Track: Case Reports

Abstract:

We present the case of a 31-year-old male with a one-week history of lethargy and altered mental status. His medical history was significant for neurofibromatosis type 1 and an intracranial astrocytoma with leptomeningeal dissemination treated with chronic corticosteroids, selumetinib, and bevacizumab. He was found to have hydrocephalus, pneumonia, and bacteremia. Dermatology was consulted for four weeks of painful, bleeding ulcers within striae on the axillae, groin, and abdomen. A punch biopsy of a left abdominal lesion revealed ulceration with a mild neutrophil-rich infiltrate. Microorganisms were not identified on acid-fast bacilli, Periodic Acid–Schiff, Gram, and Grocott methenamine silver stains. Tissue cultures grew Klebsiella and Staphylococcus aureus. Ulceration in striae has been associated with bevacizumab, likely due to Vascular Endothelial Growth Factor inhibition–mediated endothelial disruption, delayed epithelialization, and impaired collagen remodeling in Fuentes et al. Reported histopathologic findings in Vila-Payeras et al include septal panniculitis with capillary thrombosis, and in Ahn et al, poor connective tissue regeneration, including lack of reepithelization and vascularization on the edge and base of ulceration, respectively. This case emphasizes the variable histopathologic findings in bevacizumab-associated ulcers, highlighting a mild neutrophilic infiltrate and positive tissue cultures, likely due to secondary bacterial infection. Biopsy aids in ruling out other etiologies, including primary infection or vasculitis. Treatment includes wound care, stopping the bevacizumab, and topical diltiazem. Topical diltiazem will be trialed in our case, improving blood flow via vasodilation and smooth muscle relaxation. Addressing the varying histopathological findings in the appropriate clinical context aids in early diagnosis and treatment.

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Urmila Sivagnanalingam