Cutaneous adverse drug reaction associated with oral temozolomide presenting as dermal and subcutaneous plaques and nodules

REPORT OF A CASE A woman in her 70s had right frontal anaplastic astrocytoma (World Health Organization grade III). The patient underwent a gross total tumor resection and a 6-week course of postoperative radiation therapy (6000 cGy) with concurrent TMZ (75 mg/m) by mouth daily. Four weeks after completion of radiation, she started adjuvant TMZ (150 mg/m by mouth), following the standard schedule for high-grade gliomas (5 consecutive days per 28day cycle). During the second cycle, she had persistent red tender subcutaneous nodules on her bilateral thighs without associated systemic symptoms (Fig 1). There was no history of any recent infections or other new medications, and there was no personal or family history of inflammatory bowel disease, sarcoidosis, lupus erythematosus, or chronic lower extremity edema. Histopathologic examination of 2 skin biopsies sections found mixed septal and lobular panniculitis with a mixed cell inflammatory infiltrate containing eosinophils (Fig 2, A). Antinuclear antibody and rheumatoid factor serologic findings were