Boletus dermatitis: a new variant of flagellate erythema

Seasonality and intensity of airborne Boletus-type spores in relation to land use and weather pattern

Forests are a natural source of airborne bolete spores. The timing of sporulation and its intensity as well as the dispersal of airborne spores and in consequence their concentrations depend in particular on the type of land use determining the availability of matter on which they develop and on meteorological factors. The aim of this study was to perform a spatial and temporal analysis of the occurrence of Boletus-type spores in the warm temperate climate of the Northern Hemisphere. An assumption was made that the spore concentrations depend on the type of land cover and weather conditions. The volumetric method was applied to investigate differences in spore concentrations and using spore traps installed at different heights and at locations with different land cover types. Boletus-type spores occurred in the air at high concentrations in late summer and in the autumn. The season start dates and maximum concentrations did not differ significantly between sites and seasons, but the season intensity varied. Higher spore concentrations were usually found in the region with a larger proportion of green areas, including forests. An analysis of the diurnal cycles showed that within 24 h spore concentration reached high levels twice, which was especially noticeable in ground level monitoring. Air temperature and air humidity were the main weather factors affecting the occurrence of airborne spores. This research indicates that when studying the effects of different factors on the concentration of airborne basidiospores, many environmental elements should be analyzed, including the characteristics of habitats in which basidiomycetes grow. Climate, weather, geobotany, and land use type should be taken into account in analysis and interpretation of aeromycological phenomena.

Histological Features of Flagellate Erythema

Flagellate erythema is a distinctive eruption characterized by "whip-like" linear or curvilinear streaks and plaques, occurring mainly on the trunk. It has classically been described in 2 disparate clinical settings: chemotherapy with bleomycin and ingestion of mushrooms (most commonly Shiitake mushrooms). Most of the literature comprises single case reports, often with minimal histological description of rather nonspecific features. We describe in detail the histological features of 3 cases of flagellate erythema (2 related to bleomycin therapy and one related to ingestion of mushrooms) and review the findings described in the literature to define the spectrum of histological changes encountered in this eruption. Our 3 cases showed mild epidermal changes, with spongiosis and variable interface inflammation. All 3 showed a relatively prominent dermal lymphohistiocytic infiltrate, with features suggestive of a lymphocytic vasculopathy extending to at least the mid-reticular dermis. Eosinophils were a prominent component of the inflammatory infiltrate in 2 cases. Our review of the literature identified a total of 45 publications, representing reports of 46 patients, containing histological information. As well as bleomycin- and mushroom-related cases, similar eruptions have been reported in the context of connective tissue disease and other drugs. Although cases related to connective tissue disease show features of the underlying condition, cases secondary to drugs or mushrooms predominantly show features compatible with common patterns of exanthematous/morbilliform drug reaction. In particular, subtle spongiosis and/or interface dermatitis combined with a dermal lymphocytic infiltrate that includes increased numbers of eosinophils is a common finding. Features of a lymphocytic vasculopathy may be seen in a subset of these cases.

Trastuzumab-Associated Flagellate Erythema: Report in a Woman with Metastatic Breast Cancer and Review of Antineoplastic Therapy-Induced Flagellate Dermatoses

Introduction

Flagellate erythema presents as erythematous, individual and intermingled, linear streaks in a whiplash-like pattern. Several conditions, including antineoplastic agents, have been associated with flagellate erythema. A woman with metastatic breast cancer who developed flagellate erythema after receiving trastuzumab is described and the features of flagellate erythema associated with other antineoplastic agents are reviewed.

Methods

PubMed was used to search the following terms, separately and in combination: agent, antineoplastic, bendamustine, bleomycin, breast, cancer, chemotherapy, dermatitis, dermatosis, docetaxel, erythema, flagellate, Herceptin, pigmentation, peplomycin, therapy, and trastuzumab. All papers were reviewed and relevant manuscripts, along with their reference citations, were evaluated.

Results

The woman’s pruritus and skin lesions promptly resolved after treatment with corticosteroids (oral and topical) and antihistamines (oral); premedication with dexamethasone prior to each subsequent trastuzumab treatment prevented recurrence of flagellate erythema. Chemotherapy-induced flagellate erythema was initially described in oncology patients who received bleomycin. In addition to trastuzumab, other antineoplastic agents that have been associated with the development of flagellate erythema include bendamustine, docetaxel, and peplomycin.

Conclusion

Cutaneous adverse events to trastuzumab are uncommon. However, flagellate erythema should be added to the potential side effects of trastuzumab. In addition, trastuzumab should be added to the list of antineoplastic agents that may be associated with flagellate erythema.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-015-0085-2) contains supplementary material, which is available to authorized users.