Title:An Unexpected Cutaneous Response to a Skin Test to Paclitaxel: A Case Report
Volume: 11
Author(s): Lucía González-Bravo*, José Barbarroja-Escudero, Maria José Sánchez-González, Ana Laiseca-Antón, Dorotea Matas-Domínguez, Josefa Monjo-Paz, Ileana María Medina-Exposito, Ana Belen Piteiro and Melchor Alvarez-Mon
Affiliation:
- Servicio de Enfermedades del Sistema Inmune-Alergia, Departamento de Medicina y Especialidades Médicas, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
Keywords:
Paclitaxel, docetaxel, intradermal test, blister, converter phenotype, IDHR.
Abstract:
Introduction: Taxanes are a group of antineoplastic agents widely used in the treatment
of various cancers, including breast cancer, due to their mitotic inhibitory effects. Hypersensitivity
reactions (HRs) to paclitaxel typically occur immediately, often within the first few
minutes of infusion during the initial chemotherapy cycle.
Case Presentation: A 75-year-old woman was diagnosed with grade 1-2 invasive ductal breast
carcinoma at stage T2N1M1. During her first chemotherapy cycle, starting the infusion of
paclitaxel, the patient experienced facial flushing, dyspnea (SatO2 92%), and dizziness with hypotension.
A 0.6 mg/mL intradermal test concentration yielded a positive result, characterized by
a 10-mm blister with exudation. A punch biopsy showed a subepidermal blister with partial epidermal
necrosis. Intravascular occlusion was also described, with thrombi present in small vessels
within the dermis. No coagulation alterations were detected after a complete workup.
Desensitization to paclitaxel was dismissed for caution, as there was a high risk of severe delayed
drug reaction. Desensitization to docetaxel with premedication was scheduled for patient
safety in order to continue taxane-based treatment. Despite docetaxel desensitization, the patient
presented a progressive, severe dermatitis on the hands. After six cycles, docetaxel was finally
suspended because of this severe dermatitis. She continued receiving pertuzumab and
trastuzumab, and she started on hormone therapy with letrozole.
Conclusion: We present a case of an immediate reaction during paclitaxel infusion, as indicated
by a positive immediate-reading intradermal test, suggestive of a T-cell-mediated delayed-type
hypersensitivity reaction. Desensitization to paclitaxel was avoided out of caution. Desensitization
to docetaxel with premedication was planned following negative skin tests (STs); however,
the development of severe hand dermatitis necessitated discontinuation of taxanes due to suspected
cross-reactivity. We hypothesize that the patient exhibited a “converter phenotype,” transitioning
from an initial immediate drug hypersensitivity reaction (IDHR) to a non-immediate
drug hypersensitivity reaction (NIDHR) upon docetaxel exposure. In this case, the intradermal
test with paclitaxel may have served as a predictive marker for this phenomenon.
