Migraine is associated with livedo reticularis: a prospective study

OBJECTIVE

To investigate the relationship of livedo reticularis, an ischemic dermatopathy, and migraine, an ischemic stroke risk factor.

BACKGROUND

Livedo reticularis refers to the reddish-blue reticular mottling of the skin resulting from narrowing of small and medium arteries at the dermis-subcutis border. A subset of patients with livedo reticularis develop stroke in the absence of other vascular risk factors, which has been termed Sneddon syndrome. We undertook this prospective study in a non-neurology clinic to delineate further the relationship of livedo reticularis and migraine.

METHODS

Patients in a general dermatology clinic were interviewed for vascular risk factors and history of migraine in accordance with the International Headache Society (IHS) criteria. A dermatologist, not familiar with the interview, recorded the primary dermatological diagnosis and the presence or absence of livedo reticularis on examination.

RESULTS

Two hundred eighty-one consecutive patients (184 women and 97 men; average age, 52 years) were interviewed and examined. Seventy-five (27%) had migraine (IHS codes 1.1, 1.2) and an additional 18 (6%) had atypical migraine (IHS 1.7). Livedo reticularis was noted in 46 patients (16%), with the frequency higher in women than men (42 [23%] of 184 versus 4 [4%] of 97; P <.0001). The frequency of livedo reticularis in patients with migraine was higher than in those without migraine (24 [26%] of 93 versus 22 [12%] of 188; P =.002), and higher in female than male migraineurs (23 [32%] of 72 versus 1 [5%] of 21; P =.012). In logistic regression analysis of the women, migraine was associated with livedo reticularis (odds ratio [OR], 2.3; confidence interval [CI], 1.08 to 4.71), as well as with stroke (OR, 4.0; CI, 0.87 to 18.21), coronary artery disease (OR, 3.5; CI, 1.16 to 10.33), and deep venous thrombosis (OR, 3.2; CI, 0.98 to 10.32).

CONCLUSIONS

In women, migraine is associated with stroke, coronary artery disease, deep venous thrombosis, as well as livedo reticularis, a dermatopathy which has been pathologically linked to cerebral vasculopathy. Whether migraineurs with livedo reticularis compose a subset at higher risk of thrombosis, including stroke, deserves further investigation.

[Livedo reticularis in patients with systemic lupus erythematosis and its association with anticardiolipin antibodies]

With the purpose of determining whether a relationship exists between Livedo Reticularis (LR) and anticardiolipine antibodies (ACA) in patients with Systemic Lupus Erithemathosus (SLE), a clinical prospective and descriptive study was carried out on 17 female lupus patients with LR, aged 15-46, from the Immunology and Dermatology outpatient clinic of the Enrique Tejera Hospital Compound in Valencia, Venezuela, during 1998. A complete clinical evaluation of each patient was done, from which a diagnosis of LR was made. This was categorized as mild, moderate or severe (Weinstein and col. criteria), depending on the severity of the lesions. Immunoenzymatic techniques were used to determine ACA Ig or IgM. The study followed the Guidelines of Good Practices in Clinical Research, and a signed informed consent was obtained from each patient. The average age of the studied patients was 28.5 +/- 10.9 years; 52.9% of them presented serum levels of ACA IgG above normal. In all cases, levels of ACA IgM were within normal limits (4.41 +/- 2.63 U/mL. Range: 0.51-9.53). All patients with mild LR had normal levels of ACA IgG, and 83.3% and 80% of those in the Moderate and Severe categories, respectively, had high levels of ACA IgG (> or = 10 U/mL), and there was a statistically significant association between each of the three categories and their respective ACA levels (p < 0.05). 82.4% of the patients had severe manifestations of the disease which included: CNS involvement, lower limb vasculitis, renal insult, pericarditis, thrombocytopenia, and recurrent miscarriages. No statistically significant association was found between each of these manifestations and the severity of LR (p > 0.05), probably due to the small number of patients studied in each group; nor between the medium serum levels of ACA IgG and each of the manifestations, except for lower limb vasculitis (ACA IgG'values-presence or absence: Fisher p: < 0.05) However, a statistically significant association (p < 0.05) was observed when the number of severe manifestations of the disease of each patient was related to the levels of ACA IgG, and the severity of LR.

Acquired nevoid telangiectasia

BACKGROUND

Acquired nevoid telangiectasia (ANT) is a segmental dilatation of papillary plexus vessels.

OBJECTIVE

In the present study, the frequency of ANT and its associations with collagen vascular and spinal disease have been investigated.

METHODS

188 unselected patients, seen at an interdisciplinary dermatorheumatologic outpatient clinic, were clinically examined for the presence of ANT and possible associations to preexisting disease.

RESULTS

ANT was seen in 17% of patients, all females. The mean age of ANT patients was 57.5 +/- 8.2 years. Most common diseases were lupus erythematosus and scleroderma. Twenty-four of them suffered from generalized fibromyalgia, 8 had spondylitis deformans, 1 suffered from thoracal syringomyelia and 1 had a spine trauma. Two types of ANT have been seen: the cervicothoracal transition type and the lumbosacral transition type.

CONCLUSIONS

ANT is not uncommon among patients attending a dermatorheumatologic outpatient clinic. ANT indicates spinal or neuromuscular complaints, but is not related to collagen vascular disease itself.

Antiphosphatidylethanolamine antibodies contribute to the diagnosis of antiphospholipid syndrome in patients with systemic lupus erythematosus

OBJECTIVE

To evaluate the correlation between antiphosphatidylethanolamine antibodies (aPE) and some antiphospholipid antibodies (aPL)-related clinical manifestations in patients with systemic lupus erythematosus (SLE).

METHODS

Patients with SLE (n=217) were tested for the presence of aPE, anticardiolipin antibodies (aCL), and lupus anticoagulant (LA). The prospective aPL-related clinical manifestations studied were: thrombosis, thrombocytopenia, recurrent fetal losses, heart valvulopathies, hemolytic anemia, livedo reticularis, and pulmonary hypertension.

RESULTS

A total of 109 SLE patients (50.23%) were IgG aPE-positive; 17.51% presented aPE as the sole autoantibody and had some clinical features of aPL-related clinical manifestations. IgG aPE were associated to the presence of heart valvulopathies (p=0.002). A statistical difference was also found when considering high levels of IgG aPE (O.D.>0.600) in patients with livedo reticularis (p=0.008).

CONCLUSION

The evaluation of IgG aPE may allow us to detect some more patients with aPL-related clinical manifestations in the SLE population, aPE correlated particularly with valvulopathies and livedo reticularis.

Leg ulcer diagnosis and management

Lower extremity ulcers can be challenging diagnostically and therapeutically. This article, provides an overview of the different kinds of lower extremity wounds typically seen by the medical dermatologist. It also reviews new treatment modalities, including topical growth factors and bioengineered skin. A team approach is emphasized.

Cold agglutinin disease--the importance of cutaneous signs

We present the case of a woman where the diagnosis of cold agglutinin disease could be made after we had noticed slight cutaneous manifestations during a routine examination. Leading symptoms were livedo reticularis of the thighs and a history of acrocyanosis and Raynaud's phenomenon upon cold exposure. The current knowledge about the etiology, clinical presentation and treatment of the disease is briefly discussed.

Reactive angioendotheliomatosis secondary to dermal amyloid angiopathy

Reactive angioendotheliomatosis (RAE) is a rare benign cutaneous vascular proliferation characterized by intravascular hyperplasia of endothelial cells and tuft-like proliferation of vessels. A 75-year-old man had erythematous and violaceous macules, some stellate and others arranged in a livedoid pattern, evolving toward necrosis with central areas having an "atrophie blanche" appearance spread on the trunk, inguinal folds, and right thigh. He was on hemodialysis and had a benign monoclonal gammopathy. Cutaneous biopsy revealed RAE characterized by the proliferation of epithelioid and spindle-shaped cells in superficial and middermis lining vascular channels, arranged in clusters, and sometimes displaying an intravascular growth pattern. These cells stained for CD31, CD34, and actin. Interestingly, prominent amyloid deposits were found in the wall of some vessels in deep dermis, often causing obstruction of their lumina. The cause of RAE is unknown, but it can be associated with infections, antiphospholipid syndrome, dysglobulinemia, cryoproteinemia, and lower extremities arteritis, and it may occur near arteriovenous fistulas. In this patient, we believe that RAE was caused by obliteration of dermal vessels by amyloid deposits. Indeed, it is thought that RAE could be caused by ischemia secondary to vascular obstruction. This is the first reported patient with RAE associated with amyloid deposits.

Cutaneous leukocytoclastic vasculitis in dermatomyositis suggests malignancy

BACKGROUND

Dermatomyositis (DM) is a rare connective tissue disease which has been shown to be associated with an underlying malignancy.

OBJECTIVE

Evaluation of the prevalence of malignancy in DM at our clinic and search for characteristics of the paraneoplastic form of disease.

METHODS

Retrospective review of patient files and histology reports over the period from 1991 to 1998.

RESULTS

23 patients (14 women and 9 men) with DM could be identified in this time period with a median age at diagnosis of 48 years. Malignancies were found in 5 (22%) cases. The skin biopsies of all patients showed features of DM; in 7 cases, a leukocytoclastic vasculitis was detected. Four of the 5 cases with an associated malignancy demonstrated histologically a vasculitis in lesional skin, compared to only 3 out of 18 cases without malignancy (p < 0.05, Fisher's exact test).

CONCLUSION

Our data suggest that vasculitis in lesional skin biopsies has a predictive value for the presence of underlying malignancy.

Livedo Reticularis: An Underutilized Diagnostic Clue in Cholesterol Embolization Syndrome

BACKGROUND

Cholesterol embolization syndrome (CES) is an increasingly recognized cause of acute renal insufficiency, which must be differentiated from other forms of systemic vasculitis by histologic examination of biopsies from involved organs. This report describes the optimal methods for detection and biopsy of areas of skin involved with livedo reticularis to confirm the diagnosis of CES.

METHODS

This report describes 8 patients with unexplained acute renal insufficiency in whom the diagnosis of CES was suspected based on their clinical history.

RESULTS

A detailed skin examination performed in both supine and upright postures demonstrated the presence of previously unrecognized livedo reticularis, which was more evident during upright posture in all subjects. In 2 subjects, questionable areas of livedo reticularis noted in supine posture became readily demonstrable during upright posture. Livedo reticularis was apparent only during upright posture in 2 subjects. Biopsies of areas of skin involved with livedo reticularis demonstrated cholesterol emboli in 6 of 8 patients and were normal in the remaining 2 patients. One patient progressed to end-stage renal disease and one was lost to follow-up. In the remaining 6 patients, renal insufficiency initially progressed but did not require dialytic therapy. Renal function returned to baseline levels and livedo reticularis resolved without recurrence in these patients. No subjects developed clinical or laboratory evidence of systemic vasculitis.

CONCLUSIONS

Livedo reticularis is a common but often unrecognized finding in CES that may not be evident during routine examination performed in the supine posture. Deep cutaneous biopsy of areas of livedo reticularis can be safely used to confirm the presence of cholesterol emboli, thus avoiding the increased morbidity of biopsy of either pregangrenous skin lesions or visceral organs. Many patients with CES regain renal function during long-term follow-up.

Cutis marmorata telangiectatica congenita: an unusual cause of lower extremity hypoplasia

Cutis marmorata telangiectatica congenita is a relatively benign, rare cutaneous disorder with various manifestations. A seven-year-old girl, who presented with extremity hypoplasia, had the characteristic reticular, patchy, blue-pink cutaneous lesions, which became more prominent with exposure to cold temperatures. She had 4.8 cm shortening of her right lower extremity, which was also thinner than on the left side. The patient did not have skin atrophy, ulcers, glaucoma or macrocephaly. She is being followed for a future extremity lengthening procedure.

Sensory perineuritis presented as a mononeuritis multiplex associated with livedo vasculitis

We report a 52-year-old patient affected by a mononeuritis multiplex and livedo vasculitis. Sural nerve biopsy showed mild thickening of the perineurium, vascular alterations with inflammatory cell infiltration in the perineurium, and remarkable loss of large and small myelinated fibers. A therapeutic trial of acetylsalicylic acid, danazol, and dipyridamole controlled the skin lesion without improvement of nerve conduction studies.

Mixed connective tissue disease associated with skin defects of livedoid vasculitis

A 21-year-old woman who had a 2-year history of mixed connective tissue disease (MCTD) developed rapidly evolving ulcers consistent with livedoid vasculitis (LV) in all distal extremities. She presented clinically with Raynaud's phenomenon, polyarthritis and swollen hands; serologically with high titres of ANA and anti-nRNP; and immunogenetically with HLA-DR4 and HLA-DR53. Although there was initial success in treatment except for the skin defects over the ankles, the patient died from disseminated intravascular coagulation. We suggest that LV may be a poor prognostic manifestation in MCTD.

NGF, a useful tool in the treatment of chronic vasculitic ulcers in rheumatoid arthritis

Vasculitic necrosis and ulceration of the skin are frequent complications of connective tissue diseases and are very difficult to heal. We treated chronic vasculitic leg ulcers in rheumatoid arthritis and systemic sclerosis by topical application of nerve growth factor (NGF). In all patients with rheumatoid arthritis, NGF led to rapid healing, whereas less striking results were obtained in patients with systemic sclerosis. The efficacy of NGF could be due to its promoting activity on keratinocytes proliferation and vascular neoangiogenesis. We suggest that topical application of NGF could represent a powerful pharmacological tool for the treatment of vasculitic ulcers.

Annular leukocytoclastic vasculitis associated with monoclonal gammopathy of unknown significance

Leukocytoclastic vasculitis is a condition characterized by necrotizing neutrophilic inflammation of small dermal blood vessels usually resulting in palpable purpuric lesions. Leukocytoclastic vasculitis may be secondary to a variety of medications and underlying disease processes, including infections, connective tissue disorders, and malignancies. We describe a patient with a monoclonal gammopathy of unknown significance in whom leukocytoclastic vasculitis developed, manifested by a few prominent annular plaques on the lower extremity. The rare association between monoclonal gammopathy of unknown significance and leukocytoclastic vasculitis as well as the unusual annular presentation of the disease in this patient is discussed, and the relevant literature is reviewed.

Acute necrotising vasculitis in hairy cell leukemia--rapid response to cladribine: case report and a brief review of the literature

A 61-year-old woman with extensive cutaneous vasculitis and hairy cell leukemia treated with cladribine is described. She achieved a dramatic hematological and dermatological response which has lasted more than 6 years.

Abscess-forming neutrophilic dermatosis: report of three cases associated with hemopathies

BACKGROUND

The development of different types of neutrophilic dermatosis is reported to occur in the course of malignant hemopathies. These concern mainly Sweet's syndrome, pyoderma gangrenosum, erythema elevatum et diutinum and neutrophilic eccrine hidradenitis.

OBSERVATIONS

We have recently encountered the cases of 3 patients who presented all with multiple acneiform papules and dome-shaped aseptic abscesses leaving scars. Pus was sterile in all except case 3 in which slight Staphylococcus aureus growth was shown. However, in this patient, only steroids were effective demonstrating that this bacterium was not responsible for the disease. Histopathology disclosed a dense dermal polymorphonuclear neutrophil infiltrate and some mononuclear cells. Two of these patients had myelodysplastic syndromes while one had IgA myeloma.

CONCLUSION

Abscess-forming neutrophilic dermatosis seems to be another type of neutrophilic dermatosis associated with hematological malignancies.

Takayasu arteritis and cutaneous necrotizing vasculitis

Takayasu arteritis (TA) is an inflammatory arteriopathy involving predominantly the aorta and its main branches. The disease evolves in two phases: a first, nonspecific inflammatory stage and a late 'pulseless' stage, in which complications related to arterial stenosis and aneurysm formation predominate. In both phases, skin manifestations, such as inflammatory nodules, erythema-nodosum- and pyoderma-gangrenosum-like ulcers, have been described. We report 2 patients with TA, who had cutaneous necrotizing vasculitis as presenting manifestation of the disease. A review of the literature revealed 8 similar cases. TA does not only involve large arteries, but also small blood vessels. The observation that in TA the inflammatory process of the large arteries affects regions of the walls supplied by the vasa vasorum, the anatomy of which bears resemblance to the cutaneous vessel system, suggests that primary involvement of small vessels contributes to the development of the clinicopathological features of TA. Knowledge of the skin manifestations associated with TA remains important for its diagnosis and prompt instauration of life-saving treatment.

Coincidence of multiple, disseminated, tardive-eruptive blue nevi with cutis marmorata teleangiectatica congenita

A 71-year-old woman reported a slow progression of multiple bluish dark asymptomatic macules and papules on the pretibial region of both lower legs for over 30 years. At birth a left-sided hypoplasia of the leg including the buttock accompanied by a connatal vascular nevus had been diagnosed. The ipsilateral deep veins of the pelvis and leg had a normal anlage. Histopathological examination revealed multiple blue nevi of the common type. The association of multiple blue nevi and cutis marmorata teleangiectatica congenita with limb hypoplasia has not previously been reported and is discussed in this paper. One could speculate whether these symptoms represent a new syndrome, because by thorough examination the NAME syndrome could be ruled out.