Correspondence

A Patient with Myeloid Metaplasia of the Skin and Mouth

N Engl J Med 2000; 343:1270-1271October 26, 2000

Article

To the Editor:

Post-polycythemic myeloid metaplasia is characterized by increasing splenomegaly, dacryocytes, anemia, extensive bone marrow fibrosis, and a leukoerythroblastic blood picture.1 We describe a patient with post-polycythemic myeloid metaplasia in whom mucocutaneous myeloid metaplasia developed during treatment with epoetin.

In 1990, myeloid metaplasia developed in a 74-year-old man with a history of polycythemia vera and a history of splenectomy after abdominal trauma. Anemia developed that did not respond to treatment with hydroxyurea, danazol, and epoetin (10,000 U subcutaneously three times a week) and that became transfusion-dependent in December 1994. In December 1997, the patient underwent an abdominal hernia repair and was found to have a mesenteric mass whose features were consistent with those of myeloid metaplasia on biopsy. A second trial of epoetin was initiated at a dose of 40,000 U subcutaneously per week.

Within two weeks after the initiation of epoetin therapy, the patient presented with a rapidly growing, ulcerated lesion at the site of the epoetin injection on the abdominal wall (Figure 1AFigure 1Lesions of the Skin (Panel A) and Mouth (Panel B) in a Patient with Post-Polycythemic Myeloid Metaplasia.). He also had tender, fungating lesions in his mouth (Figure 1B) and oropharynx and a lesion at the incision site of the recently repaired abdominal hernia. Biopsies of the skin and tongue lesions revealed numerous immature erythroid and myeloid cells consistent with the presence of myeloid metaplasia. The patient was hospitalized for fever and dehydration. He received radiation to the abdominal-wall lesion, with no improvement in his condition, and he eventually died of multiorgan failure and sepsis.

In this patient, mucocutaneous myeloid metaplasia developed in association with epoetin therapy. The lesion at the injection site was most likely secondary to the seeding of progenitor cells in an erythropoietin-rich environment. The other lesions were most likely secondary to the stimulation of blood-borne progenitor cells, which seeded abdominal areas traumatized by surgery and areas in the mouth that were damaged by chewing (Koebner's phenomenon). This serious exacerbation of post-polycythemic myeloid metaplasia in a patient who was receiving epoetin may be uncommon, but it is striking and should be recognized as a potential sequela of such treatment.

Abdul Rahman Jazieh, M.D., M.P.H.
University of Cincinnati, Cincinnati, OH 45267

Mohammad J. Kyasa, M.D.
University of Arkansas for Medical Sciences, Little Rock, AR 72205

1 References