Oral tacrolimus for Severe recalcitrant eosinophilic Celluli
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A 43 years old female presented with multiple erythematous, edematous infiltrated plaques, some with annular configuration and raised borders, located on the trunk and extremities. Her history was significant for hypothyroidism, hyperlipidemia, obesity and previous excision of carcinoid tumor of the appendix. Nineteen years prior to admission she was diagnosed with EC but lost to follow up.

Previous treatments included topical and oral corticosteroids (prednisone 40 mg/d), dapsone (200 mg/d), and azathioprine (200 mg/d), with no relief. Treatment was discontinued and the patient later experienced spontaneous remission that lasted almost two decades. Several months before her admission, an exacerbation occurred, with the re-appearance of widespread annular plaques on the trunk and extremities accompanied by severe pruritus.

Upon her admission, a 4 mm punch biopsy was obtained. Laboratory evaluation revealed normal blood eosinophil counts and IgE levels. Additional tests for serum protein electrophoresis, immunoglobulins, complement, serology for antinuclear antibodies and antineutrophil cytoplasmic antibodies were within normal limits. Pulmonary function tests and echocardiography showed no abnormalities. Treatment with oral prednisone 1 mg/kg/d (80 mg daily) in combination with oral methotrexate 17.5 mg per week failed to induce remission. Methotrexate was withdrawn and oral cyclosporin (500 mg /d) was initiated with complete remission. However, Hypertension and hirsutism ensued, and therefore prednisone and cyclosporin were gradually tapered. Six months later, while on cyclosporine, the patient experienced a relapse with reappearance of new lesions, sleep disturbance, pruritus and general fatigue.

She was then started on oral tacrolimus 3 mg BD in combination with minimal dosage of oral prednisone dosage 5mg/d, due to “steroidinduced adrenal insufficiency”. After two weeks a rapid and dramatic response was noticed, with flattening of all active lesions, followed by complete remission shortly afterwards and disappearance of the pruritus. During the following year the patient underwent close monitoring, and the tacrolimus dosage was tapered down and terminated after 2 years. The patient remained disease free, and no relapse occurred after additional year of follow up.

source: https://www.jaadcasereports.org/article/S2352-5126(20)30732-3/fulltext?rss=yes