A 51-year-old man comes to the physician with a rash on his hands and feet for the past 2 weeks. The rash is associated with a tingling and burning sensation but no pruritus. He has no fevers or chills. He has a history of advanced renal cell carcinoma that is treated with sunitinib. His other medical problems include acid reflux disease and hypertension, and his medications include over-the-counter antacids and amlodipine. An HIV test performed 2 months ago was negative.
The patient's vital signs are normal. Skin examination shows tender, erythematous lesions on his palms and soles with areas that look like blisters.
Laboratory results are as follows:

Which of the following conditions is the most likely diagnosis?

Question

A 51-year-old man comes to the physician with a rash on his hands and feet for the past 2 weeks.  The rash is associated with a tingling and burning sensation but no pruritus.  He has no fevers or chills.  He has a history of advanced renal cell carcinoma that is treated with sunitinib.  His other medical problems include acid reflux disease and hypertension, and his medications include over-the-counter antacids and amlodipine.  An HIV test performed 2 months ago was negative.
The patient's vital signs are normal.  Skin examination shows tender, erythematous lesions on his palms and soles with areas that look like blisters.
Laboratory results are as follows:

Which of the following conditions is the most likely diagnosis?

Quizplus · Accepted Answer

This patient with history of advanced renal cell carcinoma treated with sunitinib presents with skin blisters suggestive of hand-foot skin reaction (HFSR). Small molecule tyrosine kinase inhibitors (eg, imatinib, sorafenib, and sunitinib) are associated with various cutaneous reactions. Symptoms usually start within the first 2-4 weeks of therapy. Patients with HFSR present with focal tender lesions that appear as blisters or hyperkeratosis in areas of friction or trauma. Paresthesias, painful sensations on the palms and soles, and decreased tolerance to contact with hot objects are common. Desquamation is seen in severe cases. HFSR is diagnosed clinically, and treatment consists of topical emollients/steroids, pain control, and, if necessary, reduction or discontinuation of tyrosine kinase inhibitor. However, treatment interruptions have been associated with rapid tumor progression and decreased survival and should be avoided unless the rash is severe. (Choice A) Allergic contact dermatitis presents as an eczematous reaction with pruritus (the dominant symptom) in the areas exposed to allergens. The rash of HFSR is nonpruritic, making allergic contact dermatitis a less likely diagnosis. Allergic contact dermatitis (Choice B) Coxsackievirus causes hand-foot-mouth syndrome, which is most common in children (but can occur in adults) and presents with fever, rash, and blister-like sores in the mouth. Lack of fever and mouth sores makes this syndrome a less likely diagnosis. (Choice D) Rash of secondary syphilis is most often a maculopapular eruption that involves the trunk, extremities, palms, and soles. Blisters and vesicles are uncommon. secondary syphilis (Choice E) Patients with Sweet's syndrome (acute febrile neutrophilic dermatosis) usually have fever and peripheral neutrophilia. It is commonly associated with hematologic malignancies. Cutaneous lesions typically have well-demarcated, erythematous plaques with an irregular, pseudovesiculated surface. Sweet's syndrome Educational objective: Small molecule tyrosine kinase inhibitors (eg, imatinib, sorafenib, and sunitinib) are associated with skin reactions such as hand-foot skin reaction (HFSR). Patients with HFSR present with focal, tender lesions that appear as blisters or hyperkeratosis in areas of friction or trauma. Treatment is supportive and discontinuation of tyrosine kinase inhibitor is not usually necessary. __________ References: Sunitinib in metastatic renal cell carcinoma: recommendations for management of noncardiovascular toxicities. (http://www.ncbi.nlm.nih.gov/pubmed/21490127) Evolving strategies for the management of hand-foot skin reaction associated with the multitargeted kinase inhibitors sorafenib and sunitinib. (http://www.ncbi.nlm.nih.gov/pubmed/18779536)

A 51-Year-Old Man Comes to the Physician with a Rash