Letter to the editor: “Reaction to cytarabine (Ara-C) treatment in patients with concurrentStaphylococcus aureus infection: A coalition between Ara-C and Superantigens?”
✍ Scribed by Savaşan, Süreyya; Warrier, Indira; Can, Emine; Can, Mehmet; Gedikoğlu, Gündüz
- Publisher
- John Wiley and Sons
- Year
- 1998
- Tongue
- English
- Weight
- 15 KB
- Volume
- 30
- Category
- Article
- ISSN
- 0098-1532
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✦ Synopsis
Cytarabine (Ara-C) is known to cause the Ara-C syndrome that is characterized by fever, myalgia, maculopapular rash, conjunctivitis, and occasionally skin peeling [1]. Transverse nail ridges (Beau lines) can also be observed in patients receiving chemotherapy. A relationship between the dose of Ara-C and the severity of the nail changes induced has been reported [2]. White transverse stripes are seen after conventional doses and Beau lines after higher doses. Fever, polymorphous exanthem, extremity changes including peeling of the palms and soles, and oropharyngeal erythema are the common findings of toxic shock syndrome (TSS) and Kawasaki disease (KD).
Two of our patients with leukemia and concurrent Staphylococcus aureus infection developed fever, peeling of the palms and soles, Beau lines, and nail shedding following conventional-dose Ara-C treatment. We hypothesize that Ara-C and possible toxin(s) produced by S. aureus could have collectively induced this clinical picture.
The first of the two children was a 4-year-old boy with acute lymphoblastic leukemia who developed fever and oropharyngeal hyperemia on the second day of the consolidation chemotherapy consisting of cyclophosphamide (1 g/m 2 , 1 day), Ara-C (75 mg/m 2 /d, 4 days), and thioguanine (60 mg/m 2 /d). His WBC was 3.3 × 10 9 /L and he was started on ceftriaxone and aztreonam. A culture from the Hickmann catheter exit site grew out S. aureus while all the other cultures had remained sterile. Vancomycin was therefore added. Chemotherapy was discontinued on the 4th day and he was given a dose of intravenous immunoglobulin G (IVIG; 200 mg/kg). Penicillin G was started due to a suspected pneumonia 3 days later. Fever defervesced on the 6th day of antibiotic treatment. He developed thrombocytosis on day 13 of admission (maximum platelet count of 927 × 10 9 /L) which had never occurred with the prior courses of chemotherapy. He had peeling of the palms and soles starting from the tips of the fingers and toes on day 19. Beau lines on his finger and toe nails with eventual nail shedding appeared by the 6th week.
The second child was a 2-year-old girl with relapsed acute myeloid leukemia who received induction treatment consisting of Ara-C (200 mg/m 2 /d, 5 days) and idarubicin (12 mg/m 2 , 3 days). On the 5th day, ceftazidime was started when she developed fever, diarrhea, and