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No clinical or radiological response was observed&#44; and the treatment was poorly tolerated &#40;asthenia&#44; vomiting&#44; and moderate kidney failure&#41;&#46; He had a 42-year history of mild psoriasis affecting the elbows and knees&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Twelve days after the first infusion of atezolizumab&#44; his existing lesions began to worsen&#44; and new lesions began to appear on the extensor aspects of both limbs and the trunk&#46; These were intensely pruritic and compatible with a clinical diagnosis of psoriasis &#40;Psoriasis Area Severity Index<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#44; body surface area affected<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#44; visual analog scale for itching<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; These findings were accompanied by distal edema affecting both lower limbs&#46; The patient was prescribed oral prednisone 30<span class="elsevierStyleHsp" style=""></span>mg for 7 days to be tapered by 10<span class="elsevierStyleHsp" style=""></span>mg every week&#44; bilastine 20<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>hours&#44; and topical treatment with clobetasol propionate 0&#46;1&#37; cream every 12<span class="elsevierStyleHsp" style=""></span>hours for 15 days&#46; His lesions resolved in 3 weeks&#44; and no residual lesions were observed&#46; Atezolizumab was discontinued because of the skin toxicity&#46; Given the patient&#39;s poor general status&#44; he refused all cancer medication and is currently receiving palliative care&#46; He was diagnosed with probable adverse reaction to atezolizumab &#40;Naranjo algorithm&#44; 6 points&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Programmed death 1 &#40;PD-1&#41; is a key immune checkpoint receptor that is expressed on T cells and functions mainly in peripheral tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Atezolizumab is the first PD ligand 1 &#40;PD-L1&#41; inhibitor approved by the United States Food and Drug Administration&#46; This human immunoglobulin G1 monoclonal antibody binds selectively to PD-L1 and prevents interaction with PD-1 and B7-1 &#40;also known as CD80&#41;&#44; while sparing the interaction between PD ligand 2 &#40;PD-L2&#41; and PD-1&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> When PD-1 is activated&#44; the immune system is inhibited&#44; thus enabling tumor growth&#46; In their various indications for different cancers&#44; new anti&#8211;PD-1 drugs &#40;nivolumab&#44; pembrolizumab&#44; pidilizumab&#41; and anti&#8211;PD-L1 drugs &#40;atezolizumab and durvalumab&#41; curb this inhibition by enabling the immune system to control tumor progression&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There have been various reports of adverse reactions to PD-1 and PD-L1 inhibitors in up to 50&#37; of patients&#46; These were mainly cutaneous &#40;lichenoid reactions&#44; eczema&#44; vitiligo&#44; and pruritus&#41; and mild and did not require treatment to be discontinued&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;4</span></a> However&#44; other authors report these inflammatory reactions to be severe&#44; requiring treatment with oral corticosteroids&#44; and highlight an objective antitumor response&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> One group of cutaneous reactions to this drug are those based on neutrophils&#44; which&#44; owing to their increased count in the skin&#44; cause Sweet syndrome&#44; acute generalized exanthematous pustulosis&#44; intracorneal pustular drug eruption&#44; and psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Other&#44; less common cutaneous adverse reactions include actinic keratosis&#44; squamous cell carcinoma&#44; and seborrheic keratosis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Peripheral edema is an adverse reaction that affects 10&#37; of patients receiving treatment with atezolizumab&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Cases of psoriasis triggered or exacerbated by this drug family are starting to be reported&#44; although the condition was due to atezolizumab in only 1 case&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8&#44;9</span></a> In a recent series&#44; 66&#37; of patients had a previous history of psoriasis&#44; which&#44; in most cases&#44; was controlled with topical treatment&#46; Given the intensity of skin involvement&#44; it was rarely necessary to suspend treatment or prescribe oral corticosteroids&#44; as in the present case&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8&#44;9</span></a> In most cases&#44; psoriasis is triggered after several doses&#46; In the only case where psoriasis was triggered by atezolizumab&#44; onset was after the first dose&#44; as occurred in the present case&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In terms of etiology and pathogenesis&#44; murine models have shown that PD-1 deficiency increases the likelihood of the psoriasis-like skin disease phenotype and that PD-1 can play a regulatory role in the development of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> Under normal conditions&#44; the PD-1 pathway maintains normal immune homeostasis&#44; which prevents autoimmune reactions or damage to healthy tissue&#46; T-cell activation induced by PD-1 inhibitors&#8212;together with other factors&#8212;can contribute to development of psoriasis or exacerbations of existing psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The low number of cases of psoriasis associated with atezolizumab is probably due to the mechanism of action&#44; 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Case and Research Letters
Plaque Psoriasis Flare and Peripheral Edema in a Patient Treated With Atezolizumab
Brote de psoriasis en placas y edema periférico en un paciente tratado con atezolizumab
J. Santos-Juanesa,
Autor para correspondencia
jorgesantosjuanes@gmail.com

Corresponding author.
, P. Munguia-Calzadaa, C. Álvarez-Fernádezb
a Servicio de Dermatología, Hospital Universitario Central de Asturias, Oviedo, España
b Servicio de Oncología Médica, Hospital Universitario Central de Asturias, Oviedo, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 75-year-old man was referred to the dermatology clinic for evaluation of skin lesions after receiving his first dose of atezolizumab &#40;1200<span class="elsevierStyleHsp" style=""></span>mg&#41; for treatment of poorly differentiated stage <span class="elsevierStyleSmallCaps">iv</span> urothelial carcinoma of the prostatic urethra &#40;metastasis to the lungs&#44; liver&#44; bone&#44; and lymph nodes&#41;&#46; Twelve months previously&#44; the patient had completed systemic treatment with chemotherapy &#40;cisplatin 75<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> day 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>gemcitabine 1250<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> on days 1 and 8 and every 21 days&#41; in 4 cycles&#46; No clinical or radiological response was observed&#44; and the treatment was poorly tolerated &#40;asthenia&#44; vomiting&#44; and moderate kidney failure&#41;&#46; He had a 42-year history of mild psoriasis affecting the elbows and knees&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Twelve days after the first infusion of atezolizumab&#44; his existing lesions began to worsen&#44; and new lesions began to appear on the extensor aspects of both limbs and the trunk&#46; These were intensely pruritic and compatible with a clinical diagnosis of psoriasis &#40;Psoriasis Area Severity Index<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#44; body surface area affected<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#44; visual analog scale for itching<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; These findings were accompanied by distal edema affecting both lower limbs&#46; The patient was prescribed oral prednisone 30<span class="elsevierStyleHsp" style=""></span>mg for 7 days to be tapered by 10<span class="elsevierStyleHsp" style=""></span>mg every week&#44; bilastine 20<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>hours&#44; and topical treatment with clobetasol propionate 0&#46;1&#37; cream every 12<span class="elsevierStyleHsp" style=""></span>hours for 15 days&#46; His lesions resolved in 3 weeks&#44; and no residual lesions were observed&#46; Atezolizumab was discontinued because of the skin toxicity&#46; Given the patient&#39;s poor general status&#44; he refused all cancer medication and is currently receiving palliative care&#46; He was diagnosed with probable adverse reaction to atezolizumab &#40;Naranjo algorithm&#44; 6 points&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Programmed death 1 &#40;PD-1&#41; is a key immune checkpoint receptor that is expressed on T cells and functions mainly in peripheral tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Atezolizumab is the first PD ligand 1 &#40;PD-L1&#41; inhibitor approved by the United States Food and Drug Administration&#46; This human immunoglobulin G1 monoclonal antibody binds selectively to PD-L1 and prevents interaction with PD-1 and B7-1 &#40;also known as CD80&#41;&#44; while sparing the interaction between PD ligand 2 &#40;PD-L2&#41; and PD-1&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> When PD-1 is activated&#44; the immune system is inhibited&#44; thus enabling tumor growth&#46; In their various indications for different cancers&#44; new anti&#8211;PD-1 drugs &#40;nivolumab&#44; pembrolizumab&#44; pidilizumab&#41; and anti&#8211;PD-L1 drugs &#40;atezolizumab and durvalumab&#41; curb this inhibition by enabling the immune system to control tumor progression&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There have been various reports of adverse reactions to PD-1 and PD-L1 inhibitors in up to 50&#37; of patients&#46; These were mainly cutaneous &#40;lichenoid reactions&#44; eczema&#44; vitiligo&#44; and pruritus&#41; and mild and did not require treatment to be discontinued&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;4</span></a> However&#44; other authors report these inflammatory reactions to be severe&#44; requiring treatment with oral corticosteroids&#44; and highlight an objective antitumor response&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> One group of cutaneous reactions to this drug are those based on neutrophils&#44; which&#44; owing to their increased count in the skin&#44; cause Sweet syndrome&#44; acute generalized exanthematous pustulosis&#44; intracorneal pustular drug eruption&#44; and psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Other&#44; less common cutaneous adverse reactions include actinic keratosis&#44; squamous cell carcinoma&#44; and seborrheic keratosis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Peripheral edema is an adverse reaction that affects 10&#37; of patients receiving treatment with atezolizumab&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Cases of psoriasis triggered or exacerbated by this drug family are starting to be reported&#44; although the condition was due to atezolizumab in only 1 case&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8&#44;9</span></a> In a recent series&#44; 66&#37; of patients had a previous history of psoriasis&#44; which&#44; in most cases&#44; was controlled with topical treatment&#46; Given the intensity of skin involvement&#44; it was rarely necessary to suspend treatment or prescribe oral corticosteroids&#44; as in the present case&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8&#44;9</span></a> In most cases&#44; psoriasis is triggered after several doses&#46; In the only case where psoriasis was triggered by atezolizumab&#44; onset was after the first dose&#44; as occurred in the present case&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In terms of etiology and pathogenesis&#44; murine models have shown that PD-1 deficiency increases the likelihood of the psoriasis-like skin disease phenotype and that PD-1 can play a regulatory role in the development of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> Under normal conditions&#44; the PD-1 pathway maintains normal immune homeostasis&#44; which prevents autoimmune reactions or damage to healthy tissue&#46; T-cell activation induced by PD-1 inhibitors&#8212;together with other factors&#8212;can contribute to development of psoriasis or exacerbations of existing psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The low number of cases of psoriasis associated with atezolizumab is probably due to the mechanism of action&#44; which spares PD-1 and PD-L2 binding&#46; Owing to the different nature &#40;IgG4 isotopes or IgG1 isotope&#41;&#44; mechanisms of action&#44; and antitumor action of anti&#8211;PD-1 and &#8211;PD-L1 agents&#44; it has been recommended not to consider them as a group&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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