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JAMA Clinical Challenge
September 14, 2020

Pruritus and Tense Bullae After Discontinuation of Pembrolizumab in a Patient With Renal Cell Carcinoma

Author Affiliations
  • 1The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
JAMA. Published online September 14, 2020. doi:10.1001/jama.2020.10159

A 53-year-old woman with stage IV renal cell carcinoma was treated with pembrolizumab, a PD-1 inhibitor, for 20 months before developing a diffuse pruritic eruption recalcitrant to topical and oral corticosteroids. After 1 month of ongoing rash, pembrolizumab was discontinued. Her pruritic eruption persisted over the next 5 months despite treatment with up to 80 mg/d of oral prednisone. She did not report fever during this period. A shave biopsy performed while the patient was receiving systemic corticosteroids demonstrated spongiotic dermatitis with a mixed-cell infiltrate suggesting an incipient autoimmune bullous process. Results of follow-up direct immunofluorescence (DIF) performed on a sample taken 15 days after steroid discontinuation were negative. The eruption continued to worsen when the patient was not receiving systemic corticosteroids, with blisters developing 7.5 weeks after their discontinuation, prompting her presentation to the emergency department.

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