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LETTER TO THE EDITOR
Year : 2022  |  Volume : 54  |  Issue : 4  |  Page : 295-296
 

Severe progressive dermatomyositis in a patient with metastatic ovarian cancer using bevacizumab


1 Department of Dermatology and Venerology, Hacettepe University School of Medicine, Ankara, Turkey
2 Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
3 Department of Internal Medicine Division of Rheumatology, Hacettepe University School of Medicine, Ankara, Turkey
4 Department of Internal Medicine Division of Medical Oncology, Hacettepe University School of Medicine, Ankara, Turkey

Date of Submission04-Jan-2022
Date of Decision31-Jul-2022
Date of Acceptance06-Aug-2022
Date of Web Publication04-Oct-2022

Correspondence Address:
Dr. Dilek Mentesoglu
Department of Dermatology and Venerology, Hacettepe University School of Medicine, 06100, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijp.ijp_11_22

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How to cite this article:
Mentesoglu D, Gunaydin SD, Ersoy-Evans S, Atakan N, Gokoz O, Karadag O, Kilickap S. Severe progressive dermatomyositis in a patient with metastatic ovarian cancer using bevacizumab. Indian J Pharmacol 2022;54:295-6

How to cite this URL:
Mentesoglu D, Gunaydin SD, Ersoy-Evans S, Atakan N, Gokoz O, Karadag O, Kilickap S. Severe progressive dermatomyositis in a patient with metastatic ovarian cancer using bevacizumab. Indian J Pharmacol [serial online] 2022 [cited 2022 Dec 3];54:295-6. Available from: https://www.ijp-online.com/text.asp?2022/54/4/295/357824




Sir,

Dermatomyositis is an inflammatory muscle disease of unknown origin marked by progressive symmetrical muscle debility, a variety of skin changes such as heliotrope rash, Gottron lesions, photodistributed poikiloderma, and cuticular and nail fold capillary changes.[1] Dermatomyositis may develop as a paraneoplastic phenomenon as to various malignancies, and ovarian cancer is one of the most related. Cancers can appear before and after the diagnosis of dermatomyositis (DM).[2] We describe the case report of paraneoplastic dermatomyositis (PDM) concerning metastatic ovarian cancer while on bevacizumab therapy.

A 48-year-old female with a history of metastatic ovarian cancer and peritoneal carcinomatosis was on bevacizumab and gemcitabine combination chemotherapy and was consulted to asses of painful skin lesions on her hands. On dermatological examination, facial edema along with a violaceous rash on both upper eyelids, erythematous, painful papules, plaques, fissures overlying dorsal interphalangeal joints, flagellate erythema on the back, subungual infarcts, and eroded plaques were noted in the oral mucosa [Figure 1]a and [Figure 1]b. In addition, physical examination was significant for weakness in the upper (3+/5) and lower extremities (3/5). She also defined extreme tenderness over her muscles.
Figure 1: (a) Purpuric fissured erythematous papules and plaques in bilateral hand fingers. (b) Flagellate erythema on the back. (c) Epidermal atrophy, basal vacuolar change, dyskeratotic cells. Mild inflammation of the dermis melanin incontinence (H and E, ×200). (d) Mucin deposition with alcian blue (×200)

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Laboratory examination showed elevated levels of creatine kinase 19305 IU/L (<145), aldolase 31.7 U/L (0.5–3), lactate dehydrogenase 1332 IU/L (<247), and C-reactive protein level 6.72 mg/dL (0–0.8). A skin biopsy was taken from the eruptions on the back, which showed epidermal atrophy, interphase changes, and dermal mucin deposition concordant with DM. There was no immunoglobulin G (IgG), C3, IgA, and IgM deposition on direct immunofluorescence [Figure 1]c and [Figure 1]d. Capillaroscopy showed extensive hemorrhages and dilated capillary loops. Electromyography showed myopathic changes, consistent with DM. However, the patient refused to perform a muscle biopsy. Our case was diagnosed with PDM with typical skin lesions, proximal muscular weakness, elevated serum muscle enzymes, and electromyographic and skin biopsy findings.

She received treatment with pulse steroid (methylprednisolone 500 mg/d) and intravenous immunoglobulin (0.5 mg/kg/d) for 5 days within a month. Afterward, we added oral prednisolone (1 mg/kg/d) to the treatment protocol. Despite the improvement of cutaneous lesions, these drugs showed a limited effectiveness against the progression of muscle weakness. Unfortunately, the patient died of aspiration pneumonia and sepsis.

Ovarian carcinoma may display paraneoplastic manifestations like dermatomyositis. PDM rarely overlaps with other rheumatologic diseases and resists treatment.[3] Bevacizumab is a humanized monoclonal antibody that inhibits Vascular endothelial growth factor (VEGF) and helps treat advanced ovarian cancer as first-line therapy in combination with a carboplatin chemotherapy regimen and used in the treatment of platinum-resistant patients.[4] Interestingly, our patient developed PDM after she had a second course of bevacizumab. It is unclear if its act of mechanism unmasked or induced the initiation of this paraneoplastic phenomenon. Further reports of associations between new drugs and PDM onset are therefore noteworthy due to the rarity of PDM.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Callen JP, Wortmann RL. Dermatomyositis. Clin Dermatol 2006;24:363-73.  Back to cited text no. 1
    
2.
Hill CL, Zhang Y, Sigurgeirsson B, Pukkala E, Mellemkjaer L, Airio A, et al. Frequency of specific cancer types in dermatomyositis and polymyositis: A population-based study. Lancet 2001;357:96-100.  Back to cited text no. 2
    
3.
Scheinfeld N. A review of the cutaneous paraneoplastic associations and metastatic presentations of ovarian carcinoma. Clin Exp Dermatol 2008;33:10-5.  Back to cited text no. 3
    
4.
Garcia J, Hurwitz HI, Sandler AB, Miles D, Coleman RL, Deurloo R, et al. Bevacizumab (Avastin®) in cancer treatment: A review of 15 years of clinical experience and future outlook. Cancer Treat Rev 2020;86:102017.  Back to cited text no. 4
    


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