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Fenofibrate-induced photosensitivity
Journal of the American Academy of Dermatology Volume 35, Number 5, Part 1
5. Murata Y, Tani M, Amano M. Erythema muNforme due to clofibrate [letter]. J Am Acad Dermatol 1988;18:381-2. 6. Howard EJ, Brown SM. Clofibrate-induced anlinuclear factor and lupus-like syndrome. JAMA 1973;226:1358-9. 7. Heid E, Samsoen M, Juillard J, et al. Eruptions papulo-v6siculeuses endog~nes 5 la m6thyldopa et au clofibrate. Ann Derm Venereol 1977;104:494-6. 8. Merino MV, Menendez F, Calvo MJ, et al. Fotosensibilidad a fenofibratos. Actas Dermo-Sff 1989;80:703-4. 9. Merino V, Llamas R, Iglesias L. Phototoxic reaction to fenofibrate. Contact Delmatitis 1990;23:284. 10. Leroy D, Dompmartin A, Lorier E, et al. Photosensitivity induced by fenofibrate. Photodermatol Photoimmunol Photomed 1990;7:136-8. 11. Serrano G, Fortea JM, Latasa JM, et al. Photosensitivity induced by fibric acid derivatives and its relation to photo-
Brief communications 777
12.
13. 14.
15.
contact dermatitis to ketoprofen. J Am Acad Dermatol 1992;27:204-8. Mutzhas MF, H61zle E, Hofmann C, et al. A new apparatus with high radiation energy between 320-460 nm: physical description and dermatological applications. J Invest Dermatol 1981;76:42-7. H61zle E, Plewig G, Lehmann P. Photodermatoses: diagnostic procedures and their interpretation. Photodermatology 1987;4:109-14. Vargas F, Canudas N, Miranda MA, et al. Photodegradation and in vitro phototoxicity of fenofibrate, a photosensitizing anti-hyperlipoproteinemic drag. Photochem Photobiol 1993;58:471-6. Miranda MA, Bosca F, Vargas F, et al. Photosensitization by fenofibrate: II. In vitro phototoxicity of the major metabolites. Photochem Photobiol 1994;59:171-4.
Primary cutaneous plasmocytoma in a patient with chronic lymphatic leukemia Isabel Belinch6n, M D , a Jos6 M. Ramos, M D , c J o s 6 0 n m b i a , M D , c and Mar/a J. Mayol, M O b
Alicante and Murcia, Spain P l a s m o c y t o m a m a y be either primary or secondary. Primary p l a s m o c y t o m a occurs in the absence of multiple m y e l o m a and can arise in the bone m a r r o w or in soft tissue. Primary extramedullary plasmocyt o m a (EMP) of the skin is rare.l, 2 W e describe a patient with chronic lymphatic leukemia (CLL) in w h o m an E M P developed at the site of a previous herpes simplex lesion.
CASE REPORT A 73-year-old woman had a small nodule on the left upper lip for 8 months. She had insulin-dependent diabetes mellitus and CLL. Examination revealed a 0.8 cm, orange-red, translucent nodule. Shortly thereafter, a typical lesion of herpes simplex developed on the middle of her upper tip. One month later, a 6 cm nodule similar to the first lesion developed (Fig. 1). Biopsy specimens from each lesion revealed a diffuse, dense infiltration of the dermis by mature plasma cells (Fig. 2). Occasionally more atypical plasma ceils with binucleated forms were From the Unit of Dermatologya and Department of Pathology, b Hospital Universitario San Juan, Alicante, and the Department of Internal Medicine, Hospital Morales Meseguer, Murcia. c Reprint requests: Isabel Belinch6n, Avda Libertad 26 2-C, 03690 San Vicente, Alicante, Spain. J A m Acad Dermatol 1996;35:777-8. Copyright © 1996 by the American Academy of Dermatology, Inc. 0190-9622/96 $5.00 + 0
16154/73956
Fig. 1. Two nodules on upper lip.
identified. Immunohistochemically, the plasma cells showed k fight-chain restriction. A routine blood examination showed a white blood cell count of 4.6 x 109/L (50% neutrophils, 45% lymphocytes, 5% monocytes, and no plasma cells), hemoglobin of 10.9 gm/L, erythrocyte sedimentation rate of 66 mrrd hr, glucose level of 10.6 mmol/L, and serum creatinine level of 132 pmol/L. Total protein was 75 gm/L with a serum albumin of 34 gin/L, alphaa 3 gm/L, alpha2 8 gm/L, and gamma 19 gm/L (slightly elevated). On serum immunoelectrophoresis a slight increase of IgG level was
778
Brief communications
Fig. 2. Photomicrograph of biopsy specimen shows heavy infiltration of dermis by mature plasma cells.
Journal of the American Academy of Dermatology November 1996
al. 4 found a disease-related mortality rate o f at least 40%. Green et al. 3 described a patient in w h o m multiple primary cutaneous plasmocytomas developed after a possible insect bite reaction. Altcheck and Kurtin 7 described a patient with a cutaneous plasmocytoma on the cheek at the site o f a previous arthropod bite at the same site. Suster et al. 8 described a patient undergoing adjuvant immunotherapy with methanol extraction residue o f bacillus Calmette-Gu6rin for l y m p h o m a in w h o m a cutaneous plasma cell tumor developed at the injection site o f the drug. T o m e et al. 4 described a patient with a cutaneous lesion at the site o f previous herpes zoster, but no monoclonality was found in the plasma cells. In our patient her second lesion developed at the site of a previous herpes simplex infection. These cases m a y represent a polyclonal reaction from which a clone o f abnormal plasma cells develops. On the other hand, it is well known that there is an increase in frequency of solid neoplasms in patients with CLL. This could be explained by an immunologic deficiency in these patients or the carcinogenic effects o f chemotherapy. L6pez-Guillerm o et al. 9 in a review of 232 patients with C L L found that 13.8% had an associated neoplastic disease, but none had EMP. REFERENCES
observed (23.6 gm/L). Urinalysis, including a test for Bence-Jones protein, was negative. A skeletal survey disclosed no osteolyfic or osteoblastic changes. A bone marrow biopsy specimen showed 18% mature lymphocytic elements, without plasma cells. Immunologic studies showed 20% to 25% lymphocytes B, CD19 +, CD20 +, CD21-, CD25-, and CD10-. She received local radiotherapy with Iridio 192 (total dose, 48 Gy). The patient has remained flee of disease for 2.5 years since treatment. DISCUSSION
Wiltshaw 1 reviewed 272 cases o f E M P and found that it presents most c o m m o n l y in the upper aerodigestive tract. Primary cutaneous plasmocytoma without evidence o f marrow involvement is rare, accounting for only 3% to 12% o f cases. 1 The disease usually affects men in their 60s or 70s. 3-4 Previous reviews 2'3 5' 6' identified only about 30 cases o f primary cutaneous EMP, and a significant proportion o f the patients progressed to systemic disease. W o n g et
1. Wiltshaw E. The natural history of extramedullary plasmocytoma and its relation to solitary myeloma of bone and myelomatosis. Medicine (Baltimore) 1976;56:217-38. 2. Green T, Grant J, Pye R, et al. Multiple primary cutaneous plasmocytomas. Arch Dermatol 1992;128:962-5. 3. Wong KF, Chan JKC, Li LPK, et al. Primary cutaneous plasmocytoma: report of two cases and review of the literature. Am J Dermatopathol 1994;16:392-7. 4. Tome R, Su WPD, Winkelmann RK, et al. Clinicopathologic study of cutaneous plasmocytoma. Int J Derrnatol 1990;29:562-6. 5. Llamas-Martfn R, Postigo-Llorente C, Vanaclocha-Sebastifin F, et al. Primary cutaneous extramedullary plasmocytoma secreting lambda IgG. Clin Exp Dermatol 1993; 18:351-5. 6. Chang YT, Wong CK. Primary cutaneous plasmocytomas. Clin Exp Dermatol 1994;19:177-80. 7. Altchek DD, Kurfn SB. An unusual histopathologic response to an insect bite. Cuffs 1980;25:169-70. 8. Suster SM, Ronnen M, Huszar M, et al. Induction of cutaneous plasma cell tumor as a complication of adjuvant immunotherapy with methanol extraction residue of Bacillus Calmette-Gu6rin. Oncology 1987;44:279-82. 9. L6pez-Guillermo A, Reverter JC, Cervantes F, et al. Neoplasias asociadas a la leucemia linfiificacr6nica. Incidencia y caracterfsficas en una sefie de 232 pacientes. Med Clin (Barc) 1989;93:681-3.
5. Murata Y, Tani M, Amano M. Erythema muNforme due to clofibrate [letter]. J Am Acad Dermatol 1988;18:381-2. 6. Howard EJ, Brown SM. Clofibrate-induced anlinuclear factor and lupus-like syndrome. JAMA 1973;226:1358-9. 7. Heid E, Samsoen M, Juillard J, et al. Eruptions papulo-v6siculeuses endog~nes 5 la m6thyldopa et au clofibrate. Ann Derm Venereol 1977;104:494-6. 8. Merino MV, Menendez F, Calvo MJ, et al. Fotosensibilidad a fenofibratos. Actas Dermo-Sff 1989;80:703-4. 9. Merino V, Llamas R, Iglesias L. Phototoxic reaction to fenofibrate. Contact Delmatitis 1990;23:284. 10. Leroy D, Dompmartin A, Lorier E, et al. Photosensitivity induced by fenofibrate. Photodermatol Photoimmunol Photomed 1990;7:136-8. 11. Serrano G, Fortea JM, Latasa JM, et al. Photosensitivity induced by fibric acid derivatives and its relation to photo-
Brief communications 777
12.
13. 14.
15.
contact dermatitis to ketoprofen. J Am Acad Dermatol 1992;27:204-8. Mutzhas MF, H61zle E, Hofmann C, et al. A new apparatus with high radiation energy between 320-460 nm: physical description and dermatological applications. J Invest Dermatol 1981;76:42-7. H61zle E, Plewig G, Lehmann P. Photodermatoses: diagnostic procedures and their interpretation. Photodermatology 1987;4:109-14. Vargas F, Canudas N, Miranda MA, et al. Photodegradation and in vitro phototoxicity of fenofibrate, a photosensitizing anti-hyperlipoproteinemic drag. Photochem Photobiol 1993;58:471-6. Miranda MA, Bosca F, Vargas F, et al. Photosensitization by fenofibrate: II. In vitro phototoxicity of the major metabolites. Photochem Photobiol 1994;59:171-4.
Primary cutaneous plasmocytoma in a patient with chronic lymphatic leukemia Isabel Belinch6n, M D , a Jos6 M. Ramos, M D , c J o s 6 0 n m b i a , M D , c and Mar/a J. Mayol, M O b
Alicante and Murcia, Spain P l a s m o c y t o m a m a y be either primary or secondary. Primary p l a s m o c y t o m a occurs in the absence of multiple m y e l o m a and can arise in the bone m a r r o w or in soft tissue. Primary extramedullary plasmocyt o m a (EMP) of the skin is rare.l, 2 W e describe a patient with chronic lymphatic leukemia (CLL) in w h o m an E M P developed at the site of a previous herpes simplex lesion.
CASE REPORT A 73-year-old woman had a small nodule on the left upper lip for 8 months. She had insulin-dependent diabetes mellitus and CLL. Examination revealed a 0.8 cm, orange-red, translucent nodule. Shortly thereafter, a typical lesion of herpes simplex developed on the middle of her upper tip. One month later, a 6 cm nodule similar to the first lesion developed (Fig. 1). Biopsy specimens from each lesion revealed a diffuse, dense infiltration of the dermis by mature plasma cells (Fig. 2). Occasionally more atypical plasma ceils with binucleated forms were From the Unit of Dermatologya and Department of Pathology, b Hospital Universitario San Juan, Alicante, and the Department of Internal Medicine, Hospital Morales Meseguer, Murcia. c Reprint requests: Isabel Belinch6n, Avda Libertad 26 2-C, 03690 San Vicente, Alicante, Spain. J A m Acad Dermatol 1996;35:777-8. Copyright © 1996 by the American Academy of Dermatology, Inc. 0190-9622/96 $5.00 + 0
16154/73956
Fig. 1. Two nodules on upper lip.
identified. Immunohistochemically, the plasma cells showed k fight-chain restriction. A routine blood examination showed a white blood cell count of 4.6 x 109/L (50% neutrophils, 45% lymphocytes, 5% monocytes, and no plasma cells), hemoglobin of 10.9 gm/L, erythrocyte sedimentation rate of 66 mrrd hr, glucose level of 10.6 mmol/L, and serum creatinine level of 132 pmol/L. Total protein was 75 gm/L with a serum albumin of 34 gin/L, alphaa 3 gm/L, alpha2 8 gm/L, and gamma 19 gm/L (slightly elevated). On serum immunoelectrophoresis a slight increase of IgG level was
778
Brief communications
Fig. 2. Photomicrograph of biopsy specimen shows heavy infiltration of dermis by mature plasma cells.
Journal of the American Academy of Dermatology November 1996
al. 4 found a disease-related mortality rate o f at least 40%. Green et al. 3 described a patient in w h o m multiple primary cutaneous plasmocytomas developed after a possible insect bite reaction. Altcheck and Kurtin 7 described a patient with a cutaneous plasmocytoma on the cheek at the site o f a previous arthropod bite at the same site. Suster et al. 8 described a patient undergoing adjuvant immunotherapy with methanol extraction residue o f bacillus Calmette-Gu6rin for l y m p h o m a in w h o m a cutaneous plasma cell tumor developed at the injection site o f the drug. T o m e et al. 4 described a patient with a cutaneous lesion at the site o f previous herpes zoster, but no monoclonality was found in the plasma cells. In our patient her second lesion developed at the site of a previous herpes simplex infection. These cases m a y represent a polyclonal reaction from which a clone o f abnormal plasma cells develops. On the other hand, it is well known that there is an increase in frequency of solid neoplasms in patients with CLL. This could be explained by an immunologic deficiency in these patients or the carcinogenic effects o f chemotherapy. L6pez-Guillerm o et al. 9 in a review of 232 patients with C L L found that 13.8% had an associated neoplastic disease, but none had EMP. REFERENCES
observed (23.6 gm/L). Urinalysis, including a test for Bence-Jones protein, was negative. A skeletal survey disclosed no osteolyfic or osteoblastic changes. A bone marrow biopsy specimen showed 18% mature lymphocytic elements, without plasma cells. Immunologic studies showed 20% to 25% lymphocytes B, CD19 +, CD20 +, CD21-, CD25-, and CD10-. She received local radiotherapy with Iridio 192 (total dose, 48 Gy). The patient has remained flee of disease for 2.5 years since treatment. DISCUSSION
Wiltshaw 1 reviewed 272 cases o f E M P and found that it presents most c o m m o n l y in the upper aerodigestive tract. Primary cutaneous plasmocytoma without evidence o f marrow involvement is rare, accounting for only 3% to 12% o f cases. 1 The disease usually affects men in their 60s or 70s. 3-4 Previous reviews 2'3 5' 6' identified only about 30 cases o f primary cutaneous EMP, and a significant proportion o f the patients progressed to systemic disease. W o n g et
1. Wiltshaw E. The natural history of extramedullary plasmocytoma and its relation to solitary myeloma of bone and myelomatosis. Medicine (Baltimore) 1976;56:217-38. 2. Green T, Grant J, Pye R, et al. Multiple primary cutaneous plasmocytomas. Arch Dermatol 1992;128:962-5. 3. Wong KF, Chan JKC, Li LPK, et al. Primary cutaneous plasmocytoma: report of two cases and review of the literature. Am J Dermatopathol 1994;16:392-7. 4. Tome R, Su WPD, Winkelmann RK, et al. Clinicopathologic study of cutaneous plasmocytoma. Int J Derrnatol 1990;29:562-6. 5. Llamas-Martfn R, Postigo-Llorente C, Vanaclocha-Sebastifin F, et al. Primary cutaneous extramedullary plasmocytoma secreting lambda IgG. Clin Exp Dermatol 1993; 18:351-5. 6. Chang YT, Wong CK. Primary cutaneous plasmocytomas. Clin Exp Dermatol 1994;19:177-80. 7. Altchek DD, Kurfn SB. An unusual histopathologic response to an insect bite. Cuffs 1980;25:169-70. 8. Suster SM, Ronnen M, Huszar M, et al. Induction of cutaneous plasma cell tumor as a complication of adjuvant immunotherapy with methanol extraction residue of Bacillus Calmette-Gu6rin. Oncology 1987;44:279-82. 9. L6pez-Guillermo A, Reverter JC, Cervantes F, et al. Neoplasias asociadas a la leucemia linfiificacr6nica. Incidencia y caracterfsficas en una sefie de 232 pacientes. Med Clin (Barc) 1989;93:681-3.