Dear Editor,
A 34 years-old woman was admitted to the hematology department with complaints of fatigue and pancytopenia. On physical examination, she was pale and there was sternal tenderness. There was no evidence of skin lesions. Her white blood cells count was 2100x10³/µL, hemoglobin level was 8.5 gr/dL platelet count was 54000x109/L. The differential counts revealed blasts 8%, promyelocytes 42%, metamyelocytes 8%, bands 6%, neutrophils 28%, and lymphocytes 8%. Coagulation parameters were normal. Leukemic promyelocytes rates were 42% and blastic cells 46% in the bone marrow. The leukemic promyelocytes contained multiple Auer rods (Phaggot cells) (Figure 1, x100). Flow cytometer analysis marked myeloid leukemia. FISH analysis showed t(15;17)(q22;q11-12) positivity. The patient was diagnosed with acute promyelocytic leukemia (APL). We started patient as induction treatment trans retinoic acid (ATRA) 45 mg/m2 until remission, cytosine arabinoside (Ara-C) 200 mg/m2 for 7 days, and daunorubicine 60 mg/m2 for 3 days (1).
On the seventh day, prominent multiple cutaneous erythematous papules appeared on the thigh and periumbilical region with a diameter of 2-3 mm (Figure 1B). The lesions progressed on the body on day 9. Firstly, we thought of them as chemotherapy toxicity. Some papules had typical burrows suggesting scabies. The aspiration of dermal papules showed that live Sarcoptes Scabiei forms and egg in the evaluation under the microscope. Aspiration from dermal papules was made with standard syringe 25G. Diagnosis of disseminated scabies was confirmed by visualization of mites in aspiration material (Figure 1C x10). Topical permethrin as scabicide is applied from the jawline down after bathing and is removed 12-16 hours later with soap (2). Treatment repeated after 1 week. The papules began do disappear after 5th day. The patient was discharged from our clinic after induction treatment with complete remission. Then she completed consolidation and maintenance treatment. Now, she has been living a normal life leukemia-free for 5 three years.
The skin lesions can develop during the treatment of patients with leukemia and they can be evaluated for leukemia cutis and drug adverse effects (3,4). Cutaneous papules are not usual with intermediate-dose Ara-C treatment in leukemic patients. Leukemia cutis is a cutaneous infiltration with leukemic cells. It can appear as papules, nodules, plaques and bullae on the skin (5). The patient had no signs of scabies at the time of admission, and it was thought that the scabies was in the incubation period during this time. We believe that induction therapy with Ara-C and ATRA of APL accelerates the emergence of disseminated scabies.
Information about the coexistence of acute myeloid leukemia (AML) and scabies is very limited in the literature. The association of AML and scabies has been reported in only two cases so far. The first case was reported 52 years ago in a case with monocytic leukemia (4). The second case is the disseminated scabies case, which developed during antileukemic chemotherapy, similar to our patient (6).
In conlusion, scabies should be remembered in the development of papular lesions during induction therapy in patients with AML.
Keywords: Leukemia, scabies, skin
Anahtar Kelimeler: Lösemi, skabies, deri
Ethics
Peer-review: Internally peer-reviewed.
Authorship Contributions
Design: A.Z.B., İ.Y., Data Collection or Processing: A.Z.B., İ.Y., A.H.E.K., Analysis or Interpretation: A.Z.B., İ.Y., A.H.E.K., Literature Search: A.Z.B., İ.Y., A.H.E.K., Writing: A.Z.B., İ.Y.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
