YO33 - Muco-cutaneous adverse drug reaction associated with oral Temozolomide in a case of GBM : when rare become common.

Case summary

Abstract:

A woman in her 40s had right frontal anaplastic astrocytoma (World Health Organization grade III). The patient underwent a sub total tumor resection on 2^nd February 2023. Post-op MRI after 10 days of surgery reveals 2.6x1.9 cm mass in rt upper anterior parietal region. A 6-week course of postoperative radiation therapy (6000 cGy) with concurrent TMZ (75 mg/m²) by mouth daily was prescribed. During that period, antiemetic treatment with ondansetron was started. On February 10 , 2023, antiepileptic treatment (levetiracetam 500 mg twice daily) was administered to prevent seizures. The patient tolerated treatment well, with no side effects.

Radiotherapy treatment was started from 25^th February 2023. Within 2^nd weeks of concurrent chemoradiation, she started to develop vesicular-bular lesions in head & face area and maculopapular rash in trunk and extremities. Intially it was thought to be a hypersensitivity reaction to some food or allergen and given some anti-hypersensitivity medication but her condition didn’t improved. During the 3^rd week of concurrent chemoradiation, she had persistent worsening skin findings without associated systemic symptoms. There was no history of any recent infections or other new medications, and there was no personal or family history of inflammatory bowel disease, sarcoidosis, lupus erythematosus.

Within 4^th week of radiotherapy she experienced severe skin reaction in the form of skin sheding, painful ulceration, mucosal erosion, mucosal bleeding, lip edema and fever. SCORETEN score was 4 with a mortality rate of 54.3%. Patients treatment was stopped, immediately hospitalization was done and treatment started as a case of overlapping Steven Johnson Syndrome & Toxic Epidermal Necrolysis. Parenteral nutrition, Antihistamines, high dose steroids (methylprednisolone) and antibiotics was given. After 7 days her condition improved and we re-introduced radiotherapy with reduced dose TMZ (50mg/m2) with antihistamine and methylprednisolone. Her maculopapular rash again re-appear but not worsen and finished her proposed treatment without any further event. During maintainence phases of 6 cycles TMZ she developed same rash without severe adverse event.

Clinical trial identification

Editorial acknowledgement