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Zhang L, Peng C, Li J. Shedding light on dermographism: a narrative review. Int J Dermatol 2024; 63:999-1006. [PMID: 38419351 DOI: 10.1111/ijd.17102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/02/2024] [Accepted: 02/07/2024] [Indexed: 03/02/2024]
Abstract
Dermographism is a common subtype of chronic urticaria. It generally manifests as a linear wheal after scratching or friction, with or without angioedema. The pathophysiology is not clear, but currently, we believe that the stimulation of the skin by mechanical stress leads to the activation of mast cells, which provoke the release of histamine and pro-inflammatory mediators, ultimately forming wheal along the stressed area. The gold standard for diagnosis is a medical history and provocation test or dermatographic test. As one of the subtypes of chronic urticaria, the Urticaria Control Test (UCT), Chronic Urticaria Quality of Life questionnaire (CU-Q2oL), and Dermatology Life Quality Index (DLQI) are also effective tools for evaluating disease control in dermographism patients. In addition to avoiding triggers, nonsedating H1 antihistamines are the first-line medications recommended by EAACI and other guidelines; for those who do not respond to standard doses, the recommended dosage can be increased up to 4 times. When necessary, the off-label use of omalizumab can be considered, and some drugs with potential therapeutic effects are still being explored. However, there is still a lack of biomarkers for predicting disease severity, efficacy, and prognosis. Here, we review what we know about dermographism and some points that need exploration in the future.
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Affiliation(s)
- Li Zhang
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Cong Peng
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jie Li
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Lou J, Zhang X. Atypical cutaneous presentation of AOSD with persistent itchy urticaria: A case report. Medicine (Baltimore) 2023; 102:e36251. [PMID: 38115334 PMCID: PMC10727623 DOI: 10.1097/md.0000000000036251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023] Open
Abstract
RATIONALE Adult-onset Still's disease (AOSD) is a rare multisystem disorder considered a complex autoinflammatory syndrome. The clinical and biological features of AOSD typically include a high fever with arthritic symptoms, evanescent skin rash, sore throat, striking neutrophilic leukocytosis, hyperferritinemia, and abnormal liver function. The typical rash and fever are important diagnostic clues for AOSD. Here, we report a case of atypical rash manifesting as persistent itchy urticaria. PATIENT CONCERNS A 57-year-old female presented with a 6-day history of fever. During her hospital stay, she progressively developed rashes that were not associated with fever, primarily distributed on her back and the distal extremities, and associated with pronounced itching. The rash was initially suspected to be urticaria; however, the patient exhibited a poor response to antihistamines. After malignancies and other rheumatic diseases were excluded, the diagnosis leaned towards AOSD based on diagnostic criteria. The patient's fever was well controlled with the initiation of glucocorticoids, and no further rashes were observed. DIAGNOSES Although the patient exhibited atypical rashes, after ruling out malignancies and other rheumatic diseases, she met 2 major and 3 minor criteria. Based on Yamaguchi's criteria, the patient was diagnosed with AOSD. INTERVENTIONS Initially, the patient was administered an intravenous infusion of methylprednisolone at 40 mg once daily. This was later transitioned to oral administration with gradual dose reduction. OUTCOMES Follow-up at 1 year showed no recurrence of the rash, with a stable condition and no relapse. LESSONS This case provides valuable insights for the early diagnosis of AOSD, emphasizing the importance of considering this diagnosis even when presenting with atypical skin rash.
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Affiliation(s)
- Jingfeng Lou
- Department of General Medicine, Chengdu Second People’s Hospital, Chengdu, China
| | - Xingping Zhang
- Department of General Medicine, Chengdu Second People’s Hospital, Chengdu, China
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Daghor-Abbaci K, Ait Hamadouche N, Makhloufi CD, Mechid F, Otmani F, Makrelouf M, Otmane A, Smail N, Boucelma M, Aissat FZ, Lefkir-Teffiani S, Bengana B, Boukheris N, Tebaibia A, Taharbouchet B, Ayoub S, Benziane B, Oumnia N, Haouichet C, Hanni F, Laraba N, Hakem D, Benfenatki N, Berrah A. Proposal of a new diagnostic algorithm for adult-onset Still's disease. Clin Rheumatol 2023; 42:1125-1135. [PMID: 36694091 DOI: 10.1007/s10067-023-06509-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVE This study was performed to develop a new diagnostic algorithm for adult-onset Still's disease (AOSD). METHODS We conducted a multicenter prospective nationwide case-control study in tertiary Internal Medicine, Rheumatology, and Infectious Diseases departments, to include successively patients with suspected AOSD based on the presence of two or more major criteria of Yamaguchi and/or Fautrel classifications. Patients were classified as AOSD or controls according to a predefined procedure. A receiving operating characteristic curve was used to determine the best cutoff value of the points-based score for disease classification. A diagnostic algorithm was developed to help the physician in the diagnostic approach. RESULTS A total of 160 patients were included, 80 patients with AOSD and 60 controls with different diagnoses. Twenty patients with incomplete data were excluded. In the multivariate analysis, 6 items remained independently associated with AOSD diagnosis: typical rash (OR: 24.01, 3 points), fever ≥ 39 °C (OR: 17.34, 3 points), pharyngitis (OR: 10.23, 2 points), arthritis (OR: 9.01, 2 points), NLR ≥ 4 (OR: 11.10, 2 points), and glycosylated ferritin ≤ 20% (OR: 1.59, 1 point). AOSD should be considered if the patient satisfies 7 points with a sensitivity of 92.5%, specificity of 93.3%, and accuracy of 92.8% (area under the curve (AUC): 0.97 [95% CI: 0.94-0.99]). The present points-based score was more accurate and sensitive than the Yamaguchi classification (78.8%, 92.5%, p = 0.01) and Fautrel classification (76.3%, 92.5%, p = 0.004). A typical rash associated with a points-based score ≥ 7 points leads to a very likely disease. CONCLUSION The proposed new algorithm could be a good diagnostic tool for adult-onset Still's disease in clinical practice and research. Key Points • A diagnostic algorithm was performed to help the physician in the diagnostic approach of AOSD. • The points-based score included in this algorithm had a high sensitivity and accuracy. • This diagnostic algorithm can be useful in the clinical research.
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Affiliation(s)
- Karima Daghor-Abbaci
- Internal Medicine Department, University of Algiers 1, Faculty of Medical Sciences, Benyoucef Benkhedda, Bab El Oued University Hospital Center, 16000, Bab El Oued City, Algiers, Algeria. .,Biochemistry, Hemotology and Genetics Laboratory of Research, Bab El Oued University Hospital Center, Bab El Oued City, Algiers, Algeria.
| | - Nadia Ait Hamadouche
- Department of Epidemiology, Bab El Oued University Hospital Center, Bab El Oued City, Algiers, Algeria
| | - Chafia Dahou Makhloufi
- Rheumatology Department, Bab El Oued University Hospital Center, Bab El Oued City, Algiers, Algeria
| | - Farida Mechid
- Rheumatology Department, Bab El Oued University Hospital Center, Bab El Oued City, Algiers, Algeria
| | - Fifi Otmani
- Internal Medicine Department, Mustapha Bacha University Hospital Center, 1st May City, Algiers, Algeria
| | - Mohamed Makrelouf
- Biochemistry, Hemotology and Genetics Laboratory of Research, Bab El Oued University Hospital Center, Bab El Oued City, Algiers, Algeria
| | - Amel Otmane
- Biochemistry, Hemotology and Genetics Laboratory of Research, Bab El Oued University Hospital Center, Bab El Oued City, Algiers, Algeria
| | - Nourredine Smail
- Department of Epidemiology, Mustapha Bacha University Hospital Center, 1st May City, Algiers, Algeria
| | - Malika Boucelma
- Internal Medicine Department, Kouba University Hospital Center, Kouba City, Algiers, Algeria
| | - Fatma Zohra Aissat
- Infectious Diseases Department, El Hadi Flici University Hospital Center, Casbah City, Algiers, Algeria
| | - Salima Lefkir-Teffiani
- Rheumatology Department, Benimessous University Hospital Center, Algiers, Benimessous City, Algeria
| | - Bilel Bengana
- Rheumatology Department, Benimessous University Hospital Center, Algiers, Benimessous City, Algeria
| | - Nadia Boukheris
- Internal Medicine Department, Annaba University Hospital Center, Annaba City, Algeria
| | - Amar Tebaibia
- Internal Medicine Department, Birtraria University Hospital Center, El Biar City, Algiers, Algeria
| | - Baya Taharbouchet
- Internal Medicine Department, Bouloughine University Hospital Center, Algiers, Bouloughine City, Algeria
| | - Soraya Ayoub
- Internal Medicine Department, Benimessous University Hospital Center, Algiers, Benimessous City, Algeria
| | - Brahim Benziane
- Internal Medicine Department, Laghouat University Hospital Center, Laghouat City, Algeria
| | - Nadia Oumnia
- Internal Medicine Department, Zmirli University Hospital Center, El Harrache City, Algiers, Algeria
| | - Chafika Haouichet
- Rheumatology Department, Douera University Hospital Center, Blida City, Algeria
| | - Fella Hanni
- Rheumatology Department, Benaknoun University Hospital Center, Benaknoun City, Algiers, Algeria
| | - Nazim Laraba
- Internal Medicine Department, University of Algiers 1, Faculty of Medical Sciences, Benyoucef Benkhedda, Bab El Oued University Hospital Center, 16000, Bab El Oued City, Algiers, Algeria
| | - Djennete Hakem
- Internal Medicine Department, Mostaghanem University Hospital Center, Mostaghanem City, Algeria
| | - Nacera Benfenatki
- Internal Medicine Department, Rouiba University Hospital Center, Rouiba City, Algiers, Algeria
| | - Abdelkrim Berrah
- Internal Medicine Department, University of Algiers 1, Faculty of Medical Sciences, Benyoucef Benkhedda, Bab El Oued University Hospital Center, 16000, Bab El Oued City, Algiers, Algeria
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Daghor Abbaci K, Ait Hamadouche N, Otmani F, Dahou Makhloufi C, Mechid F, Makrelouf M, Otmane A, Smail N, Boucelma M, Aissat FZ, Lefkir-Teffiani S, Bengana B, Boukheris N, Tebaibia A, Taharbouchet B, Ayoub S, Benziane B, Oumnia N, Haouichet C, Hanni F, Laraba N, Hakem D, Benfenatki N, Berrah A. Validation of the neutrophil-to-lymphocyte ratio as a new simple biomarker of adult onset Still's disease: A STROBE-Compliant prospective observational study. Medicine (Baltimore) 2022; 101:e29970. [PMID: 35960098 PMCID: PMC9371519 DOI: 10.1097/md.0000000000029970] [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: 01/04/2023] Open
Abstract
This study was performed to investigate the role of neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of adult onset Still disease (AOSD) and its performance to improve the sensitivity of the classifications criteria (Yamaguchi and Fautrel Classifications). We conducted a multicenter prospective nationwide case-control study in Internal medicine, Rheumatology and Infectious disease departments, to include successively patients with suspected AOSD (2 or more major criteria of Yamaguchi or Fautrel classifications). All clinical and biological features were collected in a consensual and standardized clinical assessment at baseline and during follow-up. A receiving operating characteristic (ROC) curve was used to reassess the cutoff value of NLR. After determination of the cutoff value for NLR by ROC curve, 2 composite sets (Yamaguchi classification + NLR as a major criterion and Fautrel classification + NLR as a major criterion) were performed and evaluated. One hundred sixty patients were included, 80 patients with AOSD and 60 controls with different diagnoses. Twenty patients with incomplete data were excluded. The cutoff value for NLR equals 4 (area under the curve, AUC: 0.82). The NLR was ≥ 4 in 93.7% (75/80) of AOSD patients with a sensitivity of 93.8% and specificity of 61.7%. The association of NLR as a major criterion with the classification of Yamaguchi or Fautrel improved their sensitivity, respectively for Fautrel (76.3% to 92.5%, P = .004) and Yamaguchi (78.8% to 90%, P = .05). This study validates the NLR as a good simple biomarker of AOSD with a cutoff value of 4 and high sensitivity (93.8%). The addition of NLR (NLR ≥ 4) as a major criterion to the classifications (Yamaguchi and Fautrel) improved significantly their sensitivity and accuracy.
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Affiliation(s)
- Karima Daghor Abbaci
- Internal Medicine Department, University of Algiers 1, Faculty of Medical Sciences, Benyoucef Benkhedda, Bab El Oued University Hospital Center, Bab El Oued city, Algiers, Algeria
- Biochemistry, Hemotology and Genetics Laboratory of Research, Bab El Oued University Hospital Center, Bab El Oued City, Algiers Algeria
- * Correspondence: Karima Daghor Abbaci, Department of Internal medicine, University of Algiers 1, Faculty of Medical sciences, Benyoucef Benkhedda, Bab El Oued University Hospital center, Bab El Oued City, 16 000, Algiers, Algeria, North Africa (e-mail: )
| | - Nadia Ait Hamadouche
- Department of epidemiology, Bab El Oued University Hospital Center, Bab El Oued city, Algiers, Algeria
| | - Fifi Otmani
- Internal Medicine Department, Mustapha Bacha University Hospital Center, 1st May City, Algiers, Algeria
| | - Chafia Dahou Makhloufi
- Rheumatology department, Bab El Oued University Hospital center, Bab El Oued city, Algiers, Algeria
| | - Farida Mechid
- Rheumatology department, Bab El Oued University Hospital center, Bab El Oued city, Algiers, Algeria
| | - Mohamed Makrelouf
- Biochemistry, Hemotology and Genetics Laboratory of Research, Bab El Oued University Hospital Center, Bab El Oued City, Algiers Algeria
| | - Amel Otmane
- Biochemistry, Hemotology and Genetics Laboratory of Research, Bab El Oued University Hospital Center, Bab El Oued City, Algiers Algeria
| | - Nourredine Smail
- Department of Epidemiology, Mustapha Bacha University Hospital Center, 1st May City, Algiers, Algeria
| | - Malika Boucelma
- Internal Medicine Department, Kouba University Hospital center, Kouba City, Algiers, Algeria
| | - Fatma Zohra Aissat
- Infectious Diseases Department, El Hadi Flici University Hospital Center, Casbah City, Algiers, Algeria
| | - Salima Lefkir-Teffiani
- Rheumatology Department, Benimessous University Hospital Center, Benimessous City, Algiers, Algeria
| | - Bilel Bengana
- Internal Medicine Department, Annaba University Hospital Center, Annaba City, Algeria
| | - Nadia Boukheris
- Internal Medicine Department, Annaba University Hospital Center, Annaba City, Algeria
| | - Amar Tebaibia
- Internal Medicine Department, Birtraria University Hospital Center, El Biar City, Algiers, Algeria
| | - Baya Taharbouchet
- Internal Medicine Department, Bouloughine University Hospital Center, Bouloughine City, Algiers, Algeria
| | - Soraya Ayoub
- Internal Medicine Department, Benimessous University Hospital Center, Benimessous City, Algiers, Algeria
| | - Brahim Benziane
- Internal Medicine Department, Laghouat University Hospital center, Laghouat City, Algeria
| | - Nadia Oumnia
- Internal Medicine Department, Zmirli University Hospital Center, El Harrache City, Algiers, Algeria
| | - Chafika Haouichet
- Rheumatology Department, Douera University Hospital Center, Blida city, Algeria
| | - Fella Hanni
- Rheumatology Department, Benaknoun University Hospital Center, Benaknoun City, Algiers, Algeria
| | - Nazim Laraba
- Internal Medicine Department, University of Algiers 1, Faculty of Medical Sciences, Benyoucef Benkhedda, Bab El Oued University Hospital Center, Bab El Oued city, Algiers, Algeria
| | - Djennete Hakem
- Internal Medicine Department, Mostaghanem University Hospital Center, Mostaghanem City, Algeria
| | - Nacera Benfenatki
- Internal Medicine Department, Rouiba University Hospital Center, Rouiba City, Algiers, Algeria
| | - Abdelkrim Berrah
- Internal Medicine Department, University of Algiers 1, Faculty of Medical Sciences, Benyoucef Benkhedda, Bab El Oued University Hospital Center, Bab El Oued city, Algiers, Algeria
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Tremble KC, Sangle SR, D'Cruz DP. Dermographia as a first manifestation of lupus. Rheumatology (Oxford) 2021; 60:e154-e155. [PMID: 33332563 DOI: 10.1093/rheumatology/keaa662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kathryn C Tremble
- Louise Coote Lupus Unit, Rheumatology Department, Guy's Hospital, London, UK
| | - Shirish R Sangle
- Louise Coote Lupus Unit, Rheumatology Department, Guy's Hospital, London, UK
| | - David P D'Cruz
- Louise Coote Lupus Unit, Rheumatology Department, Guy's Hospital, London, UK
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Daghor KA, Berrah A. Melanoderma in adult-onset Still's disease. Rheumatology (Oxford) 2021; 61:1299. [PMID: 34022035 DOI: 10.1093/rheumatology/keab458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/14/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Karima Abbaci Daghor
- Internal Medicine Department, Bab El Oued University Hospital Centre, University of Algiers 1 Benyoucef Benkhedda, Algiers, Algeria
| | - Abdelkrim Berrah
- Internal Medicine Department, Bab El Oued University Hospital Centre, University of Algiers 1 Benyoucef Benkhedda, Algiers, Algeria
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Shams S, Rathore SS, Anvekar P, Sondhi M, Kancherla N, Tousif S, Rojas GA, Ahmed NK, Munawwar M, Noman M. Maculopapular skin eruptions associated with Covid-19: A systematic review. Dermatol Ther 2021; 34:e14788. [PMID: 33481314 PMCID: PMC7995033 DOI: 10.1111/dth.14788] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/01/2021] [Accepted: 01/17/2021] [Indexed: 01/08/2023]
Abstract
In this systematic review, we anticipated in summarizing clinical features, histopathological hallmarks, and possible pathology behind the maculopapular skin eruptions occurring in Covid-19 patients. A literature search was executed using MEDLINE/PubMed and Embase databases for articles published till 20 November 2020. All eligible articles including observational studies, case reports, and case series reporting the maculopapular skin lesion in Covid-19 patients were included. Data were obtained for 354 Covid-19 patients presenting with maculopapular lesions from 40 studies. The mean age of these patients was 53 years, and with 42% of them being male. These maculopapular lesions differed considerably in terms of distribution and appearance, ranging from diffuse erythematous maculopapular lesions to scattered erythematous macules coalescing into papules to maculopapular lesions in plaques. The mean duration of the lesion was 8 days. These lesions were frequently localized on trunks and extremities. Superficial perivascular dermatitis with lymphocytic infiltrate was a histopathological hallmark of these lesions. As these skin lesions may have a possible association with diagnosis, management, prognosis, and severity of the disease, all health practitioners need to be well acquainted with these Covid-19 skin lesions. Also, in the middle of this worldwide pandemic, early identification of this eruption may help manage this infection's further spread.
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Affiliation(s)
- Saad Shams
- Internal MedicineRoss University School of MedicineMiramarFloridaUSA
| | | | - Priyanka Anvekar
- Internal MedicineMGM Medical College and HospitalAurangabadIndia
| | - Manush Sondhi
- Internal MedicineKasturba Medical CollegeManipalIndia
| | | | - Sohaib Tousif
- Internal MedicineZiauddin Medical UniversityKarachiPakistan
| | - Gianpier Alonzo Rojas
- Internal Medicine, School of medicineUniversidad Peruana Cayetano HerediaLimaPeru
- Scientific Society of Medical StudentsCayetano HerediaLimaPeru
| | | | - Mehwish Munawwar
- Internal MedicineLiaquat College of Medicine and DentistryKarachiPakistan
| | - Muhammad Noman
- Internal MedicineZiauddin Medical CollegeKarachiPakistan
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Larenas-Linnemann D, Luna-Pech J, Navarrete-Rodríguez EM, Rodríguez-Pérez N, Arias-Cruz A, Blandón-Vijil MV, Del Rio-Navarro BE, Estrada-Cardona A, Onuma-Takane E, Pozo-Beltrán CF, Valencia-Herrera AM, Ortiz-Aldana FI, Toledo-Bahena ME. Cutaneous Manifestations Related to COVID-19 Immune Dysregulation in the Pediatric Age Group. Curr Allergy Asthma Rep 2021; 21:13. [PMID: 33630167 PMCID: PMC7905763 DOI: 10.1007/s11882-020-00986-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2020] [Indexed: 01/04/2023]
Abstract
Purpose of Review At the juncture of the COVID-19 pandemic, the world is currently in an early phase of collecting clinical data and reports of its skin manifestations, and its pathophysiology is still highly conjectural. We reviewed cutaneous manifestations associated with COVID-19 in the pediatric age group. Recent Findings Children infected by SARS-CoV-2 usually develop milder respiratory symptoms, but cutaneous manifestations seem a little more prevalent than in adults. These skin features of infection by the coronavirus can be similar to those produced by other common viruses, but there are also reports of cases with more heterogeneous clinical pictures, which have made their classification difficult. To date, the more frequently reported skin variants featured in pediatric cases are purpuric (pseudo-chilblain, necrotic-acral ischemia, hemorrhagic macules, and/or cutaneous necrosis), morbilliform/maculopapular, erythema multiforme, urticarial, vesicular, Kawasaki-like, and miscellaneous (highly variable in both frequency and severity). Their pathophysiological mechanism is still elusive and is likely to be the result of the complex involvement of one or more mechanisms, like direct virus-induced skin damage, vasculitis-like reactions, and/or indirect injury as a consequence of a systemic inflammatory reaction. Summary In this review, we presented and discussed clinical cases as examples of different cutaneous responses reported in some children with SARS-CoV-2 infection, differential diagnosis considerations, and a preliminary conceptual approach to some of their probable associated pathologic mechanisms.
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Affiliation(s)
- Désirée Larenas-Linnemann
- Médica Sur Fundación Clínica y Hospital, Mexico City, Mexico
- Hospital Médica Sur, Torre 2, cons. Puente de piedra 150, T2-602 Toriello-Guerra; delegación Tlalpan, Mexico City, Mexico
| | - Jorge Luna-Pech
- Departamento de Disciplinas Filosóficas Metodoloógicas e Instrumentales, Universidad de Guadalajara, Guadalajara, Jalisco Mexico
| | | | - Noel Rodríguez-Pérez
- Consulta Privada, Universidad Autónoma de Tamaulipas, Matamoros, Tamaulipas Mexico
| | - Alfredo Arias-Cruz
- Facultad de Medicina y Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - Blanca E. Del Rio-Navarro
- Servicio de Alergia e Inmunología Clínica, Hospital Infantil de Mexico Federico Gómez, Mexico City, Mexico
| | | | | | - Cesar Fireth Pozo-Beltrán
- Subdirección de Enseñanza e Investigación, Hospital General de Especialidades Juan María Salvatierra, La Paz, Baja California Sur Mexico
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Criado PR, Pagliari C, Carneiro FRO, Quaresma JAS. Lessons from dermatology about inflammatory responses in Covid-19. Rev Med Virol 2020; 30:e2130. [PMID: 32656939 PMCID: PMC7404593 DOI: 10.1002/rmv.2130] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 02/06/2023]
Abstract
The SARS-Cov-2 is a single-stranded RNA virus composed of 16 non-structural proteins (NSP 1-16) with specific roles in the replication of coronaviruses. NSP3 has the property to block host innate immune response and to promote cytokine expression. NSP5 can inhibit interferon (IFN) signalling and NSP16 prevents MAD5 recognition, depressing the innate immunity. Dendritic cells, monocytes, and macrophages are the first cell lineage against viruses' infections. The IFN type I is the danger signal for the human body during this clinical setting. Protective immune responses to viral infection are initiated by innate immune sensors that survey extracellular and intracellular space for foreign nucleic acids. In Covid-19 the pathogenesis is not yet fully understood, but viral and host factors seem to play a key role. Important points in severe Covid-19 are characterized by an upregulated innate immune response, hypercoagulopathy state, pulmonary tissue damage, neurological and/or gastrointestinal tract involvement, and fatal outcome in severe cases of macrophage activation syndrome, which produce a 'cytokine storm'. These systemic conditions share polymorphous cutaneous lesions where innate immune system is involved in the histopathological findings with acute respiratory distress syndrome, hypercoagulability, hyperferritinemia, increased serum levels of D-dimer, lactic dehydrogenase, reactive-C-protein and serum A amyloid. It is described that several polymorphous cutaneous lesions similar to erythema pernio, urticarial rashes, diffuse or disseminated erythema, livedo racemosa, blue toe syndrome, retiform purpura, vesicles lesions, and purpuric exanthema or exanthema with clinical aspects of symmetrical drug-related intertriginous and flexural exanthema. This review describes the complexity of Covid-19, its pathophysiological and clinical aspects.
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Affiliation(s)
- Paulo Ricardo Criado
- Dermatology DepartmentCentro Universitário Saúde ABCSanto AndréBrazil
- Dermatology Department, Faculdade de MedicinaCentro Universitário Saúde ABCSanto AndréBrazil
| | - Carla Pagliari
- Pathology Department, Faculdade de MedicinaUniversidade de São PauloSão PauloBrazil
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Criado PR, Abdalla BMZ, de Assis IC, van Blarcum de Graaff Mello C, Caputo GC, Vieira IC. Are the cutaneous manifestations during or due to SARS-CoV-2 infection/COVID-19 frequent or not? Revision of possible pathophysiologic mechanisms. Inflamm Res 2020; 69:745-756. [PMID: 32488318 PMCID: PMC7266387 DOI: 10.1007/s00011-020-01370-w] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/24/2020] [Accepted: 05/27/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND SARS-Cov-2 is a single-stranded RNA virus, a Betacoronavirus, composed of 16 non-structural proteins, with specific roles in replication of coronaviruses. The pathogenesis of COVID-19 is not yet fully understood. The virus and host factors interplay among distinct outcomes of infected patients. METHODS Using MeSH (Medical Subject Headings) in PubMed, authors searched for articles cotaining information on COVID-19 and the skin. RESULTS The pathophysiology of the disease is multifactorial: association with innate immune response, hypercoagulability state, lung tissue damage, neurological and/or gastrointestinal tract involvement, monocytic/macrophage activation syndrome, culminating in exaggerated cytokine secretion, called "cytokine storm", which leads to worsening and death. These systemic conditions may be associated with cutaneous lesions, that have polymorphic aspects, where at histopathological level show involvement in different skin changes. These lesions may be associated with multisystemic manifestations that could occur due to angiotensin-converting enzyme 2 receptor and transmembrane serine protease action, allowing the pulmonary infection and possibly skin manifestation. Several reports in literature show cutaneous lesions similar to chilblain, urticarial eruptions, diffuse or disseminated erythema, livedo racemosa, blue toe syndrome, retiform purpura, vesicle trunk, purpuric exanthema or exanthema with clinical aspects of symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) and others. CONCLUSIONS This review describes the complexity of Covid-19, pathophysiological and clinical aspects, dermatological finding and other dermatological conditions associated with SARS-CoV-2 infection or COVID-19.
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Affiliation(s)
- Paulo Ricardo Criado
- Department of Dermatology, Faculdade de Medicina do ABC, Príncipe de Gales, Avenida Príncipe de Gales, 821, Santo André, SP, 09060-650, Brazil
| | - Beatrice Martinez Zugaib Abdalla
- Department of Dermatology, Faculdade de Medicina do ABC, Príncipe de Gales, Avenida Príncipe de Gales, 821, Santo André, SP, 09060-650, Brazil.
| | - Isabelle Carvalho de Assis
- Department of Dermatology, Faculdade de Medicina do ABC, Príncipe de Gales, Avenida Príncipe de Gales, 821, Santo André, SP, 09060-650, Brazil
| | | | - Gabriela Cacciolari Caputo
- Department of Dermatology, Faculdade de Medicina do ABC, Príncipe de Gales, Avenida Príncipe de Gales, 821, Santo André, SP, 09060-650, Brazil
| | - Ingrid Campos Vieira
- Department of Dermatology, Faculdade de Medicina do ABC, Príncipe de Gales, Avenida Príncipe de Gales, 821, Santo André, SP, 09060-650, Brazil
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11
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Damevska K, França K, Nikolovska S, Gucev F. Adult-onset Still's disease as a cutaneous marker of systemic disease. Clin Dermatol 2019; 37:668-674. [PMID: 31864446 DOI: 10.1016/j.clindermatol.2019.07.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Adult-onset Still's disease (AOSD) is a rare, systemic, inflammatory disorder characterized by spiking fevers, an evanescent eruption, arthritis, and multiorgan involvement. The disease has been recently classified as a polygenic autoinflammatory disorder at the "crossroads" of autoinflammatory and autoimmune diseases. The highly characteristic salmon-colored eruption is a cutaneous manifestation of a generalized inflammatory reaction and an important diagnostic criterion. In addition to the evanescent eruption, there are atypical persistent papules and plaques in many patients with AOSD. Emerging data suggest that AOSD with this typical evanescent eruption has a different clinicopathologic presentation and clinical course than AODS with atypical cutaneous manifestations. It appears that there are two subtypes of AOSD with different immunologic profiles, including (1) a systemic disease with high fever, organ involvement, and elevated levels of ferritin, and (2) a chronic disease course with arthritis as the predominant finding. These observations provide novel insight into the disease pathogenesis, suggesting that the underlying mechanisms might differ between these two forms, partially explaining the reported differences in drug response. Recent advances in the understanding of AOSD are summarized with a focus on the spectrum of cutaneous manifestations and its relationship to systemic inflammation.
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Affiliation(s)
- Katerina Damevska
- University Clinic of Dermatology, Ss Cyril and Methodius University, Skopje, Macedonia.
| | - Katlein França
- Department of Dermatology and Cutaneous Surgery, Department of Psychiatry and Behavioral Sciences, Institute for Bioethics and Health Policy, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Suzana Nikolovska
- University Clinic of Dermatology, Ss Cyril and Methodius University, Skopje, Macedonia
| | - Filip Gucev
- Univeristy Clinic of Rheumatology, Ss Cyriland Methodius University, Skopje, Macedonia
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12
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Brance ML, Neffen EL. Oral mucosa lesions as atypical manifestation of adult-onset Still´s disease. An Bras Dermatol 2018; 93:271-273. [PMID: 29723378 PMCID: PMC5916405 DOI: 10.1590/abd1806-4841.20186836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 06/18/2017] [Indexed: 11/22/2022] Open
Abstract
Adult-onset Still's disease is a systemic inflammatory disorder of unknown etiology, characterized by skin rash, spiking fever, arthralgias or arthritis, and leukocytosis. The typical skin rash is evanescent, salmon-pink, nonpruritic and maculopapular, predominantly on the extremities. It is considered one of the major Yamaguchi's criteria in adult-onset Still's disease. However, atypical skin lesions are also described. Here, a 61-year-old woman with sore throat, spiking fever, polyarthritis and evanescent salmon-pink nonpruritic maculopapular skin rash on the extremities was diagnosed with adult-onset Still's disease. In addition, atypical brown macules on oral mucosa, localized on the inner lips and tongue were also observed. Biopsy revealed a neutrophilic infiltrate. Despite treatment and improvement of the adult-onset Still's disease, the atypical oral mucosal lesions persisted.
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Affiliation(s)
- María Lorena Brance
- Rheumatology Centre - Rosario, Argentina
- Bone Biology Laboratory. School of Medicine, Universidad Nacional
de Rosario- Rosario, Argentina
- National Council of Scientific and Technical Research (CONICET) -
Rosario, Argentina
| | - Eldo Luis Neffen
- Pathological Anatomy Deparment, Clínica Pergamino -
Pergamino, Argentina
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13
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Fustà-Novell X, García-Herrera A, Mascaró JM. Dermographism in a patient with fever. Int J Dermatol 2017; 57:19-20. [DOI: 10.1111/ijd.13791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/13/2017] [Accepted: 09/13/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Xavier Fustà-Novell
- Department of Dermatology; Hospital Clínic, Universitat de Barcelona; Barcelona Spain
| | | | - José M. Mascaró
- Department of Dermatology; Hospital Clínic, Universitat de Barcelona; Barcelona Spain
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14
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Diagnostic Challenge: A Report of Two Adult-Onset Still's Disease Cases. Case Rep Dermatol Med 2017; 2017:3768603. [PMID: 29147588 PMCID: PMC5632890 DOI: 10.1155/2017/3768603] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/07/2017] [Accepted: 08/10/2017] [Indexed: 11/17/2022] Open
Abstract
This study reports two adult-onset Still's disease (AOSD) cases that met both Yamaguchi's and Fautrel's criteria and that presented with notable clinical manifestations. One case presented with atypical dermographism-like rash with an extremely high ferritin level. The other case presented with typical salmon-pink maculopapular rash but had atypical positive rheumatoid factor. This suggests that although negative rheumatoid factor is one of the criteria used for the diagnosis of AOSD, a positive rheumatoid factor result does not exclude AOSD. Beside a classic rash, characterized by transient salmon-pink maculopapular rash, we also find atypical dermographism-like rash. These findings remind us that there exist various types of rash from AOSD.
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15
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Narváez Garcia FJ, Pascual M, López de Recalde M, Juarez P, Morales-Ivorra I, Notario J, Jucglà A, Nolla JM. Adult-onset Still's disease with atypical cutaneous manifestations. Medicine (Baltimore) 2017; 96:e6318. [PMID: 28296747 PMCID: PMC5369902 DOI: 10.1097/md.0000000000006318] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The diagnosis of adult-onset Still's disease (AOSD) can be very difficult. There are no specific tests available, and diagnosis is usually based on a symptom complex and the well-described typical evanescent rash seen in the majority of patients. However, in recent years, other atypical cutaneous manifestations of AOSD have been reported. These atypical skin eruptions often present in addition to the typical evanescent rash but may also be the only skin manifestation, resulting in delayed diagnosis because of under-recognition.In this study, we present 3 new cases of AOSD with atypical cutaneous manifestations diagnosed during a 30-year period in our department and review 78 additional cases previously reported (PubMed 1990-2016). These 81 patients form the basis of the present analysis.The overall prevalence of atypical cutaneous manifestations in our AOSD population was 14%. These manifestations may appear at any time over the course of the disease, and usually occur in patients who have persistent and severe disease, with a considerable frequency of clinical complications (23%), including serositis, myopericarditis, lung involvement, abdominal pain, neurologic involvement, and reactive hemophagocytic syndrome.The most representative and frequent lesion among the nonclassical skin rashes is the development of persistent pruritic papules and/or plaques. Interestingly, these lesions show a distinctive histological pattern. Other, less frequently observed lesions include urticaria and urticaria-like eruptions, generalized or widespread non-pruritic persistent erythema, vesiculopustular eruptions, a widespread peau d'orange appearance of the skin, and edema of the eyelids mimicking dermatomyositis without any accompanying skin lesion.The great majority of these patients required medium or high doses of glucocorticoids (including intravenous methylprednisolone pulse therapy in some cases) and, in nearly 40%, a more potent or maintenance immunotherapy with immunosuppressant drugs and/or biologic agents (mainly anakinra or tocilizumab) to control or manage symptoms because of a polycyclic or chronic course. The development of atypical cutaneous manifestations seems to be associated with a potentially worse prognosis, with a mortality rate reaching 8% primarily because of infectious complications related to immunosuppressive therapy.In conclusion, the appearance of atypical cutaneous manifestations is not uncommon in AOSD. Recognition of this clinical variant is crucial for the early diagnosis of AOSD, as it might imply persistent disease activity and the need for more aggressive treatment.
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Affiliation(s)
| | | | | | | | | | - Jaime Notario
- Department of Dermatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
| | - Anna Jucglà
- Department of Dermatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
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16
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Michailidou D, Shin J, Forde I, Gopalratnam K, Cohen P, DeGirolamo A. Typical evanescent and atypical persistent polymorphic cutaneous rash in an adult Brazilian with Still's disease: a case report and review of the literature. AUTO- IMMUNITY HIGHLIGHTS 2015; 6:39-46. [PMID: 26423534 PMCID: PMC4633415 DOI: 10.1007/s13317-015-0071-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/11/2015] [Indexed: 12/18/2022]
Abstract
Adult onset Still's disease (AOSD) is a systemic auto-inflammatory condition of unknown etiology, characterized by high fever, an evanescent, salmon-pink maculopapular skin rash, arthralgia or arthritis and leukocytosis. AOSD can also present with atypical cutaneous manifestations, such as persistent pruritic coalescent papules or plaques and linear lesions that have highly distinctive pathological features and are usually associated with severe disease. Herein, we present a 31-year-old Brazilian man with both typical Still's rash and atypical persistent polymorphic cutaneous manifestations associated with severe systemic inflammatory response syndrome. Eosinophils that are consistently lacking in the AOSD-associated skin lesions were evident in the skin biopsy of the persistent atypical cutaneous manifestations and were either drug-related or AOSD-associated.
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Affiliation(s)
- Despina Michailidou
- Department of Internal Medicine, Bridgeport Hospital, Yale-New Haven Health System, Bridgeport, CT, USA.
| | - Junghee Shin
- Department of Internal Medicine, Bridgeport Hospital, Yale-New Haven Health System, Bridgeport, CT, USA
| | - Inga Forde
- Section of Pulmonary, Critical Care and Sleep Medicine, Bridgeport Hospital, Yale-New Haven Health System, Bridgeport, CT, USA
| | - Kavitha Gopalratnam
- Department of Internal Medicine, Bridgeport Hospital, Yale-New Haven Health System, Bridgeport, CT, USA
| | - Paul Cohen
- Department of Pathology, Bridgeport Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Angela DeGirolamo
- Department of Internal Medicine, Bridgeport Hospital, Yale-New Haven Health System, Bridgeport, CT, USA
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18
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Cutaneous manifestations of adult-onset Still's disease: a case report and review of literature. Clin Rheumatol 2014; 35:1377-82. [PMID: 24737284 DOI: 10.1007/s10067-014-2614-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 04/01/2014] [Accepted: 04/02/2014] [Indexed: 02/07/2023]
Abstract
Adult onset Still's disease (AOSD) is a systemic inflammatory disorder of unknown etiology and pathogenesis characterized by high spiking fever, arthralgia or arthritis, sore throat, lymphadenopathy, hepatosplenomegaly, serositis, and transient cutaneous manifestations. Although more common in children, cases are seen also in adults. Cutaneous involvement is common and may be suggestive for the diagnosis. A case of AOSD in a 35-year-old man is reported here, presenting with urticarial maculopapular rash of trunk, high spiking fever, acute respiratory distress syndrome, and myopericarditis. Skin biopsy showed interstitial and perivascular mature CD15(+) neutrophils. A comprehensive review of literature showed that cutaneous involvement occurs in about 80 % of patients, with various clinical presentations. The most common skin manifestation is an evanescent salmon pink or erythematous maculopapular exanthema, predominantly on the trunk and proximal limbs, with rare involvement of face and distal limbs. Less common manifestations include persistent erythematous plaques and pustular lesions. A constant histopathologic finding is the presence of interstitial dermal neutrophils aligned between the collagen bundles. This pattern may provide an easy accessible clue for the definitive diagnosis of AOSD and exclude other diagnosis such as drug eruptions or infectious diseases.
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19
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Refractory urticaria in adult-onset Still's disease. Rheumatol Int 2014; 34:1029-30. [PMID: 24497040 DOI: 10.1007/s00296-014-2952-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 01/22/2014] [Indexed: 11/27/2022]
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20
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Yamamoto T. Cutaneous manifestations associated with adult-onset Still's disease: important diagnostic values. Rheumatol Int 2011; 32:2233-7. [PMID: 22198666 DOI: 10.1007/s00296-011-2330-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 12/10/2011] [Indexed: 11/24/2022]
Abstract
Adult-onset Still's disease (AOSD) is a systemic inflammatory condition, characterized by a high spiking fever, leukocytosis with neutrophilia, arthralgia, and skin rash. Typical skin rash is an evanescent, salmon-pink erythema predominantly involving extremities, which is included as one of the diagnostic criteria; however, recent findings show that not only typical evanescent rash but also various skin lesions are associated with AOSD. The representative characteristic skin lesion among the non-classical skin rash is called persistent pruritic papules and plaques, which presents erythematous, slightly scaly papules with linear configuration on the trunk. Interestingly, persistent pruritic papules and plaques show unique histological features such as peculiar, distinctive distribution of dyskeratotic keratinocytes in the cornified layers as well as in the epidermis. Other non-classical skin lesions include urticaria. Current insights suggest that several inflammatory cytokines such as interleukin-1 (IL-1), IL-6, IL-18, interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-α) play a pathogenic role in AOSD. In particular, IL-18 is suggested to play a crucial role in activating macrophages, favoring Th1 type cytokine production. IL-18 induces IFN-γ, IL-17, and TNF-α, which may play an important pathogenic role in AOSD. It is important to recognize the common and/or uncommon skin conditions of AOSD for early correct diagnosis. In this review, various skin lesions are introduced, and the complication with histiocytic necrotizing lymphadenitis (Kikuchi disease) is further discussed.
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Affiliation(s)
- Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Hikarigaoka 1, Fukushima 960-1295, Japan.
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