4. Hinuma Y, Nagata K, Hanaoka M, et al. Antigen in anadult T-cell leukemia cell line and detection of antibodiesto the antigen in human sera. Proc Natl Acad Sci USA1981 ;78:6476-80.

5. Shimoyama M, Minato K, Saito H, et al. Comparison ofclinical, morphologic and immunologic characteristics ofadult T-cell leukemiallymphoma and cutaneous T-celllymphoma. Jpn J Clin Oneal 1979;9(suppl):357-72.

------.-----.------1 Antibody

IAlkaline phos·1 Lactic dehy- against

ea+ + phatase I drogenase HTLV·IM

Volume 18Number 2, Part 1February 1988

Serum levels of'

t t +

Monoclonalintegration of

HTLV·Iproviral DNA'

+

Correspondence 381

Fig. 1. Exudative erythematous patches and target le­sions on the thighs and legs.

Erythema multiforme due to clofibrate

To the Editor: Erythema multiforme is a relatively com­mon acute dermatosis characterized by distinct targetlesions, Although a variety of etiologic factors havebeen implicated as precipitating erythema multiforme,there is no known provocative factor in about one halfof the cases. Here we report a case of erythema mul­tiforme due to clofibrate (ethyl a-[parachlorophenoxy]­isobutyrate, Deliva), which was confirmed by read­ministration test.

Case report. A 72-year-old woman was admitted to ourclinic because of generalized pruritic erythematous eruption,general malaise, and fever of sudden onset. She had had mildhypertension and hyperlipidemia and had been given somehypotensive agents and clofibrate (750 mg/day) for about1 year. On the day when the eruption developed she stoppedtaking clofibrate on her own. On physical examination shelooked ill and had a temperature of 38S C, EXl\dative freshred erythematous patches of various sizes were seen on theentire body and extremities. The extensor surfaces of theupper limbs exhibited several bullae, exudative erythematousmacules, and so-called target lesions in which the centercleared, becoming cyanotic or purpuric (Fig. I). The faceand the distal parts of her limbs showed marked edema. Bi­opsy specimens obtained from a macular lesion on the rightthigh showed marked edema of the papillary dermis and Iym­phohistiocytic, patchy infiltration around the dilated small

vessels, with a moderate number of eosinophils in the upperto mid dermis (Fig. 2). Biopsy examination of a bullous lesiondisclosed subepidermal blister formation.

Laboratory values were not remarkable except for stronglypositive C-reactive protein (6 +). Lipid values were as fol­lows: cholesterol, 232 mg/dl; I)-lipoprotein, 607 mg/dl; andtriglyceride, 154 mg/dL

Four days after admission she became afebrile, and therash and edema gradually disappeared over 17 days. Aftercomplete disappearance of the eruptions a test dose of 500mg clofibrate was given with her consent. Thirty minutesafter oral readministration of clofibrate she noted pruritic,erythematous macules developing on her abdomen, buttocks,and limbs. A patch test with clofibrate showed negative find­ings. Photopatch test and photodrug test with clofibrate and1% parachlorophenol (a precursor of clofibrate) also showednegative findings.

Comment. Clofibrate is used worldwide as a hy­polipidemic agent. There have been only few reportsof eruptions that occurred as an adverse side effect oftherapy with clofibrate. Cumming' reported a patientwith acute renal failure and generalized erythematousrash due to clofibrate. Immunofluorescence studies sug­gested that the possible general hypersensitivity to clo­fibrate caused the renal failure and generalized rash.Clofibrate is produced from parachlorophenol by ad·

382 Correspondence

Fig. 2. Histopathology of the macular lesion on the rightthigh: the edema of papillary dermis and perivascularinfiltrate of lymphoid cells and histiocytes with inter­mingled eosinophils in the dennis. (Hematoxylin-eosinstain; X 200.)

dition of chloroform and acetone, and it also containsa small amount of parachlorophenol. Parachlorophenolhas a structural resemblance to parachloro-m-cresol,which is well known to be a photosensitizer and mayprovoke photoallergic reaction. Dujovne et al2 de­scribed a patient with transient pruritic papular rash onthe exposed areas while taking clofibrate. Heid et aPreported a patient who had been treated with clofibrateand had vesiculobullous, edematous eruptions on theface, arms, and ankles after sun exposure. In their case,photopatch test with clofibrate was positive, but read­ministration test was not performed. Orgain et a14 re­ported a patient with erythematous facial rash due toclofibrate, which was confirmed by a provocation test.The cases reported by Heid et a13 and Orgain et a14 mayrepresent systemic photoallergic reaction to clofibrate.However, it was not thought that our patient's rash wasdue to the photoallergic reaction to clofibrate becausethe eruptions were not confined to sun-exposed areasand neither photopatch test nor photodrug test was pos­itive. On readministration of clofibrate, erythematous

Journal of theAmerican Academy of

Dennatology

eruptions were induced on non-sun-exposed areasrather than on sun-exposed areas. Although drugs areconsidered to be the cause of erythema multiforme inmany cases, only few drugs such as long-acting sul­fonamides seem to have a direct link with its etiology.Since clofibrate is frequently used for the treatment ofatherosclerosis and hyperlipidemia, it should be listedamong those drugs capable of inducing erythema mul­tiforme.

REFERENCES

1. Cumming A. Acute renal failure and interstitial nephritisafter clofibrate treatment. Br Med J 1980;281:1529-30.

2. Dujovne CA, Weiss P, Bianchine JR. Comparative clinicaltherapeutic trial with two hypolipidemic drugs: clofibrateand nafenopin. Clin Pharmacol Ther 1971;12:117-25.

3. Heid E, Samsoen M, Juillard J, et a!. ElUptions papulo­vesiculeuses endogenes a la methyldopa et au clofibrate.Ann Dermatol Venereol 1977;104:494-6.

4. Orgain ES, Bogdanoff MD, Cain C. Clofibrate and an­drosterone effect on serum lipids. Arch Intern Med1967;119:80-5.

Yozo Murata, M.D., Masahiro Talli, M.D., * alldMasahiko Amano, M.D.**

Kobe University School of MedicineChuo-Ku, Kobe, 650, Japan, * alld

Nishiwaki City Hospital, Nishiwaki City 677, Japan**

Primary nodular endophytic basalcell carcinoma

To the Editor: Primary nodular endophytic basal cellcarcinoma almost always has a visible exophytic por­tion, such as a papule or ulcer, with characteristic fea­tures of pink color, translucency, and telangiectases.This is in sharp contrast to the sclerosing and infiltratingvarieties, which can extend far beyond their clinicalborders because microscopic tumor strands infiltrateinto the dennis far from the obvious margins. Bothsclerosing and infiltrative varieties lack the pearlinessand rolled borders of the nodular basal cell epithe­liomas, the former occurring as a smooth, atrophic,shiny, waxy, indurated plaque traversed by telangiec­tases and the latter having a yellow-white color. I

... The endophytic portion of the nodular variety canpenetrate deeply into muscle and bone but is normallywell circumscribed. 2 In this brief case report we pointout the rare occurrence of invasive primary nodularendophytic basal cell carcinoma with no associated vis­ible change in the overlying epidermis.

Case report. A 54-year-old white man came to theNew York Veterans Administration Medical Center with a