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Pediatric Cancer

Red Plaques in a Pediatric Patient With Acute Leukemia of Ambiguous Lineage

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Oncology

Published Online: December 30, 2020

JAMA Oncology Clinical Challenge

Article Information and Disclosures

Arabella Wallett, MBBS¹;

Rebecca Manudhane, MBBS¹;

Jill Lipsett, BMBS, PhD²

Author Affiliations

¹Women’s and Children’s Hospital, North Adelaide, Adelaide, South Australia, Australia
²SA Pathology, Women’s and Children’s Hospital, North Adelaide, Adelaide, South Australia, Australia

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A 16-year-old boy with acute leukemia of ambiguous lineage developed tender, 1- to 2-cm erythematous plaques and nodules during treatment with chemotherapy. Previously, he had been well, with morphological remission found on a recent bone marrow biopsy. The patient had no significant dermatological history, except an allergy to cashew nuts and a prior episode (6 mo) of urticaria during a platelet transfusion that had resolved with 1 dose of oral antihistamine. The patient’s medications included ondansetron, aprepitant, prednisolone, and oxycodone (supportive care initiated with chemotherapy), and long-term posaconazole and trimethoprim/sulfamethoxazole treatment.

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A 16-year-old boy with acute leukemia of ambiguous lineage developed tender, 1- to 2-cm erythematous plaques and nodules during treatment with chemotherapy. Previously, he had been well, with morphological remission found on a recent bone marrow biopsy. The patient had no significant dermatological history, except an allergy to cashew nuts and a prior episode (6 mo) of urticaria during a platelet transfusion that had resolved with 1 dose of oral antihistamine. The patient’s medications included ondansetron, aprepitant, prednisolone, and oxycodone (supportive care initiated with chemotherapy), and long-term posaconazole and trimethoprim/sulfamethoxazole treatment.

Lesions were noted on day 2 of the fourth cycle of a chemotherapy regimen comprising fludarabine, cytarabine, and filgrastim (G-CSF). Initially present over the distal limbs, palms, and soles, the lesions progressed to the proximal limbs and lower trunk during 24 hours (Figure, A and B). The patient developed a fever, which we extensively investigated. Intravenous cefotaxime was commenced, but because no infectious source was identified, the fever was thought to be secondary to cytarabine.

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Article Information

Corresponding Author: Arabella Wallett, MBBS, Women’s and Children’s Hospital, South Australia, 72 King William St, North Adelaide, Adelaide, South Australia 5006, Australia (arabella.wallett@sa.gov.au).

Published Online: December 30, 2020. doi:10.1001/jamaoncol.2020.6134

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s mother for granting permission to publish this information.

References

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Bachmeyer C , Aractingi S . Neutrophilic eccrine hidradenitis. Clin Dermatol. 2000;18(3):319-330. doi:10.1016/S0738-081X(99)00123-6 PubMed Google Scholar Crossref

Bassas-Vila J , Fernández-Figueras MT , Romaní J , Ferrándiz C . Infectious eccrine hidradenitis: a report of 3 cases and a review of the literature. Actas Dermosifiliogr. 2014;105(2):e7-e12. doi:10.1016/j.ad.2013.04.016 PubMed Google Scholar Crossref

Shih IH , Huang YH , Yang CH , Yang LC , Hong HS . Childhood neutrophilic eccrine hidradenitis: a clinicopathologic and immunohistochemical study of 10 patients. J Am Acad Dermatol. 2005;52(6):963-966. doi:10.1016/j.jaad.2005.01.009 PubMed Google Scholar Crossref

Shear NH , Knowles SR , Shapiro L , Poldre P . Dapsone in prevention of recurrent neutrophilic eccrine hidradenitis. J Am Acad Dermatol. 1996;35(5 pt 2):819-822. doi:10.1016/S0190-9622(96)90092-4 PubMed Google Scholar Crossref

Martínez-Leboráns L , Victoria-Martínez AM , Torregrosa-Calatayud JL , Alegre de Miquel V . Leucemia cutis. Serie de 17 casos y revisión de la literatura. Actas Dermosifiliogr. 2016;107(9):e65-e69. doi:10.1016/j.ad.2016.02.015 PubMed Google Scholar Crossref

Patterson J. Weedon’s Skin Pathology. 4th ed. Elsevier Health Sciences; 2015.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.