DRUGS
Skin Ulceration due to
Faulty Adriamycin Administration
Paulette Mehta, M.D., Nina
SKIN
KI~
ulceration in patients with may be ascribed to tumor invasion,’ bacterial infection, or radiation.’ For proper therapy with such patients it is
malignancy
imperative that the proper diagnosis be made. Now that more and more patients with malignancies are surviving on chemotherapy, complications and side effects of drug therapy are becoming evident. Faulty administration of drugs can lead to iatrogenic problems. A patient with such a preventable complication resulting from drug administration is here reported. Case
Report 15-year-old white male was diagnosed as having chronic myelogenous leukemia in October, 1976. He was treated with myleran 6 mg orally daily, prednisone 60 mg daily for one month and vincristine 2 mg intravenously weekly. He did well on this regimen until four months later when blast crisis developed. He then underwent treatment consisting of intravenous cyclophosphamide, arabinoside-c, vincristine and oral prednisone. He failed to respond to this regimen. He was then given courses of adriamycin intravenously combined with vincristine intravenously and prednisone orally. The first course of adriamycin was given by slow injection into a slowly flowing intravenous solution. This
Najar,
P.A.
A #21 gauge needle was used in a vein of the dorsum of the right hand. During the infusion he complained of burning at the site of the needle. No puffiness was evident and a good backflow of blood was obtained. Nevertheless, the needle was moved to a second site. Several days later he had burning and itching at the site of the first injection. Erythema appeared and progressed. During the next four weeks sloughing of the skin occurred, with gradual full thickness loss of skin. Ulcers formed, surrounded by rims of inflamed, tender skin. Tendons and muscles became visible through loss of skin. Functional impairment of motion of the wrist and hand developed. The ulcer deepened and became necrotic and infected (Fig. 1). Cultures of the ulcer grew Pseudomonas ae~ru~ino5a. The infection was treated with debridement, local irrigation and cleansing of the area, and gradually subsided. Functional impairment of motion of the wrist and hand has persisted, and graft excision is currently being considered. The present drugs were unsuccessful in inducing remission and the patient remained in blast crisis. He is presently receiving 5-azacytidine which has brought about a partial remission. He has remained neutropenic and thrombocytopenic. The neutropenia should not be a contraindication to skin grafting since the eradication of a source of infection overshadows the risks of surgery done under sterile conditions. Platelet transfusions may be advisable just prior to or during surgery.
Discussion From the Division of Hematology, Department of Pediatrics, University of Florida College of Medicine,
Gainesville, Florida.
is a drug commonly used in of leukemia,3 Wilms’ tumor4 and metastatic solid tumors of childhood.5 Its side effects are well recognized.6 This report
Adriamycin
treatment
Correspondence to: Dr. Paulette Mehta, Department of Pediatrics, Box J296 JHMHC, University of Florida, Gainesville, FL 32610.
663
Downloaded from cpj.sagepub.com at Purdue University on June 29, 2015
receiving this drug are already immunosuppressed and become neutropenic due to bone marrow depressive actions of adriamycin, local infections become potential life threatening complications. ulcer forms, treatment should be aggressive. Wide excision of the necrotic skin is advisable. Secondary infection can be
Once
an
prevented by aggressive antiseptic washings. Skin grafting to cover the ulcerated area is often necessary thereafter. The best treatment is prevention. Wrist veins should preferably not be used as injection sites. A scalp vein needle, securely attached with good backflr~w of blood tested during administration of the drug, should be used. Burning or stinging, even in the absence of puf’finess, should be looked upon as evidence of extravasation, as in this case, and any infusion of adriamycin should be terminated at once.
References Fcr., 1. Ulceration of dorsum of hand in response to adhamycin extravasation.
the need for its very careful administration. Ulcers due to extravasation of adriamycin can be difficult to treat; they may lead to opportunistic local systemic infections and loss of extremity function.’ They may develop insidiously and progress deeper than stresses
Initial superficial loss of skin may be followed by exposure of muscle, tendon and bone, structures which have very little overlying skin. The ulcers are characterized by lack of granulation tissue. Since patients
expected.
1. Van Scott. E. J.: Cutaneous oncology, 1950-1975. J. Invest. Dermatol. 67: 195, 1976. 2. Moss, W. T., vt al.: Radiation oncology: Rationales, techniques, results. St. Louis. C. V. Mosby Co., 1973, pp. 53-63. 3. Regab, A. H., et al.: Adriamycin in the treatment of childhood acute leukemia: A Southwest C)ncology Group Study. Cancer 36: 1223, 1975. 4. Bellani, F. F., et .: al Adriamycin in Wilms’ tumors previously treated with chemotherapy. Eur. J. Cancer 11: 693, 1975. 5. Cangir, A., et al.: Combination chemotherapy with adriamycin and dimethyl triazeno imidazole carboxamide in children with metastatic solid tumors. Med. Pediatr. Oncol. 2: 183, 1976. 6. Blum, R. H., and Carter, S. K.: Adriamycin—a new anticancer drug with significant clinical activity. Ann. Intern. Med. 80: 249, 1974. 7. Rudolph, R., Stein, R., and Pattillo, R.: Skin ulcers due to adriamycin. Cancer 38: 1087, 1976.
664
Downloaded from cpj.sagepub.com at Purdue University on June 29, 2015
Skin Ulceration due to
Faulty Adriamycin Administration
Paulette Mehta, M.D., Nina
SKIN
KI~
ulceration in patients with may be ascribed to tumor invasion,’ bacterial infection, or radiation.’ For proper therapy with such patients it is
malignancy
imperative that the proper diagnosis be made. Now that more and more patients with malignancies are surviving on chemotherapy, complications and side effects of drug therapy are becoming evident. Faulty administration of drugs can lead to iatrogenic problems. A patient with such a preventable complication resulting from drug administration is here reported. Case
Report 15-year-old white male was diagnosed as having chronic myelogenous leukemia in October, 1976. He was treated with myleran 6 mg orally daily, prednisone 60 mg daily for one month and vincristine 2 mg intravenously weekly. He did well on this regimen until four months later when blast crisis developed. He then underwent treatment consisting of intravenous cyclophosphamide, arabinoside-c, vincristine and oral prednisone. He failed to respond to this regimen. He was then given courses of adriamycin intravenously combined with vincristine intravenously and prednisone orally. The first course of adriamycin was given by slow injection into a slowly flowing intravenous solution. This
Najar,
P.A.
A #21 gauge needle was used in a vein of the dorsum of the right hand. During the infusion he complained of burning at the site of the needle. No puffiness was evident and a good backflow of blood was obtained. Nevertheless, the needle was moved to a second site. Several days later he had burning and itching at the site of the first injection. Erythema appeared and progressed. During the next four weeks sloughing of the skin occurred, with gradual full thickness loss of skin. Ulcers formed, surrounded by rims of inflamed, tender skin. Tendons and muscles became visible through loss of skin. Functional impairment of motion of the wrist and hand developed. The ulcer deepened and became necrotic and infected (Fig. 1). Cultures of the ulcer grew Pseudomonas ae~ru~ino5a. The infection was treated with debridement, local irrigation and cleansing of the area, and gradually subsided. Functional impairment of motion of the wrist and hand has persisted, and graft excision is currently being considered. The present drugs were unsuccessful in inducing remission and the patient remained in blast crisis. He is presently receiving 5-azacytidine which has brought about a partial remission. He has remained neutropenic and thrombocytopenic. The neutropenia should not be a contraindication to skin grafting since the eradication of a source of infection overshadows the risks of surgery done under sterile conditions. Platelet transfusions may be advisable just prior to or during surgery.
Discussion From the Division of Hematology, Department of Pediatrics, University of Florida College of Medicine,
Gainesville, Florida.
is a drug commonly used in of leukemia,3 Wilms’ tumor4 and metastatic solid tumors of childhood.5 Its side effects are well recognized.6 This report
Adriamycin
treatment
Correspondence to: Dr. Paulette Mehta, Department of Pediatrics, Box J296 JHMHC, University of Florida, Gainesville, FL 32610.
663
Downloaded from cpj.sagepub.com at Purdue University on June 29, 2015
receiving this drug are already immunosuppressed and become neutropenic due to bone marrow depressive actions of adriamycin, local infections become potential life threatening complications. ulcer forms, treatment should be aggressive. Wide excision of the necrotic skin is advisable. Secondary infection can be
Once
an
prevented by aggressive antiseptic washings. Skin grafting to cover the ulcerated area is often necessary thereafter. The best treatment is prevention. Wrist veins should preferably not be used as injection sites. A scalp vein needle, securely attached with good backflr~w of blood tested during administration of the drug, should be used. Burning or stinging, even in the absence of puf’finess, should be looked upon as evidence of extravasation, as in this case, and any infusion of adriamycin should be terminated at once.
References Fcr., 1. Ulceration of dorsum of hand in response to adhamycin extravasation.
the need for its very careful administration. Ulcers due to extravasation of adriamycin can be difficult to treat; they may lead to opportunistic local systemic infections and loss of extremity function.’ They may develop insidiously and progress deeper than stresses
Initial superficial loss of skin may be followed by exposure of muscle, tendon and bone, structures which have very little overlying skin. The ulcers are characterized by lack of granulation tissue. Since patients
expected.
1. Van Scott. E. J.: Cutaneous oncology, 1950-1975. J. Invest. Dermatol. 67: 195, 1976. 2. Moss, W. T., vt al.: Radiation oncology: Rationales, techniques, results. St. Louis. C. V. Mosby Co., 1973, pp. 53-63. 3. Regab, A. H., et al.: Adriamycin in the treatment of childhood acute leukemia: A Southwest C)ncology Group Study. Cancer 36: 1223, 1975. 4. Bellani, F. F., et .: al Adriamycin in Wilms’ tumors previously treated with chemotherapy. Eur. J. Cancer 11: 693, 1975. 5. Cangir, A., et al.: Combination chemotherapy with adriamycin and dimethyl triazeno imidazole carboxamide in children with metastatic solid tumors. Med. Pediatr. Oncol. 2: 183, 1976. 6. Blum, R. H., and Carter, S. K.: Adriamycin—a new anticancer drug with significant clinical activity. Ann. Intern. Med. 80: 249, 1974. 7. Rudolph, R., Stein, R., and Pattillo, R.: Skin ulcers due to adriamycin. Cancer 38: 1087, 1976.
664
Downloaded from cpj.sagepub.com at Purdue University on June 29, 2015
