Abstract
We present a case of a woman in her early 60s with multiple myeloma who, while undergoing treatment with cyclophosphamide, bortezomib and dexamethasone (CyBorD), noticed a whitish nodular swelling on the eyelid. This occurred after one cycle of CyBorD and on subsequent treatment, it also involved the contralateral eyelid. The lesions were initially managed with conservative measures by applying warm compresses, but the lesions progressively increased in size. CyBorD was discontinued and topical antibiotics and anti-inflammatories were initiated, resulting in a decrease in size of the lesions. On resolution of symptoms, she was rechallenged with CyBorD, and symptoms did not recur. The temporal relationship between bortezomib and the development of chalazion is based on connection and no association has been proven.
Keywords: Eye, Haematology (drugs and medicines)
Background
Bortezomib is a first-generation proteosome inhibitor used to treat a variety of haematolymphoid malignancies, predominantly multiple myeloma. Common side effects of this medication include nausea, peripheral sensory and motor neuropathy, and pancytopenia, but rarely has chalazion been reported. The temporal relationship between bortezomib and the development of the chalazion is based on connection and no association has been proven. This case report discusses the presentation, diagnosis, differential diagnosis, management and a literature review of chalazion in patients treated with bortezomib.
Case presentation
A woman in her early 60s with a recent diagnosis of lambda-restricted multiple myeloma on cyclophosphamide, bortezomib and dexamethasone (CyBorD) presented to the clinic with a nodular lesion with whitish discolouration in the right eyelid, which she noted after completing cycle 1 of treatment.
Differential diagnosis
Early differential diagnoses investigated include hordeolum, chalazion, xanthelasma, molluscum contagiosum and seborrhoeic keratosis. Hordeolum was ruled out because the lesion was not painful, swollen or erythematous. It was less likely xanthelasmas as these are usually bilateral yellowish lesions on eyelids that gradually build up over time, and molluscum contagiosum was ruled out because the lesion was not flesh coloured and did not have central umbilication. Seborrhoeic keratosis appears as a stuck-on well-demarcated wart-like lesion, which did not match this appearance. Her lesion was painless, non-tender and rubbery, which is typical of chalazion.
Treatment
The patient was advised to maintain proper eye hygiene and administer warm compresses to the eyelid for 10 min, six times daily to promote drainage of the occluded duct. On completion of cycle 2 with bortezomib at a dose of 1.5 mg/m2, examination revealed the right eyelid lesion had progressively increased in size, with development of a contralateral left eyelid lesion (figure 1). Cycle 3 was delayed. In addition to the warm compression, topical antibiotics/anti-inflammatory agents were initiated.
Figure 1.
Bilateral chalazion.
Outcome and follow-up
Symptoms improved within 2 weeks and completely resolved within 4 weeks of withholding CyBorD therapy (figure 2). On rechallenge with CyBorD, there was no recurrence. Due to the temporal relationship of the lesion with treatment, chalazion was attributed to bortezomib therapy.
Figure 2.
Resolution of chalazion.
Discussion
Chalazion is the occlusion of the duct at the base of the eyelid resulting in a painless lump. It is a rare complication of bortezomib therapy with a few case reports in the literature.1–3 The mechanism by which bortezomib induces chalazion has theoretically been associated with a systemic inflammatory process.1 The mean age at diagnosis is 61 years with a mean onset of about 3 months after initiation of therapy.1 Spontaneous resolution has been noted in patients managed with ocular therapy only or combined bortezomib discontinuation and ocular therapy, with a rapid time to response in the latter (3.1 months vs 1.8 months, respectively).2 In some patients, symptoms have recurred with bortezomib rechallenge.3 Dennis et al conducted a single-centre study on patients with plasma cell disorders treated with a bortezomib-based regimen. Twenty-one of the 139 patients included in the study developed ocular side effects of which 10 were diagnosed to have chalazion. Chalazion developed after a median of four cycles with some developing symptoms after 10 cycles. Among all the patients who developed ocular toxicity, 3 patients had completed therapy at the time of presentation of symptoms, 12 patients continued bortezomib with no dose adjustments, 2 patients required a reduction in the frequency of bortezomib, while 4 patients stopped or switched to another regimen. Interestingly, the authors report ocular symptoms occurring up to 5 weeks after discontinuation of bortezomib.4 Grob et al studied six cases of chalazion in patients receiving bortezomib for multiple myeloma and followed them for an average of 7.8 months. These patients did not respond to conservative treatment measures with warm compress and lid hygiene. Of the six patients, five suspended or discontinued bortezomib. Of those five patients, two patients had persistent symptoms for months after discontinuation. Bortezomib was re-initiated in three patients and unfortunately recurrence of chalazion necessitated alternate therapy.5 Laaribi et al reported a case of multiple chalazion in upper and lower eyelids 3 months after initiation of bortezomib. The patient’s symptoms improved with conservative measures and surgical incision and drainage without discontinuation of bortezomib.6 Paravathaneni et al reported a case of bilateral chalazion that developed after three cycles of bortezomib-based therapy. Bortezomib therapy was interrupted for 3 weeks, and symptoms improved with conservative measures, and bortezomib was resumed after resolution of symptoms.7 Second-generation proteosome inhibitors such as ixazomib have been administered in cases where rechallenge was not an option due to persistent disease, resulting in successful resolution of chalazion with no evidence of chalazion recurrence on follow-up.8
Learning points.
Painless nodular lesions in the eyelid of patients on bortezomib typically improve with warm compress treatment.
If no improvement, stop bortezomib and refer to an ophthalmologist.
If symptoms recur on rechallenge, switch to second-generation proteosome inhibitor.
Footnotes
Contributors: BG and NA contributed to manuscript writing and review. LC-C reviewed the paper. YH took pictures, managed the patient and reviewed the paper.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Ethics statements
Patient consent for publication
Obtained.
References
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