Diagnosis and classification of eosinophilic fasciitis

Severe eosinophilic fasciitis: comparison of treatment with D-penicillamine plus corticosteroids vs. corticosteroids alone

OBJECTIVES

To compare the therapeutic effectiveness of corticosteroids (CS) alone vs. CS plus d-penicillamine (d-Pen) in severe eosinophilic fasciitis.

METHOD

A long-term prospective non-randomized trial of d-Pen plus CS vs. CS alone in patients with severe eosinophilic fasciitis, defined as clinically apparent cutaneous fibrotic involvement affecting more than 15% body surface area (BSA) or more than 10% BSA with joint flexion contractures.

RESULTS

Sixteen patients with severe eosinophilic fasciitis entered the study. Ten patients received d-Pen plus CS and six received CS alone. Affected BSA decreased from an average of 29% to 8.9% in the d-Pen plus CS group compared to a decrease in affected BSA from 28% to 22.83% in the CS-alone group. The reduction in affected BSA in the d-Pen plus CS group was significantly greater than in the CS-alone group (p = 0.038). Clinical improvement occurred in all d-Pen plus CS patients compared to only 33.3% of CS-alone patients (p = 0.008). There was no difference in overall frequency of adverse events between the groups (p = 0.60). The most common adverse event in the d-Pen plus CS group was proteinuria (33.3%). However, proteinuria also occurred in 16.6% in the CS-alone group.

CONCLUSIONS

Treatment with CS alone failed to induce clinical improvement in the majority of the severe eosinophilic fasciitis patients. By contrast, d-Pen plus CS resulted in significantly greater clinical improvement. These results suggest that initial treatment of severe eosinophilic fasciitis with CS alone is not sufficient for optimal therapeutic response and that addition of an antifibrotic agent results in an improved outcome.

Eosinophilia in Dermatologic Disorders

Eosinophil infiltration can be observed in skin disorders, such as allergic/immunologic, autoimmune, infectious, and neoplastic diseases. Clinical presentations are variable and include eczematous, papular, urticarial, bullous, nodular, and fibrotic lesions; pruritus is a common symptom in all. In this review, we present representative eosinophilic skin diseases according to their clinical pattern, together with histologic findings and diagnostic procedures. We also discuss the potential roles of eosinophils in the pathogenesis of dermatologic disorder. Current pathogenesis-based diagnostic and therapeutic approaches are outlined.

Eosinophilia in Rheumatologic/Vascular Disorders

Peripheral and tissue eosinophilia can be a prominent feature of several unique rheumatologic and vascular diseases. These diseases span a wide range of clinical features, histologic findings, therapeutic approaches, and outcomes. Despite the rare nature of these entities--which makes large-scale studies challenging--knowledge has continued to grow regarding their epidemiology, pathophysiology, and management. This review compares and contrasts 5 rheumatologic and vascular conditions in which eosinophilia can be seen: eosinophilic granulomatosis with polyangiitis (Churg-Strauss), immunoglobulin G4-related disease, diffuse fasciitis with eosinophilia, eosinophilia-myalgia syndrome, and eosinophilic myositis.

Eosinophilic fasciitis associated with myositis

Eosinophilic fasciitis is clinically characterized by symmetrical scleroderma-like indurations of the skin with pain. The histological features are fascial inflammation with lymphocytes and eosinophils as well as thickened and fibrotic fascia. Lymphocytic infiltration and degeneration of the underlying muscle are rarely observed. We report a 69-year-old Japanese woman who presented with multiple areas of glossy induration and painful peau d'orange-like lesions on the chest and four extremities. T2-weighted magnetic resonance imaging showed significant hyperintense thickening of the fascia of the lower extremities. Histopathological examination of a biopsy specimen from the induration showed marked fibrinoid degeneration of the fascia and the neighboring muscle with mixed cellular infiltration of lymphocytes and eosinophils. The predominant CD8+ lymphocytic infiltrates were observed by immunohistological study. A diagnosis of eosinophilic fasciitis with myositis was made. Oral administration of prednisolone and discontinuation of exercise significantly improved the lesions and pain.

Forearm compartment syndrome as a result of eosinophilic fasciitis: case report

Eosinophilic fasciitis is an uncommon scleroderma-like connective tissue disease, usually characterized by symmetrical and painful swelling and induration of the skin and thickened fascia infiltrated with lymphocytes and eosinophils. A middle-aged woman with follicular lymphoma being treated with chemotherapy presented with acute onset atraumatic forearm swelling and severe pain. The history, physical examination, and pressure measurements were consistent with compartment syndrome. Intraoperative biopsy of the forearm fascia confirmed eosinophilic fasciitis.

The use of an elevated aldolase in diagnosing and managing eosinophilic fasciitis

Eosinophilic fasciitis (EF) is a rare localized fibrosing disorder of the fascia whose diagnosis is often suspected based on clinical findings and laboratory values. These lab abnormalities can be transient in early disease and may not always be present. We have reviewed a case series of patients to assess the utility of the various laboratory abnormalities in diagnosing EF. We performed a retrospective review of EF patients seen at Georgetown University Hospital in the Division of Rheumatology during 2009 and 2013. This review included 15 adult patients with EF with a mean age at diagnosis of 45 years (range 18 to 77 years). The majority of patients 13/15 had classic skin thickening documented on all four extremities Only eight patients had peripheral eosinophilia ranging between 8 and 38 %. In these patients, the peripheral eosinophilia was an early but transient finding. Inflammatory markers including the erythrocyte sedimentation rate (ESR) was elevated in 5/14 and C-reactive Protein (CRP) was elevated in 7/11. At disease presentation, only one of eleven patients checked had an elevated creatine phosphokinase (CPK). Aldolase levels were available for 12 of the 15 patients, and they were increased in 11 out of 12 patients. We have found that in this case series, aldolase was more likely to be abnormal than peripheral eosinophilia, hypergammaglobulinemia, and ESR particularly after starting treatment. Aldolase should be measured in all patients suspected of having EF, and may also play a useful role in following disease activity.