2 Case presentation
A 67-year-old man had a one-month history of erythema and multiple
bullae with itching and pain over the whole body (Figure 1A). Two years
ago, the patient was diagnosed with advanced hepatocellular carcinoma
and underwent chemoembolization and systemic treatment, including
half-year treatment of sorafenib (0.8 g/d) and one-year treatment of
lenvatinib (0.8 mg/d). However, he developed intermittent diarrhea after
the systemic treatment. One month prior, the patient began taking
apatinib mesylate (850 mg/d). After ten days, the patient presented with
patchy erythema, blisters, bullae, and erosion accompanying the oral
mucosa, which was affected by itching and pain. He was admitted to local
hospital and an initial diagnosis of pemphigus was considered, while
discontinuation of apatinib mesylate and symptomatic treatments were
ineffective. Then the patient was admitted to our department. Physical
examination revealed a few vesicles on the trunk, blood blisters on the
hands, and multiple erosions on the trunk, limbs, and scalp, while some
were covered with crust. Skin biopsy and immunofluorescence (IF) were
obtained from the right waist. The skin biopsy demonstrated subepidermal
blisters, individual dyskeratinized cells in the spinous layer,
vacuolized focal basal cells, and sparse lymphocyte infiltration around
the small vessels in the superficial dermis (Figure 2). Direct IF
displayed a basement membrane with linear deposition of IgA, IgG, and
C3, with negative indirect IF (Figure 3). His blood pressure was
120-150mmHg/60-90mmHg while fasting blood glucose fluctuates between 8
and 15mmol/L and postprandial blood glucose fluctuates between 5 and
23mmol/L. Furthermore, laboratory investigations depicted mild anemia,
hypoproteinemia, abnormal liver function, coagulopathy, fecal occult
blood, and urinary tract infection with negative serum autoantibodies
including anti-BP180, anti-Dsg1, anti-Dsg3, and anti-nuclear antibody.
Staphylococcus squirrels and Corynebacterium striatum were cultured from
buttock secretions. Chest CT indicated chronic bronchitis,
pneumonectasis, and mild pulmonary infection.
Based on these findings, the patient was diagnosed with apatinib-induced
bullous dermatosis (BP). The body weight of the patient was 45 kg.
Methylprednisolone (80 mg daily at the initial dose), antibiotics,
symptomatic treatments including albumin, niferex, furosemide, fresh
frozen plasma, insulun and skin care were initiated. Owing to his
multiple underlying diseases, he and his family were discharged after
two weeks of treatment (Figure 1A). Methylprednisolone was replaced with
oral prednisone 30 mg daily, and recombinant human epidermal growth
factor gel was added to promote wound healing. Then the patient took
prednisone 30 mg/d for 2 months by himself, the cutaneous and oral
erosions mostly healed, with a few epithelial islands growing. At the
3-month-follow up visit, the skin lesions of the patient completely
resolved (Figure 1B).