Sorafenib-Induced Eruption Mimicking Erythema Multiforme

Sorafenib-Induced Erythema Multiforme Major and Severe Hepatic Failure in Metastatic Hepatocellular Carcinoma: A Case Report

Sorafenib, a kinase inhibitor, is known to cause skin toxicity, which sometimes leads to treatment interruption or drug dose reduction. Erythema multiforme (EM) is one of these dermatologic toxicities induced by sorafenib. We report the case of a 28-year-old male with hepatocellular carcinoma (HCC). Two months after surgery, the patient presented with multiple metastases to the retroperitoneal lymph nodes and lungs. Therefore, systemic therapy with sorafenib was indicated. While receiving the medication, the patient presented signs compatible with EM. The signs occurred on the torso and then spread to the rest of the body. Sorafenib treatment was interrupted the same day when skin lesions appeared and moisturizers with topical steroids and oral antihistamines were prescribed. The skin lesions decreased in size but without significant cutaneous improvement. The patient showed biologically severe liver failure and radiological progression. Because of the severe hepatic failure, initiation of intravenous steroids and establishment of another line of chemotherapy following tumor progression were contraindicated. The decision of the multidisciplinary staff with patient consent was to proceed with the best supportive care. The patient died in ambulatory care 12 days after discharge and local treatment. This report highlights the possibility of developing severe EM while receiving sorafenib. Patients with HCC who have liver resection without liver dysfunction should not be administered sorafenib, or it must be used with caution at very low doses and accompanied by close and regular follow-ups to avoid disease progression and deaths.

Epidermal necrolysis in the context of immuno-oncologic medication as well as kinase inhibitors and biologics

BACKGROUND

Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, primarily drug-induced reactions of skin and mucosa. Since they differ in the extent of skin detachment but not in etiology, they are grouped together as epidermal necrolysis (EN). Due to nationwide registration, representative data are available at the German Center for the Documentation of Severe Skin Reactions (dZh). Here, an increasing number of case notifications in the context with new immuno-oncologic drugs, kinase inhibitors and biologics have been observed.

MATERIAL AND METHODS

Of 4,150 cases notifications between January 2003 and February 2019, 102 cases with exposure to these drug groups underwent systematic analysis, validation and causality assessment.

RESULTS

Two cases of EN to vemurafenib were confirmed and one case to afatinib and pembrolizumab, respectively. In 14 EN cases other drugs - predominantly allopurinol or cotrimoxazole - were the causative agent. Fourteen cases were EN-like reactions: six bullous lichenoid drug eruptions (DE) to pembrolizumab (2), obinutuzumab, nivolumab, rituximab, infliximab/nivolumab, and eight multiforme-like DE to rituximab (2), adalimumab, ramucirumab, bevacizumab, vemurafenib, sorafenib (2). Lichenoid DE were differentiated from EN through histopathology and by the protracted course of EN, multiforme-like DE by variable skin manifestations with only sparse epidermolysis or mucosal involvement.

CONCLUSIONS

A correct diagnosis is highly relevant in terms of prognosis and use of these drugs in malignoma treatment. Re-exposure is contraindicated in EN, but possible in other DE after rigorous risk-benefit evaluation.

Anaphylaxis preceded by erythema multiforme with sorafenib: First case report

A 63-year-old female patient with recent diagnosis of hepatitis C and cirrhosis and no other comorbidities, on no medications, was found to have Barcelona Clinic Liver Cancer stage C hepatocellular carcinoma and began systemic therapy with sorafenib 400mg twice daily. Five days after starting treatment, the patient went to an emergency department with pruritic, target-shaped, erythematous papules compatible with erythema multiforme, painful oral aphthous ulcers, and fever. Sorafenib was suspended and the patient underwent oral corticosteroid treatment for 5 days, showing significant improvement of the lesions. One month after discharge, the patient was reassessed at an outpatient clinic. As she was asymptomatic and had no skin lesions, sorafenib was resumed at a lower dose (200mg daily). Three hours after ingesting a single dose of sorafenib, the patient experienced chills, fever, rash, angioedema and stridor. She immediately sought the emergency department and was diagnosed with anaphylaxis. The patient received intravenous corticosteroid therapy, which improved her respiratory and cutaneous symptoms in 72h. Sorafenib was permanently suspended, and regorafenib could not be prescribed as second-line therapy. This is the first description of anaphylaxis to sorafenib.