2
been reported to date. Sarcoidosis is a multisystem granulomatous disease characterized by Th1 cells and activated macrophages with increased amounts of interleukin-2 and interferon-gamma, but the exact etiology remains unknown. It is conceivable that sarcoidosis is an inflammatory reaction induced by multiple different causes. In addition to ipilimu- mab, sarcoidosis-like drug reactions have been reported with alpha-interferon and tumor necrosis factor inhibitor therapy. 5 The precise mechanism of these immunomodulatory medications in the path- ogenesis of sarcoidosis-like drug reactions is un- known. However, the association of such a reaction in the context of blockade of CTLA-4 may provide additional insight into the pathophysiology of sar- coidosis and the role of inhibitory signaling in lymphocytes in this disease. At least in this case, a sarcoidosis-like response with ipilimumab did not portend a better tumor response, as this patient progressed to stage IV disease. With the increasing use of CTLA-4 inhibitors in patients with melanoma, dermatologists should become familiar with this associated adverse event. Ross B. Reule, MD, and Jeffrey P. North, MD Department of Dermatology, University of Missouri, Columbia, Missouri Funding sources: None. Conflicts of interest. None declared. Correspondence to: Jeffrey P. North, MD, Department of Dermatology, University of Missouri-Columbia, One Hospital Drive MA-111, Columbia, MO, 65212 E-mail: [email protected] REFERENCES 1. Berthod G, Lazor R, Letovanec I, Romano E, Noirez L, Mazza Stalder J, et al. Pulmonary sarcoid-like granulomatosis induced by ipilimumab. J Clin Oncol 2012;30:e156-9. 2. Eckert A, Schoeffler A, Dalle S, Phan A, Kiakouama L, Thomas L. Anti-CTLA-4 monoclonal antibody induced sarcoidosis in a metastatic melanoma patient. Dermatol 2009;218:69-70. 3. Vogel W, Guislain A, Kvistborg P, Schumacher T, Haanen J, Blank C. Ipilimumab-induced sarcoidosis in a patient with metastatic melanoma undergoing complete remission. J Clin Oncol 2012;30:e7-10. 4. Wilgenhof S, Morlion V, Seghers A, Du Four S, Vanderlinden E, Hanon S, et al. Sarcoidosis in a patient with metastatic melanoma sequentially treated with anti-CTLA-4 monoclonal antibody and selective BRAF inhibitor. Anticancer Res 2012;32:1355-60. 5. Cathcart S, Samni N, Elewski B. Sarcoidosis as an adverse effect of tumor necrosis factor inhibitors. J Drugs Dermatol 2012;11:609-12. http://dx.doi.org/10.1016/j.jaad.2013.07.028 Eccrine squamous syringometaplasia associated with dabrafenib therapy To the Editor: Eccrine squamous syringometaplasia (ESS) is histologically defined as the transformation of the normal cuboidal epithelial cells of the eccrine sweat ducts into 2 or more layers of squamous epithelial cells. It has been reported particularly in patients with cancer receiving various chemotherapeutic regimens. Recently Martorell-Calatayud and Sanmart ın 1 pro- posed the term ‘‘chemotherapy-related bilateral dermatitis associated with eccrine squamous syrin- gometaplasia’’ to describe a distinctive subtype of chemotherapeutic drug reaction clinically character- ized as affecting the intertriginous areas, together with the presence of ESS as the main histologic feature. BRAF mutations occur in 40% to 60% of melano- mas. To date, treatment of BRAF-mutated metastatic melanomas with the selective BRAF inhibitors has resulted in response rates of 50% to 80% across clinical trials. A 24-year-old man was diagnosed with a malig- nant melanoma on his back in May 2011. Positron emissionecomputed tomography detected multiple subcutaneous, lung and lymph node metastases. A molecular analysis of lymph node metastasis showed a BRAFV600E mutation, making the patient eligible for targeted therapy with vemurafenib. During the treatment the patient developed a self- limited acneiform eruption and multiple warts. After 6 months of treatment, vemurafenib was discontin- ued because of the appearance of brain metastases. The patient was treated with cranial radiotherapy and chemotherapy (carboplatin/dacarbazine and fote- mustine). Because of the progression of the disease dabrafenib was started at the end of January 2013 at a daily dose of 150 mg. Concurrent medications in- cluded morphine and levetiracetam. The patient rapidly developed an asymptomatic rash 1 week after treatment initiation. Numerous pinpoint papules with surrounding erythema and central confluence were symmetrically distributed in skin folds of the axillae, groin, and intergluteal cleft. Surrounding satellite patches 1 to 3 mm in diameter with similar characteristics were also noted (Fig 1). Two skin punch biopsies from a submammary area papule and intergluteal cleft plaque were performed. Histologic evaluation of both specimens demon- strated squamous metaplasia of the eccrine coils and ducts with a paucicellular infiltrate of lymphocytes, histiocytes, and eosinophils (Fig 2). JAM ACAD DERMATOL VOLUME 69, NUMBER 5 Letters e273 CRP 5.1.0 DTD ĸ YMJD6306_8945_proof ĸ 9 October 2013 ĸ 1:37 am
