Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Letter to the Editor
2009:75:4;418-419
doi: 10.4103/0378-6323.53160
PMID: 19584479

Hemorrhagic cystitis following dexamethasone: Cyclophosphamide pulse therapy

CR Srinivas, C Shanmuga Sekar, L Sornakumar
 Department of Dermatology, PSG Hospitals, Coimbatore, India

Correspondence Address:
C Shanmuga Sekar
Department of Dermatology, PSG Hospitals, Peelamedu, Coimbatore - 641 004, Tamil Nadu
India
How to cite this article:
Srinivas C R, Sekar C S, Sornakumar L. Hemorrhagic cystitis following dexamethasone: Cyclophosphamide pulse therapy. Indian J Dermatol Venereol Leprol 2009;75:418-419
Copyright: (C)2009 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Cyclophosphamide was originally used as an anti-cancer drug; however, its uses have broadened and is now commonly used in many dermatologic disorders like bullous disorders, vasculitis and connective tissue disorders. Dexamethasone-cyclophosphamide pulse (DCP) therapy, [1] designed by Pasricha and Gupta for pemphigus was first used in 1981 with the aim of reducing the toxicity of corticosteroids and also achieve better therapeutic results. Dexamethasone-cyclophosphamide pulse therapy is used as first-line therapy in pemphigus in many centres in India. Hemorrhagic cystitis occurs in 5-10% of patients treated with cyclophosphamide and is believed to be caused by the metabolite acrolein. [2] Acrolein is toxic to the bladder epithelium and can lead to hemorrhagic cystitis. Mesna (is an acronym for 2 Mercapto Ethane Sulfonate Sodium [na]) is used therapeutically to reduce the incidence of hemorrhagic cystitis. Mesna assists to neutralize these metabolites by binding through its sulfhydryl-moieties, and also increases urinary excretion of cysteine. [3] Side effects of mesna include nausea, vomiting, headache, diarrhea and generalized weakness. We report a 73-year-old female with pemphigus who was controlled with standard DCP therapy. After receiving her seventh pulse ( phase 1 - total cumulative dose of 10.5 g of cyclophosphamide ), she presented with gross hematuria, dysuria and increased frequency of micturition. Her urine routine showed plenty of RBCs/high power field. Hemogram, renal parameters, bleeding time and clotting time were within normal limits. USG pelvis was normal. Urine culture was sterile. Hence a diagnosis of hemorrhagic cystitis secondary to cyclophosphamide was made. She was treated with 1 pint of normal saline followed by 2.5 l of oral fluids per day for 4 days. Tolterodine, a muscarinic receptor antagonist, was given to treat dysuria. Her symptoms subsided after a week. This is probably the first case report of hemorrhagic cystitis following DCP therapy.

Ballen et al. [4] reported 100 consecutive patients who underwent autologous or allogeneic bone-marrow transplantation and received high-dose cyclophosphamide with hyperhydration using 5% dextrose normal saline at the rate of 250 ml/h and furosemide with only two patients developing clinically significant hemorrhagic cystitis. Shepard et al . [5] compared mesna versus hyperhydration for the prevention of cyclophosphamide-induced hemorrhagic cystitis in bone-marrow transplantation and concluded that both mesna and hyperhydration were equally effective in preventing cyclophosphamide-induced hemorrhagic cystitis. The efficacy of hyperhydration or mesna in prevention of cyclophosphamide-induced hemorrhagic cystitis secondary to DCP therapy has not been evaluated. Since mesna is associated with side effects, we decided to use hyperhydration prophylactically to prevent hemorrhagic cystitis.

We have adapted a new protocol to prevent hemorrhagic cystitis.

Day 1: Dexamethasone 100 mg in 500 ml of 5% dextrose.

Day 2: Dexamethasone 100 mg in 500 ml of 5% dextrose was given followed by 500 mg of cyclophosphamide in 250 ml of 5% dextrose which is then followed by 500 ml of normal saline.

Day 3: Dexamethasone 100 mg in 500 ml of 5% dextrose.

Patients were also asked to take adequate oral fluids and frequently void urine. It can be argued that oral fluids alone would be adequate to prevent hemorrhagic cystitis; however, we found that patients admitted in bed were not taking adequate fluids in spite of being advised (personal observation).

We administered this revised form of DCP for 15 patients and found no signs of fluid overload. None of our patients had congestive cardiac failure or renal failure. We recommend this above modification of DCP to prevent cyclophosphamide-induced hemorrhagic cystitis.

References
1.
Thappa DM, Karthikeyan K, Jeevankumar B. Dexamethasone- Cyclophosphamide Pulse therapy in pemphigus: An appraisal of its outcome in a tertiary health care center in South India. Indian J Dermatol 2004;49:9-13.
[Google Scholar]
2.
Korkmaz A, Topal T, Oter S. Pathophysiological aspects of cyclophosphamide and ifosfamide induced hemorrhagic cystitis; implication of reactive oxygen and nitrogen species as well as PARP activation. Cell Biol Toxicol 2007;23:303-12.
[Google Scholar]
3.
Kanat O, Kurt E, Yalcinkaya U, Evrensel T, Manavoglu O. Comparison of uroprotective efficacy of mesna and amifostine in cyclophosphamide-induced hemorrhagic cystitis in rats. Indian J Cancer 2006;43:12-15.
[Google Scholar]
4.
Ballen KK, Becker P, Levebre K, Emmons R, Lee K, Levy W et al . Safety and cost of hyperhydration for the prevention of hemorrhagic cystitis in bone marrow transplant recipients. Oncology 1999;57:287-92.
[Google Scholar]
5.
Sheperd JD, Pringle LE, Barnett MJ, Klingemann HG, Reece DE, Phlipps GL. Mesna versus hyperhydration for the prevention of cyclophosphamide-induced hemorrhagic cystitis in bone marrow transplantation. J Clin Oncol 1991;9:2016-20.
[Google Scholar]

Fulltext Views
181

PDF downloads
112
Show Sections