Case of engraftment syndrome appearing as scratch dermatitis

Dear Editor, Scratch dermatitis, or flagellate erythema, is characterized by linear erythematous/hyperpigmented streaks, and can be caused by shiitake mushroom, bleomycin, dermatomyositis and Still’s disease. Engraftment syndrome (ES) presents with pyrexia, maculopapular eruption and edema during neutrophil recovery following hematopoietic stem cell transplantation. Here, we describe a case with scratch dermatitis encountered as a clinical manifestation of ES. A 44-year-old Japanese woman was referred to us with a 2day history of distinct scratch marks due to severe pruritus 18 days after unrelated allogeneic bone marrow transplantation (BMT) from an unrelated donor to treat blast crisis of chronic myeloid leukemia. Human leukocyte antigens between patient and donor were matched at eight of eight loci serologically, and seven of eight loci by DNA typing (mismatch for DRB1). The patient denied having eaten shiitake mushrooms recently. Neither bleomycin nor peplomycin had been administrated. Physical examination showed severe pruritus and erythematous streaks on the trunk on post-BMT day 18 (Fig. 1a). Maculopapular eruptions appeared on the trunk and extremities on day 19 (Fig. 1b). No diarrhea or jaundice was observed. Bodyweight was 56.0 kg, 57.2 kg and 56.2 kg on day 16, 18–21 and 22, respectively. Maximum daily axillary temperature was 37.9°C on day 16, 39.5°C on day 17, 39.1°C on day 18, 39.5°C on day 19 and 38.0°C on day 20. Neutrophil counts were 400/lL on day 16, 1300/lL on day 18 and 3500/lL on day 19. Aspartate transaminase and alanine transaminase concentrations were 173 IU/mL and 340 IU/mL, respectively, on day 18. Histopathological examination of the streaks on the