1
|
Suh YS, Jung EC, Moon YS, Lee SG, Kim HO. A Case of Palisaded Neutrophilic and Granulomatous Dermatitis Associated with an Initial Presentation in Ankylosing Spondylitis. Ann Dermatol 2023; 35:S34-S37. [PMID: 37853861 PMCID: PMC10608376 DOI: 10.5021/ad.21.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/21/2021] [Accepted: 05/25/2021] [Indexed: 10/20/2023] Open
Abstract
Palisaded neutrophilic and granulomatous dermatitis (PNGD) is an inflammatory dermatosis associated with systemic immune-mediated diseases such as rheumatoid arthritis, systemic sclerosis, lupus erythematosus, and ulcerative colitis. Histologically, serial development of leukocytoclastic vasculitis is shown from an early stage, which can progress to palisading granuloma in the fully developed stage and to fibrosis in the final stage. A 32-year-old man presented with ankylosing spondylitis showing multiple erythematous papules on his fingers, elbows, knees, and left auricle. Histologic examination from his skin lesion revealed a perforating palisading granuloma with leukocytoclastic vasculitis, which was consistent with PNGD. Therefore, this study reported a case of PNGD accompanied by ankylosing spondylitis as an initial presentation.
Collapse
Affiliation(s)
- Young Sun Suh
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Eui Chang Jung
- Department of Dermatology, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Yun Sun Moon
- Department of Dermatology, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Seung-Geun Lee
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicne, Busan, Korea
| | - Hyun-Ok Kim
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Jinju, Korea.
| |
Collapse
|
2
|
Rodríguez-Garijo N, Bielsa I, Mascaró JM, Quer A, Idoate MA, Paricio JJ, Iranzo P, España A. Reactive granulomatous dermatitis as a histological pattern including manifestations of interstitial granulomatous dermatitis and palisaded neutrophilic and granulomatous dermatitis: a study of 52 patients. J Eur Acad Dermatol Venereol 2020; 35:988-994. [PMID: 33098595 DOI: 10.1111/jdv.17010] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 10/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Confusion exists regarding interstitial granulomatous dermatitis (IGD) and palisaded neutrophilic and granulomatous dermatitis (PNGD). OBJECTIVE To determine whether IGD and PNGD are two different entities, or whether they must be considered as two subtypes of the same reactive pattern, and thus whether the unification of the nomenclature is necessary. METHODS Observational retrospective multicentre study of patients with IGD and PNGD evaluated between 1999 and 2019 and review of their clinical and histological features. RESULTS We identified 52 patients (38 women and 14 men). Clinical and histological findings of IGD were observed in 88.4% of cases. The most common cutaneous lesions were plaques/macules (IGD) or annular plaques and papules/nodules (PNGD), located mostly on the limbs and trunk. The rope sign was developed in two patients with IGD that associated autoimmune disorders. Similar associated comorbidities (75%) were found in both entities, mainly autoimmune diseases (53.8%). In IGD, the infiltrate was predominantly lympho-histiocytic. Neutrophilic infiltrates, karyorrhexis and skin lesions with limited clinical course were mainly associated with PNGD biopsies. In biopsies with a limited recurrent course, a predominant lymphocytic inflammatory infiltrate was found. Collagen degeneration was present in 75.9% of cases. The floating sign was observed only in IGD type patients (63%). Overlapping histological findings were found in one fourth of cases, especially between IGD and interstitial granuloma annulare. Interface dermatitis, apparently unrelated to drug intake, was observed in 4 cases of IGD. CONCLUSION We support the term reactive granulomatous dermatitis to unify both the clinical and histological findings of IGD and PNGD, and the overlapping between IGD and interstitial granuloma annulare. According to this, a spectrum of histological changes will be found depending on the clinical course of the skin lesions.
Collapse
Affiliation(s)
- N Rodríguez-Garijo
- Department of Dermatology, School of Medicine, University Clinic of Navarra, University of Navarra, Pamplona, Spain
| | - I Bielsa
- Department of Dermatology, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - J M Mascaró
- Department of Dermatology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - A Quer
- Department of Pathology, Hospital Germans Trias i Pujol University, Universitat Autònoma de Barcelona, Badalona, Spain
| | - M A Idoate
- Department of Pathology, School of Medicine, University Clinic of Navarra, University of Navarra, Pamplona, Spain
| | - J J Paricio
- Department of Pathology, School of Medicine, University Clinic of Navarra, University of Navarra, Pamplona, Spain
| | - P Iranzo
- Department of Dermatology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - A España
- Department of Dermatology, School of Medicine, University Clinic of Navarra, University of Navarra, Pamplona, Spain
| |
Collapse
|
3
|
|
4
|
Inozume T, Ando N, Sano S, Harada K, Kawamura T, Shibagaki N, Shimada S. Case of rheumatoid papules: is this a link between vasculitis and rheumatoid nodules? J Dermatol 2012. [PMID: 23181622 DOI: 10.1111/j.1346-8138.2012.01597.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
5
|
Yamamoto T. Cutaneous necrobiotic conditions associated with rheumatoid arthritis: important extra-articular involvement. Mod Rheumatol 2012; 23:617-22. [PMID: 23053722 DOI: 10.1007/s10165-012-0774-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 09/11/2012] [Indexed: 10/27/2022]
Abstract
Rheumatoid arthritis (RA) presents with various skin conditions as extra-articular manifestations. Rheumatoid nodule is the representative specific skin lesion, histologically exhibiting central necrosis (necrobiosis) surrounded by palisaded macrophages, and being further perivascularly infiltrated with inflammatory cells in the outer regions. Also, there are several skin lesions which histologically show necrobiotic conditions with altered connective tissue degeneration. Necrobiosis may be closely associated with the pathogenesis of RA, i.e., collagen degeneration, recruitment of activated neutrophils, production of various cytokines, and vascular injury. On the other hand, rheumatoid nodule is suggested to develop during therapies with certain drugs such as methotrexate and biologics. These findings may be a clue to understanding the pathomechanisms of rheumatoid nodules. This paper describes several necrobiotic conditions associated with RA, and also discusses the possible pathogenesis and differential diagnosis of rheumatoid nodules. Necrobiosis is the major pathologic condition of cutaneous involvement associated with RA.
Collapse
Affiliation(s)
- Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Hikarigaoka 1, Fukushima 960-1295, Japan.
| |
Collapse
|
6
|
Mahmoodi M, Ahmad A, Bansal C, Cusack CA. Palisaded neutrophilic and granulomatous dermatitis in association with sarcoidosis. J Cutan Pathol 2010; 38:365-8. [PMID: 20528967 DOI: 10.1111/j.1600-0560.2010.01560.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Palisaded and neutrophilic granulomatous dermatitis (PNGD) has been associated with many conditions including rheumatoid arthritis, systemic lupus erythematosus, systemic vasculitis, and other diseases with circulating immune complexes. Lymphoproliferative conditions, bacterial endocarditis, and various drugs can also induce this condition. Many patients also have symmetric polyarthritis with various serological abnormalities. We present a case of a 46-year-old female who presented with painful erythematous annular plaques and nodules on her legs. The lesions started a week prior to visit and increased in number over the course of the week. The patient had an established history of sarcoidosis with past episodes of uveitis and erythema nodosum. The histopathological findings included a diffuse pandermal infiltrate mostly composed of neutrophils, nuclear debris, and strands of deeply eosinophilic degenerated collagen. Vasculitis was not present. No significant increase in dermal mucin was detected. Based on the clinical and pathological findings, the patient was diagnosed with late-stage PNGD. To our knowledge, this is the first case of PNGD described in an adult patient of sarcoidosis.
Collapse
Affiliation(s)
- Mandana Mahmoodi
- Department of Dermatology, Tufts Medical Center and Caris/Cohen Dx, Boston, MA 02464, USA.
| | | | | | | |
Collapse
|
7
|
Misago N, Shinoda Y, Tago M, Narisawa Y. Palisaded neutrophilic granulomatous dermatitis with leukocytoclastic vasculitis in a patient without any underlying systemic disease detected to date. J Cutan Pathol 2009; 37:1092-7. [DOI: 10.1111/j.1600-0560.2009.01466.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
8
|
Kim SK, Park CK, Park YW, Jun JB, Yoo DH, Bae SC. Palisaded neutrophilic granulomatous dermatitis presenting as an unusual skin manifestation in a patient with Behçet's disease. Scand J Rheumatol 2009; 34:324-7. [PMID: 16195168 DOI: 10.1080/03009740510015195] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A 32-year-old Korean woman with painful oral ulcers and a sore throat presented with multiple erythematosus papules on both legs. Histological examination of the papular lesions on the legs demonstrated palisaded granuloma with degeneration of collagen fibres in the dermis, compatible with palisaded neutrophilic granulomatous dermatitis (PNGD). This condition is known to be an unusual disease entity associated with various systemic autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, other connective tissue diseases, and systemic vasculitis. To our knowledge a case with typical Behçet's disease coinciding with PNGD among systemic autoimmune diseases has not been described before.
Collapse
Affiliation(s)
- S-K Kim
- Department of Internal Medicine, Division of Rheumatology, The Hospital for Rheumatic Diseases, The Hospital for Rheumatic Diseases, Hanyang University, Seoul 133-792, Korea
| | | | | | | | | | | |
Collapse
|
9
|
|
10
|
Yamamoto T. Cutaneous manifestations associated with rheumatoid arthritis. Rheumatol Int 2009; 29:979-88. [PMID: 19242695 DOI: 10.1007/s00296-009-0881-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Accepted: 02/09/2009] [Indexed: 12/16/2022]
Abstract
Rheumatoid arthritis presents various cutaneous manifestations, either specific or nonspecific skin features, which are induced by the activation of inflammatory cells (neutrophils, lymphocytes, macrophages), vasculopathy, vasculitis, acral deformity, drugs, and so on. These include (1) specific findings, (2) findings due to vascular impairment, (3) findings due to immune dysfunction, (4) characteristic neutrophilic conditions, and (5) miscellaneous conditions. On the other hand, some of the specific manifestations show common histopathological features such as palisading granulomas with necrobiosis. It is important to recognize the common and/or uncommon skin conditions of RA for all clinicians associated with RA therapy.
Collapse
Affiliation(s)
- T Yamamoto
- Department of Dermatology, Fukushima Medical University, Hikarigaoka 1, Fukushima, 960-1295, Japan.
| |
Collapse
|
11
|
Abstract
A patient with systemic lupus erythematosus who developed a distinctive nodular eruption demonstrating typical features of palisading granuloma is presented herein. A 60-year-old woman was admitted complaining of an elastic-hard, indurated nodule on the right dorsal aspect of the metacarpophalangeal joint of her third finger with a history of several years. She was successfully treated for her lupus nephritis with oral predonisolone. She had experienced erythema on her cheeks after sun exposure and polyarthralgia for a decade. Laboratory examination revealed positive results for antinuclear antibody and rheumatoid factor. Peripheral blood cell counts showed leukocytopenia and lymphocytopenia. Results of hand X-ray were unremarkable. Histological examination of the skin biopsy specimen from the nodule revealed a structure composed of a central area of fibrinoid necrosis, surrounded by a middle zone of palisading cells and an outer zone of chronic lymphocyte infiltrate. These findings led us to the histological diagnosis of palisading granuloma. She was diagnosed as having systemic lupus erythematosus complicated with a rheumatoid nodule. She is currently under treatment with cyclophosphamide (50 mg/day) without exaggeration of her systemic lupus erythematosus and nodule.
Collapse
Affiliation(s)
- Tsutomu Ohtsuka
- Department of Dermatology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan.
| |
Collapse
|
12
|
Biswas A, Chittari K, Gey van Pittius D, Stephens M, Tan B. Palisaded neutrophilic and granulomatous dermatitis in a child with type I diabetes mellitus and coeliac disease. Br J Dermatol 2008; 159:488-9. [DOI: 10.1111/j.1365-2133.2008.08636.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Palisaded neutrophilic and granulomatous dermatitis associated with limited systemic sclerosis. J Am Acad Dermatol 2008; 58:661-4. [DOI: 10.1016/j.jaad.2007.09.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 09/06/2007] [Accepted: 09/19/2007] [Indexed: 11/23/2022]
|
14
|
Kawachi Y, Nakamura Y, Yoh K, Suzuki T, Fujisawa Y, Furuta J, Takahashi T, Otsuka F. Rheumatoid papules successfully treated with oral tacrolimus. J Eur Acad Dermatol Venereol 2008; 22:241-2. [PMID: 18211423 DOI: 10.1111/j.1468-3083.2007.02295.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
15
|
Germanas JP, Mehrabi D, Carder KR. Palisaded neutrophilic granulomatous dermatitis in a 12-year-old girl with systemic lupus erythematosus. J Am Acad Dermatol 2006; 55:S60-2. [PMID: 16843132 DOI: 10.1016/j.jaad.2005.08.050] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2005] [Revised: 08/23/2005] [Accepted: 08/28/2005] [Indexed: 11/23/2022]
|
16
|
Sayah A, English JC. Rheumatoid arthritis: a review of the cutaneous manifestations. J Am Acad Dermatol 2006; 53:191-209; quiz 210-2. [PMID: 16021111 DOI: 10.1016/j.jaad.2004.07.023] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Rheumatoid arthritis is a chronic inflammatory arthritis with significant extra-articular manifestations. Of note are unique cutaneous manifestations that the dermatologist may encounter. This article will make the dermatologist more cognizant of these skin findings in patients with this systemic inflammatory disorder. It examines rheumatoid arthritis, focusing on the general nonspecific and disease-specific rheumatoid arthritic skin changes. Classic rheumatoid nodules, accelerated rheumatoid nodulosis, rheumatoid nodulosis, rheumatoid vasculitis, Felty syndrome, pyoderma gangrenosum, interstitial granulomatosus dermatitis with arthritis, palisaded neutrophilic and granulomatosis dermatitis, rheumatoid neutrophilic dermatitis, juvenile rheumatoid arthritis, and adult-onset Still disease are reviewed. Understanding the cutaneous expressions of rheumatoid arthritis may lead to early diagnosis, prompt treatment, and lower morbidity and mortality for the affected persons. Learning objective At the completion of this learning activity, participants should be able to describe rheumatoid arthritis in terms of its epidemiology, etiology, pathogenesis, and general and specific cutaneous manifestations.
Collapse
Affiliation(s)
- Anousheh Sayah
- Department of Dermatology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | |
Collapse
|
17
|
Draft KS, Wiser EB, Elenitsas R. Dermatopathology update of "newer" dermatologic manifestations of systemic disease. ACTA ACUST UNITED AC 2005; 21:101-32. [PMID: 16350440 DOI: 10.1016/j.yadr.2005.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Karla S Draft
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | |
Collapse
|
18
|
Bremner R, Simpson E, White CR, Morrison L, Deodhar A. Palisaded neutrophilic and granulomatous dermatitis: an unusual cutaneous manifestation of immune-mediated disorders. Semin Arthritis Rheum 2004; 34:610-6. [PMID: 15609265 DOI: 10.1016/j.semarthrit.2004.06.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Palisaded neutrophilic and granulomatous dermatitis (PNGD) is an uncommon skin eruption most often associated with rheumatoid arthritis and other immune-mediated diseases. We present 4 cases to familiarize rheumatologists with the clinical presentation and histopathology of PNGD. METHODS We report 4 cases to illustrate the clinical and histologic spectrum of this rare skin disease found in rheumatologic patients. The disease pathogenesis and treatment options are discussed. RESULTS All 4 patients presented with symmetric erythematous-to-violaceous papules and plaques that, upon biopsy, revealed a dermatitis composed of variable numbers of histiocytes and neutrophils. Some cases responded to topical corticosteroid treatment or to dapsone, whereas others resolved spontaneously. CONCLUSIONS PNGD is a rare cutaneous finding in patients with a variety of immune-mediated systemic diseases, most often rheumatoid arthritis. It is a benign condition that may spontaneously remit or may respond favorably to topical corticosteroids or dapsone.
Collapse
Affiliation(s)
- Rebecca Bremner
- Department of Dermatology, Oregon Health and Science University, Portland, OR 97239, USA
| | | | | | | | | |
Collapse
|
19
|
Abstract
A patient with a long history of seropositive rheumatoid arthritis presented with a progressive papular eruption on the trunk. A skin biopsy showed a neutrophilic and palisaded granulomatous dermatitis compatible with rheumatoid papules. The eruption failed to respond to topical and systemic corticosteroids and the patient was treated with dapsone with complete resolution of the rash. Rheumatoid papules are a rare disorder seen in a variety of collagen vascular diseases. The literature concerning the treatment of rheumatoid papules is scanty. In this patient, dapsone was an effective treatment.
Collapse
Affiliation(s)
- J A Martin
- Department of Dermatology, Tauranga Public Hospital, New Zealand.
| | | |
Collapse
|
20
|
|
21
|
Abstract
As the skin is commonly involved in systemic vasculitic disorders as well as those hypersensitivity states whose expression is largely skin-confined, cutaneous vasculitic lesions offer a window to diagnosis and a ready source of accessible tissue for biopsy. In this review, we discuss the pathologic manifestations of chronic vasculitic syndromes such as granuloma faciale and erythema elevatum diutinum; IgA-associated vasculitis including Henoch-Schonlein purpura; vasculitis seen in the setting of cryoglobulinemia and hypergammaglobulinemia of Waldenstrom, hereditary deficiencies of complement, and IgA deficiency; those leukocytoclastic vasculitides resulting from hypersensitivity reactions to drug, chemical and foodstuff ingestion; and those vasculitides seen in patients with systemic diseases such as polyarteritis nodosa, rheumatoid arthritis, mixed connective tissue disease, systemic lupus erythematosus, Sjogren's syndrome, relapsing polychondritis, Behcet's disease, Wegener's granulomatosis, and allergic granulomatosis of Churg and Strauss.
Collapse
Affiliation(s)
- A Neil Crowson
- Dermatology and Pathology, University of Oklahoma, Tulsa, OK, USA.
| | | | | |
Collapse
|
22
|
Magro CM, Crowson AN. The spectrum of cutaneous lesions in rheumatoid arthritis: a clinical and pathological study of 43 patients. J Cutan Pathol 2003; 30:1-10. [PMID: 12534797 DOI: 10.1034/j.1600-0560.2003.300101.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is an idiopathic arthropathy syndrome that has a propensity to affect the small joints of the hands and feet with extra-articular manifestations comprising skin lesions, neuropathy, pericarditis, pleuritis, interstitial pulmonary fibrosis and a systemic polyarteritis nodosa (PAN)-like vasculitic syndrome. The most widely recognized skin lesion is the rheumatoid nodule. Other skin manifestations are poorly defined. MATERIALS AND METHODS Using a natural language search of the authors' outpatient dermatopathology databases, skin biopsies from 43 patients with RA were selected for retrospective analysis in an attempt to define the dermatopathological spectrum of RA and its clinical correlates. RESULTS The biopsies were categorized by the dominant histologic pattern, recognizing that in most cases there were additional minor reaction patterns. Palisading and/or diffuse interstitial granulomatous inflammation was the dominant pattern seen in 21 patients; the lesions included nodules, plaques and papules with a predilection to involve skin over joints. Besides interstitial histiocytic infiltrates and variable collagen necrobiosis, these cases also showed interstitial neutrophilia, vasculitis and pauci-inflammatory vascular thrombosis. The dominant morphology in 11 other patients was vasculopathic in nature: pauci-inflammatory vascular thrombosis, glomeruloid neovascularization, a neutrophilic vasculitis of pustular, folliculocentric, leukocytoclastic or benign cutaneous PAN types, granulomatous vasculitis, and lymphocytic vasculitis and finally occlusive intravascular histiocytic foci for which the designation of "RA-associated intravascular histiocytopathy" is proposed. Rheumatoid factor (RF) positivity and active arthritis were common in this group, with anti-Ro and anticardiolipin antibodies being co-factors contributing to vascular injury in some cases. Immunofluorescent testing in three patients revealed dominant vascular IgA deposition. In nine patients, the main pattern was one of neutrophilic dermal and/or subcuticular infiltrates manifested clinically as urticarial plaques, pyoderma gangrenosum and panniculitis. CONCLUSIONS The cutaneous manifestations of RA are varied and encompass a number of entities, some of which define the dominant clinical features, such as the rheumatoid papule or subcutaneous cords, while others allude to the histopathology, i.e. rheumatoid neutrophilic dermatosis. We propose a more simplified classification scheme using the adjectival modifiers of "rheumatoid-associated" and then further categorizing the lesion according to the dominant reaction pattern. Three principal reaction patterns are recognized, namely extravascular palisading granulomatous inflammation, interstitial and/or subcuticular neutrophilia and active vasculopathy encompassing lymphocyte-dominant, neutrophil-rich and granulomatous vasculitis. In most cases, an overlap of the three reaction patterns is seen. Co-factors for the vascular injury that we believe are integral to the skin lesions of RA include RF, anti-endothelial antibodies of IgA class, anti-Ro and anticardiolipin antibodies.
Collapse
Affiliation(s)
- C M Magro
- Department of Pathology, Ohio State University, Columbus, OH, USA
| | | |
Collapse
|
23
|
Chen KR, Toyohara A, Suzuki A, Miyakawa S. Clinical and histopathological spectrum of cutaneous vasculitis in rheumatoid arthritis. Br J Dermatol 2002; 147:905-13. [PMID: 12410699 DOI: 10.1046/j.1365-2133.2002.04933.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cutaneous manifestations are the most frequent, and often the initial feature of extra-articular involvement in patients with rheumatoid vasculitis. OBJECTIVES The purpose of the study was to evaluate the clinical and histological spectrum of cutaneous vasculitis and the associated systemic involvement in patients with rheumatoid vasculitis. METHODS Among 525 patients with rheumatoid arthritis, 20 tissue specimens with histologically proven cutaneous necrotizing vasculitis from 11 patients were investigated by studying the types and levels of affected vessels and related clinical features. RESULTS Small-vessel vasculitis identified as dermal necrotizing venulitis was found in 10 patients, clinically characterized by palpable purpura, maculopapular erythema, erythema elevatum diutinum and haemorrhagic blisters. Arteritis histologically resembling cutaneous polyarteritis nodosa, clinically characterized by subcutaneous nodules, livedo reticularis, atrophie blanche and deep ulcers was identified in four patients all with systemic complications. Coexistence of venulitis and arteritis was identified in three patients. Different cutaneous vasculitic manifestations often coexisted and recurred in the same patient. Three patients with systemic complications of mononeuritis multiplex (two of three), interstitial pulmonary fibrosis (two of three) and abdominal microaneurysms (one of three) died within 1 year of onset of the cutaneous vasculitis. Immunofluorescence demonstrated vessel wall deposition of IgM and/or complement in six of the seven patients examined. CONCLUSIONS Features of cutaneous rheumatoid vasculitis overlapping both the characteristics of cutaneous necrotizing venulitis and cutaneous polyarteritis nodosa together with coexistence of these different type of vasculitis in the same or different lesional skin account for the associated diverse cutaneous vasculitic manifestations. Although dermal venulitis (leucocytoclastic vasculitis) was the most common presentation, the presence of leucocytoclastic vasculitis in rheumatoid patients did not necessarily indicate a favourable prognosis. Associations with mononeuritis multiplex and bowel involvement had a fatal prognosis, while patients with superficial dermal venulitis without other extra-articular involvement may follow a favourable prognosis.
Collapse
Affiliation(s)
- K-R Chen
- Department of Dermatology, Kawasaki City Hospital, Kawasaki, Japan.
| | | | | | | |
Collapse
|
24
|
Obermoser G, Zelger B, Zangerle R, Sepp N. Extravascular necrotizing palisaded granulomas as the presenting skin sign of systemic lupus erythematosus. Br J Dermatol 2002; 147:371-4. [PMID: 12174116 DOI: 10.1046/j.1365-2133.2002.04790.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We recently examined a patient who presented clinically with tender, erythematous papules associated with a febrile illness and polyarthralgias. Histopathological examination revealed extravascular palisaded neutrophilic granulomas, a skin reaction pattern originally described in Churg-Strauss disease but subsequently observed in a variety of other systemic disorders characterized by immune complex generation. A diagnosis of systemic lupus erythematosus (SLE) was established. To our knowledge, this is the first report of extravascular necrotizing palisaded granulomas as the presenting skin sign of SLE.
Collapse
Affiliation(s)
- G Obermoser
- Department of Dermatology, University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | | | | | | |
Collapse
|
25
|
Sangueza OP, Caudell MD, Mengesha YM, Davis LS, Barnes CJ, Griffin JE, Fleischer AB, Jorizzo JL. Palisaded neutrophilic granulomatous dermatitis in rheumatoid arthritis. J Am Acad Dermatol 2002; 47:251-7. [PMID: 12140472 DOI: 10.1067/mjd.2002.124620] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Palisaded neutrophilic granulomatous dermatitis (PNGD) is an entity that has not been clearly defined either clinically or histopathologically. It is seen in patients with rheumatoid arthritis and other connective tissue diseases. In the past, many cases of PNGD have been described under several different names including palisaded neutrophilic and granulomatous dermatitis, linear subcutaneous bands, interstitial granulomatous dermatitis with cutaneous cords and arthritis, rheumatoid papules, and Churg-Strauss granuloma. We report 7 additional cases of PNGD. Clinically, 6 patients presented with erythematous to violaceous plaques, papules, and nodules on multiple body sites; one presented with subcutaneous linear bands on the shoulder. Five had rheumatoid arthritis; one had adult-onset Still's disease; and one showed clinical signs of rheumatoid arthritis, although serologically the rheumatoid factor was negative. On histologic examination, a spectrum of changes was observed ranging from urticaria-like infiltrates to leukocytoclastic vasculitis and granuloma annulare with neutrophils. We report these cases to expand the histologic spectrum of this entity and to further delineate the different forms of clinical presentation.
Collapse
Affiliation(s)
- Omar P Sangueza
- Department of Dermatology, Wake Forest University, School of Medicine, Winston-Salem, North Carolina 27157-1072, USA
| | | | | | | | | | | | | | | |
Collapse
|
26
|
DiCaudo DJ, Connolly SM. Interstitial granulomatous dermatitis associated with pulmonary coccidioidomycosis. J Am Acad Dermatol 2001; 45:840-5. [PMID: 11712027 DOI: 10.1067/mjd.2001.117522] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Coccidioides immitis is a soil-dwelling fungus found in arid regions of the Western Hemisphere. Interstitial granulomatous dermatitis is a histopathologic pattern that may be a reactive manifestation of diverse systemic diseases. OBJECTIVE Our purpose was to describe clinical and histopathologic findings in 5 patients who presented with interstitial granulomatous dermatitis associated with pulmonary coccidioidomycosis. METHODS Medical records and skin biopsy slides from 5 patients were retrospectively reviewed. RESULTS In each patient, edematous papules, nodules, and plaques developed abruptly during the onset of an acute febrile illness. Coccidioidomycosis was confirmed by serology. Skin biopsy specimens revealed interstitial granulomatous dermatitis with neutrophils, leukocytoclasis, and eosinophils. Fungal stains (5/5 cases) and fungal cultures (2/2 cases) revealed no organisms within the skin biopsy specimens. CONCLUSION Interstitial granulomatous dermatitis may be a presenting feature of pulmonary coccidioidomycosis and may possibly represent a reactive manifestation of the infection.
Collapse
Affiliation(s)
- D J DiCaudo
- Department of Dermatology, Mayo Clinic Scottsdale, Arizona 85259, USA.
| | | |
Collapse
|
27
|
Corbí Llopis R, Antonia Ronco Poce M, Javier Galindo Ocaña F, Pulpillo Ruiz A, Rodríguez-Cañas T, Zulueta Dorado T, Navarrete Ortega M. Granuloma necrosante extravascular de Churg-Strauss. ACTAS DERMO-SIFILIOGRAFICAS 2001. [DOI: 10.1016/s0001-7310(01)76524-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
28
|
Ghersetich I, Comacchi C, Jorizzo JL, Katsambas A, Lotti TM. Proposal for a working classification of cutaneous vasculitis. Clin Dermatol 1999; 17:499-503. [PMID: 10590842 DOI: 10.1016/s0738-081x(99)00058-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- I Ghersetich
- Department of Dermatology, University of Florence, Italy
| | | | | | | | | |
Collapse
|
29
|
Affiliation(s)
- G Hautmann
- Department of Dermatology, University of Florence, Italy
| | | | | |
Collapse
|
30
|
Tran TA, DuPree M, Carlson JA. Neutrophilic lobular (pustular) panniculitis associated with rheumatoid arthritis: a case report and review of the literature. Am J Dermatopathol 1999; 21:247-52. [PMID: 10380046 DOI: 10.1097/00000372-199906000-00007] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Rheumatoid nodules, which affect the subcutis around joints, are the most frequent specific cutaneous lesions of rheumatoid arthritis (RA). Panniculitis is a rarely reported and nonspecific complication of RA. We report a 42-year-old woman with seropositive RA who presented with a 2-month history of lower leg panniculitis. Biopsy of a leg nodule showed a lobular neutrophilic infiltrate with lipophages and central basophilic necrosis. In addition, focal changes of lipomembranous fat necrosis indicative of ischemic damage were identified at the margins of the lobular infiltrate. Neutrophilic lobular panniculitis is commonly detected in panniculitis secondary to bacterial infections, pancreatitis, and factitial causes. However, this pattern of panniculitis has also been reported in some cases of erythema nodosum-like lesions found in Behçet disease or bowel bypass syndrome and in rare cases of seropositive RA. These reported histologic findings fall into the spectrum of neutrophilic vascular reactions described by Jorizzo and Daniels for RA-associated dermatoses. In view of these findings. RA and related neutrophilic dermatoses (e.g., Behçet disease) should be included in the differential diagnosis of neutrophilic lobular panniculitis.
Collapse
Affiliation(s)
- T A Tran
- Department of Pathology and Laboratory Medicine, Albany Medical Center, New York 12208, USA
| | | | | |
Collapse
|
31
|
Goerttler E, Kutzner H, Peter HH, Requena L. Methotrexate-induced papular eruption in patients with rheumatic diseases: a distinctive adverse cutaneous reaction produced by methotrexate in patients with collagen vascular diseases. J Am Acad Dermatol 1999; 40:702-7. [PMID: 10321597 DOI: 10.1016/s0190-9622(99)70150-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the past few years, low doses of methotrexate have been used for treatment of patients with rheumatoid arthritis and other collagen vascular diseases, mainly as an immunosuppressive and corticosteroid-sparing drug. Several cutaneous adverse reactions have been described in association with methotrexate therapy. OBJECTIVE We describe the clinical and the histopathologic features of distinctive cutaneous lesions that appeared in 4 patients with acute bouts of collagen vascular diseases who were receiving methotrexate therapy. METHODS We clinically and histopathologically evaluated cutaneous lesions caused by methotrexate therapy in 4 patients, 2 with systemic lupus erythematosus, 1 with rheumatoid arthritis, and 1 with Sharp syndrome. RESULTS Clinically, lesions consisted of erythematous indurated papules most commonly located on proximal areas of the extremities. Histopathologic examination of these papules showed an inflammatory infiltrate mainly composed of histiocytes interstitially arranged between collagen bundles of the dermis, intermingled with few neutrophils. In some foci of deeper reticular dermis, small rosettes composed of clusters of histiocytes surrounding a thick central collagen bundle were seen. Cutaneous lesions showed a direct chronologic relationship with methotrexate therapy, and they disappeared when the drug was tapered or withdrawn and corticosteroids were increased. CONCLUSION Patients receiving low doses of methotrexate for acute bouts of collagen vascular diseases may experience characteristic cutaneous lesions with distinctive clinical and histopathologic findings shortly after methotrexate administration. We discuss the differential diagnosis with other dermatoses showing similar histopathologic findings that have been described in patients with collagen vascular diseases.
Collapse
Affiliation(s)
- E Goerttler
- Department of Dermatology, Albert Ludwig Universitaet, Freiburg, Germany
| | | | | | | |
Collapse
|
32
|
Lee MW, Jang KA, Lim YS, Choi JH, Sung KJ, Moon KC, Koh JK. Cutaneous extravascular necrotizing granuloma (Churg Strauss granuloma). Clin Exp Dermatol 1999; 24:193-5. [PMID: 10354178 DOI: 10.1046/j.1365-2230.1999.00452.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Churg Strauss granuloma (cutaneous extravascular necrotizing granuloma) is a distinct entity which is associated with systemic immunoreactive or autoimmune diseases in a majority of cases. Typically, Churg Strauss granuloma presents as symmetrical papules or nodules on the extremities. There are two histological patterns: the classic pattern reveals palisading granuloma with central degenerated collagen, interspersed polymorphonuclear leukocytes, and leukocytoclastic debris; the focal basophilic necrosis pattern does not show palisading granuloma. We report two cases of Churg Strauss granuloma with different histopathological patterns.
Collapse
Affiliation(s)
- M W Lee
- Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | | | | | | | | | | | | |
Collapse
|
33
|
Abstract
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.
Collapse
MESH Headings
- Aminocaproates/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Antibodies, Monoclonal/therapeutic use
- Antigen-Antibody Complex/immunology
- Dapsone/therapeutic use
- Fibrinolytic Agents/therapeutic use
- Glucocorticoids/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Lymphocytes/pathology
- Potassium Iodide/therapeutic use
- Purpura/pathology
- Skin Diseases, Vascular/drug therapy
- Skin Diseases, Vascular/etiology
- Skin Diseases, Vascular/immunology
- Skin Diseases, Vascular/pathology
- Vasculitis/drug therapy
- Vasculitis/etiology
- Vasculitis/immunology
- Vasculitis/pathology
- Vasculitis, Leukocytoclastic, Cutaneous/drug therapy
- Vasculitis, Leukocytoclastic, Cutaneous/etiology
- Vasculitis, Leukocytoclastic, Cutaneous/immunology
- Vasculitis, Leukocytoclastic, Cutaneous/pathology
- Venules/pathology
Collapse
Affiliation(s)
- T Lotti
- Department of Dermatology, University of Florence, Italy
| | | | | | | |
Collapse
|
34
|
|
35
|
Affiliation(s)
- T Lotti
- Department of Dermatology, University of Siena, Italy
| | | | | |
Collapse
|
36
|
Wilmoth GJ, Perniciaro C. Cutaneous extravascular necrotizing granuloma (Winkelmann granuloma): confirmation of the association with systemic disease. J Am Acad Dermatol 1996; 34:753-9. [PMID: 8632069 DOI: 10.1016/s0190-9622(96)90008-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND An unusual palisading granuloma has been described in patients with immunoreactive diseases. Multiple names have been given to this lesion. OBJECTIVE Our aim was to verify whether a distinct palisading granuloma can be used as a marker for systemic disease. We also propose unifying nomenclature. METHODS Thirty-four biopsy specimens from 22 patients were selected for study on the basis of histologic criteria. The medical histories of these patients were subsequently reviewed for clinical information. RESULTS At least 21 of the 22 patients with cutaneous extravascular necrotizing granuloma had evidence of an underlying immunoreactive systemic illness. In each, the systemic disease preceded or was diagnosed concurrently with the cutaneous lesions. CONCLUSION The cutaneous extravascular necrotizing granuloma has unique clinical and histologic features. In a great majority of cases, a systemic immunoreactive disease is present.
Collapse
Affiliation(s)
- G J Wilmoth
- Department of Dermatology, Mayo Clinic Jacksonville, FL 32224, USA
| | | |
Collapse
|
37
|
Abstract
We examined cutaneous manifestations of rheumatoid arthritis (RA) of 142 Japanese patients who visited both the Departments of Dermatology and Rheumatology of our hospital. We classified cutaneous lesions into specific and/or characteristic or nonspecific ones. Nonspecific lesions predominated in our series. Among the specific skin manifestations, which comprised 10% of the total, rheumatoid nodules, rheumatoid papules, rheumatoid neutrophilic dermatitis, and severe vasculitic ulcers correlated with high titers of rheumatoid factors and progression of RA, while purpura and livedo did not. Nonspecific skin manifestations failed to correspond with the level of rheumatoid factors. Among the nonspecific lesions, asteatotic eczema, candida interdigitalis, and tinea unguium were commonly detected.
Collapse
Affiliation(s)
- T Yamamoto
- Department of Dermatology, Metropolitan Bokuto Hospital, Tokyo, Japan
| | | | | |
Collapse
|
38
|
Gibson LE, el-Azhary RA, Smith TF, Reda AM. The spectrum of cutaneous granulomatous vasculitis: histopathologic report of eight cases with clinical correlation. J Cutan Pathol 1994; 21:437-45. [PMID: 7868756 DOI: 10.1111/j.1600-0560.1994.tb00286.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Cutaneous granulomatous vasculitis is an uncommon histopathologic finding that has been associated with lymphoproliferative disorders, systemic vasculitis, autoimmune inflammatory diseases, and infection. To define further the concept of cutaneous granulomatous vasculitis and to emphasize its clinical importance, we reviewed biopsy material from 8 patients seen from 1985 through 1992. All biopsies showed evidence of blood vessel damage with fibrinoid change or hemorrhage (or both) and granulomatous inflammation in and around vessel walls. Special stains for microorganisms were negative in all cases. Associated medical disorders included neuropathy (2 patients), sarcoid-like disease (2), systemic vasculitis (1), lymphoma and suspected lymphoma (1 each), and associated herpes simplex virus (1). T-cell gene-rearrangement studies were negative in a patient with suspected lymphoma. Granulomatous cutaneous vasculitis is most commonly associated with lymphoma and systemic vasculitis. In selected cases, infection should be considered as an underlying cause.
Collapse
Affiliation(s)
- L E Gibson
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota 55905
| | | | | | | |
Collapse
|
39
|
Craig SD, Jorizzo JL, White WL, Sutej PG, Wieselthier JS. Cutaneous signs of rheumatic disease: acral purpuric papules in a patient with clinical rheumatoid arthritis. ARTHRITIS AND RHEUMATISM 1994; 37:957-9. [PMID: 8003070 DOI: 10.1002/art.1780370627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- S D Craig
- Wake Forest University Medical Center, Winston-Salem, North Carolina
| | | | | | | | | |
Collapse
|
40
|
Higaki Y, Yamashita H, Sato K, Higaki M, Kawashima M. Rheumatoid papules: a report on four patients with histopathologic analysis. J Am Acad Dermatol 1993; 28:406-11. [PMID: 8445055 DOI: 10.1016/0190-9622(93)70059-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The rheumatoid papule is a recently described skin manifestation of rheumatoid arthritis. OBJECTIVE Rheumatoid papules from four patients with classic rheumatoid arthritis were examined to determine the origin of this palisading granulomatous reaction. METHODS Immunofluorescence and electron microscopic studies were performed on biopsy specimens of rheumatoid papules. RESULTS Leukocytoclastic vasculitis with collagen alteration and lymphohistiocytic infiltration were observed. The immunofluorescence study revealed deposits of immunoglobulins and complement in the vessel walls and in the area of collagen alteration. Electron microscopy revealed epithelioid cell-like histiocytes among altered collagen fibers. These cells contained abundant lysosomes and were connected to neighboring cells by well-developed intricate processes. CONCLUSION Vasculitis is important in the pathogenesis of rheumatoid papules. In patients with rheumatoid papules, systemic evaluation should be performed because these are a manifestation of rheumatoid vasculitis.
Collapse
Affiliation(s)
- Y Higaki
- Department of Dermatology, Tokyo Women's Medical College, Japan
| | | | | | | | | |
Collapse
|
41
|
Abstract
A working classification of necrotizing vasculitis based on size of the affected vessel is proposed. The classification proposed by Gilliam and Fink in 1976 is a basis for the current proposal. A revised working classification of vasculitis is presented. Small vessel necrotizing vasculitis and larger vessel necrotizing vasculitis categories are further subdivided. Improved understanding of the basic science aspects of vasculitis will hopefully give rise to a better consensus on the classification of vasculitis.
Collapse
Affiliation(s)
- J L Jorizzo
- Department of Dermatology, Bowman Gray School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
42
|
Abstract
A 71-year-old man was admitted to the Wake Forest University/Baptist Hospital Medical Center on February 1, 1989, with pharyngitis and a cutaneous eruption that began that day. The past history was significant for a diagnosis of chronic lymphocytic leukemia (CLL) made in 1984, and for longstanding hypertension, severe coronary artery disease, and prostatic hypertrophy. The patient had required no therapy for his CLL until August, 1988, when he developed hemolytic anemia and was treated with oral chlorambucil, 4 mg/day, and a tapering course of prednisone. By December, 1988, the prednisone therapy had been discontinued, but the patient required hospital admission for pneumococcal pneumonia, which responded well to intravenous antibiotic therapy. One day prior to the current admission the patient complained of persistent fevers, sore throat, productive cough, and headache. He noted a new cutaneous eruption on the day of admission in February, 1989. The past history was positive for occasional herpes stomatitis. The patient did not know if he had previously been infected with varicella. Skin examination revealed multiple (greater than 20), single, and grouped vesicles in a generalized distribution involving the bilateral trunk, head, neck, arms, and legs. The heaviest involvement was on the right posterior auricular area and on the neck. A Tzanck preparation obtained from an early lesion was positive for multinucleated giant cells. Viral culture was negative at 24 hours and at 1 week. A skin biopsy of an early vesicular lesion was performed and revealed intraepidermal vesicles with acantholysis and giant cells.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- M D Zanolli
- Department of Dermatology, Wake Forest University, Bowman Gray School of Medicine, Winston-Salem, North Carolina 27103
| | | | | | | | | |
Collapse
|