Eosinophilic vasculitis syndrome: recurrent cutaneous eosinophilic necrotizing vasculitis

We recently identified a syndrome of recurrent cutaneous eosinophilic vasculitis in three patients. These patients had in common widespread pruritic, erythematous, purpuric papules and angioedema of face and hands associated with peripheral blood eosinophilia. Eight skin biopsies from these three patients all showed necrotizing vasculitis of the small vessels of the skin, with exclusively eosinophilic infiltration and minimal or no leukocytoclasis. The disease followed a chronic course, with recurrent, itchy, swelling skin lesions and without evidence of systemic involvement over observation periods of 3, 17, and 23 years. The skin lesions responded promptly to systemic steroid treatment, but two patients required maintenance doses for control of the disease. Immunofluorescence studies showed marked deposition of the cytotoxic eosinophil granule major basic protein in the affected vessel walls. Eosinophil-active cytokine IL-5 was detected in the serum of one patient. Expression of the vascular cell adhesion molecule-1 for eosinophil adherence was detected on the endothelium of the affected vessels. Because this disease showed distinctive clinical manifestations and characteristic histopathological features, we believe it is a distinct entity and should be distinguished from other types of vasculitis.

Malignant angioendotheliomatosis is an angiotropic intravascular lymphoma. Immunohistochemical, ultrastructural, and molecular genetics studies

Malignant angioendotheliomatosis is a rare intravascular (angiotropic) lymphoma. Patients most often present with cutaneous or central nervous system findings. We describe three patients with malignant angioendotheliomatosis involving the skin. The initial lesions in each were tender, indurated nodules on the lower extremities, resembling inflammatory panniculitis. Skin biopsies and immunohistochemical studies from all patients confirmed intravascular B-cell lymphoma. Two patients had visceral involvement, and molecular genetics studies showed clonal immunoglobulin gene rearrangement in one. Electron microscopy in this case showed increased fibrin and atypical lymphocytes within blood vessels. Malignant angioendotheliomatosis is a monoclonal intravascular lymphoma, usually of B-cell phenotype. Occlusion of small blood vessels with lymphoid cells, fibrin, and degenerating cellular debris causes the cutaneous lesions. An excisional biopsy through the depth of subcutaneous tissue may be necessary to confirm the diagnosis of malignant angioendotheliomatosis.

Sweet syndrome: acute febrile neutrophilic dermatosis

Sweet, in 1964, described a skin condition characterized by fever, leukocytosis, tender erythematous plaques, and, histopathologically, a predominantly neutrophilic dermal inflammation. However, other dermatologic conditions can present with similar clinical and histological features. Therefore, diagnostic criteria are important for the correct diagnosis. Use of systemic steroids is the treatment of choice for Sweet syndrome. A number of other medications can be useful at times, such as potassium iodide, dapsone, indomethacin, and colchicine.

Sneddon syndrome

Sneddon syndrome--cerebrovascular lesions and livedo racemosa--is a distinctive and uncommon disorder delineated by Sneddon in 1965. The clinical hallmarks are generalized livedo racemosa and central nervous system ischemia. Cutaneous vascular changes begin with intimal endothelial proliferation and fibromucinous matrix formation, leading to obstruction and obliteration of the vessel. The disorder is slowly progressive. No effective treatment is available, but platelet-inhibiting agents or newer antithrombotic agents may offer some hope in preventing or minimizing serious sequelae of this disease.

Diagnostic immunohistochemistry of cutaneous metastatic breast carcinoma: a statistical analysis of the utility of gross cystic disease fluid protein-15 and estrogen receptor protein

BACKGROUND

For accurate classification of cutaneous metastatic carcinoma, reliable tumor-specific immunohistochemical markers would be valuable.

OBJECTIVE

Our purpose was to analyze the sensitivity, specificity, and positive predictive value of gross cystic disease fluid protein-15 (GCDFP-15) and estrogen receptor protein (ERP) for diagnosing cutaneous metastatic breast carcinoma.

METHODS

Tissue sections from 68 consecutive cases of cutaneous metastatic carcinoma were stained for GCDFP-15 and ERP. Hematoxylin-eosin-stained slides and immunostained slides were reviewed in a blinded fashion before retrospective chart review to ascertain the underlying primary tumor type.

RESULTS

Of 42 cases of cutaneous metastatic breast carcinoma, 30 were positive for GCDFP-15. Of 41 cases of metastatic breast carcinoma, 30 were positive for ERP. Calculated sensitivity, specificity, and positive predictive value for GCDFP-15 for diagnosing cutaneous metastatic breast carcinoma were 71%, 91%, and 94%, respectively, and 73%, 100%, and 100% for ERP, respectively. Combined values of these indices for both stains were 83%, 91%, and 95%, respectively.

CONCLUSION

GCDFP-15 and ERP are valuable markers for cutaneous metastatic breast carcinoma and should be used in combination.

Sweet's syndrome: systemic signs and symptoms and associated disorders

OBJECTIVE

To characterize the findings associated with acute febrile neutrophilic dermatosis (Sweet's syndrome [SS]) and the response of SS to treatment.

DESIGN

We retrospectively reviewed 48 cases of SS encountered at the Mayo Clinic between 1980 and 1992.

MATERIAL AND METHODS

Histopathologic specimens and medical records were studied to determine initial manifestations, patterns of involvement, systemic signs and symptoms (including mucosal, musculoskeletal, hematologic, pulmonary, hepatic, and renal findings), and conditions associated with SS.

RESULTS

In patients with SS, the typical manifestations are the acute onset of tender, erythematous or violaceous nodules or plaques in association with fever, leukocytosis, and dermal neutrophilia. In our study group, the cutaneous lesions most frequently involved the arms and legs. Of our 48 patients, 26 (54%) had a hematopoietic, plasma cell, or malignant disorder, and many of these patients had associated anemia, especially the male patients. No single laboratory finding specifically indicated an association with serious systemic disease. Most patients were treated with a tapering dose of prednisone, which yielded a good response.

CONCLUSION

Clinical acumen and appropriate laboratory tests are the main requirements for detection of hematologic disorders, internal malignant diseases, or other systemic conditions associated with SS.

Chilblain lupus erythematosus (lupus pernio): clinical review of the Mayo Clinic experience and proposal of diagnostic criteria

Five cases of chilblain lupus erythematosus were retrospectively reviewed regarding their clinical, histopathologic, serologic, and immunofluorescence findings. Ages at onset of chilblain lupus erythematosus varied from 26 to 73 years, with a female-to-male ratio of 3:2. Since other entities can be confused with this disorder, we propose the following diagnostic criteria. The two major criteria are skin lesions in acral locations induced by exposure to cold or a drop in temperature, and evidence of lupus erythematosus in the skin lesions by results of histopathologic examination or direct immunofluorescence study. The three minor criteria are coexistence of systemic lupus erythematosus or other skin lesions of discoid lupus erythematosus, response to anti-lupus erythematosus therapy, and negative results of cryoglobulin and cold agglutinin studies. We conclude that chilblain lupus erythematosus can be diagnosed and treated. Discoid lupus erythematosus lesions respond more quickly to treatment than chilblain lupus erythematosus lesions. Treatment with antimalarial agents, prednisone, pentoxifylline, or dapsone was of benefit to our patients.

Primary cutaneous large cell lymphomas. Morphologic, immunophenotypic, and clinical features of 20 cases

The morphologic, immunophenotypic, and clinical characteristics of 20 cases of primary cutaneous large cell lymphoma were analyzed. Immunoperoxidase stains in paraffin sections indicated B-cell phenotype in 14 cases and T-cell phenotype in six cases. By the Kiel classification, the B-cell lymphomas were classified into the following categories: follicular centroblastic (three patients), centroblastic/centrocytic with a predominance of large centrocytes (two patients), centroblastic (seven patients), and immunoblastic (two patients). The T-cell lymphomas (six cases) were all categorized as pleomorphic medium and large cell type. Three of these had an angiocentric growth pattern. The lymphocyte activation marker CD30 was expressed in three of the 20 cases. Among these 20 patients, the clinical course was remarkably variable. The only clinical or pathologic feature with prognostic significance was multicentricity of the skin lesions. All five patients with multifocal or disseminated skin lesions died within 13 months of their initial presentation; the median survival was 7 months. Most of the patients with localized skin lesions had an indolent clinical course with a median survival of 107 months. These results suggest that multicentricity of the skin lesions and necrosis are closely linked and are important prognostic features in cutaneous large cell lymphoma.

Cutaneous Wegener's granulomatosis: clinical, histopathologic, and immunopathologic features of thirty patients

BACKGROUND

Wegener's granulomatosis (WG) is a systemic disease characterized by necrotizing granulomatous inflammation and vasculitis. Its cutaneous manifestations vary.

OBJECTIVE

We reviewed and characterized the clinical, pathologic, and immunopathologic features of the specific cutaneous manifestations of WG and investigated the sensitivity and the specificity of anti-neutrophilic cytoplasmic antibody (c-ANCA) in the cutaneous manifestations of this disease.

METHODS

A retrospective analysis was conducted of 244 cases of WG observed between 1988 and 1992.

RESULTS

Skin involvement occurred in 14% of the patients and was more frequent in generalized WG. Skin lesions may be an early premonitory sign of renal disease. Necrotizing ulcerations resembling pyoderma gangrenosum were not uncommon. Leukocytoclastic vasculitis was the most common cutaneous pathologic pattern. Findings of c-ANCA were positive in 81% of patients with cutaneous WG.

CONCLUSION

Skin involvement usually occurred at presentation with generalized disease. c-ANCA is a valuable adjunct to diagnosis and follow-up of WG.

Clinical, histopathologic, and immunohistochemical correlations in leukemia cutis

Specific (leukemia cutis) and nonspecific (reactive or secondary) skin lesions are associated with systemic leukemia. The following categories of leukemia cutis are discussed in this article: myelogenous (granulocytic) leukemia, monocytic leukemia, myelomonocytic leukemia, lymphocytic and lymphoblastic leukemia, hairy cell leukemia, and adult T-cell leukemia/lymphoma. The temporal relationship between the diagnoses of systemic leukemia and leukemia cutis, the course, and the prognosis are also discussed. Other sites of extramedullary involvement are correlated with leukemia cutis. The appearance of specific skin lesions in leukemia is usually associated with a very poor prognosis.

Acrodermatitis chronica atrophicans in the United States: clinical and histopathologic features of six cases

Acrodermatitis chronica atrophicans is a chronic cutaneous disease caused by the Lyme disease spirochete Borrelia burgdorferi. Acrodermatitis chronica atrophicans is endemic in some regions of Europe but is only rarely seen in the United States. This report describes the clinical and histopathologic findings in six cases of acrodermatitis chronica atrophicans seen at the Mayo Clinic between 1912 and 1961. Histologic differences between early and late phases of the disease were observed, and multisystemic symptoms consistent with chronic Lyme disease were documented in a subset of the patients. All five patients from whom biographical data were available were European immigrants. Our data suggest that some of the first patients with Lyme disease in the United States came to the Mayo Clinic earlier in this century.

A subtle clue to the histopathologic diagnosis of early alpha 1-antitrypsin deficiency panniculitis

An excisional biopsy specimen of a lesion of several days' duration in an 18-year-old woman revealed moderate splaying of neutrophils between collagen bundles throughout the reticular dermis and incipient necrosis of the dermis and subcutaneous fat. Mild infiltration of neutrophils and macrophages was seen in the septal and lobular panniculus. A biopsy performed on one of the patient's more chronic lesions demonstrated dermal necrosis, degeneration and fibrosis of septa, acute lobular panniculitis with a large number of neutrophils, and foci of subcutaneous fat necrosis with islands of sparing. Splaying of neutrophils between the collagen bundles in the reticular dermis appears to be the earliest histopathologic finding of alpha 1-antitrypsin deficiency panniculitis.

Lipomembranous (membranocystic) changes associated with morphea: a clinicopathologic review of three cases

Lipomembranous (membranocystic) changes represent a distinctive form of pathology in adipose tissue. Although first described in the rare neurodegenerative disorder now called Nasu-Hakola disease, this change has also been observed in a variety of relatively common inflammatory and noninflammatory dermatoses. We report three cases of morphea associated with marked lipomembranous (membranocystic) changes in the subcutaneous adipose tissue.

Bullous morphea: clinical, pathologic, and immunopathologic evaluation of thirteen cases

BACKGROUND

Bullous morphea is a rare disease. Its pathogenesis is unknown.

OBJECTIVE

We evaluated bullous morphea clinically, pathologically, and immunopathologically and investigated the role of spirochetes and eosinophils in its pathogenesis.

METHODS

The clinical and pathologic findings from 13 patients with bullous morphea were reviewed. Tissue sections were studied with the Elias-Bosma stain for spirochetes and indirect immunofluorescence for eosinophil granule major basic protein.

RESULTS

Bullae were found in all forms of morphea; the lower extremities were the most common sites of involvement. Lymphatic dilatation was found in 77% of the patients. Deposition of major basic protein was found in 60% of cases studied. There was no evidence of spirochetes in any of the specimens examined with the Elias-Bosma stain.

CONCLUSION

Our results suggest that the pathogenesis of bullous morphea is related to lymphatic dilatation as well as release of major basic protein from eosinophils in some patients. We found no association between spirochetes and bullous morphea.

Ultrastructural evaluation of mid-dermal elastolysis

Mid-dermal elastolysis is a well-defined clinical and histopathologic entity manifested by fine wrinkling of the skin and a mid-dermal loss of elastic fibers. Ultrastructural and histologic studies were performed in an attempt to better define the cause of the elastolytic process. Biopsy specimens from the lesions of 3 patients with mid-dermal elastolysis were studied at light and electron microscopic levels. Ultrastructural evidence of normal elastic fiber engulfment by activated macrophages was observed; however, some fields also demonstrated envelopment of abnormally degenerated elastic tissue. Although there are many potential causes of this degeneration, photodistribution of the lesions suggests that ultraviolet damage is a primary inciting factor.

Paraneoplastic pemphigus: a case with high titer of circulating anti-basement membrane zone autoantibodies

Multiple flaccid bullae, erosions, and tense bullae developed in a 67-year-old man with chronic lymphocytic leukemia. A biopsy specimen revealed features of typical pemphigus vulgaris (suprabasilar clefting with acantholysis), paraneoplastic pemphigus (necrotic keratinocytes and hydropic degeneration in addition to acantholysis), and bullous pemphigoid (subepidermal separation and epidermal regeneration). Direct and indirect immunofluorescence studies revealed deposits of immunoglobulins and C3 within the intercellular substance and basement membrane zone in some specimens. Immunoprecipitation of serum revealed four polypeptides with molecular weights of 250, 230, 210, and 190 kd.

Leukemia cutis

Leukemia cutis is an uncommon manifestation of leukemia that is strongly associated with the presence of extramedullary disease at other sites. Patients usually present with leukemia cutis concomitantly with systemic leukemia or after leukemia has been diagnosed. Acute monocytic, myelomonocytic, and the T-cell leukemias show the highest incidence of leukemia cutis. The lesions show varied morphology and can be difficult to distinguish both clinically and histopathologically from nonspecific cutaneous lesions, which occur much more frequently. Immunohistochemistry is useful in making the distinction between them. The prognosis in leukemia cutis is generally poor; the best results have been achieved with a combination of systemic and local therapy.

Subcutaneous T-cell lymphoma: a clinical, histopathologic, and immunohistochemical study of six cases

Recently, T-cell lymphoma localized to the subcutaneous tissue has been reported. We report the clinical, histologic, immunohistochemical, and molecular genetic findings in 6 patients who we believe had this peculiar T-cell lymphoma with its unique morphologic and clinical features. All patients presented with deep-seated nodules, most frequently on the extremities, and with systemic complaints of low-grade fever, fatigue, myalgias, and weight loss. In all cases, the neoplastic lymphocytic infiltrate was confined to the subcutaneous tissue, predominantly in a lobular pattern. Hemorrhage, necrosis, and rare erythrophagocytosis were also seen. Immunohistochemical staining was predominantly T-cell reactive (CD43, CD3, and CD45RO). Clonal rearrangements of the beta and gamma chains of the T-cell antigen receptor genes were found in 1 case. Three of the 6 patients died within 22 months of the diagnosis of lymphoma. We believe that subcutaneous T-cell lymphomas are a distinctive group of peripheral T-cell lymphomas with unusual clinical and morphologic features and that they should be distinguished from other types of lymphoma.

Acquired reactive perforating collagenosis. Report of six cases and review of the literature

BACKGROUND

Reactive perforating collagenosis (RPC) is characterized by transepithelial elimination of altered collagen. Two types have been recognized: the childhood form and the adult form.

OBJECTIVE

Our purpose was to review the associated disorders, evaluate the possible causes, and set criteria for the diagnosis of the disease.

METHODS

The clinical and pathologic findings of six patients with the adult form of RPC are reviewed. The literature on this subject is compared with our findings.

RESULTS

Pruritus was reported in all cases. Treatment of pruritus cleared the lesions in many patients. This is the first report of an association between RPC and hyperparathyroidism, hypothyroidism, liver disorders, and neurodermatitis.

CONCLUSION

Various disorders can be associated with the adult form of RPC. Pruritus is the common factor among all types. Control of itching might be helpful for clearing the lesions. We propose the following diagnostic criteria for acquired RPC: (1) histopathologic findings of elimination of necrotic basophilic collagen tissue into a cup-shaped epidermal depression, (2) clinical presentation of umbilicated papules or nodules with a central adherent keratotic plug, and (3) onset of skin lesions after the age of 18 years.