Bullous hemorrhagic dermatosis

• Published in: Canadian Medical Association journal (CMAJ) Vol. 192; no. 1; p. E12
• Main Authors: Roy, Simon F, Watson, Philippe, Bouffard, Danielle
• Format: Journal Article
• Language: English
• Published: Canada Joule Inc 06-01-2020; CMA Impact, Inc
• Subjects: Antibodies; Anticoagulants; Blood; Carcinoma; Chicken pox; Durvalumab; Embolism; Fondaparinux; Immunotherapy; Medical diagnosis; Monoclonal antibodies; Practice; Pulmonary embolism; Respiratory system agents; Skin diseases; Targeted cancer therapy; Tinzaparin; Canada; Montreal Quebec Canada
• ISSN: 0820-3946; 1488-2329
• DOI: 10.1503/cmaj.191052

A 52-year-old woman presented with a 4-day history of painful, tense, blood-filled blisters on her ankles and dorsal feet, with no mucosal involvement. She had a history of plurimetastatic carcinoma of likely pancreatobiliary origin, for which she had received 2 cycles of immune-activating monoclonal antibodies (durvalumab and tremelimumab) 2 months earlier. For the past 5 months, she had also been receiving a therapeutic regimen of tinzaparin (16 000 units/d subcutaneously) for treatment of pulmonary embolism. Tinzaparin had been temporarily replaced with enoxaparin for an 8-day span, as it was unavailable at the hospital, 2 weeks before the eruption of blisters. Clinical and histopathologic findings were consistent with bullous hemorrhagic dermatosis, an adverse drug effect probably induced by subcutaneous low-molecular-weight heparin. It is unclear whether re-initiation of tinzaparin or the previous temporary course of enoxaparin was responsible in the case of our patient. Bullous hemorrhagic dermatosis tends to arise after a mean of 7 days of starting the drug.