Subcutaneous tuberculosis formation during FOLFIRI and bevacizumab treatment: a case report

Dear Editor: Colorectal cancer is one of the most common malignant tumors with poor prognosis. New strategies, combined chemotherapies, and antiangiogenesis agents improved the overall survival, but the side effect was also more complicated. Here, we presented a colon cancer patient who underwent subcutaneous tuberculosis during combined therapy of FOLFIRI and bevacizumab. To the best of our knowledge, this is the first reported case of subcutaneous tuberculosis that happened during bevacizumab-FOLFIRI therapy. Our case will provide diagnosis value with atypical Mycobacterium tuberculosis infection and highlight the importance of carrying out extensive evaluations for tuberculosis in cancer patients during chemotherapy. A 36-year-old female with colon cancer presented to our hospital as tumor progression. The patient was diagnosed as colon adenocarcinoma with Kras gene mutation and received radical resection 3 years ago. XELOX regimen (capecitabine tablets and oxaliplatin) was taken postoperative for seven courses. Metastasis lesions were found in the abdominal cavity, liver, and lung 1 year after the surgery. Thus, the left fallopian tube was resected by laparoscopy. Both interventional therapy and radiofrequency treatment were used to control liver metastasis. Bevacizumab (300 mg, every 2 weeks) and FOLFIRI (irinotecan 300 mg IV for 90 min on day 1, leucovorin 300 mg IV for 2 h, fluorouracil 600 mg IV for 30 min then 4400 mg IV for 46 h) were taken later for ten courses. Evaluation after 4 cycles showed a complete remission of lung lesions. Stable disease was diagnosed in following cycles. Multiple nodules, diameter between 0.5 and 3 cm, medium hard, with or without tenderness, with clear or unclear boundary, were found during the combined therapy. First, in the right popliteal fossa then groins, right little toe, right buttocks, right clavicle, and manubrium. The nodule of the right popliteal fossa ulcerated after the biopsy. Iodine tincture and mupirocin ointment were used for 2 weeks, but with no obvious improvement. Pathogenic microorganism culture was then performed, and no bacteria or fungi were found. Nodules of right groin and buttock ulcerated spontaneously 2 months later. Iodine tincture, debridement, and Tegaderm Foam Adhesive were used to treat the ulceration. Ulcers of the right popliteal fossa and groin finally healed with pigmentation after 4–12 months. A nodule in the little toe and pain of end joints seem like rheumatoid arthritis (RA), but rheumatoid factor (RF) test was negative, erythrocyte sedimentation rate (ESR) was 43 mm/h, all of which do not support the diagnosis as RA. Tuberculosis was excluded because the patient has no fever, night sweats, cough, chest pain, or any otherM. tuberculosis-infected symptoms. Therefore, a rare drug adverse reaction of bevacizumab was considered because bevacizumab can cause subcutaneous nodule (http://www.ehealthme.com/). So, bevacizumab was withdrawn, monochemotherapy of 5-FU was adopted, and no new nodule was discovered. However, 3 months later, the Xiao-wei Zheng, Li-li Ren and Yi-wen Zhang contributed equally to this work.