Sweet's syndrome associated with encephalitis

My History in Juntendo University

With my retirement as a professor, I would like to review my 47-year history of studying and working at Juntendo University. I was admitted to Juntendo University School of Medicine in 1976, and after graduation I joined the Department of Neurology in 1982, where Professor Hirotaro Narabayashi was the founding chairman. I became particularly interested in movement disorders and neurophysiology. The second chairman, Professor Yoshikuni Mizuno, established an American-style neurology training system. From 1992 to 1994, I studied electrophysiology at the University of Calgary in Canada, and my family and I enjoyed life in Canada very much. In 2000, I moved to Juntendo Izu-Nagaoka Hospital, now renamed Juntendo Shizuoka Hospital. I instructed young neurologists to write case reports in English. Owing to this achievement, the third chairman, Professor Nobutaka Hattori, recommended me to be a recipient of Alumni Scientific Award and to become a professor of neurology in 2009. I also became an executive officer of the Asian and Oceanian Section of the International Parkinson and Movement Disorders Society from 2015 to 2019. In 2017, I was appointed as the dean of the Faculty of Health Science and Nursing. I devoted myself to improving the nursing education and then I received the Best Professor Award twice. The level of the faculty improved, so that all the students were able to pass the National Nursing Examination consistently. In conclusion, I thank all my colleagues, faculty members, and family for letting me have valuable experiences and memories in Juntendo University.

Necrotising Sweet's syndrome: a rare presentation of Sweet's syndrome with unilateral painful swelling of the neck

This case describes the first documented clinical presentation of Sweet's syndrome with unilateral swelling of the neck, severe pain and fever. The clinical and radiological manifestation resembled necrotising fasciitis and the patient underwent acute neck dissection. The patient was ultimately diagnosed with a new subtype of Sweet's syndrome called necrotising Sweet's syndrome, and quickly recovered after treatment with intravenous administration of prednisolone.

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.

Neuro sweet syndrome: a systematic review. A rare complication of Sweet syndrome

Sweet's syndrome (SS) is an inflammatory disease characterized by fever, leucocytosis and distinctive skin lesions that histologically consist of a dermal infiltrate of neutrophils with nuclear fragmentation. Aseptic neutrophilic inflammation may occur also in other organs. Central nervous system involvement in SS, Neuro-Sweet's syndrome (NSS), is rare and reported especially among Asian patients. A systematic review of the literature has been performed to find articles reporting cases of SS with neurological involvement. The search terms: "Sweet's syndrome/disease with neurological involvement, Neuro Sweet Syndrome/Disease" were used in the Pubmed Database. Sixty-nine NSS patients including 46 males and 23 females, more Asian than Caucasian, have been described from 1983 to date. The average age was 48.7 year-old. The most representative neurologic symptom was the altered state of consciousness, followed by headache and memory disorders. Differently from SS with skin or other district involvement, NSS appears to be more common in Asian patients than in Caucasian ones and affects mainly the male sex in the third or fourth decade of life. A very wide range of symptoms and signs can occur, depending on which part of the nervous system is affected. Initial presentation is usually with the SS typical skin lesions followed by neurological involvement. However, also an opposite presentation or a simultaneous skin and nervous involvement may happen. Awareness of the possible neurological complications in SS is important to avoid unnecessary therapies for other forms of meningoencephalitis and lead to successful treatment with systemic corticosteroids.

Neuro-Sweet disease with positive modified acid-fast staining of the cerebrospinal fluid: A case report

Neuro-Sweet disease (NSD) is Sweet disease with central nervous system (CNS) involvement. To the best of our knowledge, the present case report is the first to describe NSD complicated by endogenous infection with Mycobacterium tuberculosis. The present case report describes a male patient who developed NSD-induced meningitis, which initially manifested as a fever, headache and neck stiffness. Painful erythematous plaques subsequently developed on his face, neck and upper trunk. Brain magnetic resonance imaging was performed and the results were normal, whereas modified acid-fast stain analysis of the cerebrospinal fluid (CSF) provided a positive result. The patient was thus diagnosed with viral meningitis and tuberculosis. However, subsequent skin biopsy results demonstrated neutrophilic infiltration into the dermis without vasculitis, and subsequent human leukocyte antigen typing was positive for Cw1 and negative for B51 and the patient was diagnosed with NSD. Following treatment with corticosteroids, and antiviral and anti-tuberculotic agents, the clinical symptoms were reduced and the previously abnormal findings in the CSF examinations and associated laboratory data were improved. The present case indicates that the diagnosis of NSD is not easily achieved, and early skin biopsy is vital to ensure a fast and effective diagnosis. In addition to systemic corticosteroids, comprehensive treatment is also recommended for patients with NSD complicated by additional complex medical problems.

EPONYM. Sweet syndrome

Sweet syndrome, also referred to as acute febrile neutrophilic dermatosis, is characterized by tender, red inflammatory nodules or papules that occur in association with infection, malignancy, connective tissue disease, or following exposure to certain drugs. Although drug-induced Sweet syndrome is rare, granulocyte colony-stimulating factor, all-trans-retinoic acid, and miscellaneous drugs have been implicated in causing this disorder in adults. In pediatric patients, granulocyte colony-stimulating factor, all-trans-retinoic acid, trimethoprim-sulfamethoxazole, and azathioprine have been implicated as potential causes of drug-induced Sweet syndrome. To date, six cases, including the patient reported here, have been reported in children.

Reversible extensive leukoencephalopathy in Sweet disease: a case report

Sweet disease, also known as acute febrile neutrophilic dermatosis, is an idiopathic multisystem inflammatory disorder characterised by erythematous skin lesions and fever. "Neuro-Sweet disease" is a rare central nervous system involvement that coexists with the characteristic cutaneous lesions of Sweet disease. Here, we report a case of Sweet disease complicated with acute encephalopathy. This case showed extensive lesions in the cerebral white matter on magnetic resonance imaging (MRI) and high protein concentration in the cerebrospinal fluid (CSF) without pleocytosis. After steroid therapy, the patient's clinical syndrome recovered completely with no significant neurological deficits or abnormal findings on brain MRI, and normalization of the high CSF protein concentration. Both clinical and MRI findings suggested that the marked leukoencephalopathy in this case was mainly due to reversible oedema rather than destructive structural alterations in the cerebral parenchyma.

Longitudinal analysis of cytokines and chemokines in the cerebrospinal fluid of a patient with Neuro-Sweet disease presenting with recurrent encephalomeningitis

BACKGROUND

Neuro-Sweet disease (NSD) has recently been identified as Sweet disease with central nervous system (CNS) involvement characterized by multisystem neutrophilic infiltration. However, the pathogenesis of this disease remains unknown. Neutrophil and other inflammatory cell activities are influenced by many cytokines and chemokines, but to date, no studies have examined the levels of these factors in patients with NSD.

PATIENT AND METHODS

The patient presented with encephalomeningitis twice in one year and was diagnosed with NSD. We measured the levels of cytokines (i.e., IL-2, IL-4, IL-6, IL-10, IFN-gamma, and TNF-alpha) and chemokines (i.e., CCL2, CCL3, CCL5, CXCL8, CXCL10 and GM-CSF) in 10 CSF samples from the patient longitudinally for one year including those during two episodes of encephalomeningitis.

RESULTS

The elevations of IL-6, IFN-gamma, CXCL8 (IL8) and CXCL10 (IP10) were markedly higher than the levels in uninfected control subjects with neurological disorders. The levels of these cytokines and chemokines were statistically correlated with total CSF cell counts (p <0.01).

CONCLUSION

CD4+ helper T (Th) cells can be divided into the Th1 and Th2 subtypes according to their cytokine secretion patterns, and IFN-gamma and IP10 are the Th1-type cytokine and chemokine indicating the involvement of Th1 cells in NSD. In addition, the level of IL8, a specific neutrophil chemoattractant, correlated well with the neutrophil cell counts in CSF. Our data suggest the important roles of Th1 cells and IL8 in the pathogenesis of NSD.

Successful treatment of relapsing neuro-Sweet's disease with corticosteroid and dapsone combination therapy

Sweet's disease with central nervous system involvement, tentatively named neuro-Sweet's disease, has rarely been reported. Although systemic corticosteroid therapy is highly effective for neurologic symptoms in neuro-Sweet's disease, relapse is common. Here, we describe the case of a 38-year-old Japanese man who presented with relapsing neuro-Sweet's disease that was successfully treated with a combination of corticosteroid and dapsone. Dapsone should be considered as a therapeutic option for neuro-Sweet's disease patients showing relapse.

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.

[Aseptic meningitis during Sweet syndrome]

BACKGROUND

Sweet syndrome is a neutrophilic skin disease that can involve extracutaneous signs. Here we describe a case of aseptic meningitis, a rare potential extracutaneous sign of Sweet syndrome.

CASE REPORT

A 42-year-old man was hospitalized for non-pruritic maculoerythematous skin lesions of the legs and back with subsequent myalgia. A histology specimen taken from a skin lesion revealed an acute neutrophilic disease consistent with Sweet syndrome. Marked inflammation and cholestasis were observed. Systemic corticosteroid therapy was given and resulted in good clinical and laboratory response. Two weeks later, in a setting of gradual dosage reduction, the patient was hospitalized for intense headaches associated with meningeal irritation in an inflammatory context. Liver function tests were again abnormal. We concluded on a diagnosis of Sweet syndrome complicated by aseptic meningitis and hepatic sites. Investigation for underlying disease, particularly digestive or hematologic, was negative. A favorable outcome was achieved following administration of higher doses of systemic corticosteroids.

DISCUSSION

Aseptic meningitis constitutes an extracutaneous localization of Sweet syndrome. A multidisciplinary approach and exclusion of infectious origin are required in order to institute systemic corticosteroid therapy.

Sweet's syndrome and sarcoidosis

In this review we summarize a number of cases of Sweet's syndrome (SS) associated with sarcoidosis that have been reported in the English literature. In all of the cases, the two disorders were diagnosed simultaneously. Patients with both disorders were younger and had a higher rate of fever than patients with SS alone. In this group of patients, we found a trend toward less skin involvement of the face and trunk, more involvement of the upper limbs, and more atypical skin lesions, particularly papules. The association of the two disorders seems to be more related to a subset of acute sarcoidosis (Lofgren's syndrome). All of the patients in this group had a benign course and self-limiting disease. Thus, SS in association with sarcoidosis could be considered a favorable prognostic factor. Although SS has a high rate of recurrence, no recurrence occurred in this group of patients during follow-up.

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's syndrome with neurologic manifestation: case report and literature review

BACKGROUND

Sweet's syndrome with involvement of the central nervous system (CNS) is rarely reported.

METHODS

We describe a Japanese woman with Sweet's syndrome associated with acute-onset encephalitis and review literatures.

RESULTS

Examination of the cerebrospinal fluid (CSF) revealed pleocytosis with lymphocytes predominant. Magnetic resonance imaging (MRI) revealed increased signal intensity on T2-weighted scans in the left temporal lobe. To our knowledge, 22 cases of Sweet's syndrome associated with CNS involvement have been reported. The mean age is 47.6 years (n = 22). Sex distribution (male : female) is 12 : 10 (n = 22). The most common neurologic symptoms are convulsions, headaches, and disturbance of consciousness. CSF cell count is increased with lymphocytes predominant in 8 cases (n = 12). Certain (HLA) types (B54 and Cw1) may be characteristic findings in Sweet's syndrome accompanied with the CNS involvement in Japanese patients, as these were found in four previous cases similar to the present case.

CONCLUSIONS

Although Sweet's syndrome with neurologic manifestations is rarely reported, it may be needed to investigate neurologic manifestations.

Idiopathic hypertrophic cranial pachymeningitis associated with Sweet's Syndrome

A case of hypertrophic cranial pachymeningitis associated with Sweet's Syndrome is presented. Both entities have been described in association with several other chronic systemic inflammatory diseases and autoimmune conditions. To our knowledge the coexistence between Sweet's Syndrome and hypertrophic cranial pachymeningitis has not been reported up to date. We suggest a possible autoimmune or dysimmune mechanism in the pathogenesis of these two entities.