Squamous Cell Skin Carcinoma in Systemic Lupus Erythematosus: Case Report and Literature Review

The case report of squamous cell skin carcinoma diagnosed in a patient with systemic lupus erythematosus 26 years after the onset of rheumatic disease is presented. The features of this case included the absence of skin manifestations of systemic lupus erythematosus, the occurrence of a tumor at the site of ulcers and trophic disorders on the leg, a long period from the ulcer occurrence to the diagnosis of skin cancer (despite multiple biopsies and consultations of various specialists), as well as the occurrence of a cytokine release syndrome, which directly led to the death of the patient after the first use of the immune checkpoint inhibitors. Possible causes of skin cancer in patients with systemic lupus erythematosus, as well as the features of the cytokine release syndrome after immunotherapy for oncological diseases, are discussed.


Introduction
Systemic lupus erythematosus (SLE) is one of the most common autoimmune rheumatic diseases. With this disease, many organs and systems are involved in the pathological process, and its main manifestations include damage to the kidneys, nervous system, cardiovascular system, skin, mucous membranes and serous membranes. SLE therapy includes the mandatory use of systemic glucocorticoids, both as monotherapy Despite the significant increase in life expectancy in patients with SLE, the likelihood of death in this disease is still two to five times higher than in the general population. Mortality in SLE is caused not only by the manifestations and complications of the underlying disease, but also by other pathologies, including cancer.
In the last decade, a number of cohort studies and metaanalyzes have been carried out to investigate the relationship between SLE and malignant neoplasms, but their results have been quite contradictory [1][2][3][4]. Thus, it has been convincingly shown that patients with SLE significantly increase the risk of onco-hematological diseases (especially non-Hodgkin's lymphomas), as well as neoplasms of the reproductive system in women. As for skin cancer, there are few data on this pathology, and they differ; it was found, for example, that the presence of SLE does not increase, but reduces the risk of skin melanoma [1][2][3]. In our observation, squamous cell skin cancer was diagnosed in a 48-year-old woman 26 years after the onset of systemic lupus erythematosus.

Case Report
Patient I., 48 years old, was observed for a long time at Nitrogen excretory function of the kidneys was relatively preserved, the creatinine level increased to a maximum of 120 μmol/L, the glomerular filtration rate corresponded to chronic kidney disease 2-3a stage.
There were no other manifestations of SLE activity.
There was a slight increase in blood pressure, dizziness, flies and double vision, and occasionally a short-term narrowing of the visual fields. In addition, the patient was worried about the increased formation of

Discussion
Squamous cell carcinoma of the skin is a malignant tumor originating from the cells of the epidermis of the skin and/or hair follicles. This is the second most common neoplasm (after basal cell carcinoma) in the group of non-melanoma skin tumors [5].  [6][7][8].
The interval between the onset of lupus and squamous cell carcinoma of the skin usually varies from 4 to 20 years [6]. The factors that increase the risk of squamous cell skin cancer in lupus are age over 40, male sex, exposure to ultraviolet radiation, skin pigmentation, and chronic inflammation [6]. The term "cytokine release syndrome" was first coined in the early 1990s, when antibodies to T lymphocytes were used as an immunosuppressive drug.
Subsequently, this syndrome was described after the use  In the patient we described, among the signs of the cytokine release syndrome, hectic fever with chills, severe arterial hypotension requiring the administration of vasopressor drugs, tachycardia that was unresponsive to standard β-blockers, severe damage to the central nervous system, a marked increase in the level of Creactive protein, and others manifestations ( Figure 6). In our observation, in contrast to other descriptions of the cytokine release syndrome or cytokine "storm", no cytopenia was noted. However, in the above-described

Conclusions
Thus, the main features of the described case are as follows: •