Empyema after radiation therapy for cutaneous squamous cell carcinoma in a patient with scleroderma

Introduction: Cutaneous squamous cell carcinoma (cSCC) is a non-melanomatous neoplasm of the skin that is more likely to develop in immunosuppressed patients or those with autoimmune diseases. Individuals with connective tissue disorders in particular, such as scleroderma, are particularly at an increased risk of developing cancer due to chronic inflammation, tissue damage, genetic susceptibility, and immunosuppressive therapy. Additionally, treatment of cSCC with surgery and radiation therapy, especially in those with autoimmune connective tissue disorders, presents an increased risk of adverse effects, including infection. Case Report: A 74-year-old woman with a history of systemic scleroderma and cSCC status post Mohs surgical resection and radiation therapy presented with an 8-cm forehead lesion at the site of excised cSCC. One year earlier, she underwent Mohs surgery after biopsy-proven cSCC of the forehead with resulting clear margins. Radiation therapy was recommended as nerve involvement was discovered within the resected tumor. Magnetic resonance imaging of the brain revealed a right parafalcine subdural empyema with peripheral blood and intraoperative cultures positive for Streptococcus intermedius and Candida albicans. Her hospitalization was complicated by the development of acute hypoxic respiratory failure and septic shock. Ultimately, her family chose to focus on her comfort and she passed peacefully from complications of septic shock. Conclusion: This case highlights a rare infection after treatment of cSCC which emphasizes that treatment of malignant skin lesions in patients with scleroderma can be challenging. Shared decision-making with a thorough assessment of risks should be emphasized with every patient before proceeding with treatment.