Acute febrile neutrophilic dermatosis (Sweet syndrome) as initial presentation in a child with acute myelogenous leukemia

Insights Into the Pathogenesis of Sweet's Syndrome

Sweet's syndrome, also known as Acute Febrile Neutrophilic Dermatosis, is a rare inflammatory condition. It is considered to be the prototype disease of neutrophilic dermatoses, and presents with acute onset dermal neutrophilic lesions, leukocytosis, and pyrexia. Several variants have been described both clinically and histopathologically. Classifications include classic Sweet's syndrome, malignancy associated, and drug induced. The cellular and molecular mechanisms involved in Sweet's syndrome have been difficult to elucidate due to the large variety of conditions leading to a common clinical presentation. The exact pathogenesis of Sweet's syndrome is unclear; however, new discoveries have shed light on the role of inflammatory signaling, disease induction, and relationship with malignancy. These findings include an improved understanding of inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic contributions. Continued investigations into effective treatments and targeted therapy will benefit patients and improve our molecular understanding of inflammatory diseases, including Sweet's syndrome.

Sweet syndrome in children

The objective of this study was to describe the clinical features of Sweet syndrome in children. Our study population consisted of seven children diagnosed with Sweet syndrome over a 22-year period. Age, sex, appearance and location of lesions, associated signs and symptoms, past medical history, pathology, and subsequent disease course were documented for each patient. Fever and typical lesions were reported in most of patients in our study. The majority of patients presented with less-typical findings, such as pustules, vesicles, bullae, oral ulcerations, atrophic scars, and evidence of pathergy. Of the seven children in our study, four were found to have a preceding nonspecific upper respiratory or gastrointestinal infection, and two were diagnosed with an underlying hematologic malignancy. Our results suggest that atypical lesions are relatively common in children with Sweet syndrome and that underlying malignancy is associated with a minority of cases of pediatric Sweet syndrome.

Pediatric sweet syndrome: case report and literature review

We report on an 18-month-old boy with a typical presentation of Sweet syndrome following an upper respiratory tract illness. No evidence of hematologic malignancy was found and he was successfully treated with oral prednisolone. A comprehensive literature review has summarized the features of pediatric Sweet syndrome from 66 reported cases. Cases occurring under the age of 3 years had a male predominance and no association with malignancy, whereas cases over the age of 3 years had an equal sex distribution and were strongly associated with myeloid line hematologic malignancies. Identified complications were serious with an overall mortality of 9% rising to 40% with cardiovascular involvement.

Acute febrile neutrophilic dermatosis (Sweet's syndrome) in childhood and adolescence: two new patients and review of the literature on associated diseases

OBJECTIVES

The objectives of this study were to analyse the literature on Sweet's syndrome in childhood focussing on associated diseases and to suggest possible screening procedures for this group of patients. Furthermore, two new patients with Sweet's syndrome are reported.

METHODS

A literature search was performed on Pub med using search terms "sweet* syndrome*" and neutrophil* dermatos*. Patients were subdivided into the following groups: classic/idiopathic, paraneoplastic, and parainflammatory Sweet's syndrome.

RESULTS

The literature search revealed 64 patients (including our two patients) who were diagnosed with Sweet's syndrome in childhood and adolescence; 27 (42%) patients were categorized as "classic/idiopathic Sweet's syndrome". In 37 patients (58%) chronic associated diseases were reported. Out of these, 21 (33%) patients were categorized as "parainflammatory Sweet's syndrome" including chronic recurrent multifocal osteomyelitis, vasculitis with aortitis, recurrent infections due to immunodeficiencies, arthritis, and systemic lupus erythematosus. Sixteen (25%) patients were categorized as "paraneoplastic Sweet's syndrome" comprising both malignant and premalignant diseases like leukemia, aplastic anaemia, and Fanconi anaemia. As all five (8%) patients treated with drugs (granulocyte-colony stimulating factor, retinoid acid) suffered from malignant, premalignant, or parainflammatory diseases, these patients were categorized according to the underlying disease. Two new children with Sweet's syndrome and associated diseases are presented here, one of them suffering from recurrent infections and trisomy 21, while the other was diagnosed with CNS vasculitis 5(1/2) years after the primary diagnosis.

CONCLUSIONS

Sweet's syndrome should be considered in differential diagnosis of prolonged fever with cutaneous involvement. As most cases of pediatric Sweet's syndrome are associated with other diseases we suggest careful screening and monitoring of these patients especially concerning malignant/premalignant diseases, immunodeficiencies, cardiovascular involvement, autoimmune diseases, and drug associations.

Sweet's syndrome--a comprehensive review of an acute febrile neutrophilic dermatosis

Sweet's syndrome (the eponym for acute febrile neutrophilic dermatosis) is characterized by a constellation of clinical symptoms, physical features, and pathologic findings which include fever, neutrophilia, tender erythematous skin lesions (papules, nodules, and plaques), and a diffuse infiltrate consisting predominantly of mature neutrophils that are typically located in the upper dermis. Several hundreds cases of Sweet's syndrome have been published. Sweet's syndrome presents in three clinical settings: classical (or idiopathic), malignancy-associated, and drug-induced. Classical Sweet's syndrome (CSS) usually presents in women between the age of 30 to 50 years, it is often preceded by an upper respiratory tract infection and may be associated with inflammatory bowel disease and pregnancy. Approximately one-third of patients with CSS experience recurrence of the dermatosis. The malignancy-associated Sweet's syndrome (MASS) can occur as a paraneoplastic syndrome in patients with an established cancer or individuals whose Sweet's syndrome-related hematologic dyscrasia or solid tumor was previously undiscovered; MASS is most commonly related to acute myelogenous leukemia. The dermatosis can precede, follow, or appear concurrent with the diagnosis of the patient's cancer. Hence, MASS can be the cutaneous harbinger of either an undiagnosed visceral malignancy in a previously cancer-free individual or an unsuspected cancer recurrence in an oncology patient. Drug-induced Sweet's syndrome (DISS) most commonly occurs in patients who have been treated with granulocyte-colony stimulating factor, however, other medications may also be associated with DISS. The pathogenesis of Sweet's syndrome may be multifactorial and still remains to be definitively established. Clinical and laboratory evidence suggests that cytokines have an etiologic role. Systemic corticosteroids are the therapeutic gold standard for Sweet's syndrome. After initiation of treatment with systemic corticosteroids, there is a prompt response consisting of dramatic improvement of both the dermatosis-related symptoms and skin lesions. Topical application of high potency corticosteroids or intralesional corticosteroids may be efficacious for treating localized lesions. Other first-line oral systemic agents are potassium iodide and colchicine. Second-line oral systemic agents include indomethacin, clofazimine, cyclosporine, and dapsone. The symptoms and lesions of Sweet's syndrome may resolved spontaneously, without any therapeutic intervention; however, recurrence may follow either spontaneous remission or therapy-induced clinical resolution.

Pediatric Sweet syndrome and immunodeficiency successfully treated with intravenous immunoglobulin

Painful erythematous plaques and a pathognomonic, dense, dermal infiltrate of neutrophils characterize Sweet syndrome. Although numerous instances of this disease have been reported in children, only four have had an associated immunodeficiency to date. Sweet syndrome has been traditionally treated with systemic corticosteroids despite an unknown pathogenesis. Prior reports suggest that immunodeficient children with Sweet syndrome may have a persistent course and fail to respond to standard treatment. We describe a child with debilitating Sweet syndrome and a primary immunodeficiency whose symptoms were controlled with intravenous immunoglobulin and dapsone.

Concurrent occurrence of Sweet's syndrome and erythema nodosum: an overlap in the spectrum of reactive dermatoses

Simultaneous occurrence of Sweet's syndrome and erythema nodosum is very rare. We describe a case of a young male with a recent history of streptococcal infection who presented with concurrent Sweet's syndrome and erythema nodosum. Although the exact pathogenesis of these dermatoses is not yet clear, their similarities and simultaneous occurrence suggest a possible common underlying mechanism and may represent a continuum of reactive dermatoses. Evaluation of the role of cytokines in the etiopathogenesis of these conditions will be useful for further assessment and treatment of these conditions. Like the association of acanthosis nigricans and certain cancers and diabetes, Sweet's syndrome and erythema nodosum may be associated with certain malignancies, autoimmune disorders, or inflammatory bowel disease. Early recognition of these skin lesions can guide a search for underlying disorders. Patients with Sweet's syndrome should undergo an age-appropriate work-up for malignancy.

Sweet's syndrome revisited: a review of disease concepts

Sweet's syndrome, also referred to as acute febrile neutrophilic dermatosis, is characterized by a constellation of symptoms and findings: fever, neutrophilia, erythematous and tender skin lesions that typically show an upper dermal infiltrate of mature neutrophils, and prompt improvement of both symptoms and lesions after the initiation of treatment with systemic corticosteroids. Hundreds of patients with this dermatosis have been reported. The manifestations of Sweet's syndrome in these individuals have not only confirmed those originally described by Dr Robert Douglas Sweet in 1964, but have also introduced new features that have expanded the clinical and pathologic concepts of this condition. The history, clinical characteristics, laboratory findings, associated diseases, pathology, and treatment options of Sweet's syndrome are reviewed. The evolving and new concepts of this dermatosis that are discussed include: (i) Sweet's syndrome occurring in the clinical setting of a disease-related malignancy, or medication, or both; (ii) detection of additional sites of extracutaneous Sweet's syndrome manifestations; (iii) discovery of additional Sweet's syndrome-associated diseases; (iv) variability of the composition and/or location of the cutaneous inflammatory infiltrate in Sweet's syndrome lesions; and (v) additional efficacious treatments for Sweet's syndrome.

Sweet syndrome developing during treatment with all-trans retinoic acid in a child with acute myelogenous leukemia

Acute febrile neutrophilic dermatosis (Sweet syndrome) has been reported in a few adults receiving all-trans retinoic acid for acute promyelocytic leukemia. The authors report a case of Sweet syndrome associated with the administration of all-trans retinoic acid for acute promyelocytic leukemia in a pediatric patient.

Familial Sweet's syndrome in 2 brothers, both seen in the first 2 weeks of life

Sweet's syndrome (or acute febrile neutrophilic dermatosis) is a rare inflammatory disease that is characterized by fever, neutrophilia, and painful erythematous plaques that histologically show a dense dermal infiltrate of neutrophils without associated vasculitis. We describe 2 neonates (10 and 15 days of age) with Sweet's syndrome; to our knowledge, this is the first reported case of siblings with Sweet's syndrome.

Systemic inflammatory response syndrome associated with Sweet's syndrome

PURPOSE: To describe the first pediatric report of systemic inflammatory response syndrome, shock, and multiple organ dysfunction syndrome associated with Sweet's syndrome. DESIGN: Case report. SETTING: Pediatric intensive care unit. PATIENTS: A patient with Sweet's syndrome and multiple organ dysfunction syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We report the case of a 7-yr-old female child with an acute nonlymphoblastic leukemia in complete remission after an autologous bone marrow transplantation, with a clinical picture of skin lesions and fever that met the criteria of Sweet's syndrome and developing systemic inflammatory response syndrome, septic shock, and multiple organ dysfunction syndrome. Her clinical condition worsened despite broad-spectrum antimicrobial therapy and standard measures of cardiovascular support. An infectious site could not be identified, and all culture results were negative. Her condition improved dramatically once steroid therapy was administered, and she made a full recovery. CONCLUSION: Although it is a rare condition, the diagnosis of Sweet's syndrome must be considered in a patient with the typical skin lesions and systemic inflammatory response syndrome. The correct diagnosis is of great clinical importance, because therapy with systemic steroids results in a fast and remarkable improvement.

Spontaneous remission of congenital leukemia: a case for conservative treatment

A newborn infant with spontaneous remission of congenital leukemia cutis is described and a literature review of this uncommon phenomenon is provided. In view of the unusual and unpredictable behavior of this disease, chemotherapy should be withheld unless there is evidence of an 11q23 translocation or progressive disease. Otherwise, overall survival does not appear to be affected by adopting a conservative approach. Because of occasional late relapses, long-term follow-up is recommended. The biologic basis underlying spontaneous remission of congenital leukemia is unknown; therefore, molecular or molecular cytogenetic analysis of DNA obtained from a skin biopsy is recommended.

[Sweet syndrome in an infant]

BACKGROUND

Acute febrile neutrophilic dermatosis (Sweet's syndrome) is very uncommon in infancy. Systemic corticosteroid treatment is the standard therapy, usually leading to dramatic improvement within a few days.

CASE REPORT

A seven-month-old female infant was admitted for investigation of a rash developing over ten days with fever. Physical examination and skin biopsy led to a diagnosis of Sweet's syndrome. The relative inefficiency of systemic corticotherapy induced the parents to stop all treatment.

CONCLUSION

This case report allows us: 1) to consider the clinical and biological features of Sweet's syndrome in infancy; 2) to describe a corticosteroid resistant disease; and 3) to observe the course of a spontaneous evolution of Sweet's syndrome.