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Pyogenic granuloma possibly associated with capecitabine therapy

developed 1 week prior. Physical examination demonstrated cyanosis and cutaneous ulcers in the toes (Fig. 1d,e). There were diffuse itchy erythema on the trunk and extremities, concomitant with brown pigmentation and red papules persisting for years (Fig. 1a–c). Laboratory tests showed abnormalities, such as serum creatinine (3.01 mg/dL), eosinophilia (60%, 5580/lL), thymus and activation-regulated chemokine (TARC) (15 120 pg/mL) and immunoglobulin E (3475 IU/mL). Because computed tomography angiography was not performed due to his severe renal dysfunction, mural thrombi were not assessed. Although skin biopsy was not performed from blue toes, a skin biopsy of erythema on his right abdomen showed characteristic needle-shaped clefts in the subcutaneous fat layer (data not shown). He had not taken any anticoagulants or undergone interventional vascular treatment before this episode. Histopathological findings of CC in the skin, blue toes, exacerbation of renal function and eosinophilia resulted in a diagnosis of CCE. CC was also detected in the kidney. Additional biopsies were obtained from the left abdomen and the both thighs (Fig. 1a–c). CC was only detected in the deep fat layer of the left abdomen (Fig. 1f,h). Histopathological changes in the epidermis and upper dermis of four specimens were consistent with chronic eczema (Fig. 1f,g). Treatment with oral prednisolone (20 mg/day), atorvastatin (10 mg/day), omega-3-acid ethyl esters (2 g/day) and beraprost sodium (60 lg/day) for 1 month restored laboratory data and blue toes. Topical treatment with betamethasone butyrate propionate improved the eczema and normalized TARC value. In this case, it is likely that numerous CC were simultaneously scattered to several organs, such as the kidney and skin. Based on the distribution pattern, in which CC was detected in both sides of abdominal skin but not in both sides of the thighs, we thought that there was a relation between blood supply and entrapment of CC. The skin of the lower abdomen is supplied by the superficial epigastric artery (SEa), and the thighs are supplied by the descending branch of the lateral circumflex femoral artery (LCFa) (Fig. 1i). These two arteries are branches of the femoral artery, but SEa runs retrograde and LCFa anterograde. We hypothesized theoretical possibilities that a turbulent flow was more often induced by upward bloodstream in SEa than by downward bloodstream in LCFa, and CC entrapment by SEa was attributed to this turbulent flow. Although similar studies are required to confirm the findings observed in the present case with CCE, it is certain that biopsy of the unaffected abdominal skin can be performed with lower risk compared with that of the affected toes or internal organs such as kidney.