Pegfilgrastim‐induced S weet's syndrome: a case report

A 43-year-old Caucasian woman presented with a 7-day history of a painful cutaneous eruption of the trunk and extremities and intermittent fever. Past medical history included hepatitis C, polysubstance abuse, a nonspecific lymphadenopathy, bipolar disorder, and schizoaffective disorder. Her medications were quetiapine and aripiprazole. The patient had recently started pegfilgrastim (Neulasta, Amgen, Inc., Thousand Oaks, CA, USA) for presumed ziprasidone-associated neutropenia. Laboratory testing demonstrated a white blood cell count of 5.5 9 10/ll (67.7% neutrophils, 26.5% lymphocytes, 1.6% eosinophils, 4.2% monocytes); hemoglobin, 11.8 g/dl; platelets, 177,000/ll; alanine aminotransferase, 38 U/l; and aspartate aminotransferase, 20 U/l. Urine toxicology was positive for opiates and cocaine. Physical examination revealed tender, edematous hemorrhagic papules and plaques, some with central crusting and erosion, diffusely involving the face, neck, trunk, and upper and lower extremities (Fig. 1). No lymphadenopathy was detected. A punch biopsy demonstrated diffuse neutrophilic dermatitis with papillary edema and signs of vasculitis, including hemorrhage, leukocytoclasia, collagen necrosis, and periand intravascular deposition of fibrin in postcapillary venules (Fig. 2). Grocott methenamine silver and Giemsa preparations did not reveal infectious bacteria or fungi. A diagnosis of pegfilgrastim-induced Sweet’s syndrome (SS) was made. The patient was treated with cessation of pegfilgrastim and intravenous methylprednisolone. She experienced marked improvement within 48 hours.