Necrotizing vasculitis

Differential diagnosis of stage 2, 3 and 4 pressure injuries of the pelvis and lower extremity: a case series

Constant, unrelieved pressure of local tissue, particularly over bony prominences, may provoke damage that progresses to necrosis and pressure injury (PI). Differentiating PIs from conditions of similar appearance is imperative to minimising complications and implementing prompt treatment. This case series describes several conditions that may be mistaken for a PI. Outlined are the key differences in patient history, presentation and clinical cues that assist in correctly identifying the true pathology behind these conditions. Conditions reviewed included: pyoderma gangrenosum; necrotising fasciitis; genital herpes; Marjolin ulcer, Rosai-Dorfman disease; vascular disease; coagulopathies; calciphylaxis; trauma and surgical wounds; pilonidal cysts; graft-versus-host disease; hidradenitis suppurativa; Stevens-Johnson syndrome; epidermolysis bullosa; radiation wounds; spider bites; and end-of-life skin failure pressure ulcers (also known as Kennedy ulcers). Although commonly recognised and diagnosed, stage 2, 3 and 4 PIs occasionally prove to be difficult to pinpoint, with undefined characteristics and similarities in presentation to several other conditions. Therefore, it is clinically vital to be aware of their appearance, risk factors and aetiology in order to make an appropriate patient assessment and avoid misdiagnosis.

Mycobacterium tuberculosis Cell Wall Antigens Induce the Formation of Immune Complexes and the Development of Vasculitis in an Experimental Murine Model

Tuberculosis (TB) of the central nervous system (CNS) presents high mortality due to brain damage and inflammation events. The formation and deposition of immune complexes (ICs) in the brain microvasculature during Mycobacterium tuberculosis (Mtb) infection are crucial for its pathobiology. The relevance of ICs to Mtb antigens in the pathogenesis of CNS-TB has been poorly explored. Here, we aimed to establish a murine experimental model of ICs-mediated brain vasculitis induced by cell wall antigens of Mtb. We administered a cell wall extract of the prototype pathogenic Mtb strain H37Rv to male BALB/c mice by subcutaneous and intravenous routes. Serum concentration and deposition of ICs onto blood vessels were determined by polyethylene glycol precipitation, ELISA, and immunofluorescence. Histopathological changes in the brain, lung, spleen, liver, and kidney were evaluated by hematoxylin and eosin staining. Our results evidenced that vasculitis developed in the studied tissues. High serum levels of ICs and vascular deposition were evident in the brain, lung, and kidneys early after the last cell wall antigen administration. Cell wall Mtb antigens induce strong type III hypersensitivity reactions and the development of systemic vasculitis with brain vascular changes and meningitis, supporting a role for ICs in the pathogenesis of TB.

Ceftriaxone-induced leukocytoclastic vasculitis: a case report and literature review of antibiotic-induced leukocytoclastic vasculitis

Leukocytoclastic vasculitis (hypersensitivity vasculitis) is defined as small blood vessel inflammation with skin or other systemic manifestations due to infections, drugs, or neoplastic disease. This clinical case report highlights an association between ceftriaxone and leukocytoclastic vasculitis in a 49-year-old female patient with a history of penicillin allergy, on mirtazapine for anxiety disorder. Articles concerning antibiotic-induced leukocytoclastic vasculitis are also reviewed. The patient reported a symptom of upper respiratory tract infection and fever 5 days previously for which she received ceftriaxone for 2 days before presenting to the emergency department with a pruritic skin rash in the upper and lower extremities and swollen lips for 1 day. The rash was erythematous, maculopapular, itchy, and non-tender, with no mucus membrane involvement. Laboratory investigations revealed leukocytosis (white blood cells, 22.3 × 10⁹/L) that was mainly eosinophilic (18.4%). The patient was administered prednisolone and antihistamine after stopping ceftriaxone empirically. A skin biopsy confirmed the diagnosis of leukocytoclastic vasculitis. Significant clinical improvement was observed after treatment initiation. Upon follow-up, the skin rash was resolved entirely with no scars; however, there was skin-peeling over the lower extremities. Recognition of antibiotic-induced leukocytoclastic vasculitis is crucial as many classes of antibiotics can contribute to this condition. Continuation of the offending drug may lead to life-threatening complications.

Systematic review of warfarin-induced skin necrosis case reports and secondary analysis of factors associated with mortality

OBJECTIVE

Warfarin-induced skin necrosis (WSN) is a rare (0.0.1%-0.1%) and severe adverse reaction. The clinical characteristics of this reaction and its mortality rate have not been explored in a large population. Therefore, we present the case of a Peruvian patient who developed WSN and perform a systematic review of case reports of WSN.

METHODS

A systematic search was performed using the Pubmed/Medline, Scopus, Web of Science and Embase databases. Patient clinical data were collected and extracted from every case report. Furthermore, we analysed the factors associated with mortality because of WSN using the Poisson regression model with robust variations, obtaining risk ratios (RR) and their respective confidence intervals (95% CI).

RESULTS

We identified 90 case reports that included a total of 111 patients with WSN (mean age 52.5 years), 20.72% of whom died of complications because of WSN. Being male (RR: 2.87; 95% CI 1.21-6.83) and having three or more affected regions (RR: 6.81; 95% CI 2.62-17.74) were associated with an increased risk of death caused by WSN.

CONCLUSION

This systematic review identified 90 case reports of WSN with three or more affected body regions. Male sex was associated with an increased risk of death. Further studies are needed to analyse and confirm these results.

Epstein-Barr virus-related cutaneous necrotizing vasculitis in a girl heterozygous for factor V Leiden

Background

Necrotizing vasculitides are basically characterized by vessel wall neutrophil infiltration and necrosis and they can occur as a primary process or secondary to an underlying disease. Although Henoch-Schönlein purpura (HSp) is the more frequent primary vasculitis in childhood, sometimes it has to be distinguished from other secondary vasculitides induced by infections, drugs, vaccines, or immune-mediated disorders.

Main observations

We report a case of a 14-year-old girl with cutaneous necrotizing vasculitis, appearing in the course of acute Epstein-Barr virus infection. Physical examination revealed highly aching erythematous-purple lesions with reticular edges localized on the back of feet. Pain was non-responsive to ibuprofen and required administration of tapentadol and pregabalin. The patient was also heterozygous for factor V Leiden that might have contributed to the development of cutaneous painful lesions.

Conclusions

To our knowledge this is the first documented pediatric case of necrotizing vasculitis associated with acute EBV infection in a girl heterozygous for factor V Leiden. In this patient the severity of skin manifestations might have been influenced by the concomitant factor V Leiden, which gave rise to hypercoagulability and occlusive vasculopathy with markedly severe pain, a symptom rather infrequent in other childhood vasculitides.

Dermatologic Problems in the Intensive Care Unit: Part IV

In this final section of our review, we discuss a variety of skin disorders often acquired during hospitalization in the intensive care unit. Environmental, nutritional, immunologic, and pharmacologic factors, among others, place patients at risk for drug eruptions, including leukocytoclastic vasculitis and anticoagulant-induced necrosis; moniliasis; acquired zinc deficiency; recurrent herpes simplex labialis; seborrheic dermatitis; contact dermatitis; and pressure sores.

Vasculite cutânea de pequenos vasos: etiologia, patogênese, classificação e critérios diagnósticos - Parte I

Vasculite é a inflamação da parede dos vasos. Pode variar em gravidade desde doença autolimitada de um único órgão até doença grave com risco de morte por falência de múltiplos órgãos. Existem várias causas, embora só se apresente por poucos padrões histológicos de inflamação vascular. Vasos de qualquer tipo e em qualquer órgão podem ser afetados, resultando em ampla variedade de sinais e sintomas. Diferentes vasculites com apresentações clínicas indistinguíveis têm evolução e tratamento muito diferentes. Essa condição representa desafio para o médico, incluindo classificação, diagnóstico, exames laboratoriais pertinentes, tratamento e seguimento adequado. Neste artigo são revistos a classificação, a etiologia, a patogênese e os critérios diagnósticos das vasculites cutâneas.

Mast cells in cutaneous allergic vasculitis: a case report

BACKGROUND

The mechanism of cutaneous allergic vasculitis still remains unclear, and to the best of our knowledge, no case has been reported in the literature in which the number of mast cells was examined.

METHODS

A 33-year-old woman, with a past history of allergic rhinitis due to Japanese cedar and Phleum pratense (timothy), presented with a chief complaint of palpable papules on both lower legs in December 2002. On blood examination, peripheral blood eosinophilia was present, but all other examinations for immunologic diseases were negative, including specific IgE. We suspected cutaneous allergic vasculitis and performed skin biopsy.

RESULTS

In December 2002, histological examination of biopsy specimens of the skin lesions showed leukocytoclastic vasculitis. The diagnosis of cutaneous allergic vasculitis was made based on the clinical symptoms and the pathological findings of biopsy specimens. Immunohistochemical staining for human mast cell tryptase using monoclonal antibody against human mast cell tryptase showed an accumulation of mast cells. Treatment with oral corticosteroid resulted in the disappearance of clinical symptoms, and the steroid tapered. A second skin biopsy was performed in June 2005 after informed consent was obtained. Histological examination showed no findings of leukocytoclastic vasculitis, and the number of mast cells had decreased. She has been well without treatment.

CONCLUSIONS

Mast cells may increase in the skin lesion of cutaneous allergic vasculitis.

Kawasaki-like syndromes and other vasculitic syndromes in HIV-infected patients

Excluding drug-related hypersensitivity reactions, vasculitic syndromes are not common in HIV-positive patients. Review of the existing literature suggests that HIV positive patients may be predisposed to polyarteritis nodosa, microscopic polyarteritis, Kawasaki-like syndromes, acute occlusion syndromes, primary angiitis of the central nervous system and erythema elevatum diutinum. With the exception of erythema elevatum diutinum, these vasculitic syndromes have significant morbidities and mortality if they are not treated. It is therefore important to make these diagnoses and to initiate appropriate therapy in a timely fashion. Because fevers, malaise, weakness, rashes, headaches and neurologic symptoms are common in HIV-positive patients, it is probable that some cases of vasculitis go undiagnosed. In this report, we review vasculitic syndromes seen in HIV-positive patients. We also re-examine a previously published case of a young HIV-positive male who died of an acute myocardial infarction without atherosclerotic disease. Immunohistopathology of the affected arteries suggests that he died of a Kawasaki-like syndrome.

Acute febrile neutrophilic vasculitis of the skin of young Shar-Pei dogs

Three young Shar-Pei dogs were presented for signs of an acute widespread dermatopathy associated with fever and malaise. Cutaneous lesions initially consisted of multifocal areas of skin discolouration (haemorrhagic papules, macules or plaques) or oedema, preferentially affecting the head and limbs. In some locations, pus-filled bullae were evident also. Cutaneous lesions exuded seropurulent liquid and, in time, usually progressed to full thickness necrosis and ulceration. Lesions were so widespread and severe that one of the dogs was euthanased because its owners could not afford the reconstructive surgery required to close the skin deficits left at the completion of otherwise successful therapy. Histological examination of representative biopsies showed neutrophilic dermatitis and vasculitis, which ultimately resulted in ischaemic necrosis of skin. Therapy with immunosuppressive doses of corticosteroids, and in one case cyclophosphamide, resulted in prompt amelioration of the underlying inflammatory process, although regions of skin deprived of their blood supply eventually became necrotic and sloughed. Healing occurred through granulation, contraction and epithelialisation. The physical findings in these three dogs were so similar that it is likely all suffered from the same breed-related syndrome, an immune-mediated vasculitis precipitated by some event, such as vaccination or an undetected infection. Whatever the inciting cause, it was most likely a one-off event, as the two surviving dogs were readily weaned off immunosuppressive medication without relapse.

Leucocytoclastic vasculitis: an update for the clinician

Leucocytoclastic vasculitis is a small vessel inflammatory disease mediated mostly by deposition of immune complexes. Infections, medications, chemicals, bacteria, viruses, and diseases associated with immune complexes have been accused in the pathogenesis. Cutaneous leucocytoclastic vasculitis presents as palpable purpura most often localized in the lower extremities, often accompanied by abdominal pain, arthralgia and renal involvement. The clinical diagnosis of leucocytoclastic vasculitis is confirmed histopathologically by skin biopsy. In order to determine the cause of the disease, depending on the patient's history, complete blood cell count, blood cultures, cryoglobulins, serum protein electrophoresis, rheumatoid factor, antinuclear antibody, and autoantibodies to neutrophilic cytoplasmic antigens and complement should be checked. Once the diagnosis of leucocytoclastic vasculitis is made, emphasis should be on the search for an etiological factor and the identification of the involved organs. If possible, the underlying cause should be treated or removed, for example discontinuation of drugs. The prognosis depends on the disease that has the cutaneous leucocytoclastic angiitis as a component, as well as the severity of internal organ involvement. For example, a patient with cutaneous leucocytoclastic angiitis and moderate nephritis as component of Henoch-Schonlein purpura has a much better prognosis than a patient with these same findings as a component of Wegener's granulomatosis. Only if physicians recognize and report severe reactions to regulatory authorities and manufacturers, new drugs associated with a risk of such reactions can be identified.

Cutaneous leucocytoclastic vasculitis associated with oxacillin

A 67-year-old man who was treated with oxacillin for one week because of Staphylococcus aureus bacteremia, developed renal failure and diffuse, symmetric, palpable purpuric lesions on his feet. Necrotic blisters were noted on his fingers. Skin biopsies showed findings diagnostic of leucocytoclastic vasculitis. Oxacillin was discontinued and patient was treated with corticosteroids. The rash disappeared after three weeks and renal function returned to normal. Leucocytoclastic vasculitis presents as palpable purpura of the lower extremities often accompanied by abdominal pain, arthralgia, and renal involvement. Etiologic factors or associated disorders include infections, medications, collagen vascular disease and neoplasia. However, in half of the cases no etiologic factor is identified. Usually it is a self-limited disorder, but corticosteroid therapy may be needed in life-threatening cases since early treatment with corticosteroids in severe cases can prevent complications. Oxacillin should be included among the drugs that can cause leucocytoclastic vasculitis.

Cutaneous small-vessel vasculitis

Cutaneous small-vessel vasculitis (CSVV) refers to a group of disorders usually characterized by palpable purpura; it is caused by leukocytoclastic vasculitis of postcapillary venules. CSVV can be idiopathic or can be associated with a drug, infection, or underlying systemic disease. Initially, the pathogenesis of CSVV is immune complex related, but in its later stages different pathogenetic mechanisms may intensify the reaction and lymphocytes may predominate in the infiltrate. Cure requires elimination of the cause (ie, drugs, chemicals, infections, food allergens) when possible, as well as therapy with nonsteroidal antiinflammatory agents, corticosteroids, dapsone, potassium iodide, fibrinolytic agents, aminocaproic acid, immunosuppressive agents (ie, cyclophosphamide, azathioprine, methotrexate, cyclosporine) or even monoclonal antibodies, depending on disease severity.

Cutaneous allergic vasculitis: clinicopathological characterization and identification of apoptosis

To elucidate the clinicopathological features of cutaneous allergic (leukocytoclastic) vasculitis (CAV), biopsied skin tissues of 32 patients with CAV were examined immunohistopathologically and compared with the main clinical features. Additionally, to obtain some clues to better understand the roles of infiltrating cells, particularly neutrophils in CAV, apoptosis and related antigens were investigated in vivo. The 32 patients with CAV were divided into two groups based on their clinical course: (i) non-recurrent (group I; nine cases); and (ii) recurrent (group II; 23 cases). Immunohistopathologically, group I was characterized by stereotypical necrotizing changes of CAV with fibrin exudation of small blood vessels in the upper cutis, and group II was characterized by CAV and fibrous thickening of the vascular walls with significant infiltration of CD3+, UCHL-1+ T cells. Group II was subdivided further: groups IIa (15 cases) and IIb (eight cases); that is, the former was notable for necrotizing changes of CAV, which tended to spread into the proper corium down to the lower cutis; whereas the latter exhibited considerably less marked histological changes of CAV without any spread to the lower cutis. In a comparison of the clinical data among the three groups, there were considerable differences in age, clinical course, localization of purpura and associated disease. In particular, group II showed a high frequency of connective tissue diseases. The presence of apoptosis was seen in a considerable number of neutrophils, and some nuclear debris turned out to be apoptotic bodies by the in situ terminal deoxytransferase (TdT)-catalyzed DNA nick end-labeling (TUNEL) method and electron microscopy. By combining immunohistochemistry with TUNEL, the majority of apoptotic neutrophils and nuclear debris was seen to be ingested by macrophages. In immunohistochemical examinations for apoptosis-related bcl-2 protein and Fas antigen, bcl-2 was recognized only in the cytoplasm of infiltrating T cells, and Fas was positively stained on the cellular membranes of infiltrating T cells and neutrophils in a scattered fashion. Thus, a novel method for neutrophil disposal in CAV was suggested.

Recurrent annular erythema with purpura: a new variant of leucocytoclastic vasculitis responsive to dapsone

Annular lesions are rarely reported in the clinical spectrum of leucocytoclastic vasculitis, except in the acute haemorrhagic oedema of the skin. We report three patients who suffered from an extraordinary recurrent annular dermatitis, for 4 years in one case and for decades in the other two. The eruption was characterized by purpuric lesions that had a centrifugal evolution, creating target- or polycyclic patches disseminated on the limbs and trunk. The patients' general condition remained excellent during the attacks. All lesions spontaneously disappeared within 2 weeks, but recurred monthly. In all three cases, the histological changes were consistent with leucocytoclastic vasculitis. One patient had ulcerative colitis and another had a benign immunoglobulin A (IgA) monoclonal gammopathy. These two patients showed a good response to dapsone therapy. This dermatosis probably represents a new and rare variant of leucocytoclastic vasculitis.

Cutaneous vasculitis and cutaneous vasculopathies

Cutaneous involvement may occur with virtually all syndromes of vasculitis. This can occur primarily as a dermatologic disorder or as a manifestation of a potentially life threatening systemic vasculitis. In this review article, classification, clinical manifestations, pathogenesis and therapy of cutaneous vasculitis will be discussed. Disorders which are primarily vascular in origin but lack a well defined inflammatory phase, referred to as 'vasculopathies' will also be discussed.

Amiodarone-induced vasculitis and a review of the cutaneous side-effects of amiodarone

Amiodarone is a valuable agent, used in the management of intractable cardiac arrhythmias. Its widespread use persists despite a list of well recognized side-effects. Skin reactions are common, usually presenting as photosensitivity or less frequently as a blue/grey pigmentation on light-exposed sites. Leucocytoclastic vasculitis following treatment with amiodarone has been reported rarely. We describe a further case and briefly review the unwanted cutaneous manifestations of amiodarone therapy.

[Vascular manifestations of dermatomyositis and polymyositis. Clinical, capillaroscopic and histological aspects]

Polymyositis is characterized by a T-cell-mediated and MHC-I-restricted cytotoxic process, whereas dermatomyositis is a primitively vascular disease with microangiopathy mediated by the complement C5b-9 membranolytic attack complex. We have tried to estimate the frequency of vascular abnormalities in polymyositis as defined by Bohan and Peter. We have retrospectively studied 17 patients with dermatomyositis and 15 patients with polymyositis. Vascular abnormalities have been defined by clinical, capillaroscopic and histologic (muscle biopsy and minor salivary glands biopsy) features. After clinical features, 5/17 dermatomyositis had a Raynaud's phenomenon, against 6/15 polymyositis. Digital necrosis has been observed for 2/17 dermatomyositis and 2/15 polymyositis. In capillaroscopy, 14/17 dermatomyositis had a microangiopathy with or no enlarged capillary loops, against 7/15 polymyositis. None of these polymyositis had enlarged capillary loops. The muscle biopsy showed a predominantly perivascular or perimysial inflammatory infiltrate (vascular process) for 10/16 dermatomyositis against 4/13 polymyositis; a perifascicular atrophy for 3/16 dermatomyositis against 2/13 polymyositis. The histological study of minor salivary glands, showed vascular lesions for 2/11 dermatomyositis and for 1/8 polymyositis. Finally, Bohan and Peter's classification is now inadequate to distinguish between dermatomyositis and polymyositis. Indeed, some dermatomyositis sine dermatitis, may exist and be recognized by their vascular features. To distinguish between dermatomyositis and polymyositis is important, to evaluate the risk of cancer which is more frequent in dermatomyositis.

Generalised granuloma annulare successfully treated with pentoxifylline

Generalised granuloma annulare (GA) is a chronic disease of unknown aetiology and is recalcitrant to many treatment regimes. Some investigators have suggested that an immune medicated vasculitis may be involved in the pathogenesis of GA. We describe a patient with a ten year history of generalised GA, who showed dramatic clearing of the majority of papules after four weeks of treatment with pentoxifylline. This drug has shown promising results in the treatment of many dermatologic disorders including necrobiosis lipoidica diabeticorum, leukocytoclastic vasculitis and Raynaud's phenomenon. Pentoxifylline is thought to reduce blood viscosity via effects on all major blood components, and its clinical effectiveness in generalised GA lends support to a model of immune-medicated vasculitis in the pathogenesis of this disorder. Thus, pentoxifylline offers a well-tolerated and effective alternative to the treatment options available for patients with granuloma annulare.

Epidermal expression of the calcium binding surface antigen 27E10 in inflammatory skin diseases

The expression of the heterodimeric complex of the calcium-binding proteins MRP-8 and MRP-14 was investigated in various inflammatory dermatoses using immunohistochemical staining with the monoclonal antibody 27E10. In addition to the inflammatory infiltrate, a positive staining was repeatedly found in the involved epidermis from patients with lichen planus, lupus erythematosus and psoriasis vulgaris, but not in normal skin epidermis and/or in epidermis from leucocytoclastic vasculitis patients. The keratinocytic expression of the 27E10 antigen was dissimilar to that of the MHC class-II molecules and the adhesion molecule ICAM-1. These data indicate that the 27E10 antigen is a distinct activation marker of inflammatory keratinocytes and may have proinflammatory properties.

Propylthiouracil-induced hypersensitivity vasculitis presenting as respiratory failure

Hypersensitivity vasculitis associated with propylthiouracil therapy is a well-documented clinical entity. Although any organ system may be involved, it is most unusual for pulmonary manifestations to be the cardinal presenting features. We report a 72-year-old woman presenting with respiratory failure and hemoptysis following initiation of propylthiouracil therapy for Graves' disease. She had cutaneous stigmata of hypersensitivity vasculitis and diffuse pulmonary infiltrates. The infiltrates improved dramatically after discontinuation of the propylthiouracil therapy and initiation of intravenous corticosteroid therapy.

Cutaneous leukocytoclastic vasculitis associated with active Wegener's granulomatosis

BACKGROUND

Cutaneous manifestations are common in Wegener's granulomatosis and may occur at any time during the illness.

OBJECTIVE

Our purpose was to describe the relation of the appearance of cutaneous leukocytoclastic vasculitis to activity and other manifestations of Wegener's granulomatosis.

METHODS

Three patients with Wegener's granulomatosis who had recent onset of skin lesions are reported. Data regarding the relation of their cutaneous disease to their systemic disease was collected.

RESULTS AND CONCLUSION

In each case, onset of the skin lesions of biopsy-proven cutaneous leukocytoclastic vasculitis was associated with activation of the systemic features of Wegener's granulomatosis.

Follicular accentuation of leukocytoclastic vasculitis in an HIV-seropositive man. Report of a case and review of the literature

Palpable purpura in a follicular localization developed in association with acute epididymitis in a white man who was seropositive for the human immunodeficiency virus (HIV). Biopsy specimens revealed a leukocytoclastic vasculitis with follicular accentuation. With antibiotic therapy the vasculitis resolved, but it recurred during repeated episodes of the epididymitis. Follicular accentuation of skin disease is often seen in HIV-seropositive patients. Leukocytoclastic vasculitis with a follicular localization may be the presenting skin manifestation of HIV infection.

Cutaneous vasculitis associated with pheochromocytoma

We describe a patient who presented with constitutional symptoms, severe hypertension, and purpuric lesions over the knees, thighs, and penis. The patient was eventually diagnosed as having multiple endocrine neoplasia type II, with cutaneous leukocytoclastic vasculitis. The cutaneous vasculitis persisted despite treatment with high-dose systemic corticosteroids, but rapidly resolved after the removal of bilateral pheochromocytomas. This case demonstrates cutaneous leukocytoclastic vasculitis in association with pheochromocytoma.

Hypergammaglobulinemic purpura of Waldenström

Hypergammaglobulinemic purpura of Waldenström is characterized by hypergammaglobulinemia, recurring purpura, an elevated erythrocyte sedimentation rate, and the presence of rheumatoid factor indicative of circulating immune complexes. There is a significant association with autoimmune diseases, especially Sjögren's syndrome and lupus erythematosus. Hypergammaglobulinemic purpura is considered primary when there is no other associated disease or secondary when associated with other diseases, usually autoimmune. Immune derangements are fundamental in its pathogenesis, although its cause is still unknown. Therapy is unrewarding and is probably unnecessary for this usually benign condition. Three cases are presented that are representative of patients with hypergammaglobulinemic purpura.

Neutrophilic vascular reactions

Dermatologic diseases are classified most commonly by morphology, by pathogenesis, or by etiology. Nontraditional classifications may be useful in terms of providing a reassessment of traditional views about disease interrelationships. This review of dermatoses characterized by neutrophilic infiltrates and dermal vessel changes reveals evidence suggesting that these dermatoses result from immune complex-mediated, neutrophil-induced dermal vessel damage. Therapeutic approaches to these heretofore unlinked dermatoses are remarkably similar.

Necrotizing vasculitis with granulomatosis

Table 1 summarizes some of the differentiating characteristics among these diseases. Clinically, the differentiating features are that classic Wegener's granulomatosis involves both the upper and lower respiratory systems and kidneys. Renal involvement is the major cause of morbidity and mortality. Churg-Strauss syndrome has the distinguishing characteristics of an allergic asthmatic prodrome and a profound eosinophilia. It encompasses and destroy's tissue not only of the lungs but also most of the other organ systems in the body. A major cause of mortality is cardiac disease, which is not a feature of either of the other two diseases. Finally, lymphomatoid granulomatosis is seen predominantly in the lungs, skin, and central nervous system and is the only one of the three that is associated with the development of a lymphoma. Although there are definitive clinical differences of these entities, as mentioned above, it is the histopathologic features that can diagnostically separate the three. Wegener's granulomatosis is predominantly a necrotizing granulomatous infiltrate that has a polymorphous infiltrate of neutrophils, plasma cells, and histiocytes and is very distinct from the eosinophilic granulomas of CSS or the lymphocytic ones of LYG. Finally, all of the diseases respond differently to medications. Patients with Churg-Strauss syndrome for the most part respond well to high dosages of oral steroids and usually do not require therapy with immunosuppressive agents. Therapy with steroids alone is not adequate for the treatment of Wegener's granulomatosis, and the therapy is a combination of steroids with chemotherapeutic agents, cyclophosphamide being the agent of choice. The most difficult disease to treat in this review is LYG.(ABSTRACT TRUNCATED AT 250 WORDS)

Peculiar papular skin lesions occurring in hepatitis B carriers

Various cutaneous signs and syndromes have been associated with hepatitis B virus infection. This is a report of the clinical, pathologic, immunofluorescence, and immunoperoxidase studies of peculiar papular lesions that have been observed to occur during the chronic phase of hepatitis B virus infection. A total of thirteen patients positive for hepatitis B surface antigen (HBsAg) were studied. Twelve had asymptomatic, recurrent, erythematous papular lesions localized on the back, chest, and proximal areas of the upper extremities that lasted 6 to 7 days. The histopathology of these skin lesions showed a superficial and deep perivascular dermal mononuclear cell infiltrate. Immunoperoxidase studies for HBsAg and direct immunofluorescence for IgG, IgM, IgA, and C3 showed negative results. An abnormal host response to viral antigens other than HBsAg is suggested as a possible mechanism responsible for appearance of these skin lesions.

Human hypersensitivity angiitis, an immune complex disease

Human hypersensitivity angiitis is an immune complex disease in which patients present with palpable purpuric lesions of the skin and may often have multiple organ involvement. The antigen may be derived from an infectious organism such as the hepatitis virus, streptococcus, or a drug, and complexes with antibody. Under circumstances of vascular turbulence or vessel wall dilatation this complex may become fixed, activating the complement sequence with elaboration of chemotactic factors for neutrophils. These cells release lysosomal enzymes resulting in vessel wall destruction. Red blood cells leak into the tissue producing purpura and the inflammatory infiltrate accounts for the palpability. Although many patients have skin lesions only, others may have involvement of joints, gastrointestinal tract, kidneys, and even the lungs. The central question in the pathogenesis of this disease is why the immune complex is so selective in its site of deposition. Part of the reason must be related to the lattice formation of a particular complex, while other reasons are related to host factors of altered vascular permeability, integrity of clearance mechanisms or even a genetically determined defect of the phagocytic system.

Wegener's granulomatosis in childhood: cutaneous manifestations as the presenting signs

Wegener's granulomatosis (WG), characterized by a necrotizing granulomatous vasculitis, is a rare systemic disease particularly infrequent in children. We report an unusual case of WG in a 16-year-old male patient in whom the cutaneous manifestations were the presenting signs that preceded the upper respiratory symptoms by several months. In addition, the finding of a calcified pulmonary lesion has never been reported in association with WG. Accurate diagnosis of early skin lesions is important in view of the available effective therapy. Clinical and pathologic features of WG and treatment are reviewed.

Necrotizing vasculitis from radiographic contrast media

Two patients in whom cutaneous necrotizing vasculitis and nephritis developed 12 to 22 hours after the intravascular injection of radiocontrast media are presented. In one patient, the fortuitous observation was made of sparing of the skin from vasculitis in an area into which xylocaine and epinephrine had been injected 4 hours prior to administration of the radiocontrast material. The possible mechanisms by which these reactions may have taken place and the potential implications are discussed.

Circulating immune complexes in Henoch-Schonlein purpura

Henoch-Schonlein purpura (HSP) is a symptom complex which may involve the skin, joints, gastrointestinal tract, and kidney. Skin involvement occurs in more than 50% of the patients and may appear as erythematous purpuric macules or papules. The skin lesions show histologic features of leukocytoclastic vasculitis. Deposits of immunoglobulin and complement may be present in the involved vessel walls. A case of HSP is described where high levels of circulating immune complexes were found. This further suggests the possible involvement of immune complexes in the pathogenesis of HSP.

Pathogenesis of rheumatoid arthritis: a vascular hypothesis

Past research into the pathogenesis of RA has generally concerned itself with established inflammation. The present review summarizes alterations in microvascular anatomy and function which occur during the hypoxic state, in various experimental and disease conditions. It further shows that tissue hypoxia is a common finding in RA and that the microvascular alterations of RA are similar to those produced by experimental hypoxia. The available data suggest that microcirculatory compromise, concomitant with an increase in metabolic needs of synovial tissue, may initiate tissue injury via anoxia and acidosis, resulting in hydrolytic enzyme release, increased vascular permeability and acceleration of inflammatory processes. It is further believed that the microcirculatory abnormality may be generalized, accounting for the systemic manifestations often seen in RA. Factors effecting arteriolar blood flow obstruction are reviewed to identify areas for future investigation in RA and other disorders involving microvasculopathy. The multitude of longknown and newly recognized factors predisposing to vasospasm and vasodilatation have been outlined as a guide to possible mechanisms which may be operative in RA. An attempt has been made to gather and synthesize the available data in the hope that it may stimulate other investigators to pursue more definitive research into specific areas which may show early microvascular abnormalities in the pathophysiology of RA. Identification of factors operative early in the pathogenesis of RA, before it becomes self-perpetuating, may well be a step in the direction of preventing the ravages of this disease, or providing insight to more effective control.