Erythema Elevatum Diutinum

Annular vasculitic lesions

Vasculitic skin findings may present with annular morphologies. This group of conditions consists of capillaritis, such as pigmented purpuric dermatoses, and vasculitis, which is often classified by the affected vessel size. Annular vasculitic lesions may be the presenting sign of systemic disease, thus requiring thorough exploration to reach an accurate diagnosis and guide proper disease management. Herein we review the clinical presentation, histopathology, and treatments for cutaneous vasculitic disease that may present with annular lesions.

Erythema elevatum diutinum: a clinical and histopathologic study of 13 patients

BACKGROUND

Erythema elevatum diutinum is a rare condition representing a chronic leukocytoclastic vasculitis.

OBJECTIVE

Clinical and laboratory features of the disease were reviewed to better understand the disease.

METHODS

The medical records and histopathologic slides of 13 patients with erythema elevatum diutinum were studied.

RESULTS

The lesions were violaceous, deep red, or brown and typically were papules or plaques. Lesions were most often located on the extensor surfaces of the extremities. Associated medical problems included hematologic abnormalities in six patients: IgA clonal gammopathies (four), multiple myeloma (one), and myelodysplasia (one). Erythema elevatum diutinum preceded the myeloproliferative disorders by an average of 7.8 years. All patients showed vasculitis. Leukocytoclasia was present in 27 of 35 specimens. The predominant cell type in the inflammatory infiltrate was polymorphonuclear leukocytes or a mixture of polymorphonuclear leukocytes and lymphocytes.

CONCLUSION

The most significant finding of this study is the association of erythema elevatum diutinum with hematologic disease, most frequently an IgA monoclonal gammopathy.

Necrotizing vasculitis

Necrotizing vasculitis is a term used to describe vessel wall necrosis due to neutrophil infiltration. Current evidence strongly suggests that these cells are responding to elaboration of chemotactic factors of the complement cascade released at the site of deposition of immune complexes in the vessel wall. The antibody is usually IgG or IgM (and rarely IgA), but the only antigens identified with even a minimum certainty are the streptococcal M protein, the hepatitis B surface antigen, and Mycobacterium tuberculosis. Vessels may be involved, leading to specific signs or symptoms, in a wide range of organs, but with those of the skin, kidney, joints, and gastrointestinal tract leading the list. Why vessels of different sizes or location become involved in individual patients is unknown. Therapy with nontoxic drugs, such as antihistamines or salicylates, is indicated when the disease is mild, but vital organ involvement may necessitate therapy with systemic corticosteroids and/or cyclophosphamide.

[Erythema elevatum diutinum. I. Electron microscopy of a case with extracellular cholesterosis (author's transl)]

1. A typical case of Erythema elevatum diutinum (E.e.d.) with extracellular cholesterosis is described clinically and histologically in a 48-year-old woman. The disease had a course of 15 years. 2. Electron microscopy confirmed the histological and immunfluorescent findings of leucocytoclastic vasculitis. In older lesions, histiocytes/macrophages predominate. Intra- and extracellular lipid depositions showed a variety of ultrastructural characteristics which differed from electron microscopical findings described in other disorders associated with lipid deposition. 3. The findings are in accordance with the hypothesis that the primary event in E.e.d. is a special type of chronic leukocytoclastic vasculitis. Subsequently, the damage of the vessel walls and focal necrosis may lead to secondary lipid deposition.

[Erythema elevatum diutinum. II. Immunoelectronmicroscopical study of leukocytoclastic vasculitis within the intracutaneous test reaction induced by streptococcal antigen (author's transl)]

A leukocytoclastic vasculitis was induced by intracutaneous injection of streptococcal antigen in a patient with erythema elevatum diutinum (E.e.d.). The immunoelectronmicroscopical demonstration of C3 was performed by use of the peroxidase-antiperoxidase multistep technique 24 h after the injection of the antigen. Deposits of C3 were found between endothelial cells, on the outer surface of endothelial cells, pericytes, and smooth muscle cells, as well as within the multilayered basal lamina of small vessels. Intact and disintegrating neutrophils accumulate within the vessel walls and in their surroundings. Necrosis and fibrin deposition are present in advanced stages. The findings demonstrate the sequence of events in leukocytoclastic vasculitis at the ultrastructural level. They also support the hypothesis that in E.e.d. an Arthus type reaction induced by bacterial antigens may be of pathogenetic significance.

Paraproteinaemia in erythema elevatum diutinum

Paraproteinaemia (IgGkappa) was observed in a 68 year-old patient with erythema elevatum diutinum. The association of this skin disease with paraproteinaemia as already reported by other authors may indicate a pathogenetic relationship.