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Case Reports

Abstract

A 43-year-old female with TP53-mutated myelodysplastic syndrome (MDS) presented with fevers and tachycardia two days after epoetin alfa administration. She was pancytopenic and transfusion-dependent, with the most recent transfusion two days prior. Broad-spectrum antimicrobials were initiated. Further history revealed initiation of filgrastim, two weeks earlier, with symptom onset after epoetin alfa exposure.

On hospital day 3, the patient developed erythematous patches and thin plaques (1–10 cm), distributed bilaterally on the upper and lower extremities. Dermatology was consulted to rule out infectious panniculitis versus leukemic cutaneous infiltration. A punch biopsy from the right shoulder demonstrated predominantly septal with focal lobular neutrophilic panniculitis. Special stains (Gram, PAS-F, and Fite) were negative for microorganisms. Immunohistochemistry for CD34 and CD117 showed no increase in cutaneous blasts in the context of the patient’s MDS history. Flow cytometry and FISH analysis reconfirmed patient’s known history of MDS.

Given the clinical timeline, histopathologic features, and absence of infectious organisms or blasts, the patient’s skin biopsy findings favor neutrophilic panniculitis related to MDS or cytokine-stimulating factor therapy. The differential included early erythema nodosum and occult infection, though these were less likely.

Neutrophilic panniculitis is an uncommon cutaneous manifestation in patients with hematologic malignancy, and its occurrence following sequential filgrastim and epoetin alfa exposure is rarely documented in the scientific literature. This case highlights the importance of clinicopathologic correlation in distinguishing between drug-related panniculitis, infectious etiologies, and leukemic infiltration, particularly in immunocompromised populations.