Chemotherapeutic metabolism presenting as a recalcitrant case of hand-foot syndrome and mucositis.

INTRODUCTION: Mercaptopurine (6MP) and methotrexate (MTX) are commonly used for maintenance chemotherapy for acute lymphoblastic leukemia (ALL). These medications have been associated with various side effects such as myelosuppression, colitis, and thyroiditis in addition to numerous cutaneous adverse events. Cutaneous side-effects most reported include mucositis, alopecia, xerosis, and pruritus. We report an interesting case of hand-foot syndrome to 6MP in a child on maintenance therapy for B-cell ALL from an alteration in medication metabolism. CASE: We report a 10-year-old male on maintenance chemotherapy for pre-Bcell ALL who presented to the hospital with worsening oral lesions and erythematous, fissured plaques on the palms and soles. Maintenance therapy consisted of IV vincristine and 5-day pulse of steroids every 12 weeks, daily 6MP, and weekly MTX, which were increased to ≥ 150% of standard dosing due to persistent absolute neutrophil counts > 1500. Metabolites obtained on admission demonstrated elevated 6MMP metabolites at 35,761 (normal < 5700). TPMT and NUDT15 enzyme activity were normal and no alterations in genotyping were discovered. OUTCOME: Patient's oral chemotherapy, including both 6MP and MTX, were stopped and allopurinol 100 mg daily was initiated, which lead to overall improvement. DISCUSSION: Clinical findings of acute mucositis and worsening of hand-foot syndrome, in the setting of inadequate myelosuppression in a child on maintenance therapy for ALL should raise concerns to consider altered metabolism pathway leading to toxic metabolite buildup. Allopurinol can play in improving cutaneous manifestation and chemotherapeutic dosing in patients with altered metabolism.

Crystal structure of {(R)-N2-[(benzo[h]quinolin-2-yl)meth-yl]-N2'-[(benzo[h]quinolin-2-yl)methyl-idene]-1,1'-binaphthyl-2,2'-di-amine-κ4N,N',N'',N'''}(trifluoromethane-sulfonato-κO)zinc(II)} trifluoromethane-sulfonate di-chloro-methane 1.5-solvate.

The zinc(II) atom in the title compound, [Zn(C48H31N4)(CF3SO3)](CF3SO3)·1.5CH2Cl2, adopts a distorted five-coordinate square-pyramidal geometry. It is coordinated by one tri-fluoro-methane-sulfonate ligand and four N atoms of the N2-[(benzo[h]quinolin-2-yl)meth-yl]-N2'-[(benzo[h]quinolin-2-yl)methyl-idene]-1,1'-binaphthyl-2,2'-di-amine ligand. The complex is present as a single-stranded P-helimer monohelical structure incorporating π-π and/or σ-π inter-actions. One of the imine bonds present in the original ligand framework is reduced, leading to variations in bond lengths and torsion angles for each side of the ligand motif. The imine-bond reduction also affects the bond lengths involving the metal atom with the N-donor atoms located on the imine bond. There are two mol-ecules of the complex in the asymmetric unit. One of the mol-ecules exhibits positional disorder within the coordinating tri-fluoro-methane-sulfonate ion making the mol-ecules symmetric-ally non-equivalent.