therapy, she developed grade 3 maculopapular rash without eosinophilia. She was diagnosed with delayed hypersensitivity to both lenalidomide and pomalidomide. Cross-sensitisation was suspected. In October 2016, she was initiated on desensitisation protocol for pomalidomide. Desensitisation protocol consisted of administration of pomalidomide at a dose of 1mg on Monday of week 1; 1mg on Monday, Thursday and Sunday of week 2; 1mg on Tuesday, Thursday, Saturday and Sunday of week 3; 1mg on Monday, Tuesday, Wednesday, Friday and Sunday and 2mg on Thursday and Saturday; and 2mg on all seven days of week 5. She reached the target dose of 2 mg/day without reoccurrence of adverse events. Following three 28 day cycles of dexamethasone and pomalidomide, her condition improved. She completed total six cycles of pomalidomide. Thereafter, she was treated with melphalan and autologous stem cell transplantation leading to continuous neurological improvement. Grandoni F, et al. Successful desensitization to pomalidomide in a patient with POEMS