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Case Reports

Abstract

Thiotepa, an alkylating agent commonly used in chemotherapy, frequently induces cutaneous reactions resembling toxic erythema of chemotherapy (TEC), characterized by erythema, hyperpigmentation, and oropharyngeal mucositis and stomatitis. Thiotepa toxicity often presents with a predilection for intertriginous areas, resembling early stages of Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). Herein, we present a case of a 31 y.o. female with a past medical history of lupus erythematous, antiphospholipid antibody, seizures, and chronic kidney disease who was admitted for CNS lymphoma. 7 days post thiotepa autologous stem cell transplant, the patient presented with severe mucositis that warranted intubation for airway protection followed by a full body dusky rash with gray sloughing involving the groin, axillae, and buttocks. Skin biopsy of the back revealed vacuolar interface changes with eccrine gland necrosis and occasional necrotic keratinocytes at the dermal-epidermal junction. No partial-to-full thickness epidermal necrosis, satellite cell necrosis, or eosinophils. The differential diagnosis included Thiotepa-induced toxicity, early SJS/TEN, and drug eruption. Based on the history of predominant involvement of intertriginous areas, erythema and hyperpigmentation, and prominent eccrine gland necrosis, Thiotepa-induced toxicity was favored. The patient's skin morphology with dusky grey discoloration and sloughing was highly suspicious for SJS/TEN or TEC associated with Thiotepa which the patient recently received. Mucositis can be seen with all these possible diagnoses. This case highlights the diagnostic challenge and the importance of considering Thiotepa-induced toxicity in patients with mucositis and skin manifestations resembling SJS/TEN post-transplant.