The Journal of the Arkansas Medical Society Med Journal June 2019 Final | Page 19

shin; warmth and tenderness were noted. (fig1).
White cell count was low at 2.7 x 10 3 /µL, neutro-
phil count was 1.97 x 10 3 /µL. He was initiated
on Vancomycin IV; he continued to be afebrile,
however he had worsening erythema and ten-
derness on account of which he was started on
imipenem. He continued to do well without any
fever. Blood culture on admission grew Staph.
Epidermidis, which was sensitive to vancomycin
and resistant to Bactrim. Blood culture repeated
two days later was negative. Absence of fever,
neutrophilia, and systemic symptoms prompted
discontinuation of parenteral antibiotics. Skin
biopsy revealed focal interface dermatitis with
underlying acute interstitial dermatitis. Since
pathology did not completely rule out cellulitis;
fungal and bacterial cultures obtained from a re-
peat skin biopsy were negative. Skin lesion sig-
nificantly improved on topical clobetasol (0.05%)
twice daily.
Figure 2: Focal interface change and an apoptotic keratinocyte.
DISCUSSION
Pseudocellulitis is a rare complication of
chemotherapy administration reported after ad-
ministration of gemcitabine and more recently
pemetrexed. Both these agents are associated
with several forms of cutaneous toxicities. In-
hibition of DNA synthesis by gemcitabine, a
pyrimidine antimetabolite and pemetrexed an
antifolate drug is thought to be responsible for
increased incidence of cutaneous toxicities. 1,4
B12 and folic acid supplementation by improv-
ing the functional folate status has been shown
to reduce myelotoxicity, mucositis, and diarrhea
associated with pemetrexed. Dexamethasone in
addition to supplementation of B12 and folic acid
has significantly reduced cutaneous toxicities. 1
Our patient received supplements of folic acid
and B12; he did not receive dexamethasone on
account of diabetes, despite which he received
multiple cycles of alimta without cutaneous tox-
icity. Increasing edema of right foot noticed by
the patient may have a causative role in devel-
opment of pseudocellulitis. 4 Differing histologic
findings have been reported in pseudocellulitis 2 .
Pseudocellulits is mainly treated with systemic
and topical steroids. Our patient recovered well
on topical steroid alone. Increased awareness of
this condition may avoid hospitalization and an-
tibiotic therapy, Procalcitonin level, which is low
in pseudocellulitis, may be used to differentiate
from cellulitis. 3
Figure 3: Interstitial infiltrate of neutrophils in the superficial and deep dermis.
REFERENCES
1. Pierard-Franchimont C, Quatresooz P, Regin-
ster M-A, Pierard G. Revisiting cutaneous
adverse reactions to pemetrexed. Oncology
Letters 2011; 2:769-772.
2. Santosa A, Liau MM,Tan KB,Tan LC. Peme-
trexed induced eccrine squamous syringo-
metaplasia manifesting as pseudocellulitis
(in a patient withnon-small cell lung cancer).
JAAD Case reports 2017; 3:64-66.
3. Wollina U, Hansel G, Zschuppe E, Tchernev G.
Pemetrexed induced pseudocellulits- A rare
cutaneous adverse reaction to multitargeted
antifolate therapy. Georgian Medical News
2017; 267: 81-84.
4. Asemota E, Reid E, Kovarik C. Gemcitabine
induced pseudocellulitis in a patient with
non-small cell carcinoma. JAAD Case reports
2015;1: 178-81.
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