Severe lymphopenia after subcutaneous cladribine in a patient with multiple sclerosis: To vaccinate or not?

OBJECTIVE: To describe a fatal case of influenza A pneumonia in a patient with severe lymphopenia after receiving subcutaneous cladribine to treat her multiple sclerosis (MS). METHODS: Case report. RESULTS: A 53-year-old woman developed fatal influenza pneumonia associated with grade 4 lymphopenia two months after receiving a total dose of 60mg subcutaneous cladribine. Despite treatment with oseltamivir, her condition deteriorated and the patient passed away after developing respiratory failure. CONCLUSION: Cladribine-related lymphopenia is usually mild to moderate, however severe lymphopenia may occur. People with MS, especially those who are immunosuppressed, should be offered the inactivated influenza vaccine annually.

Severe skin reactions associated with cladribine in people with multiple sclerosis.

OBJECTIVE: To report three cases of severe skin reactions in patients treated with cladribine for multiple sclerosis. METHODS: Case study. RESULTS: Patients developed severe rash 3-192 days after receiving cladribine. All were effectively treated with steroids and antihistamines. Additional doses of cladribine were administered after pretreatment with steroids and anti-histamines. One patient developed mild recurrence following re-exposure, which resolved within three days, whilst another patient tolerated re-exposure without further adverse reaction. CONCLUSION: Severe skin reactions, well described in patients receiving cladribine for treatment of haematological conditions, may occur in patients treated with this compound for multiple sclerosis. Neurologists need to be aware of this rare, but significant adverse reaction. Re-exposure may be safe with standard pre-treatment against allergic reactions.

Pigmented reticular structures in basal cell carcinoma and collision tumours.

BACKGROUND: The dermatoscopic diagnosis of basal cell carcinoma (BCC) is based on well-known specific criteria. Despite the fact that a pigment network is considered a negative feature for the diagnosis of BCC, its detection in a BCC context has been reported in 2.8% of cases. OBJECTIVES: To determine whether pigment networks or network-like structures might represent a pitfall for the correct diagnosis of BCC. METHODS: Dermatoscopic images of 412 histopathologically proven BCCs were analysed retrospectively. RESULTS: Pigment network or network-like structures were detected in 14 of 412 (3.4%) BCCs. Nine of 14 BCCs presented a typical pigment network, due to the association of a BCC lesion with a naevus, solar lentigo or actinic keratosis; two BCCs located on the face showed a pseudonetwork, and three of 14 lesions displayed a network-like structure characterized by light-brown irregularly meshed short linear structures, histopathologically related to a hyperpigmentation of the basal layer of the epidermis. CONCLUSIONS: The presence of a pigment network in the context of a BCC is uncommon, and it usually reflects the association of BCC with a solar lentigo, naevus or a specific location of the lesion on photodamaged skin.