PMC8586206_01
Dermatologic findings. (A-C) Initial inspection revealed generalized rash with blistering which was more severe in load-bearing areas (yellow asterisk), such as the hip, back, and posterior aspect of the arms. (D) Peripheral examination showed severe rash in the hands and feet with associated swelling. (E) Treatment with intravenous immunoglobulin gradually improved his rash.
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The clinical diagnosis of a dermatologic immune-related adverse event (irAE) was established, and he was initially treated with 80 mg methylprednisolone (1.14 mg/kg) daily for three days; however, the rash became more extensive and severe, with most of the rash becoming blisters ( Figures 1A-C ). Very interestingly, the rash was particularly severe on his hands and feet with associated swelling, which caused intolerable pain ( Figure 1D ). The rash was much more severe in areas of compression (e.g., hip, back, and posterior aspect of the arms) ( Figures 1B, C ). IVIg was first administered was defined as Day 1, and since then, the rash improved daily ( Figure 1E ). IVIg was administered for five days at a cumulative dose of 150 g (> 2 g/kg), and the methylprednisolone was tapered over approximately 1 month.
Histopathologic and immunohistochemical findings. (A) Histopathologic analysis demonstrated (1) epidermal hyperkeratosis with intraepidermal edema and blister formation (2), basal and suprabasal apoptotic keratinocytes with focal confluent apoptosis, and (3) moderate perivascular lymphocytic infiltration in the superficial dermis. Immunostaining shows (B) PD-1-positive lymphocytes (anti-PD-1, x200) and (C) no PD-L1-positive cells (anti-PD-L1, x200). Immunostaining revealed (D) CD4+ (anti-CD4, x200) and (E) CD8+ T cell infiltration (anti-CD8, x200). Immunohistochemistry confirmed the absence of (F) B cells (anti-CD20, x200) and (G) NK cells (anti-CD56, x200).
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Pathologic examination ( Figure 2A ) showed epidermal hyperkeratosis with intraepidermal edema and blister formation, basal and suprabasal apoptotic keratinocytes with focal confluent apoptosis, and moderate infiltration of lymphocytes around vessels in the superficial dermis.