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Yu KQ, Li HX, Wu J. Suspected coexistence of perianal necrotizing sweet syndrome in chronic myelomonocytic leukemia: A case report. World J Gastrointest Surg 2024; 16:1176-1183. [PMID: 38690058 PMCID: PMC11056667 DOI: 10.4240/wjgs.v16.i4.1176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/02/2024] [Accepted: 03/11/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Chronic myelomonocytic leukemia (CMML) complicated with Sweet syndrome (SS) is a rare hematological neoplasm. However, cases of concomitant development of perianal necrotizing SS (NSS) have not been reported. CASE SUMMARY We report a case of a 49-year-old male patient who underwent sequential procedures for hemorrhoids and perianal abscess. He developed postoperative incision infection and was referred to the department where the authors work. Initially, perianal necrotizing fasciitis secondary to incision infection after perianal abscess surgery was suspected. Despite receiving antibiotic therapy and undergoing surgical debridement, deeper necrotic areas formed in the patient's perianal wounds, accompanied by persistent high fever. Blood and fungal cultures yielded negative results. The final diagnosis was corrected to be CMML with suspected concomitant perianal NSS. CONCLUSION CMML with perianal NSS is a rare condition, often misdiagnosed as perianal abscess or perianal necrotizing fasciitis. Conventional antibiotic therapy and surgical debridement are ineffective in managing this condition.
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Affiliation(s)
- Ke-Qiang Yu
- Clinical Medicine School, Chengdu University of Chinese Medicine, Chengdu 610072, Sichuan Province, China
- Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hui-Xiang Li
- Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jing Wu
- Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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2
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Zaino ML, Schadt CR, Callen JP, Owen LG. Pyoderma Gangrenosum: Diagnostic Criteria, Subtypes, Systemic Associations, and Workup. Dermatol Clin 2024; 42:157-170. [PMID: 38423678 DOI: 10.1016/j.det.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis with variable clinical features. The classic presentation is an ulceration with an erythematous to violaceous undermined border. Extracutaneous manifestations may occur. Associated systemic diseases include inflammatory bowel disease, inflammatory arthritides, and hematologic disorders. The pathophysiologic mechanism of disease is not completely known but likely related to the cumulative impact of inflammation, immune-mediated neutrophilic dysfunction, and genetic predisposition. Incidence is between 3 and 10 people per million but may be greater due to under recognition. In this article, we will discuss the diagnostic criteria, disease subtypes, systemic associations, and workup.
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Affiliation(s)
- Mallory L Zaino
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA.
| | - Courtney R Schadt
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA
| | - Jeffrey P Callen
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA
| | - Lafayette G Owen
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA
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3
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Hrin ML, Huang WW. Sweet Syndrome and Neutrophilic Dermatosis of the Dorsal Hands. Dermatol Clin 2024; 42:193-207. [PMID: 38423681 DOI: 10.1016/j.det.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Sweet syndrome is a rare cutaneous condition with a broad clinical differential diagnosis. It can be classified into 3 subtypes: classic, malignancy-associated, and drug-induced. There are numerous associated disorders and provoking medications. Uncommonly, it can present as a multiorgan disease and cause significant morbidity. Systemic corticosteroids are the gold standard of treatment and yield rapid improvements in both lesions and symptoms. Nonsteroidal therapies may be effective alternatives, although high-quality comparative data are lacking. Some treatments for Sweet syndrome have paradoxically been implicated in the induction of disease.
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Affiliation(s)
- Matthew L Hrin
- Department of Dermatology, Wake Forest School of Medicine, Medical Center Boulevard, 4618 Country Club Road, Winston-Salem, NC 27157-1071, USA.
| | - William W Huang
- Department of Dermatology, Wake Forest School of Medicine, 4618 Country Club Road, Winston-Salem, NC 27104, USA
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4
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Neumann MAC, Nieper P, Simon F, Shimabukuro-Vornhagen A, Hallek M, Garcia Borrega J. A diagnostic challenge-First case of chronic lymphatic leukemia-associated necrotizing sweet syndrome. Eur J Haematol 2024; 112:650-653. [PMID: 38105522 DOI: 10.1111/ejh.14153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
Sweet syndrome, also known as acute febrile neutrophilic dermatosis, is a rare disorder typically characterized by the clinical triad including a sudden onset of fever, painful skin lesions, and neutrophilia. The histopathological findings are a dense neutrophilic infiltrate and oedema of the dermis and epidermis without evidence of a vasculitis. Besides treatment of the underlying cause, sweet syndrome is typically treated with high-dose corticosteroids leading to a relapse-free response in 70% of patients. However, if left unrecognized or untreated, the condition may lead to serious complications. Here, we report on the case of a 38-year-old patient in whom, under the assumption of the presence of necrotizing fasciitis, exarticulation of the right arm was performed. In the absence of pathogen detection and insufficient response to anti-infective therapies, the diagnosis of a sweet syndrome was assumed and, later, confirmed by an excellent response to high-dose administration of systematic glucocorticoids. The case emphasizes the need to be aware of this rare syndrome, which can be easily misdiagnosed due to its close resemblance to infection and stresses the need of further research to define distinct diagnostic tools.
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Affiliation(s)
- Marie Anne-Catherine Neumann
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Pascal Nieper
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Florian Simon
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Alexander Shimabukuro-Vornhagen
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Jorge Garcia Borrega
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
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5
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Ehyaee V, Reddy V, Ahmed A. Neoplastic or inflammatory? A case report of Sweet syndrome with CD30+ cells in a patient with B-lymphoblastic leukemia. J Cutan Pathol 2023; 50:1036-1041. [PMID: 37770419 DOI: 10.1111/cup.14535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/30/2023]
Abstract
CD30+ cells are typically part of lymphoproliferative disorders but can also be seen in inflammatory dermatoses. We present a case of 47-year-old man with a history of B-lymphoblastic leukemia (B-ALL) who presented with fever, leukocytosis, and papulonodular skin lesions, involving the extremities and trunk. A punch biopsy specimen demonstrated papillary dermal edema with a neutrophilic and histiocytic infiltrate extending into the subcutis. The infiltrate also harbored scattered large cells that were positive for CD30 and demonstrated the immunohistochemical profile of monocytes. A diagnosis of histiocytoid Sweet syndrome with CD30+ cells was made. The case is unique, demonstrating a combination of Sweet syndrome variants with subcutis involvement, histiocytoid morphology, and large CD30+ cells. A prior history of B-ALL and immunohistochemical profile of monocytes with immature morphology broadened the differential diagnosis and added to the diagnostic challenge.
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Affiliation(s)
- Vida Ehyaee
- Department of Pathology, Rush University Medical Center, Chicago, Illinois, USA
| | - Vijaya Reddy
- Department of Pathology, Rush University Medical Center, Chicago, Illinois, USA
| | - Aadil Ahmed
- Department of Pathology, Rush University Medical Center, Chicago, Illinois, USA
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6
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Hresko AM, Pickrell BB, Harper CM. Necrotizing Sweet Syndrome of the Hand and Forearm in the Immediate Postoperative Period: Case Report. Hand (N Y) 2023:15589447231207978. [PMID: 37946497 DOI: 10.1177/15589447231207978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Necrotizing soft tissue infection (NSTI) is a feared and potentially morbid postoperative complication requiring prompt surgical intervention. Cutaneous conditions that mimic NSTI have been reported and rarely occur in the postoperative period. Sweet syndrome, also known as acute febrile neutrophilic dermatosis, is a dermatologic condition characterized by fever, neutrophil-predominant leukocytosis, and painful skin lesions. Necrotizing Sweet syndrome (NSS) is an aggressive variant that causes a clinical appearance of localized skin necrosis and histologic evidence of necrotic foci extending to the deep aspects of the soft tissues and involving fascia and/or skeletal muscle. Necrotizing Sweet syndrome can be easily mistaken for NSTI. Contrary to infection, Sweet syndrome and NSS are worsened by surgical intervention due to the phenomenon of pathergy and readily respond to corticosteroid treatment. We present the case of a 54-year-old woman who developed NSS following an uncomplicated fasciectomy for Dupuytren disease.
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Affiliation(s)
- Andrew M Hresko
- Harvard Combined Orthopaedics Residency Program, Massachusetts General Hospital, Boston, USA
| | - Brent B Pickrell
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Carl M Harper
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
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7
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Varas-Rodríguez E, Cedeño F, Gonzalez-Diaz G, Vivas J, Salgueiro A, Dávila K, Nevarez Pomales O, Duyos O. Postsurgical Pyoderma Gangrenosum After Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00034. [PMID: 38015935 DOI: 10.2106/jbjs.cc.23.00087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
CASE A 61-year-old woman with lower back and radicular leg pain underwent minimally invasive spinal fusion at L5-S1. By postoperative day 6, she exhibited erythema, wound dehiscence, and necrotic changes. Although a necrotizing infection was initially suspected, multiple debridements and antibiotic therapy failed to improve her condition. The patient was eventually diagnosed with pyoderma gangrenosum (PG) and was managed with immunosuppressants and extended wound care. CONCLUSION PG is a rare dermatosis that is often misdiagnosed, leading to inappropriate treatment, debridements, and additional complications. Prompt identification and multidisciplinary collaboration are key to preventing unnecessary interventions and achieving the best outcomes.
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Affiliation(s)
| | - Francis Cedeño
- School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Joshua Vivas
- School of Medicine, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Ariana Salgueiro
- Department of Environmental Sciences, Loyola University, New Orleans, Louisiana
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8
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Santaniemi W, Åström P, Glumoff V, Pernaa N, Tallgren EN, Palosaari S, Nissinen A, Kaustio M, Kuismin O, Saarela J, Nurmi K, Eklund KK, Seppänen MRJ, Hautala T. Inflammation and Neutrophil Oxidative Burst in a Family with NFKB1 p.R157X LOF and Sterile Necrotizing Fasciitis. J Clin Immunol 2023; 43:1007-1018. [PMID: 36892687 PMCID: PMC10276129 DOI: 10.1007/s10875-023-01461-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 02/28/2023] [Indexed: 03/10/2023]
Abstract
Loss-of-function (LOF) mutations in NFKB1, coding for p105, may cause common variable immunodeficiency due to dysregulation of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κΒ) pathway. Monoallelic LOF variants of NFKB1 can predispose to uncontrolled inflammation including sterile necrotizing fasciitis or pyoderma gangrenosum. In this study, we explored the impact of a heterozygous NFKB1 c.C936T/p.R157X LOF variant on immunity in sterile fasciitis patients and their family members. The p50 or p105 protein levels were reduced in all variant carriers. Interleukin-1β (IL-1β) and interleukin-8 (IL-8) levels were elevated in vitro, potentially contributing to the very high neutrophil counts observed during fasciitis episodes. Phosphorylation of p65/RelA was reduced in p.R157X neutrophils suggesting defective activation of canonical NF-κB. Oxidative burst after NF-κB-independent phorbol 12-myristate 13-acetate (PMA) stimulation was similar in both p.R157X and control neutrophils. Comparable amounts of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex subunits were found in p.R157X and control neutrophils. However, a compromised oxidative burst was observed in p.R157X neutrophils following activation of NF-κB-dependent mechanisms following stimulation of toll-like receptor 2 (TLR2) and Dectin-1. Neutrophil extracellular trap formation was not affected by p.R157X. In summary, the NFKB1 c.C936T/p.R157X LOF variant has an impact on inflammation and neutrophil function and may play a role in the pathogenesis of sterile necrotizing fasciitis.
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Affiliation(s)
| | - Pirjo Åström
- Research Unit of Biomedicine, University of Oulu, Oulu, Finland
- Biocenter Oulu, University of Oulu, Oulu, Finland
| | - Virpi Glumoff
- Research Unit of Biomedicine, University of Oulu, Oulu, Finland
| | - Nora Pernaa
- Research Unit of Biomedicine, University of Oulu, Oulu, Finland
| | | | - Sanna Palosaari
- Cancer and Translational Medicine Research Unit, University of Oulu, Oulu, Finland
| | - Antti Nissinen
- Research Unit of Biomedicine, University of Oulu, Oulu, Finland
| | - Meri Kaustio
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
| | - Outi Kuismin
- Department of Clinical Genetics, Oulu University Hospital, Oulu, Finland
| | - Janna Saarela
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
- Centre for Molecular Medicine Norway, University of Oslo, Oslo, Norway
| | - Katariina Nurmi
- Faculty of Medicine, Clinicum, Translational Immunology Program, University of Helsinki, Helsinki, Finland
| | - Kari K Eklund
- Department of Rheumatology, Inflammation Center, University of Helsinki and Helsinki University Hospital and Orton Orthopedic Hospital, Helsinki, Finland
| | - Mikko R J Seppänen
- Adult Immunodeficiency Unit, Infectious Diseases, Inflammation Center, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
- Rare Disease Center and Pediatric Research Center, Children and Adolescents, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Timo Hautala
- Research Unit of Biomedicine, University of Oulu, Oulu, Finland.
- Infectious Diseases, Oulu University Hospital, Oulu, Finland.
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9
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Abdul-Rassoul H, Hight R, Chadha A, Strelzow J. Necrotizing Fasciitis? A Mimic Produced by an Unusual Presentation of Necrotizing Neutrophilic Dermatosis of the Hand: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00033. [PMID: 37535764 DOI: 10.2106/jbjs.cc.23.00066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
CASE A 50-year-old woman presented to our emergency department with hand pain and a laceration. Despite administration of antibiotics, the patient progressively worsened leading to a concern for a necrotizing soft-tissue infection. She underwent multiple debridements yet continued to worsen clinically. Tissue biopsy was eventually consistent with a necrotizing neutrophilic dermatosis. The patient was then started on oral steroids with rapid improvement of her clinical status and hand examination. CONCLUSION While neutrophilic dermatoses are rare, the orthopaedic surgeon treating soft-tissue infections should maintain a broad differential when treatment of a potential necrotizing infection has not led to diagnostic closure and clinical improvement.
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Affiliation(s)
- Hussein Abdul-Rassoul
- Department of Orthopedic Surgery and Rehabilitation Medicine, The University of Chicago, Chicago, Illinois
| | - Robert Hight
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois
| | - Angad Chadha
- Section of Dermatology, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Jason Strelzow
- Department of Orthopedic Surgery and Rehabilitation Medicine, The University of Chicago, Chicago, Illinois
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10
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Shayan-Moghadam R, Nejad EB, Zolghadr H, Nabian MH. A rare case of fully recovered necrotizing fasciitis. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2023; 13:1-7. [PMID: 36935879 PMCID: PMC10018066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 01/10/2023] [Indexed: 03/21/2023]
Abstract
Necrotizing fasciitis (NF) is a severe soft tissue infection caused by bacterial fascia invasion and quick spreading to the muscle and subcutaneous tissues. Treatments of NF should be conducted by extensive debridement and antibiotic therapies. This report presented a 53-year-old woman with diabetes mellitus (DM) and hypothyroid who was referred to our medical center with lower limb pain and significant swelling after mild trauma. The patient was diagnosed with NF due to E. coli. She underwent surgical interventions for debridement and long-term antibiotic therapy. The patient recovered successfully without complications or range of motion (ROM) restriction in the hip and knee. It is recommended that immediate actions be taken in NF cases to preserve the remaining tissues and provide better outcomes.
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Affiliation(s)
- Ramin Shayan-Moghadam
- Orthopedics Resident, Department of Orthopaedic Surgery, Center for Orthopedic Trans-disciplinary Applied Research, Shariati Hospital, Tehran University of Medical SciencesTehran, Iran
| | - Erfan Babaei Nejad
- Orthopedics Resident, Department of Orthopaedic Surgery, Center for Orthopedic Trans-disciplinary Applied Research, Shariati Hospital, Tehran University of Medical SciencesTehran, Iran
| | - Hassan Zolghadr
- Orthopedics Resident, Department of Orthopaedic Surgery, Center for Orthopedic Trans-disciplinary Applied Research, Shariati Hospital, Tehran University of Medical SciencesTehran, Iran
| | - Mohammad Hossein Nabian
- Associated Professor, Department of Orthopaedic Surgery, Center for Orthopedic Trans-disciplinary Applied Research, Shariati Hospital, Tehran University of Medical SciencesTehran, Iran
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11
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Limb amputation in patients with pyoderma gangrenosum: a multi-institutional case series. Arch Dermatol Res 2022; 315:1443-1448. [DOI: 10.1007/s00403-022-02484-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/31/2022] [Accepted: 11/17/2022] [Indexed: 11/30/2022]
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12
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Alosaimi MM, Sebzali F, Iqbal A, Rabbat CG, Clase CM. Pyoderma Gangrenosum After Insertion of a Hemodialysis Catheter: Koebner Phenomenon, Systemic Inflammatory Response Syndrome, and a Delay in Diagnosis. Can J Kidney Health Dis 2022; 9:20543581221120618. [PMID: 36160315 PMCID: PMC9493685 DOI: 10.1177/20543581221120618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Indexed: 12/03/2022] Open
Abstract
Rationale: Pyoderma gangrenosum is a rare neutrophilic dermatosis. Misdiagnosis of
pyoderma gangrenosum as an infection is not uncommon. Pyoderma gangrenosum
can be associated with Koebner phenomenon and rarely results in systemic
inflammatory response syndrome and shock. Presenting concerns of the patient: A 61-year-old woman had recently started maintenance hemodialysis, using a
tunneled catheter. She was admitted with fever and signs of inflammation at
the catheter exit site and along the tunnel. Diagnoses: The initial diagnosis was catheter-related tunnel infection. The exit site
broke down into a 5 cm × 5 cm lesion typical of pyoderma, and a new similar
lesion developed at a subcutaneous injection site in her abdomen. Clinical
diagnosis of pyoderma gangrenosum was made. She remained febrile despite
broad antibiotic coverage and catheter removal and developed systemic
inflammatory response syndrome (SIRS) that necessitated transfer to
intensive care unit. Interventions: She responded well to fluids and intravenous steroids. Viral and bacterial
cultures were negative throughout; echocardiography and computed tomography
were unrevealing. Insertion of a new hemodialysis catheter was deferred as
long as clinically possible, was undertaken while the patient was taking
steroids, and was uncomplicated. Outcomes: She remained hemodynamically stable and was discharged after rehabilitation.
Her wounds slowly granulated and healed. Steroids were tapered. Teaching points: To our knowledge, this is the first case report of a patient with pyoderma
gangrenosum developing at the site of tunneled hemodialysis catheter. Our
patient developed SIRS with no evidence of infection. We summarize 11
previous case reports of pyoderma leading to SIRS and responsive to
steroids.
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Affiliation(s)
- Majed M Alosaimi
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Fatemah Sebzali
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Ali Iqbal
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Christian G Rabbat
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Catherine M Clase
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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13
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Characterization of Legal Claims Involving Patients with Pyoderma Gangrenosum. Adv Skin Wound Care 2022; 35:613-616. [PMID: 35895601 DOI: 10.1097/01.asw.0000855052.83443.d8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review of the litigation of literature related to patients with pyoderma gangrenosum (PG) to characterize the legal issues they face. DATA SOURCES Data sources include law databases Casetext and Lexis Nexis. STUDY SELECTION All disability and medical liability claims directly involving patients with PG were included. DATA EXTRACTION Data extraction came directly from Casetext and Lexis Nexis. All cases extracted came from January 2003 to December 2020. This resulted in 32 cases, 18 of which were excluded because they did not mention the plaintiff having a diagnosis of PG (n = 14). DATA SYNTHESIS The review found a total of six medical liability cases in which adverse health outcomes were reported including prolonged suffering (2/6 cases), unnecessary treatments or procedures (2/6), exacerbation of disease (1/6 cases), and permanent scarring (1/6 cases). Despite this, two plaintiffs won their case and only one of them received any monetary award. Similarly, of the eight disability claims in the review, four were ruled in the favor of the plaintiffs and only two resulted in immediate awarding of benefits. CONCLUSIONS Pyoderma gangrenosum is a rare autoinflammatory disease characterized by painful ulcers with high rates of morbidity. The findings demonstrate a need for access to specialty care in incarcerated populations with half of medical liability cases occurring in correctional facilities after the denial of appropriate care. Cases that occurred in a hospital setting also stress the importance of initiatives such as telemedicine to efficiently increase access to care in a cost-effective manner. Further, PG has been recognized as a severe impairment in disability claims despite patients being denied because they were deemed able to perform other work.
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14
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Ackerman D, Phan C, Kuroki M, Helm M, Jeganathan NA. A Case Report of Necrotizing Neutrophilic Dermatosis: A Sheep in Wolf’s Clothing. Cureus 2022; 14:e26498. [PMID: 35923500 PMCID: PMC9339259 DOI: 10.7759/cureus.26498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
Neutrophilic dermatosis (ND) is a category of diseases characterized by trauma-induced, autoinflammatory cutaneous eruption. Comorbid systemic disease is common with a predilection for malignancy, inflammatory bowel disease, and rheumatologic disease. Rarely, it can manifest with aseptic shock, an entity referred to as necrotizing neutrophilic dermatosis (NND). NND may occur in the postoperative setting and is often misdiagnosed as a necrotizing soft tissue infection. Unfortunately, the treatment for a necrotizing soft tissue infection, namely, wide debridement, is often detrimental in the setting of NND. We present the case of a woman with underlying myelodysplastic syndrome who developed episodic postoperative hemodynamic collapse followed by delayed necrotic peristomal ulceration following colonic diversion for complicated diverticulitis. Infectious workup and operative re-exploration were unrevealing. Pathologic assessment of affected skin tissue showed changes consistent with ND, ultimately leading to the diagnosis of NND. Her clinical course dramatically improved with the initiation of immunosuppressive therapy. The mimicry of NND to a potentially lethal necrotizing soft-tissue infection creates a grave diagnostic dilemma in the postoperative period. A general lack of knowledge of NND among non-dermatologic specialists produces an opportunity for misdiagnosis and inappropriate surgical interventions, namely, serial debridement. Several clinical cues may aid in the earlier recognition of NND. The cornerstone of treatment involves systemic corticosteroid therapy with adjunctive therapy for refractory cases. NND must be considered in the differential diagnosis of necrotizing soft tissue infection as early recognition may result in the avoidance of deleterious surgical interventions.
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15
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Joshi TP, Friske SK, Hsiou DA, Duvic M. New Practical Aspects of Sweet Syndrome. Am J Clin Dermatol 2022; 23:301-318. [PMID: 35157247 PMCID: PMC8853033 DOI: 10.1007/s40257-022-00673-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2022] [Indexed: 12/12/2022]
Abstract
Sweet syndrome (SS), or acute febrile neutrophilic dermatosis, is an inflammatory, non-infectious skin reaction characterized clinically by tender, erythematous papules/plaques/pustules/nodules commonly appearing on the upper limbs, trunk, and head and neck; histologically, SS is characterized by dense neutrophilic infiltrate in the dermis. SS is accompanied by fever; an elevation of inflammatory markers (e.g., erythrocyte sedimentation rate, C reactive protein) in serum may also be observed. Although most cases of SS are idiopathic, SS also occurs in the setting of malignancy or following administration of an associated drug. SS has also been reported in association with pregnancy and a burgeoning list of infectious (most commonly upper respiratory tract infections) and inflammatory diseases; likewise, the litany of possible iatrogenic triggers has also grown. Over the past several years, a wider spectrum of SS presentation has been realized, with several reports highlighting novel clinical and histological variants. Corticosteroids continue to be efficacious first-line therapy for the majority of patients with SS, although novel steroid-sparing agents have been recently added to the therapeutic armamentarium against refractory SS. New mechanisms of SS induction have also been recognized, although the precise etiology of SS still remains elusive. Here, we catalogue the various clinical and histological presentations of SS, summarize recently reported disease associations and iatrogenic triggers, and review treatment options. We also attempt to frame the findings of this review in the context of established and emerging paradigms of SS pathogenesis.
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16
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Peterson DM, Damsky WE, Vesely MD. Fever, Hypotension, and a Worsening Necrotic Wound. JAMA 2022; 327:1496-1497. [PMID: 35311923 DOI: 10.1001/jama.2022.2806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - William E Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Matthew D Vesely
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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Breneman AN, Eber AE, Haque H, Levine L, Askanase A, Riley CS, Pomeranz MK, Hassan D, Mancebo SE, Polin M, Melamed A, Bordone LA, Rosser M, Gockley A, Gallitano SM. Vulvovaginal Pyoderma Gangrenosum in a Patient Treated With Ocrelizumab for Multiple Sclerosis. J Low Genit Tract Dis 2022; 26:189-191. [PMID: 35256568 DOI: 10.1097/lgt.0000000000000661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Alyssa N Breneman
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Ariel E Eber
- Department of Dermatology, Columbia University Irving Medical Center, New York, NY
| | - Hoosna Haque
- Division of Gynecology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Libby Levine
- Department of Neurology and Multiple Sclerosis Center, Columbia University Irving Medical Center, New York, NY
| | - Anca Askanase
- Department of Rheumatology, Columbia University Irving Medical Center, New York, NY
| | - Claire S Riley
- Department of Neurology and Multiple Sclerosis Center, Columbia University Irving Medical Center, New York, NY
| | - Miriam Keltz Pomeranz
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY
| | - Dahlia Hassan
- Department of Rheumatology, Columbia University Irving Medical Center, New York, NY
| | - Silvia E Mancebo
- Department of Dermatology, Weill Medical College of Cornell University, New York, NY
| | - Melanie Polin
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Alexander Melamed
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Lindsey A Bordone
- Department of Dermatology, Columbia University Irving Medical Center, New York, NY
| | - Mary Rosser
- Division of Gynecology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Allison Gockley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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Akagi Y, Yamagiwa Y, Shirai H, Suzuki T, Tsuru I, Ishikawa A, Akiyama N, Ogura M, Kobayashi K, Bae Y, Suemitsu Y, Imakado S, Mawatari M, Ueda A. Aseptic Cavernosal Abscess: An Unrecognized Feature of Neutrophilic Dermatosis. Intern Med 2022; 61:917-921. [PMID: 34483210 PMCID: PMC8987252 DOI: 10.2169/internalmedicine.7994-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 50-year-old man developed a sterile cavernosal abscess followed by prominent features of necrotizing neutrophilic dermatosis. We conducted a literature review, which revealed that aseptic abscesses in the corpus cavernosum occur in association with neutrophilic dermatosis. Patients with this condition frequently receive unnecessary antibiotic treatment and surgical interventions. Although this condition responds to systemic corticosteroids, the functional prognosis of the penis is poor. Abscess formation may be the initial presentation of neutrophilic dermatoses, and underlying conditions may even be absent. Clinicians need to be aware of this condition to distinguish it from bacterial infection and initiate early disease-specific treatments.
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Affiliation(s)
- Yu Akagi
- Department of Infectious Diseases, Japanese Red Cross Medical Center, Japan
| | - Yuri Yamagiwa
- Department of Allergology and Rheumatology, Japanese Red Cross Medical Center, Japan
| | - Harumi Shirai
- Department of Allergology and Rheumatology, Japanese Red Cross Medical Center, Japan
| | - Takeshi Suzuki
- Department of Allergology and Rheumatology, Japanese Red Cross Medical Center, Japan
| | - Ibuki Tsuru
- Department of Urology, Japanese Red Cross Medical Center, Japan
| | - Akira Ishikawa
- Department of Urology, Japanese Red Cross Medical Center, Japan
| | - Naoki Akiyama
- Department of Dermatology, Japanese Red Cross Medical Center, Japan
| | - Mizuki Ogura
- Department of Hematology, Japanese Red Cross Medical Center, Japan
| | - Kanae Kobayashi
- Department of Ophthalmology, Japanese Red Cross Medical Center, Japan
| | - Yuan Bae
- Department of Pathology, Japanese Red Cross Medical Center, Japan
| | - Yamato Suemitsu
- Department of Pathology, Japanese Red Cross Medical Center, Japan
| | - Sumihisa Imakado
- Department of Dermatology, Japanese Red Cross Medical Center, Japan
| | - Momoko Mawatari
- Department of Infectious Diseases, Japanese Red Cross Medical Center, Japan
| | - Akihiro Ueda
- Department of Infectious Diseases, Japanese Red Cross Medical Center, Japan
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19
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Patel T, Quow K, Cardones AR. Management of Infectious Emergencies for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2021; 10:232-242. [PMID: 34642610 PMCID: PMC8493951 DOI: 10.1007/s13671-021-00334-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 12/20/2022]
Abstract
Purpose of Review There are various dermatologic emergencies stemming from bacterial, viral, and fungal etiologies that can present in the inpatient setting. This review summarizes the pathogenesis and diagnosis of infections with cutaneous involvement and highlights new therapies. Recent Findings Clindamycin inhibits toxin formation and can be used as an adjunct therapy for the staphylococcal scalded syndrome. Isavuconazole therapy for mucormycosis infection is a less toxic alternative to amphotericin B. Summary Diagnosis of these infections is primarily guided by high clinical suspicion and early recognition can prevent dangerous sequelae. Treatment mainstays have been well-established, but there are adjunctive therapies that may potentially benefit the patient.
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Affiliation(s)
- Tulsi Patel
- Duke University School of Medicine, Durham, NC 27710 USA
| | - Krystina Quow
- Department of Dermatology, Duke University, Durham, NC 27710 USA
| | - Adela R Cardones
- Department of Dermatology, Duke University, Durham, NC 27710 USA
- Durham VA Medical Center, Durham, NC 27705 USA
- Durham, USA
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20
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Histologic Patterns and Clues to Autoinflammatory Diseases in Children: What a Cutaneous Biopsy Can Tell Us. Dermatopathology (Basel) 2021; 8:202-220. [PMID: 34201078 PMCID: PMC8293050 DOI: 10.3390/dermatopathology8020026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 12/11/2022] Open
Abstract
Autoinflammation is defined by aberrant, antigen-independent activation of the innate immune signaling pathways. This leads to increased, pro-inflammatory cytokine expression and subsequent inflammation. In contrast, autoimmune and allergic diseases are antigen-directed immune responses from activation of the adaptive immune system. The innate and adaptive immune signaling pathways are closely interconnected. The group of 'complex multigenic diseases' are a result of mutual dysregulation of both the autoinflammatory and autoimmune physiologic components. In contrast, monogenic autoinflammatory syndromes (MAIS) result from single mutations and are exclusively autoinflammatory in their pathogenesis. Studying the clinical and histopathological findings for the various MAIS explains the phenotypical correlates of their specific mutations. This review aims to group the histopathologic clues for autoinflammation into three recognizable patterns. The presence of these histologic patterns in a pediatric patient with recurrent fevers and systemic inflammation should raise suspicion of an autoinflammatory component in MAIS, or, more frequently, in a complex multigenic disease. The three major histopathological patterns seen in autoinflammation are as follows: (i) the 'neutrophilic' pattern, seen in urticarial neutrophilic dermatosis, pustular psoriasis, aseptic neutrophilic folliculitis, and Sweet's syndrome; (ii) the 'vasculitic' pattern seen in small vessel-vasculitis (including hypersensitivity/leukocytoclastic vasculitis, thrombosing microangiopathy and lymphocytic vasculitis), and intermediate-sized vessel vasculitis, mimicking polyarteritis nodosa; and (iii) the 'granulomatous' pattern. Beyond these three patterns, there are additional histopathologic clues, which are detailed below. It is important for a dermatopathologist to recognize the patterns of autoinflammation, so that a diagnosis of MAIS or complex multigenic diseases may be obtained. Finally, careful histopathologic analyses could contribute to a better understanding of the various clinical manifestations of autoinflammation.
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21
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Pezoulas VC, Papaloukas C, Veyssiere M, Goules A, Tzioufas AG, Soumelis V, Fotiadis DI. A computational workflow for the detection of candidate diagnostic biomarkers of Kawasaki disease using time-series gene expression data. Comput Struct Biotechnol J 2021; 19:3058-3068. [PMID: 34136104 PMCID: PMC8178098 DOI: 10.1016/j.csbj.2021.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/17/2021] [Accepted: 05/20/2021] [Indexed: 12/15/2022] Open
Abstract
Unlike autoimmune diseases, there is no known constitutive and disease-defining biomarker for systemic autoinflammatory diseases (SAIDs). Kawasaki disease (KD) is one of the "undiagnosed" types of SAIDs whose pathogenic mechanism and gene mutation still remain unknown. To address this issue, we have developed a sequential computational workflow which clusters KD patients with similar gene expression profiles across the three different KD phases (Acute, Subacute and Convalescent) and utilizes the resulting clustermap to detect prominent genes that can be used as diagnostic biomarkers for KD. Self-Organizing Maps (SOMs) were employed to cluster patients with similar gene expressions across the three phases through inter-phase and intra-phase clustering. Then, false discovery rate (FDR)-based feature selection was applied to detect genes that significantly deviate across the per-phase clusters. Our results revealed five genes as candidate biomarkers for KD diagnosis, namely, the HLA-DQB1, HLA-DRA, ZBTB48, TNFRSF13C, and CASD1. To our knowledge, these five genes are reported for the first time in the literature. The impact of the discovered genes for KD diagnosis against the known ones was demonstrated by training boosting ensembles (AdaBoost and XGBoost) for KD classification on common platform and cross-platform datasets. The classifiers which were trained on the proposed genes from the common platform data yielded an average increase by 4.40% in accuracy, 5.52% in sensitivity, and 3.57% in specificity than the known genes in the Acute and Subacute phases, followed by a notable increase by 2.30% in accuracy, 2.20% in sensitivity, and 4.70% in specificity in the cross-platform analysis.
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Affiliation(s)
- Vasileios C. Pezoulas
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina GR45110, Greece
| | - Costas Papaloukas
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina GR45110, Greece
- Department of Biological Applications and Technology, University of Ioannina, Ioannina GR45100, Greece
| | - Maëva Veyssiere
- INSERM U976, Human Immunology, Physiopathology and Immunotherapy, Paris, France
| | - Andreas Goules
- Department of Pathophysiology, School of Medicine, University of Athens, Athens GR15772, Greece
| | - Athanasios G. Tzioufas
- Department of Pathophysiology, School of Medicine, University of Athens, Athens GR15772, Greece
| | - Vassili Soumelis
- INSERM U976, Human Immunology, Physiopathology and Immunotherapy, Paris, France
- Hôpital Saint Louis, Saint Louis Research Institute, Paris, France
| | - Dimitrios I. Fotiadis
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina GR45110, Greece
- Department of Biomedical Research, FORTH (Foundation for Research & Technology)-IMBB (Institute of Molecular Biology and Biotechnology), Ioannina GR45110, Greece
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22
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Reichel CA. Rare Diseases of the Oral Cavity, Neck, and Pharynx. Laryngorhinootologie 2021; 100:S1-S24. [PMID: 34352905 PMCID: PMC8432966 DOI: 10.1055/a-1331-2851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Diseases occurring with an incidence of less than 1-10 cases per 10 000 individuals are considered as rare. Currently, between 5 000 and 8 000 rare or orphan diseases are known, every year about 250 rare diseases are newly described. Many of those pathologies concern the head and neck area. In many cases, a long time is required to diagnose an orphan disease. The lives of patients who are affected by those diseases are often determined by medical consultations and inpatient stays. Most orphan diseases are of genetic origin and cannot be cured despite medical progress. However, during the last years, the perception of and the knowledge about rare diseases has increased also due to the fact that publicly available databases have been created and self-help groups have been established which foster the autonomy of affected people. Only recently, innovative technical progress in the field of biogenetics allows individually characterizing the genetic origin of rare diseases in single patients. Based on this, it should be possible in the near future to elaborate tailored treatment concepts for patients suffering from rare diseases in the sense of translational and personalized medicine. This article deals with orphan diseases of the lip, oral cavity, pharynx, and cervical soft tissues depicting these developments. The readers will be provided with a compact overview about selected diseases of these anatomical regions. References to further information for medical staff and affected patients support deeper knowledge and lead to the current state of knowledge in this highly dynamic field.
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Affiliation(s)
- Christoph A Reichel
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, KUM-Klinikum, Ludwig-Maximilians-Universität München, München
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23
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Erickson KM, Reese AM, Ortega-Loayza AG. Gap of knowledge in diagnosis of pyoderma gangrenosum in clinical specialties education. ACTA ACUST UNITED AC 2021; 8:421-424. [PMID: 33645932 DOI: 10.1515/dx-2020-0153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Pyoderma gangrenosum (PG) is a chronic ulcerative neutrophilic dermatosis. It presents a diagnostic challenge due to the absence of disease-specific markers or histopathology, lack of universally accepted diagnostic criteria, and many mimicking diseases including necrotizing soft tissue infections (NSTI). PG cases often present first to specialties other than dermatology. We reviewed major educational resources in internal medicine, family medicine, and infectious disease for their coverage of PG. CONTENT For each specialty, we reviewed five major textbooks, five prominent journals, and any commonly used online resources. Twelve of 15 textbooks mentioned PG, only three of which included a differential, with none including NSTI in the differential. Only two of 13 journals included review articles about PG, and none of these including NSTI in their differential. Interestingly, online resources tended to be the most complete; six of nine contained PG articles, nearly all including a differential and three listing NSTI within it. SUMMARY We found an underrepresentation of PG among major textbooks and journals in clinical specialties, especially in differentiating PG from its mimickers. While online resources may help fill this gap in knowledge, texts and journals remain essential. Misdiagnosis and resultant mismanagement of PG can lead to disastrous outcomes. OUTLOOK We recommend that PG be added to the differential diagnoses of chronic ulcers in educational resources. We also suggest the addition of identification and differentiation of PG to learning materials and lectures for providers in specialties who may encounter PG, NSTI, or similarly presenting diseases to address this gap.
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Affiliation(s)
- Katherine M Erickson
- Department of Dermatology, Oregon Health and Science University School of Medicine, Portland, OR, USA
| | - Ashley M Reese
- Department of Dermatology, Oregon Health and Science University School of Medicine, Portland, OR, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
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24
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Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that presents with rapidly developing, painful skin ulcers hallmarked by undermined borders and peripheral erythema. Epidemiological studies indicate that the average age of PG onset is in the mid-40s, with an incidence of a few cases per million person-years. PG is often associated with a variety of other immune-mediated diseases, most commonly inflammatory bowel disease and rheumatoid arthritis. The cause of PG is not well understood, but PG is generally considered an autoinflammatory disorder. Studies have focused on the role of T cells, especially at the wound margin; these cells may support the destructive autoinflammatory response by the innate immune system. PG is difficult to diagnose as several differential diagnoses are possible; in addition to clinical examination, laboratory tests of biopsied wound tissue are required for an accurate diagnosis, and new validated diagnostic criteria will facilitate the process. Treatment of PG typically starts with fast-acting immunosuppressive drugs (corticosteroids and/or cyclosporine) to reduce inflammation followed by the addition of more slowly acting immunosuppressive drugs with superior adverse event profiles, including biologics (in particular, anti-tumour necrosis factor (TNF) agents). Appropriate wound care is also essential. Future research should focus on PG-specific outcome measures and PG quality-of-life studies.
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25
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Gowda A, Christensen L, Polly S, Barlev D. Necrotizing neutrophilic dermatosis: A diagnostic challenge with a need for multi-disciplinary recognition, a case report. Ann Med Surg (Lond) 2020; 57:299-302. [PMID: 32874559 PMCID: PMC7452005 DOI: 10.1016/j.amsu.2020.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/18/2020] [Accepted: 07/18/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction Necrotizing neutrophilic dermatoses can clinically resemble necrotizing fasciitis and therefore pose a diagnostic and therapeutic challenge. Given their similar presentations, misdiagnosis and inappropriate or delayed treatments are possible. Presentation of case We discuss the case of a woman with acute myeloid leukemia who presented with fevers, chills, cough, and a leg wound. She underwent amputation of her lower extremity after she was presumed to have necrotizing fasciitis; however, symptoms persisted. She was ultimately diagnosed with and treated for necrotizing Sweet's syndrome with notable clinical improvement. Discussion Both, necrotizing neutrophilic dermatoses and necrotizing fasciitis, grossly affect the skin and are associated with rapidly progressing systemic features including fevers, chills, leukocytosis, and elevated inflammatory markers. Recent literature in dermatology addresses these similarities and the appropriate approach to management; however, it is critical that medical and surgical subspecialties have an understanding of necrotizing neutrophilic dermatoses and their clinical presentations, diagnostic approaches, as well as therapeutic interventions. Familiarity with this entity can mitigate the risk of misdiagnosis, morbidity, and mortality. Conclusion With this report, we seek to review the features that are suggestive of and aid in the diagnosis of necrotizing neutrophilic dermatoses to help prevent significant and avoidable morbidity. Necrotizing neutrophilic dermatoses are a rare skin condition that can easily be misdiagnosed as necrotizing fasciitis. Providers from specialties like internal medicine, oncology, and surgery may encounter necrotizing neutrophilic dermatosis. Familiarity with the management of necrotizing neutrophilic dermatoses can reduce avoidable morbidity.
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26
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Kaustio M, Hautala T, Seppänen MRJ. Primary Immunodeficiency, a Possible Cause of Neutrophilic Necrotizing Dermatosis. JAMA Dermatol 2020; 155:863-864. [PMID: 31141111 DOI: 10.1001/jamadermatol.2019.1201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Meri Kaustio
- Institute for Molecular Medicine Finland, University of Helsinki, HiLIFE, Helsinki, Finland
| | - Timo Hautala
- Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
| | - Mikko R J Seppänen
- Rare Disease Center, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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27
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Miyagami T, Suyama Y, Takahashi Y, Yang KS, Naito T. Man With Thigh Pain. Ann Emerg Med 2020; 75:305-308. [DOI: 10.1016/j.annemergmed.2019.08.422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Indexed: 11/29/2022]
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28
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Reese AM, Haag CK, Jung E, Nauta AC, Swerlick RA, Ortega-Loayza AG. Pyoderma gangrenosum underrepresentation in non-dermatological literature. Diagnosis (Berl) 2020; 8:85-90. [DOI: 10.1515/dx-2019-0079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/06/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Pyoderma gangrenosum (PG) is a chronic, ulcerative neutrophilic dermatosis. PG presents a diagnostic challenge, largely due to the many mimicking diseases, the lack of confirmatory laboratory or biological markers, and the absence of widely accepted diagnostic criteria. In particular, PG is often mistaken for necrotizing soft tissue infections (NSTI).
Methods
We reviewed four major textbooks each in general surgery, plastic surgery, trauma surgery, vascular surgery, emergency medicine, and dermatology. We also performed a search of review articles addressing NSTI and necrotizing fasciitis (NF).
Results
Ten out of the 20 non-dermatology textbooks did not list PG anywhere, and only two listed a differential diagnosis for PG. None of the non-dermatology textbooks indicated PG in the NSTI differential diagnosis, while three of the dermatology textbooks included PG in the NSTI differential diagnosis. PG was listed in all of the dermatology textbooks. Only one of the NSTI and NF articles mentioned PG in the differential diagnosis.
Conclusions
There is an underrepresentation in major textbooks of surgery and emergency medicine and in NSTI and NF review articles when it comes to diagnosing PG. This might be leading to trainees and advanced providers in these fields being uninstructed on PG, and likely contributes to PG misdiagnosis and mismanagement. We recommend PG be included in the differential diagnosis of chronic ulcers and NSTI in non-dermatology textbooks. We also suggest adding identification and diagnosis of inflammatory mimickers of NSTI (e.g. PG) in teaching modules in surgical and emergency specialties to address this knowledge gap.
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Affiliation(s)
- Ashley M. Reese
- Department of Dermatology, School of Medicine , Oregon Health and Science University , Portland , OR , USA
| | - Carter K. Haag
- Department of Dermatology, School of Medicine , Oregon Health and Science University , Portland , OR , USA
| | - Enjae Jung
- Division of Vascular Surgery , Oregon Health and Science University , Portland , OR , USA
| | - Allison C. Nauta
- Division of Plastic and Reconstructive Surgery , Oregon Health and Science University , Portland , OR , USA
| | | | - Alex G. Ortega-Loayza
- Department of Dermatology , Oregon Health and Science University , Portland , OR , USA
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29
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Abstract
Pyoderma Gangrenosum (PG) is a rare neutrophilic dermatosis with multiple different clinical presentations and associated comorbidities. PG has historically been a challenging disorder to diagnose, leading to the development of new diagnostic criteria rather than the traditional approach of a diagnosis of exclusion. The pathophysiology is thought to involve both innate and adaptive immune system dysregulation, neutrophilic abnormalities, environmental, and genetic factors. As of today, no gold standard therapy exists for the treatment of PG, and the literature is restricted to mainly case reports, case series, and 2 small randomized clinical trials. Topical, systemic, and biologic therapy, as well as adequate analgesia and proper wound care all play a role in the management of PG. Recent studies have identified additional cytokines and signalling cascades thought to be involved in the pathogenesis of PG, ultimately leading to the development of new targeted therapies. This review will focus on recent advances in the pathophysiology, clinical presentation and associated comorbidities, diagnosis, and management of PG.
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Affiliation(s)
- Josh Fletcher
- Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
| | - Raed Alhusayen
- Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.,Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, M4N 3M5, Canada
| | - Afsaneh Alavi
- Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.,Division of Dermatology, Department of Medicine, Women's College Hospital, Toronto, Ontario, M5S 1B2, Canada
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30
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Guillaume-Jugnot P, Guégan S, Léonard-Louis S, Barete S, Benveniste O, Allenbach Y. Infliximab as effective treatment for aseptic neutrophilic myositis. Neurology 2019; 93:1009-1011. [PMID: 31662493 DOI: 10.1212/wnl.0000000000008584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 09/03/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Perrine Guillaume-Jugnot
- From the Sorbonne Université (P.G.-J., O.B., Y.A.), INSERM UMRS_974, Center of Research in Myology, AP-HP, Department of Internal Medicine and Clinical Immunology, DHU I2B, Pitié-Salpêtrière Hospital; Université Paris Descartes (S.G.), Service de Dermatologie, Hôpital Cochin-Centre Tarnier, APHP; Department of Neurology and Myology (S.L.-L.), Pitié-Salpêtrière Hospital; and Department of Dermatology (S.B.), Pitié-Salpêtrière Hospital, Paris, France.
| | - Sarah Guégan
- From the Sorbonne Université (P.G.-J., O.B., Y.A.), INSERM UMRS_974, Center of Research in Myology, AP-HP, Department of Internal Medicine and Clinical Immunology, DHU I2B, Pitié-Salpêtrière Hospital; Université Paris Descartes (S.G.), Service de Dermatologie, Hôpital Cochin-Centre Tarnier, APHP; Department of Neurology and Myology (S.L.-L.), Pitié-Salpêtrière Hospital; and Department of Dermatology (S.B.), Pitié-Salpêtrière Hospital, Paris, France
| | - Sarah Léonard-Louis
- From the Sorbonne Université (P.G.-J., O.B., Y.A.), INSERM UMRS_974, Center of Research in Myology, AP-HP, Department of Internal Medicine and Clinical Immunology, DHU I2B, Pitié-Salpêtrière Hospital; Université Paris Descartes (S.G.), Service de Dermatologie, Hôpital Cochin-Centre Tarnier, APHP; Department of Neurology and Myology (S.L.-L.), Pitié-Salpêtrière Hospital; and Department of Dermatology (S.B.), Pitié-Salpêtrière Hospital, Paris, France
| | - Stéphane Barete
- From the Sorbonne Université (P.G.-J., O.B., Y.A.), INSERM UMRS_974, Center of Research in Myology, AP-HP, Department of Internal Medicine and Clinical Immunology, DHU I2B, Pitié-Salpêtrière Hospital; Université Paris Descartes (S.G.), Service de Dermatologie, Hôpital Cochin-Centre Tarnier, APHP; Department of Neurology and Myology (S.L.-L.), Pitié-Salpêtrière Hospital; and Department of Dermatology (S.B.), Pitié-Salpêtrière Hospital, Paris, France
| | - Olivier Benveniste
- From the Sorbonne Université (P.G.-J., O.B., Y.A.), INSERM UMRS_974, Center of Research in Myology, AP-HP, Department of Internal Medicine and Clinical Immunology, DHU I2B, Pitié-Salpêtrière Hospital; Université Paris Descartes (S.G.), Service de Dermatologie, Hôpital Cochin-Centre Tarnier, APHP; Department of Neurology and Myology (S.L.-L.), Pitié-Salpêtrière Hospital; and Department of Dermatology (S.B.), Pitié-Salpêtrière Hospital, Paris, France
| | - Yves Allenbach
- From the Sorbonne Université (P.G.-J., O.B., Y.A.), INSERM UMRS_974, Center of Research in Myology, AP-HP, Department of Internal Medicine and Clinical Immunology, DHU I2B, Pitié-Salpêtrière Hospital; Université Paris Descartes (S.G.), Service de Dermatologie, Hôpital Cochin-Centre Tarnier, APHP; Department of Neurology and Myology (S.L.-L.), Pitié-Salpêtrière Hospital; and Department of Dermatology (S.B.), Pitié-Salpêtrière Hospital, Paris, France
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Ingen-Housz-Oro S. Quoi de neuf en dermatologie clinique? Ann Dermatol Venereol 2019; 146:12S1-12S10. [DOI: 10.1016/s0151-9638(20)30100-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Peetermans M, de Prost N, Eckmann C, Norrby-Teglund A, Skrede S, De Waele JJ. Necrotizing skin and soft-tissue infections in the intensive care unit. Clin Microbiol Infect 2019; 26:8-17. [PMID: 31284035 DOI: 10.1016/j.cmi.2019.06.031] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 06/19/2019] [Accepted: 06/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission. OBJECTIVES To review all aspects of care for a critically ill individual with NSTI. SOURCES Literature search using Medline and Cochrane library, multidisciplinary panel of experts. CONTENT The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial. IMPLICATIONS Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.
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Affiliation(s)
- M Peetermans
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - N de Prost
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Créteil, France; Groupe de Recherche Clinique CARMAS, Université Paris-Est Créteil, IMRB, Créteil, France
| | - C Eckmann
- Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Germany
| | - A Norrby-Teglund
- Centre for Infectious Medicine, Karolinska Institute, Karolinska University Hospital, Huddinge, Sweden
| | - S Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - J J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
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Hylwa SA, Ortega-Loayza AG, Shinkai K. Primary Immunodeficiency, a Possible Cause of Neutrophilic Necrotizing Dermatosis—Reply. JAMA Dermatol 2019; 155:864-865. [DOI: 10.1001/jamadermatol.2019.0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sara A. Hylwa
- Department of Dermatology, Hennepin Healthcare, Minneapolis, Minnesota
- Department of Dermatology, University of Minnesota, Minneapolis
| | | | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco
- Editor, JAMA Dermatology
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