Livedo reticularis and pregnancy morbidity in patients negative for antiphospholipid antibodies

BACKGROUND

Livedo may be an independent risk factor for pregnancy morbidity, additional to the known risks associated with the presence of antiphospholipid antibodies (aPL).

OBJECTIVE

To determine the prevalence of pregnancy related morbidity in patients with widespread livedo reticularis who are persistently negative for aPL.

PATIENTS AND METHODS

52 patients with widespread livedo reticularis were studied: 31 fulfilled ACR criteria for SLE, 21 had a lupus-like illness; all were negative for aPL. All patients had livedo (racemosa or reticularis type) on their extremities, trunk, and/or buttocks.

RESULT

33 (63%) patients had pregnancy related morbidity. 22 patients had up to 9 miscarriages, 15 patients had >3 miscarriages, 2 had 2 miscarriages, 4 had a fetal death (>10 weeks), 17 had pre-eclampsia, and 4 patients had premature delivery. 19 patients had no pregnancy related morbidity. Overall morbidity was similar in the patients with lupus and lupus-like disease.

CONCLUSION

Pregnancy related morbidity in lupus is known to be associated with the presence of aPL. This study suggests that pregnancy loss may also be independently associated with widespread livedo reticularis in patients who are aPL negative. A larger study is needed.

Intravascular or intralymphatic histiocytosis associated with rheumatoid arthritis: a report of 4 cases

BACKGROUND

Various skin lesions occur in association with rheumatoid arthritis (RA).

OBSERVATION

We report a distinctive skin lesion observed in 4 patients with RA. All patients had RA for many years and developed asymptomatic, irregularly shaped erythema over the swollen elbow joints and the nearby part of the forearm. Histopathologically, all cases showed massive aggregates mainly composed of histiocytes in markedly dilated vessels in the dermis, accompanied by a dermal infiltrate of lymphocytes, plasma cells, neutrophils, or a combination of these. A total of 9 cases, including ours, showing similar histopathologic findings have been reported in the literature, of which 7 were associated with RA and presented relatively common clinical appearance.

CONCLUSION

In spite of some disagreement as to whether the dilated vessels are blood vessels or lymphatics, it is most likely that these 7 cases belong to the same clinical entity closely associated with RA.

Cutis marmorata telangiectatica congenita

A case of cutis marmorata telangiectatica congenita (CMTC) is reported. A young girl had an unusual presentation with sclerosis in the skin lesions, senile features, hypoplasia of the mandible, transverse nail dystrophy, and transverse toe defects resembling Adams-Oliver syndrome. These associated abnormalities are very rare and some have not been documented before with CMTC. The possible relationship of CMTC with Adams-Oliver syndrome is also discussed.

Mononeuropathy multiplex in association with livedoid vasculitis

Livedoid vasculitis is a chronic dermatological disorder associated with petechiae and recurrent, unusually shaped ulcers that heal to form hyperpigmentated areas and atrophie blanche. This condition is more correctly termed a vasculopathy, rather than a vascultis, and is often associated with an underlying hypercoagulable disorder. We report a patient with livedoid vasculitis and mononeuropathy multiplex. We propose that peripheral nervous system involvement arises from multifocal areas of ischemia due to fibrin and thrombin deposition within both the wall and lumen of vasa nervorum.

Livedo reticularis associated with the use of a midline catheter

We report a case of livedo reticularis as an unusual complication of a midline catheter in a patient being treated for pyelonephritis with intravenous antibiotics. The rash resolved completely after catheter removal. The constellation of symptoms suggested an aberrant autonomic response as the cause of the illness.

Cobb syndrome associated with a verrucous (angiokeratomalike) vascular malformation

Cobb syndrome is defined by a cutaneous vascular lesion and a corresponding spinal cord vascular malformation within a segment or two of the involved dermatome. Even though Cobb syndrome has been reported in association with various cutaneous vascular lesions, to our knowledge, only one other previous report describes verrucous changes overlying the cutaneous vascular lesion. We describe a patient with verrucous vascular malformation extending from his right chest to his right upper back in a dermatomal distribution. The patient's medical history included excision of a cavernous vascular malformation from the corresponding segment of his thoracic spinal cord 4 years prior, reversing 7 years of progressive leg weakness and neural deficits. Cobb syndrome was diagnosed based on the dermatomally distributed vascular malformation and the corresponding spinal cord vascular malformation. His skin lesions initially improved with erbium: YAG laser treatment but later recurred. This is the second reported case of Cobb syndrome associated with verrucous angiokeratomalike changes overlying the cutaneous vascular malformation. Because of the potentially severe neurologic sequelae caused by spinal cord lesions, clinicians should evaluate patients with dermatomally distributed cutaneous lesions on the trunk or extremities, including vascular malformations with verrucous features.

Livedo reticularis in a child with moyamoya disease

Moyamoya disease is a rare, chronic cerebrovascular occlusive disease of unknown etiology. It is characterized by progressive stenosis of the arteries of the circle of Willis leading to an abnormal capillary network and resultant ischemic strokes or cerebral hemorrhages. The association of moyamoya disease with livedo reticularis has been described in a previously reported patient with a factor V Leiden mutation, leading to hypercoagulation. We describe a girl with livedo reticularis and moyamoya disease with extensive cardiovascular malformations, but without a primary coagulopathy.

Severe livedo vasculitis treated with potassium iodide

A young woman presenting severe livedo vasculitis (LV) was successfully treated with potassium iodide (KI). Previous attempts to cure her disorder with corticosteroids, low-dose aspirin, and azathioprine in various combinations had failed. To our knowledge, this is the first report of LV treated with KI.

Cutis marmorata telangiectatica congenita and extensive mongolian spots: type 5 phacomatosis pigmentovascularis

Two patients with an unusual association of extensive cutis marmorata telangiectatica congenita and aberrant mongolian spots are reported. We believe that such association is best explained as a phenomenon of non-allelic twin spotting. We found only one previous similar case in a textbook, and we support the classification of this condition as phacomatosis pigmentovascularis type V.

Presentation of Degos syndrome as acute small-bowel perforation

Malignant atrophic papulosis is an uncommon vasculopathy affecting multiple systems and frequently associated with a poor prognosis. We describe a 56-year-old patient with this rare disorder whose death was the result of intestinal involvement. Clinical diagnostic features of malignant atrophic papulosis as well as the main therapeutic approaches suggested in the literature are presented herein.

Vascular variant of keratosis lichenoides chronica associated with hypothyroidism and response to tacalcitol and acitretin

Keratosis lichenoides chronica (KLC) is a rare chronic progressive cutaneous disease that is part of the heterogeneous group of lichenoid dermatoses. The typical clinical presentation is characterized by lichenoid hyperkeratotic papules and nodules arranged in a linear and reticular pattern on the trunk and extremities. Our case confirms the existence of a vascular variant of KLC. There is no consensus about its treatment, since it is refractory to many different treatment modalities. We report the effectiveness of acitretin in KLC in combination with tacalcitol. KLC is of unknown aetiology, but is perhaps associated with systemic diseases, most importantly glomerulonephritis and lymphoma. This is the second case associated with hypothyroidism.

First reported convergence of premature ovarian failure and cutis marmorata telangiectatica congenita

OBJECTIVE

To describe the convergence of five rare phenotypic features in a woman with premature ovarian failure referred for reproductive endocrinology evaluation.

DESIGN

Case report and literature review.

SETTING

Major urban infertility referral center.

PATIENT(S)

A 24-year-old nulligravida with cutis marmorata telangiectatica congenita (CMTC), premature ovarian failure, unilateral ovarian agenesis, septate uterus, and de novo balanced autosomal translocation.

INTERVENTION(S)

High-resolution chromosomal evaluation, radiographic study of reproductive organs, and assessment of endogenous estrogen production.

MAIN OUTCOME MEASURE

Patient counseling regarding future reproductive options (i.e., donor oocyte in vitro fertilization/embryo transfer), and satisfactory management of hypoestrogenism using oral contraceptives.

RESULT(S)

We identified a balanced reciprocal translocation 46,XX t(8;9)(q22.1;p24.1), and confirmed unilateral ovarian agenesis with midline intrauterine septum.

CONCLUSION(S)

Although genetic factors considered contributory to premature ovarian failure usually involve the X chromosome, in our patient a previously undescribed autosomal translocation was identified in association with CMTC, a rare vascular disorder. The fundamental role of follicular oxygenation in oocyte competence and subsequent ovarian function is discussed. From the clinical and laboratory findings evident in this unusual case, a developmental hypothesis connecting the vascular abnormalities of CMTC and premature ovarian failure is offered.

Dextran sulfate (Selesorb) plasma apheresis improves vascular changes in systemic lupus erythematosus

Apheresis has been effective as rescue therapy in patients with severe, therapy-resistant, systemic lupus erythematosus (SLE). Its benefit in patients with less severe but therapy-resistant SLE is not known. Dextran sulfate apheresis was applied as a rescue therapy for therapy-resistant vasculitic skin lesions in a 30 year old female patient with a 9 year history of SLE in combination with antiphospholipid syndrome and Raynaud's phenomenon. Partial remission was achieved after 9 immunoadsorption sessions, as documented by marked improvement of skin lesions and an increase of capillary density in the nailfold area. Further improvement was noted with maintenance therapy using mycophenolate mofetil. Dextran sulfate apheresis can be applied safely in patients with moderate therapy-resistant SLE disease activity when severe immunodeficiency and cytotoxic adverse effects should be avoided.

[Liveoid vasculopathy with combined thrombophilia: efficacy of iloprost]

INTRODUCTION

Livedoid vasculopathy is characterized by early, focal painful purpuric lesions of the lower skin extremities without histologic finding of small vessel vasculitis.

EXEGESIS

A 38-year-old man was seen in our unit for painful purpuric lesions of both feet localized on toes and external sides. Skin biopsy showed dermic vessel thrombosis and endothelial cell proliferation. Lupus anticogulant antibody was positive in association with a heterozygous factor V (Leiden) gene mutation (G1691A). Anticoagulation failed to relieve pain and cutaneous lesions. Intravenous iloprost, a prostacylcin analogous (Ilomedine) was dramatically and rapidly effective in our patient.

CONCLUSION

Livedoid vasculopathy is a cutaneous affection related to vascular thrombotic events in which thrombophilia plays a central role. Iloprost might be an interesting alternative treatment of painful purpuric lesions when anticoagulant treatments are ineffective.

Livedo reticularis and migraine: a marker for stroke risk?

BACKGROUND AND PURPOSE

Livedo reticularis is a dermatopathy characterized by an irregular, violaceous, netlike pattern which spares the face. Associated with a variety of conditions, it occurs consequent to pathological or physiological narrowing of small and medium arteries at the dermis-subcutis border. Sneddon syndrome refers to the idiopathic coupling of livedo reticularis and stroke in the absence of traditional vascular risk factors. Over 50% of persons with Sneddon syndrome describe a history of headache. We undertook this study to determine the frequency of livedo reticularis in our headache clinic.

METHODS

We performed a retrospective chart review of consecutive patients attending a headache clinic over a period of 6 months. The patients had all been seen by one physician (G.E.T.) who noted the presence or absence of livedo reticularis. The charts were reviewed for age, sex, and vascular risk factors, including current use of oral contraceptives, and history of smoking, coronary artery disease, hypertension, diabetes mellitus, stroke, or arthritis.

RESULTS

Charts from 133 patients with headache were reviewed (24 men [18%], 109 women [82%]; mean age, 42 +/- 13 years). Livedo reticularis was observed in 29 patients (22%) and in a similar proportion in men (25%) and women (21%). When we stratified the migraine population by presence or absence of livedo, we found no significant difference in age (44.5 versus 41.7 years, P =.16). There was a higher frequency of stroke diagnosis in the cohort with livedo reticularis (28%[8 of 29] versus 7%[7 of 104], P =.005), but we found no significant differences in frequency of hypertension, oral contraceptive use, diabetes mellitus, coronary artery disease, arthritis, or cigarette smoking.

CONCLUSIONS

In our headache clinic, livedo reticularis is present in more than one fifth of patients. A history of stroke is more frequent in this subset of migraineurs, raising the possibility that livedo reticularis can be used as a clinical marker to identify those migraineurs with an increased risk of stroke.

Calciphylaxis with peau d'orange induration and absence of classical features of purpura, livedo reticularis and ulcers

Calciphylaxis is an ill-defined syndrome that is commonly associated with chronic renal failure. Its heterogeneous clinical features include painful livedo reticularis-like purpuric patches and plaques, vesicles, irregularly shaped ulcers, and black eschars. Despite demonstration of extensive vascular arteriolar calcification in this syndrome, its exact pathogenesis remains unknown. Here, we report a case of calciphylaxis presenting with indurated plaques without the usual clinical picture of livedo reticulate purpura, ulcers or necrotic eschars. This case provides an opportunity to review the clinical spectrum of calciphylaxis and to discuss the therapeutic approaches and pathogenesis of this syndrome from deep intra-wall vascular calcification to the resulting infarctions of adjacent tissues.