Leukocytoclastic vasculitis and necrolytic acral erythema in patients with hepatitis C infection: do viral load and viral genotype play a role?

Necrolytic Acral Erythema: Current Insights

Necrolytic acral erythema (NAE) is now considered as a distinct clinical entity. It clinically presents as well demarcated hyperpigmented papules and plaques with thick adherent scales distributed symmetrically over dorsum of feet. It usually develops in patients with Hepatitis C virus (HCV) infection. Cases of NAE have been reported in patients without HCV infection. Hepatic dysfunction resulting in metabolic alterations like hypoalbuminemia, hypoaminoacidemia, hyperglucagonemia and transient zinc deficiency has been proposed as underlying pathogenic mechanism of NAE. Clinically, NAE resembles other necrolytic erythemas like necrolytic migratory erythema (NME), acrodermatitis enteropathica (AE) and pellagra. Better understanding of etiopathogenesis and histopathological features is important to distinguish NAE from other necrolytic erythemas. The disease runs a natural course of exacerbations and remissions. Non-invasive diagnostic tools like dermoscopy can be used in differential diagnosis of NAE. Oral zinc therapy is the most effective treatment of NAE reported in most of the cases irrespective of HCV status or serum zinc levels.

Leukocytoclastic vasculitis caused by hepatitis C virus in a liver transplant recipient: A case report

BACKGROUND

Infection by the hepatitis C virus (HCV) is currently considered to be a global health issue, with a high worldwide prevalence and causing chronic disease in afflicted individuals. The disease largely involves the liver but it can affect other organs, including the skin. While leukocytoclastic vasculitis has been reported as one of the dermatologic manifestations of HCV infection, there are no reports of this condition as the first symptom of HCV recurrence after liver transplantation.

CASE SUMMARY

We report here a case of leukocytoclastic vasculitis in a liver transplant recipient on maintenance immunosuppression. The condition presented as a palpable purpura in both lower extremities. Blood and urine cultures were negative and all biochemical tests were normal, excepting evidence of anemia and hypocomplementemia. Imaging examination by computed tomography showed a small volume of ascites, diffuse thickening of bowel walls, and a small bilateral pleural effusion. Skin biopsy showed leukocytoclasia and fibrinoid necrosis. Liver biopsy was suggestive of HCV recurrence in the graft, and HCV polymerase chain reaction yielded 11460 copies/mL and identified the genotype as 1A. Treatment of the virus with a 12-wk direct-acting antiviral regimen of ribavirin, sofosbuvir and daclatasvir led to regression of the symptoms within the first 10 d and subsequent complete resolution of the symptoms.

CONCLUSION

This case highlights the difficulties of diagnosing skin lesions caused by HCV infection in immunosuppressed patients.

Acral manifestations of viral infections

Viruses are considered intracellular obligates with a nucleic acid RNA or DNA. They have the ability to encode proteins involved in viral replication and production of the protective coat within the host cells but require host cell ribosomes and mitochondria for translation. The members of the families Herpesviridae, Poxviridae, Papovaviridae, and Picornaviridae are the most commonly known agents for cutaneous viral diseases, but other virus families, such as Adenoviridae, Togaviridae, Parvoviridae, Paramyxoviridae, Flaviviridae, and Hepadnaviridae, can also infect the skin. Herpetic whitlow should be considered under the title of special viral infections of the acral region, where surgical incision is not recommended; along with verruca plantaris with its resistance to treatment and the search for a new group of treatments, including human papillomavirus vaccines; HIV with maculopapular eruptions and palmoplantar desquamation; orf and milker's nodule with its nodular lesions; papular-purpuric gloves and socks syndrome with its typical clinical presentation; necrolytic acral erythema with its relationship with zinc; and hand, foot, and mouth disease with its characteristics of causing infection with its strains, with high risk for complication.

Zinc-Responsive Necrolytic Acral Erythema in a Patient With Psoriasis: A Rare Case

Necrolytic acral erythema (NAE) is a recently recognized dermatosis almost exclusively associated with hepatitis C virus (HCV) infection, and closely related to zinc deficiency. We present the case of a 60-year-old man with a history of psoriasis and chronic HCV infection, who developed new lesions of NAE extending from previous elephantine psoriatic plaques on bilateral lower legs. According to previous reports, resolution of NAE has been successfully achieved by treatment of the underlying HCV infection, or the use of oral zinc therapy. Our patient exhibited good response to zinc therapy. By reporting this case, we would like to raise the awareness of physicians to this unique acrally distributed dermatosis, which is distinct from psoriasis by its pathological feature of aggregated necrotic keratinocytes and its good response to zinc therapy rather than topical corticosteroids.

Zinc-responsive acral hyperkeratotic dermatosis-A novel entity or a subset of some well-known dermatosis?

BACKGROUND

We are reporting a series of interesting cases, which presented to us with psoriasiform lesions distributed over the acral regions of the body. The cases are unusual because they were resistant to conventional treatment modalities like topical corticosteroids, tacrolimus and oral methotrexate but showed significant improvement on oral zinc therapy.

MATERIALS AND METHODS

Ten patients with characteristic clinical features of distinctive hyperkeratotic plaque in the acral areas, who were resistant to treatment by different modalities including potent topical steroids and oral methotrexate, were included for detailed investigations. A proper history was taken and relevant laboratory investigations were done which included blood count, urine, liver function, renal function, hepatitis-C virus serology and serum zinc levels. Patients were followed up every 2 weeks. Histopathological examinations of the lesional tissue were done at baseline and after 6 weeks of therapy. Patients were given oral zinc daily and no other treatment during the 6 weeks course.

RESULTS

All our patients were non-reactive to hepatitis-C. Of the ten patients only one patient (10%) showed low titer of serum zinc, another (10%) showed higher zinc level, while the rest of the patients had normal zinc level. Five of our patients had chronic renal failure, one had Grave's disease and the remaining had no associated systemic illness. Histopathology mostly showed hyperkeratosis, acanthosis, prominent granular layer, spongiosis and dermal infiltrate. After 6 weeks of follow up, all patients showed rapid and remarkable therapeutic response with zinc.

CONCLUSIONS

We here report a series of patients, discernible because of their uniform clinical presentation of acral hypekeratotic plaques and in showing a noticeable response to zinc. Clinical, histopathological and laboratory investigations were done to rule out diseases of similar morphology including psoriasis, acral necrolytic erythema and lichen simplex chronicus. Authors understand that further studies with greater number cases and more detailed investigations are required to establish exact etio-pathogenesis and nomenclature of this distinct subset of patients.

Current knowledge in inflammatory dermatopathology

The complex and fascinating spectrum of inflammatory skin disease, and the comprehension of it, is ever expanding and evolving. During the first decade of the 21st century, numerous advances in the understanding of inflammatory disease mechanisms have occurred, particularly in psoriasis and atopic dermatitis. Continuation of this trend will assure a future in which molecular tests for biomarkers of immediate clinical relevance are used in routine patient care, not only for diagnosis but also for prognosis and management. This article focuses on selected recent or noteworthy developments that are clinically relevant for the histologic diagnosis of inflammatory skin diseases.

Necrolytic acral erythema in an adolescent

In 1996 el Darouti and Abu el Ela described seven Egyptian patients with similar cutaneous lesions and proposed necrolytic acral erythema (NAE) as a distinct entity of the necrolytic erythema family. Since then, NAE has emerged as a cutaneous manifestation of hepatitis C virus infection and taken its place in the literature as a marker for systemic disease. NAE initially presents with burning, pruritic eruptions of circumscribed, erythematous papules with flaccid vesiculation on the acral surfaces universally affecting the dorsum of the feet. The presenting papules of acute NAE evolve over time into confluent, velvety, hyperkeratotic plaques with decreased central erythema but a characteristic dark erythematous rim and adherent scale. Although mostly misdiagnosed as psoriasis or inflammatory dermatitis, NAE can be definitively placed among the necrolytic erythema family as a distinct entity based on clinical and histopathologic characteristics. We report a case of necrolytic acral erythema in a 17-year-old followed by a review of the literature.