Background and Aims

We report on a 66 years old female patient with systemic sclerosis (first diagnosed in year 2016 with limited skin sclerosis, anti-Scl-70-antibody, raynaud symptoms) who developed metastatic parotiscarcinoma (lung, lymph nodes) in march 2019 and was introduced to chemotherapy with paclitaxel.

Methods

After four cycles of therapy with paclitaxel, CT-scan showed regression of lung metastases. At the same time, massive progression of systemic sclerosis with diffuse skin sclerosis and new manifestations like digital ulcers, dysphagia with oesophageal hypomotility, lung fibrosis and pulmonal arterial hypertension occurred. Moreover, the patient developed leuco- and thrombocytopenia due to chemotherapy.

Results

Since several cases of induction of scleroderma-like skin lesions during the therapy with paclitaxel were described in the literature, chemotherapy with paclitaxel was paused after consultation of an oncologist. We started prednisolone (10 mg daily) and mycophenolate-mofetil (1 g daily) in order to improve lung fibrosis and skin sclerosis which were the most prominent manifestations of systemic sclerosis in our patient. Unfortunately, the patient could not take mycophenolate-mofetil because of dysphagia and burning in the mouth. Currently we are planning to start extracorporeal photopheresis as well as therapy with nintedanib.

Conclusions

Management of patients with autoimmune and metastatic tumour diseases demands interdisciplinary exchange, for which we suggest autoimmune board meetings (including dermatologists, cardiologists, oncologists, pulmonologists, pathologists, rheumatologists and radiologists).

Background and Aims

We report on a 33 years old female patient who visited our clinic in September 2019 with several symptoms of unclear origin (progressive eosinophilic fasciitis on extremities, recurrent fever, strong headache and loss of hearing).

Two years before, the patient was diagnosed with high malignant follicular lymphoma (stage 4a, intermediate risk) and was treated with chemotherapy (6 cycles G-CHOP) and maintenance therapy with obinutuzumab (anti-cd20-antibody). During the therapy with obinutuzumab the patient developed recurrent high fever, myalgia, conjunctivitis and weight loss and the therapy was stopped.

Methods

As symptoms did not improve during the following months, detailed screening for cancer diseases (PET-scan, bone marrow biopsy, mamma sonography, colonoscopy), for infections (tests for tuberculosis; PCR from serum and bone marrow analysis for DNA of infectious antigens; bronchoalveolar lavage analyses) and for autoimmune diseases (rheumatic factor, ANA antibodies, complement, ANCA, genetical analysis for CAPS) was performed and all results came negative.

Results

As the patient developed new symptoms like progressive loss of hearing and strong headache, we performed MR-scan (which was normal) and liquor biopsy (pathological cell count with dominance of t-cells). Further microbiological analyses of liquor showed positive RNA-tests for enterovirus (coxsackie A9) infection. We administered a high dose of intravenous immunoglobulin therapy which stabilized the symptoms. In literature, a case of fatal disseminated infection with enterovirus in patients with follicular lymphoma under maintenance therapy with obinutuzumab was described.

Conclusions

In patients who receive anti-cd20-antibody therapy and experience recurrent fever, medical doctors should be aware of enterovirus infection as a rare but life-threatening complication.