Side effects of Chemotherapy and Immunotherapy in the feet. Is this one?

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What medical condition do these signs and symptoms represent?

75 year old male
Chronic Lymphocytic Leukaemia
Incurable Adenocarcinoma of the Lung
Completed Chemotherapy and started Immunotherapy previous week
Hypertension and Heart Disease with history of two stents 10 years ago and last one 6 months ago
Hypercholesterolaemia

Presented with bilateral plantar metatarsal area pain especially when walking barefoot on hard floors. Greatly helped by the addition of slow recovery poron innersoles to patient's extra depth footwear. Two days later returned concerned about three small 3mm dark deep lesions appearing on the plantar surface of both hallux and on the left lateral subungual 3rd digit. Oncologist admitted patient to hospital on the third day for tests on his feet. Vascular Specialist palpated all pulses and found them to be good. No dopplers performed. Heart ECG WNL. Lesions increased in number and slightly in size. Inflammation now noted over all digits with mild swelling at lesions. No pain or itch reported although patient has a history of non Diabetes related mild Peripheral Neuropathy. No hand involvement. Medications include Paracetamol, Avapro, Ezetrol, Lipitor, Minax.

What is this? Is it a side effect of the Immunotherapy drug? Or something else unrelated? The Oncology Professor and Immunology Specialist say they have not seen this before.

Trauma?
Severe Erythema Pernio?
Trash Feet?
Palmar-Plantar Erythrodysesthesia?
Vasculitis?
Autoimmune disease due to immunotherapy?
Infection due to low immunity?

 

Thank you for the detailed presentation and medical history. The lesions appear to be a form of Leukocytoclastic vasculitis (LCV). However, with the vascular investigations that are reported, the most common causes of vasculitis can probably be ruled out, which suggest that the lesions are associated with the underlying malignancy. All histologic types of lung cancer can metastasize to the skin, with the most common type causing metastasis to the skin being adenocarcinoma.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4372943/

 

Thank you Belinda for the information and journal article which was very interesting. A punch biopsy was taken of the lesion on the left hallux and results are so far "inconclusive". The Professor of Oncology has taken the results to a multidisciplinary meeting.

Would a zinc cream be of benefit here to help maintain skin integrity?
Any other recommended Podiatric treatments you would suggest?

Thank you again.

 

Amazing what this poor client has been through, can ask did the number of lesions and size increase whilst he was still in hospital? Where else did they appear on the foot?

"...admitted patient to hospital on the third day for tests on his feet. Vascular Specialist palpated all pulses and found them to be good. No dopplers performed. Heart ECG WNL. Lesions increased in number and slightly in size."

 

Thank you for your interest Boots n all. The existing lesions did not increase in size but a few more developed in hospital over the digits only. I saw the patient again yesterday and the original lesions appear to have healed but all the digits are now pale with haemorrhagic tiny dots covering them.

New lesions have developed. They appear oval in shape approximately 5mm in length, 3 on each plantar metatarsal area and 3 painful ones on the right central plantar calcaneal area. They are raised and hard, resemble a cross between Intractable Plantar Keratoses (IPK) and the pitting you get with Hyperhidrosis with approximately 2mm subcutaneous haemorrhage in the centre. Usually I would debride but definitely not in this case due to very fragile surrounding skin, loss of fatty padding and high risk of infection. I keep in mind Verrucae Pedis due to the low immune system but it does not look like verrucae.

I am told the Oncologist says the lesions are a Vasculitis rare side effect of the Immunotherapy agent which the patient has now ceased for this reason but the agent will remain active in the body for another 3 months.

The biopsy result : Sections show a punch biopsy of skin with partial epidermal necrosis with the ghost outline of keratinocytes in the upper one-third of the epidermis. There is lymphocytic infiltration around deep dermal vessels and within the walls of vessels of capillary size suggesting a pattern of perniosis/chilblain. The remaining dermal vessels more superficially show fibrin within lumina but some of this may be related to the overlying changes of epidermal necrosis with incipient ulceration. Conversely the epidermal necrosis may reflect changes of small vessel vasculitis. There are no features of melanocytic tumour or malignancy. Overall the changes of epidermal necrosis and lymphocytic vasculitis/perniosis/chilblain predominate but the presence of fibrin thrombi in some of the capillaries may represent an associated small vessel vasculitis or thromboemboli depending upon the clinical circumstances.