Ocular Involvement in Acute Febrile Neutrophilic Dermatosis (Sweet Syndrome): New Cases and Review of the Literature

Periorbital necrotizing sweet syndrome: A report of two cases mimicking necrotizing soft tissue infections

Purpose

Two cases are described of necrotizing Sweet syndrome (nSS), a rare variant of acute febrile neutrophilic dermatosis that mimics necrotizing soft tissue infections.

Observation

A 74-year-old female with myelodysplastic syndrome (MDS) presented with isolated periorbital nSS that closely mimicked necrotizing fasciitis (NF); she displayed pathergy to debridement, was exquisitely responsive to corticosteroids, and underwent successful first-stage reconstruction of the eyelid with full-thickness skin grafting. A second 40-year-old female patient with relapsed acute myelogenous leukemia (AML) presented with multifocal nSS most prominently involving the eyelid. Positive herpes zoster virus (HSV) PCR and bacterial superinfection complicated the diagnosis. She improved with chemotherapy for AML and corticosteroid therapy.

Conclusion

nSS is rare and a high level of clinical suspicion as well as an understanding of its distinguishing features is necessary to avoid undue morbidity. Identification of pathergy, histopathology, microbiology, and clinical context are critical to avoid misdiagnosis of infection.

Sweet Syndrome and Neutrophilic Dermatosis of the Dorsal Hands

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.

Elevated Intraocular Pressure in Periorbital Sweet's Syndrome

A 66-year-old immunocompromised man presented with cellulitis around the left eye that was initially concerning for necrotizing fasciitis. Exam findings were remarkable for exquisite periocular tenderness with rigid, immobile eyelids resulting from severe erythema, edema, and induration. Given the concern for orbital compartment syndrome and a necrotizing infection, the patient was taken urgently to the operating room for debridement of the eyelid skin as well as an urgent lateral canthotomy and cantholysis. His eye exam revealed 360° of hemorrhagic chemosis, no relative afferent pupillary defect, and an ipsilateral elevated intraocular pressure of 35 mm Hg. No visual acuity measurement could be obtained secondary to the patient's altered mental status. His intraocular pressure normalized after treatment with antihypertensive drops and further extension of the canthotomy. Histopathological analysis showed extensive neutrophilic infiltrate of the dermis which was compatible with a diagnosis of Sweet's syndrome.

Sweet Syndrome Associated with Myelodysplastic Syndrome—A Review of a Multidisciplinary Approach

Sweet syndrome (SS) is a rare disease described as a febrile neutrophilic dermatosis with acute onset, the pathogenesis of which has not yet been elucidated. The syndrome is characterized by the sudden onset of erythematous infiltrated papules or plaques located on the upper body and is associated with fever, leukocytosis and neutrophilia. The lesions show a dense dermal infiltration with mature neutrophils. The condition is responsive to systemic steroids. The central nervous system, bones, muscles, eyes, ears, mouth, heart, lung, liver, kidneys, intestines, and spleen may be affected by SS as extracutaneous manifestations. More and more cases have been found to be associated with malignancies, particularly myelodysplastic syndrome, and, less frequently, other hematologic malignancies or solid tumors. Approximately 21% of patients with SS have an associated malignancy and up to 80% of MASS cases are associated with hematological diseases, predominantly myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). Myelodysplastic syndrome is a clonal disease of the bone marrow characterized by inefficient hematopoiesis, dysplasia of the bone marrow and peripheral cytopenias. Affected patients have a high risk of leukemic transformation. After analyzing later studies and current practical aspects regarding MDS-related SS, we suggest an algorithm for evaluating these patients.

New Practical Aspects of Sweet Syndrome

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.

Sweet's Syndrome: A Case Report of a Rare Extraintestinal Manifestation of Ulcerative Colitis

Sweet’s syndrome is a neutrophilic dermatosis of unknown etiology and a rare extraintestinal manifestation of ulcerative colitis.

Classically, it is more common in women with active inflammatory bowel disease (IBD). This syndrome typically presents in patients with acute-onset painful tender erythematous skin lesions and is usually accompanied by fever, arthralgia, and elevated inflammatory markers. Histological examination is characterized by diffuse dense dermal neutrophilic infiltrate with leukocytoclasia, without vasculitis.

The treatment goals are to reduce morbidity and complications, and the most effective therapy is systemic corticosteroids. Early recognition of this syndrome is essential to improve our diagnostic and therapeutic abilities.

We report a case of a 59-year-old female with ulcerative colitis, which presented with manifestations of Sweet’s syndrome.

Systematic Review: Sweet Syndrome Associated with Inflammatory Bowel Disease

BACKGROUND AND AIMS

Sweet syndrome [SS] is a dermatological condition associated with both inflammatory bowel disease [IBD] and azathioprine use. We performed a systematic review to better delineate clinical characteristics and outcomes of SS in IBD patients.

METHODS

Peer-reviewed, full-text journal publications from inception to April 2020 in English language and adult subjects with IBD were included. Skin biopsy was required as SS gold-standard diagnosis. Azathioprine-associated SS required recent azathioprine introduction or recurrence of SS after azathioprine re-challenge.

RESULTS

We included 89 publications with 95 patients [mean age of SS diagnosis: 44 years; 59% female; 20 with azathioprine-associated SS and 75 without]. SS was diagnosed prior to IBD in 5.3%, at time of IBD diagnosis in 29.5% and after diagnosis in 64.2%. In total, 91% of patients with SS had known colonic involvement and the majority [76%] had active IBD at diagnosis; 22% had additional extra-intestinal manifestations. Successful therapies for SS included corticosteroids [90.5%], anti-tumour necrosis factor [TNF]-α inhibitor therapy [14.8%] and azathioprine [11.6%]. Azathioprine-associated SS was distinct, with 85% male patients, mean age of SS diagnosis of 50 years and a lower likelihood to be prescribed corticosteroids for treatment [75% vs 94.7% of non-azathioprine-associated SS, p = 0.008]. All patients with azathioprine-associated SS improved with medication cessation and developed recurrence after re-challenge.

CONCLUSIONS

SS may precede or occur with IBD diagnosis in almost one-third of cases. Azathioprine and IBD-associated SS present and behave distinctly, especially with regard to gender, age at diagnosis and recurrence risk. Corticosteroids and TNF-α inhibitors have demonstrated efficacy in treating SS in IBD.

Relentlessly Progressive Sweet Syndrome of the Eye with Scleritis and Choroidal Infiltration

PURPOSE

To describe a case of Sweet syndrome, a dermatologic inflammatory disease, with progressive, unrelenting ocular findings.

METHODS

Case report.

RESULTS

A 73-year-old male was evaluated with a six-month history of Sweet syndrome, manifesting as cutaneous erythematous edematous papules on the dorsal arms and shins and confirmed with biopsy demonstrating neutrophil infiltration with nuclei fragmentation and lack of vasculitis. He initially noted a unilateral red eye with ocular pain and was found to have scleritis and choroidal infiltration. The patient's ocular disease progressed despite treatment with systemic corticosteroids, intraocular Ozurdex ®, systemic dapsone, and subtenons triamcinolone. Systemic evaluation was negative for malignancy or other inflammatory syndromes. Following 7 months of non-manageable ocular pain enucleation was offered to the patient, but he declined.

CONCLUSION

Sweet syndrome, a dermatologic condition, can be associated with unilateral scleritis and choroidal infiltration that are relentlessly progressive despite maximal systemic and ocular corticosteroid therapy.

Ocular involvement in a patient with Sweet syndrome: report of a case and review of the literature

The case presented is a 66-year-old woman who attended the emergency department due to skin lesions on the limbs, facial oedema, and eye redness accompanied by haemorrhagic conjunctivitis. The symptoms resolved after one week of systemic steroid treatment. Skin biopsy confirmed Sweet syndrome. Sweet syndrome is rare disorder and unknown by most ophthalmologists despite its frequent ophthalmological manifestations. Ocular involvement is present in one third of patients, with episcleritis and conjunctivitis being the most repeated. Pathology findings confirm the diagnosis which is also characterised by a rapid response to systemic corticosteroids.

Neutrophilic drug reactions

Neutrophilic drug reactions are unique eruptions that can affect hospitalized patients and share a common pathophysiology with neutrophils as the key mediators of inflammation. They range in clinical presentation from papules and plaques to bullae and erosions to pustules. Although there is some overlap in presentation, each has distinguishing features that aid the clinician in differentiation from one another and from other drug hypersensitivity reactions. Much of the data on these reactions are from case reports and series or retrospective review studies. There are limited prospective observational studies dedicated to these adverse drug reactions. We review the more common and life-threatening neutrophilic drug reactions, their proposed mechanism of action, and their management.

Exophthalmos due to sterile neutrophilic dermatosis in a dog

An 8-year-old castrated male Bichon Frise was presented to the Kansas State University Veterinary Health Center for evaluation of unilateral right-sided exophthalmos, suspected secondary to a retrobulbar abscess. The dog had acutely developed right-sided periorbital swelling, exophthalmos with pain on retropulsion, as well as multiple cutaneous exudative plaques on the feet and tail base. On ophthalmic examination, the dog also exhibited mild left-sided exophthalmos with decreased, nonpainful retropulsion. Orbital ultrasound and CT were performed to evaluate the extent of bilateral orbital disease. Incisional biopsies were obtained from the affected right periorbital tissues and skin of the feet, and histopathology revealed severe neutrophilic inflammation of the dermis with no organisms detected. Histologic changes were consistent with sterile neutrophilic dermatosis. The dog achieved clinical remission following treatment with initial immunosuppressive doses of corticosteroids and subsequent long-term maintenance therapy using oral cyclosporine.

Neuro-Ophthalmic Presentation of Neuro-Sweet Disease

Acute febrile neutrophilic dermatosis (Sweet syndrome) is a systemic inflammatory condition usually associated with autoimmune or neoplastic processes and characterised by inflammatory dermatologic lesions such as erythematous plaques and papules associated with fever and leukocytosis. Neurological and ophthalmological involvement is rare. The authors describe an unusual case of Sweet syndrome associated with microscopic polyangiitis presenting with papilloedema, anterior uveitis, and skin rash. Years later, he developed acute posterior multifocal placoid pigment epitheliopathy. Treatment with immunosuppressive medications led to a relapsing remitting course with maximum benefit from use of steroids. The authors describe the difficulties in diagnosis and treatment of this rare case.

Sweet's syndrome complicating ulcerative colitis: a rare association

Sweet's syndrome (SS) is a neutrophilic dermatosis disorder of unknown aetiology, characterised by acute fever, neutrophilia, painful erythematous papules, nodules and plaques, and an infiltrate consisting predominantly of mature neutrophils in the upper dermis. Classical SS is a rare extra-intestinal manifestation of inflammatory bowel disease (IBD). It is more common in Crohn's disease than in ulcerative colitis (UC). There is a predilection for women, and for patients with colonic disease and active IBD. We report the case of a 39-year-old woman with a flare of moderate severity UC treated with mesalazine who presented with a 5-day history of acute fever, painful papules and plaques on forearms and legs, episcleritis and cervical pain. Skin biopsies showed papillary dermis inflammatory cell infiltration composed mainly of neutrophils, without evidence of leukocytoclastic vasculitis or panniculitis, compatible with SS. The patient had an excellent response to systemic corticosteroids. Symptoms promptly improved and skin lesions resolved after 7 weeks.

Neuro-Sweet Disease Causing Orbital Inflammation

Neuro-Sweet disease is a rare condition causing encephalitis or meningitis in addition to the erythematous skin plaques of Sweet syndrome. Neuro-Sweet disease has been associated with several ocular manifestations, including ocular movement disorders, episcleritis, conjunctivitis, uveitis, and optic disc oedema. The author reports a patient with orbital inflammation, cranial neuropathies, and a skin rash in the setting of myelodysplastic syndrome. Biopsy of her skin lesion confirmed the diagnosis of neuro-Sweet disease. To the author's knowledge, this is the first reported case of neuro-Sweet disease causing orbital inflammation. Her ocular inflammation resolved with the use of systemic corticosteroid treatment.

[A case of neuro-Sweet disease showing the close association between disease activity and levels of soluble IL-2 receptor]

A 76-year-old man was admitted to our hospital presenting with fever, redness and pain in both the periocular regions, and disturbance of consciousness. He had neck stiffness, and cerebrospinal fluid analysis suggested aseptic meningoencephalitis. Laboratory tests showed increased levels of C-reactive protein, soluble IL-2 receptor (sIL-2R) and MPO-ANCA. Magnetic resonance imaging revealed hyperplastic bone marrow in the clivus and cervical vertebra. Although T-cell receptor gene rearrangement was detected in the bone marrow blood, bone marrow biopsy of the ilium showed no malignant findings. Then he experienced bilateral auricular inflammation and painful erythema of the ankle. A leg skin biopsy demonstrated neutrophilic infiltration into the dermis with no signs of vasculitis. His HLA-type was defined as Cw1. He was subsequently diagnosed with neuro-Sweet disease. Intravenous administration of methylprednisolone (1,000 mg/day) for 5 days and subsequent oral intake of prednisolone (60 mg/day) improved his symptoms. When the prednisolone dose was reduced to 30 mg/day, his symptoms returned and a new lesion was detected in the splenium of the corpus callosum. Upon additional treatment with cyclosporine, the prednisolone dose could be reduced without symptom relapse; sIL-2R and MPO-ANCA levels also decreased to normal. The present case suggested that the activity of neuro-Sweet disease may be associated with myeloid hyperplasia, T-cell receptor gene rearrangement and the amounts of soluble interleukin-2 receptor and MPO-ANCA.

Neutrophilic dermatoses as systemic diseases

Neutrophilic dermatoses (ND) are inflammatory skin conditions characterized by a sterile infiltrate of normal polymorphonuclear leukocytes. The main clinical forms of ND include Sweet syndrome, pyoderma gangrenosum, erythema elevatum diutinum, subcorneal pustular dermatosis, and their atypical or transitional forms. ND are often idiopathic, but they may be associated with myeloid hematologic malignancies (Sweet syndrome), inflammatory bowel disease or rheumatoid arthritis (pyoderma gangrenosum), and monoclonal gammopathies (erythema elevatum diutinum, subcorneal pustular dermatosis). The possible infiltration of internal organs with neutrophils during the setting of ND underlies the concept of a neutrophilic systemic disease. ND may be seen as a polygenic autoinflammatory syndrome due to their frequent association with other autoinflammatory disorders (monogenic or polygenic) and the recent published efficacy of interleukin-1 blocking therapies in their management.

Campylobacter gastroenteritis associated with Sweet's syndrome

Sweet's syndrome or acute febrile neutrophilic dermatosis has been associated with underlying infection, malignancy, inflammatory disease and certain medications. The infection agents associated with this include Streptococcus species, Yersinia species, Chlamydia species, Salmonella species and Helicobacter pylori. We report a case of Sweet's syndrome in a 73-year-old woman following a 2 week course of severe gastroenteritis caused by Campylobacter species. Histological examination of skin lesions showed marked inflammatory infiltrate throughout the dermis, composed of neutrophils and histiocytes. The patient was successfully treated with topical and systemic steroids. To date, this is the first case of Sweet's syndrome to be reported linked to Campylobacter species to our knowledge.