Intravascular large cell lymphoma: a patient with asymptomatic purpuric patches and a chronic clinical course

Intravascular large cell lymphoma (malignant angioendotheliomatosis) is a rare, multifocal, intravascular neoplasm of lymphoid cells that preferentially involves the vasculature of the skin and central nervous system. We describe a 54-year-old man with asymptomatic purpuric patches on the lower extremities for 10 years duration and a more recent lesion on the right arm. A biopsy specimen showed intravascular collections of tumor cells with irregular nuclear contours and prominent nucleoli. These cells were leukocyte common antigen (CD45), CD20, and CDW75 positive, but CD3, CD43, CD45RO, and cytokeratin negative. Polymerase chain reaction analysis of the skin for immunoglobulin heavy chain gene rearrangement detected a clonal population of B cells, supporting the diagnosis of a B-cell lymphoma. Peripheral blood showed no abnormal circulating cells. This case of malignant angioendotheliomatosis is unusual for its prolonged clinical course and presence of purpuric patches.

Acute hemorrhagic edema of infancy

Acute hemorrhagic edema of infancy (AHEI), also called postinfectious cockade purpura, is a leukocytoclastic vasculitis that was first described in the United States by Snow in 1913. AHEI affects children between 4 and 24 months of age; the cutaneous finding, similar to those of Henoch-Schönlein purpura (HSP), are dramatic in both appearance and rapidity of onset. We present a toddler with AHEI and compare the epidemiology, histology, and clinical manifestations of this disorder and HSP.

Livedo reticularis and Raynaud's phenomenon associated with cryoglobulinaemia but not related to hepatitis C virus in an HIV-1-positive patient

Symptomatic cryoglobulinaemia is infrequent in HIV-1-infected patients, but a few cases have been described [1-3], occasionally associated with hepatitis C virus (HCV) infection [1, 3]. These cases showed rheumatologic [1] or neurologic manifestations [2, 3], but until now no cutaneous symptoms associated with cryoglobulinaemia in HIV-infected patients have been described. We report what we believe to be the first case of cutaneous, symptomatic cryoglobulinaemia in an HIV-1-positive patient, who, in addition, was HCV-negative.

Adult dermatomyositis with livedo reticularis and multiple skin ulcers

Skin ulcers are commonly described in the juvenile form of dermatomyositis; however, in the adult form they are rarely described. We report on a patient with adult dermatomyositis, deep cutaneous ulcers in the skin folds and livedo reticularis eruption.

Degos disease in a patient with acquired immunodeficiency syndrome

Malignant atrophic papulosis is a rare disorder characterized by pathognomonic cutaneous lesions that consist of infarctive thrombosis. Visceral involvement often occurs; the gastrointestinal tract and the central nervous system are most frequently involved. Malignant atrophic papulosis has not been previously described in an AIDS patient. We describe a 58-year-old homosexual man with AIDS who developed typical cutaneous lesions of malignant atrophic papulosis. No visceral involvement has been detected in 2 years.

Peripheral ulcerative keratitis associated with erythema elevatum diutinum and a positive rheumatoid factor: a report of three cases

Peripheral ulcerative keratitis (PUK) is a complication of collagen-vascular diseases such as rheumatoid arthritis (RA) and other systemic vasculitides. We report three cases of erythema elevatum diutinum with PUK. These patients presented with nodules and plaques consistent with erythema elevatum diutinum on the extremities and crusted or ulcerated purpuric lesions on the soles. Histopathological examination of these lesions revealed a dense neutrophilic infiltrate with nuclear dust and fibrin around blood vessels. All the patients developed PUK concomitant with the development of the skin lesions. The rheumatoid factor was positive at high titre in all three patients; this was associated with probable RA in one. Cutaneous lesions were dramatically improved by administration of dapsone in all cases. Dapsone was also effective in treating the ocular lesions in two patients.

Strokes, cutis marmorata telangiectatica congenita, and factor V Leiden

Cutis marmorata telangiectatica congenita is an uncommon, congenital cutaneous condition typified by persistent cutis marmorata and other associated abnormalities. Progressive neurologic complications are generally not a feature of the disorder. A case is reported of cutis marmorata telangiectatica congenita associated with diffuse cerebrovascular infarcts at 7 months of age. Moyamoya-like vascular abnormalities were demonstrated in addition to the factor V Leiden mutation, a congenital hypercoagulable disorder. This novel case illustrates the importance of evaluating children with strokes for congenital thrombophilic disorders.

Prognostic factors in leukocytoclastic vasculitis: a clinicopathologic study of 160 patients

OBJECTIVE

To analyze risk factors for systemic involvement and long-term course in leukocytoclastic vasculitis.

DESIGN

A clinicopathological study of 160 patients with leukocytoclastic vasculitis followed up for at least 3 years. Univariate and multivariate analysis were conducted by logistic regression methods.

SETTING

The Bellvitge Hospital, a referral center in Barcelona, Spain.

PATIENTS

One hundred sixty patients with cutaneous leukocytoclastic vasculitis. Patients in the categories cutaneous/systemic vasculitis and acute/chronic cutaneous vasculitis were selected for comparative analysis.

MAIN OUTCOME MEASURES

Clinical, laboratory, and histopathological findings.

RESULTS

Of 89 females and 71 males, aged 14 to 89 years, systemic involvement was documented in 20% of cases. Perinuclear-staining antineutrophil cytoplasmic autoantibodies were found in 21% of patients and cryoglobulins in 25.4%. Of the patients, 1.9% died of systemic vasculitis. The average duration of cutaneous lesions was 27.9 months. In 67.2%, a cause or associated condition was identified. Of the skin specimens, 59.6% showed vasculitis limited to superficial dermal vessels. Direct immunofluorescence was positive in 84.3% of cases. In the multivariate analysis, paresthesia, fever, and absence of painful lesions were found to be risk factors for systemic involvement. Cryoglobulins, arthralgia, and normal temperature were risk factors for chronic cutaneous disease.

CONCLUSION

Our results identify prognostic factors in leukocytoclastic vasculitis and may provide some aid in the management of this heterogeneous group of patients.

Livedo reticularis, developmental delay and stroke-like episode in a 7-year-old male

Livedo reticularis is a vascular abnormality of the skin resulting in an erythematous reticular rash. The combination of livedo reticularis and stroke-like episodes in adults is known as Sneddon syndrome [Sneddon, IB (1965). Br J Dermatol 77:180-188]. A similar combination of stroke-like episodes and livedo reticularis has been reported to occur in children [Baxter P et al. (1993). Dev Med Child Neuro 35:917-926]. We present here a 7-year-old male with congenital livedo reticularis, obesity, developmental delay, stroke-like episode, hypertension and cystic kidneys. We summarize our patient's findings and family history, and compare his disorder to other possibly related conditions.

Köhlmeier-Degos's disease with primary intestinal manifestation

Disseminated intestinal and cutaneous thromboangiitis (synonyms: Köhlmeier-Degos's syndrome, malignant atrophic papulosis, progressive arterial mesenterial vascular occlusive disease) is a rare, systemic vascular disease that is mainly manifested in the skin, gastrointestinal tract, and nervous system. The disease first appears as a necrotizing papulous dermatosis; as it generalizes, infarcted necroses develop in internal organs. These ischemic complications are the reason for the usually fatal outcome of the disease. A case report of a primary intestinal manifestation of this disease illustrates the clinical course, diagnosis, histopathologic findings, and differential diagnosis, with consideration of the current literature. Deposits of acid mucopolysaccharides and humoral immune mechanisms appear to play a role in the etiology and pathogenesis of this usually fatal vascular disease.

[Neurocutaneous syndromes with vascular alterations]

There are several syndromes in which neurological and cutaneous alterations of vascular origin, among other symptoms, occur. The key point of this fact is that these cutaneous signs permit early diagnosis, thus helping in further recognition of more complex syndromes and preventing unnecessary, harmful and costly diagnostic procedures or having to wait until the appearance of neurological signs. Therefore, these diseases should be classified attending to the most notorious vascular lesions they show, though they may show other less frequent cutaneous vascular lesions. In this way, these syndromes can be classified as associated with nevus flammeus (Sturge-Weber, Shapiro-Shulman, Bonnet-Dechaume-Blanc, Cobb, Klippel-Trenaunay, Fegeler, Robert), cavernous hemangiomas (Maffucci, blue-rubber-bleb-nevus, Proteus, Bannayan-Zonana, Riley-Smith, familial cavernous angiomatosis, POEMS syndrome), capillary hemangiomas (Rubinstein-Tayabi, Coffin-Siris, PHACE syndrome), telangiectasia (congenital telangiectatic cutis marmorata, Rendu-Osler-Weber, ataxia telangiectasia, Cockayne, De Sanctis-Cacchione), livedo reticularis (Sneddon, Divry-van-Bogaert), angioqueratoma (Fabry disease, Fucosidosis) and hemangioblastoma (Von Hippel-Lindau). Though we have tried that these vascular lesions should be named as angiomas if they are malformations and hemangiomas if they are benign neoplasias, they are called following morphological aspects rather than other criteria, due to their unknown origin.

Primary hyperoxaluria in an adult with renal failure, livedo reticularis, retinopathy, and peripheral neuropathy

We present the case of a young woman who developed renal failure of unknown cause, and after 2 months of maintenance hemodialysis developed livedo reticularis, retinopathy, and peripheral sensory neuropathy. The patient was subsequently shown to have primary oxalosis type I, a rare autosomal recessive error of metabolism characterized by accumulation of calcium oxalate crystals in the kidneys, eyes, skin, and other organs. Intravascular obstruction, caused by deposition of calcium oxalate crystals in cutaneous arterioles, is thought to be responsible for the ischemic livedo reticularis lesions observed in this patient. A method is described for measuring serum glycolate by isotope dilution gas chromatography-mass spectrometry (GC-MS). An approach to the diagnosis and management is also briefly mentioned.

Cryofibrinogenemia with polyarthralgia, Raynaud's phenomenon and acral ulcer in a patient with Graves' disease treated with methimazole

Cryofibrinogenemia is a cryopathy in which hypersensitivity to cold is a prominent feature. Cryofibrinogenemia developed in an 18-year-old Japanese female patient during methimazole therapy for Graves' disease. She developed cryopathy (livedo reticularis, Raynaud's phenomenon and acral ulcer) and polyarthralgia during methimazole therapy, and we detected cryofibrinogen in her plasma. Her symptoms resolved after administration of prostaglandins and anticoagulants. Several reports indicate that methimazole therapy induces autoantibody-related disease. In the present case, we cannot exclude the possibility that methimazole therapy contributed to the cryofibrinogenemia.

Cutis marmorata telangiectatica congenita: report of one case

Cutis marmorata telangiectatica congenita is an uncommon, congenital cutaneous lesion. It is usually present at birth, and is characterized by persistent fixed, flat, blue-violet cutaneous marmorata, telangiectasia, and phlebectasia. Frequently, there is associated skin atrophy and ulceration. There is an association with other abnormalities in at least 50% of the patients with cutis marmorata telangiectatica congenita. Thus, obtaining a thorough history and detailed physical examination are needed. We present a 38-day-old female infant with cutis marmorata telangiectatica congenita, with uneven growth of bilateral lower limbs, and review the literature on this rare lesion.

Cytoplasmic antineutrophil cytoplasmic antibody-positive vasculitis associated with ulcerative colitis

The case of a man with poorly controlled ulcerative colitis, who developed a cytoplasmic antineutrophil cytoplasmic antibody-positive systemic vasculitis, causing small bowel infarction is reported. Antineutrophil cytoplasmic antibodies occur in 50-70% of patients with ulcerative colitis, but are usually of the perinuclear or atypical pattern; the cytoplasmic pattern seen in this case is indicative of systemic vasculitis. A variety of vasculitic diseases have been reported as occurring rarely with ulcerative colitis, but this report is the first description of a cytoplasmic antineutrophil cytoplasmic antibody-positive vasculitis with this association.

Malignant atrophic papulosis

We describe a 34-year-old woman presenting with a 1-year history of asymptomatic, atrophic papules disseminated mainly on the trunk. The clinical features were characteristic of malignant atrophic papulosis, and the histopathologic features were confirmatory. The etiology of this rare condition, described for the first time in 1941, remains unknown. Also the pathogenesis is still controversial. A vascular disorder has been postulated by most authors, primary inflammatory or thrombotic vascular changes as well as primary endothelial proliferation being often mentioned in the literature. In the present case, the biopsy specimen of a recent efflorescence showed these three alterations all together, making it impossible to identify conclusively the primary event. Thrombosis, being already noticed in such early lesions, is likely to be of pathogenic importance. Rheological therapy as described in the literature may therefore be the most appropriate. In the present case, the lesions came spontaneously to a standstill without drug therapy.

Eosinophilic vasculitis in connective tissue disease

BACKGROUND

Neutrophilic and lymphocytic vascular inflammation is common in vasculitis associated with connective tissue disease (CTD). We recently identified eight patients with CTD and eosinophilic vasculitis.

OBJECTIVE

The purpose of this study was to characterize a variant form of vasculitis in CTD with eosinophilic infiltration.

METHODS

Of 98 CTD patients with cutaneous necrotizing vasculitis, eight were found with predominantly eosinophilic vascular infiltration. Nine CTD patients with cutaneous neutrophilic vasculitis were identified for comparison. Clinical and laboratory findings were reviewed and compared. Indirect immunofluorescence for eosinophil granule major basic protein (MBP), neutrophil elastase, and mast cell tryptase was performed on lesional tissue. MBP levels and eosinophil survival enhancing activity were assayed in sera from three patients.

RESULTS

The patients with eosinophilic vasculitis had depressed serum complement levels and peripheral blood eosinophilia; MBP levels were elevated in serum and eosinophil survival was prolonged. Immunofluorescence of tissue showed marked angiocentric eosinophil MBP staining with peripheral neutrophil elastase staining; mast cell tryptase staining was notably absent. The patients with neutrophilic vasculitis were variably hypocomplementemic and did not have peripheral blood eosinophilia. Immunofluorescence showed marked angiocentric neutrophil elastase staining with scattered eosinophil MBP staining; mast cell tryptase staining showed normal mast cell numbers.

CONCLUSION

Patients with eosinophilic vasculitis, CTD, and hypocomplementemia show vessel wall destruction in association with vessel wall deposition of cytotoxic eosinophil granule MBP, which suggests that eosinophils mediate vascular damage in this disease process. In addition, perivascular mast cells appear diminished, thereby suggesting that mast cell degranulation occurs.

Antiphosphatidylethanolamine antibodies as the only antiphospholipid antibodies. I. Association with thrombosis and vascular cutaneous diseases

OBJECTIVE

To detect antiphosphatidylethanolamine antibodies (aPE) as the only antiphospholipid antibodies (aPL) in 122 patients we investigated for aPL and to correlate the presence of aPL with clinical manifestations.

METHODS

Patients with autoimmune diseases (n = 41), thromboembolic episodes (TEE) (n = 34), livedo reticularis (LR) without (n = 17) or with (n = 14) thrombosis or recurrent fetal losses (RFL), systemic vasculitides (n = 10), and miscellaneous disorders (n = 6) were investigated for antibodies directed against 4 anionic phospholipids (PL) (cardiolipin, phosphatidylserine, inositol, phosphatidic acid) and lupus anticoagulant (LAC) and then for aPE by modified ELISA.

RESULTS

15 patients had aPE and no antibodies to anionic PL including LAC. 7 had IgM, 4 had IgG plus IgM, and 4 had IgG. These aPE were significantly more often associated with TEE alone, with TEE and LR, or with LR alone (p = 0.004) than with autoimmune diseases.

CONCLUSION

The detection of aPE as the sole aPL in one patient with mesenteric infarcts and RFL led to the diagnosis of primary antiphospholipid syndrome. Followup of 3 patients showed that aPE cannot be considered as transient autoantibodies. Therefore, patients whose clinical symptoms suggest antiphospholipid syndrome but whose sera are negative for antibodies to cardiolipin or another anionic PL should be screened for aPE, particularly patients with thrombosis, RFL, and/or LR.

[An unusual course in hairy-cell leukemia with marked abdominal lymphadenopathy, leukemic infiltration of the cornea and skin changes]

The authors describe a female patient suffering from hairy-cell leukaemia. Already at the onset of the disease, apart from marked splenomegaly, sonography revealed marked retroperitoneal lymphadenopathy. During the subsequent course skin changes developed such as vasculitis and leukaemic infiltrates of the cornea on both eyes. The patient was successfully treated with 2-chlorodeoxyadenosine (2-CdA, Leustatin).

Erythema elevatum diutinum in human immunodeficiency virus-infected patients--report of a case and review of the literature

Erythema elevatum diutinum (EED) is a rare chronic disease of unknown origin, part of the spectrum of cutaneous leucocytoclastic vasculitis. A case of EED in a 32-year-old HIV-infected male patient, with no previous opportunistic infections and a CD4+ cell count of less than 200/mm3, is reported. Therapy with oral dapsone (100 mg/day for 15 days) resulted in clinical cure with no relapse after 6 months of follow-up. To our knowledge, only six cases of EED in HIV-positive patients have been reported to date. A brief review of these seven cases is described.

Chronic hepatitis C, cryoglobulinemia, and cutaneous necrotizing vasculitis. Clinical, pathologic, and immunopathologic study of twelve patients

BACKGROUND

Several patients with chronic hepatitis C infection and cutaneous vasculitis have been described.

OBJECTIVE

The objective of this study was to define better the features of necrotizing vasculitis and mixed cryoglobulinemia in patients with hepatitis C infection.

METHODS

A retrospective review of 611 patients with hepatitis C antibodies was conducted. Patients with clinical and histopathologic findings of cutaneous necrotizing vasculitis were identified. Clinical, histologic, and laboratory data were recorded.

RESULTS

Twelve patients with necrotizing vasculitis and chronic hepatitis C infection were identified. Palpable purpura was the most common clinical presentation. Onset of skin lesions was usually more than 10 years after infection. The lower extremities were affected in all patients. Cryoglobulinemia of the mixed type II was present in 10 of 11 patients. Liver function tests were evaluated at the time of vasculitis in most of the patients. Rheumatoid factor was elevated in all nine patients tested. Total complement was decreased in seven of nine patients, and C4 was decreased in six of seven patients.

CONCLUSION

Cutaneous vasculitis associated with cryoglobulinemia and hypocomplementemia is not uncommon in the course of chronic active hepatitis C infection. The triad of necrotizing vasculitis, chronic hepatitis C infection, and cryoglobulinemia occurs late after initial infection with hepatitis C. Antibodies to hepatitis C virus should be determined in a patient with necrotizing vasculitis, especially if liver function tests are elevated.

Leukocytoclastic vasculitis in subacute cutaneous lupus erythematosus: clinicopathologic study of three cases and review of the literature

BACKGROUND

Leukocytoclastic vasculitis associated with subacute cutaneous lupus erythematosus (SCLE) was observed by Sontheimer et al. in their first clinical series of patients with SCLE, although recent reports have suggested that its frequency was rare.

OBJECTIVE

To evaluate the prevalence of cutaneous leukocytoclastic vasculitis (CLV) in patients with SCLE and to describe the clinicopathologic manifestations, response to treatment and prognosis of this subgroup of patients.

METHODS

We reviewed all cases of SCLE seen at the Hospital de la Princesa from 1980 to 1995.

RESULTS

Three (9%) of our 27 patients with SCLE exhibited CLV and SCLE. Purpura, maculoerythematous lesions, urticaria, nodules and necrotic lesions on the leg, trunk and palmoplantar regions were present in our patients with CLV and SCLE. Histologically, SCLE-associated CLV was a small-sized vessel leukocytoclastic vasculitis with intravascular thrombosis in the deep dermis and coexistence of lesions of CLV and SCLE.

CONCLUSION

In our patients, CLV was self-limited and not associated with a worsened prognosis, with only cutaneous involvement in their further relapses of SCLE.

Livedo reticularis and thrombotic purpura related to the use of diphenhydramine associated with pyrithyldione

We describe the case of a young woman who habitually took large doses of a combination of diphenhydramine and pyrithyldione. She complained of arthralgia, painful recurring plaques and nodules, together with persistent reticular purpuric mottling and areas of necrosis on her legs. There were positive antinuclear antibodies and rheumatoid factor and histologically massive thrombosis of the dermal vessels without signs of vasculitis. Other cases of similar adverse reactions attributed to this drug combination used as a hypnotic have been described.

Cutis marmorata telangiectatica congenita associated with a double aortic arch

We report a patient with cutis marmorata telangiectatica with the hitherto unreported anomaly of a double aortic arch. The presence of two major vascular anomalies in this patient may be secondary to a developmental defect of the mesoderm during embryogenesis.

Acro-angiodermatitis: review of the literature and report of a case

Acro-angiodermatitis is a very common disorder, with a close clinical, anatomical and morphological resemblance to Kaposi's sarcoma. Several types of this disorder can be found in different settings. However, these conditions are often misdiagnosed and therefore mistreated. A review of the literature and a classification of all types of acro-angiodermatitis are presented. We also describe a case of a patient with acro-angiodermatitis which completely regressed following a course of dapsone combined with leg elevation and elastic support stockings.

[Periarteritis nodosa cutanea. 20 years follow-up with leg pain, Raynaud syndrome and nail changes]

Polyarteritis nodosa is a multi-systemic vasculitic disease process involving small and medium-sized arteries throughout the body. Cutaneous polyarteritis nodosa has been described as a limited form involving the skin, skeletal muscles, and peripheral nerves. A protracted course of 20 years or longer, with few cases eventually developing visceral involvement, has been emphasized by many authors. A case of polyarteritis with a 20-year history of exacerbations and spontaneous remissions that never seriously compromised the patient's health is presented. The initial and predominant symptoms were leg pains, Raynaud's phenomenon, and nail defects (onychoschizia).

Giant chest wall arteriovenous malformation with spinal cord compression

Images

Necrotizing vasculitis associated with hepatitis C virus infection: successful treatment of vasculitis with interferon-alpha despite persistence of mixed cryoglobulinemia

Type II cryoglobulinemia may be associated with chronic hepatitis C virus (HCV) infection and may be characterized by vascular purpura. We report on a case of histologically proven necrotizing vasculitis associated with type II cryoglobulinemia and HCV infection. Within 14 days of interferon-alpha therapy (3 x 3 million IU/ml/week), purpuric skin lesions disappeared as well as fatigue and arthralgia; 9 months after initiation of therapy, liver enzyme values were nearly normal despite persistence of HCV RNA tested by PCR and mixed cryoglobulinemia. Rheumatoid factor activity, however, decreased markedly. To our knowledge, our patient is the first reported case with histologically proven necrotizing vasculitis with a beneficial effect of interferon-alpha. Because of the persistence of cryoglobulins, but reduction of the IgM fraction in the cryoglobulin complex under interferon-alpha treatment, it would seem worthwhile to further elucidate the pathogenic role of qualitative instead of quantitative changes of cryoglobulins and the mechanism of action of interferon-alpha.

[A case of Sneddon syndrome]

Sneddon syndrome is a clinical entity that is characterized by livedo reticularis and cerebrovascular lesions and is considered to be a subtype of antiphospholipid antibody syndrome. Central retinal artery occlusion is one of the ophthalmic complications of this syndrome and its prognosis of visual acuity is generally poor. We report here a 50-year-old man with Sneddon syndrome who had recurrent central retinal artery occlusion with recovery of visual function after each episode.

[Sneddon's syndrome vasculopathy with antiphospholipid antibodies in a child]

We studied a ten-year old girl with livedo reticularis and multiple central nervous system ischemic attacks beginning when she was five. Blood tests were positive for cryoglobulins and antiphospholipid antibodies; superior limb angiography showed occlusion and irregularities of the vessel walls and temporal artery biopsy revealed concentric thickening of the vessel wall due to fibrotic subendothelial proliferation. Sneddon's syndrome was diagnosed. Onset of this syndrome during early childhood has not been previously reported.

Secondary erythermalgia associated with an autoimmune disorder of undetermined significance

A 50-year-old female patient is described with an acquired, persisting and yet incurable erythermalgia featured by symmetric burning pain and red congestion of the extremities secondary to cutaneous vasculitis. A weakly positive antinuclear antibody titer and high titers of antibodies against gastric parietal mucosa cells pointed to an underlying but unclassifiable autoimmune disorder. It is concluded that histopathology of lesional skin contributes to the differential diagnosis of primary and secondary erythermalgia.

Correlation of liver and skin histopathology with serology in a patient with cutaneous vasculitis and hepatitis C infection

A strong body of evidence supports a viral etiology for many forms of vasculitis. Recent literature supports the association of the hepatitis C virus (HCV) with essential mixed cryoglobulinemia. We describe a case of cutaneous vasculitis associated with simultaneous active hepatic inflammation demonstrated by skin and liver biopsies. Immunofluorescence, hepatitis C serology, and study of the cryoprecipitate all confirmed HCV infection and deposition of immune complexes. Treatment with interferon alpha-2b was extremely effective as compared with prednisone and colchicine. This case provides further evidence that active hepatic infection with HCV may be a cause of cryoglobulinemia and cutaneous vasculitis. It also suggests that further studies of antiviral therapy for vasculitis should be explored.

Dermatomyositis with multiple skin ulcers showing vasculitis and membrano-cystic lesion

A 63-year-old woman with dermatomyositis (DM) developed multiple punched-out ulcers of the skin. She had not only a past history of gastric cancer 10 years prior to the onset of DM, but also a familial history of cancer. A skin biopsy from one of the ulcers revealed both vasculitis and membrano-cystic lesion in the same specimen. She died of interstitial pneumonitis one year after the onset of DM. Vasculitis and membrano-cystic lesion may be an important marker of a poor prognosis in DM.

[Sneddon syndrome: 9 cases]

We observed a series of 9 patients (1 male, 8 females, mean age 49 years) who had experienced cerebral vascular events with livedo racemosa (Sneddon's syndrome). Vascular dementia occurred in 3 patients and in the 6 others there was a single or several acute cerebral ischaemic events. Angiography of the brain revealed multiple distal arterial occlusions in 5 cases and a moya-moya type collateral network in 2. Positivity for anticardiolipid antibodies fluctuated in 4 cases and there was a lupic syndrome in 2. Systemic lupus erythemosus was diagnosed in the last patient. Mitral valve defects were seen in 5 patients, including 3 due to post-rhematitis sequelae which became symptomatic before the appearance of signs of neurocutaneous involvement. Among these three patients, laboratory tests revealed a lupus band in one, anticardilipid antibodies in another and obliterating fibrous endartiritis of the renal arteries in the third. Sneddon's syndrome presents with heterogeneous signs related to its complex pathophysiology.

[Sneddon's syndrome: an unusual cause of cerebral infarct at a relatively young age]

Sneddon's syndrome was diagnosed in a man of 56, and two women aged 48 and 22 years. It is a rare disease characterised by the combination of skin lesions (livedo racemosa) and cerebral infarctions at a relatively early age. Apart from the clinical presentation, the diagnosis can sometimes be confirmed by a typical microscopical image of a biopsy taken from a region adjacent to the livedo (endothelitis, perivascular lymphocyte infiltration and hypertrophy of the artery wall). The cause of the syndrome is unknown and a specific therapy is lacking. Early recognition of Sneddon's syndrome may protect patients against unnecessary ancillary investigations.

Sneddon and antiphospholipid antibody syndromes causing bilateral thalamic infarction

A child suffered bilateral thalamic infarction secondary to Sneddon and antiphospholipid antibody syndromes. Her initial findings of hypersomnolence, mood disturbance, and amnesia are characteristic of bilateral thalamic infarction. Clinical and laboratory evaluation confirmed the diagnosis of both Sneddon and antiphospholipid antibody syndromes as the cause of her unusual stroke. The treatment of this patient, based on experience with adult patients, was long-term, high-intensity warfarin anticoagulation.