Two cases of leukocytoclastic vasculitis with tuberculosis

Fatal gastrointestinal bleeding due to IgA vasculitis complicated with tuberculous lymphadenitis: A case report and literature review

We report a case of IgA vasculitis that developed during the treatment of tuberculosis. Patients with tuberculosis who are on antituberculosis treatment can be administered steroids for severe disease or complications.

Mycobacterium avium-intracellulare pulmonary infection complicated by cutaneous leukocytoclastic vasculitis in a woman with anorexia nervosa

A 53-year-old Caucasian woman with a history of anorexia nervosa developed a bilateral lower extremity rash comprised of palpable red to violaceous, sub-centimeter papular lesions that increased in quantity rapidly. She also noted a 2-month history of non-productive cough. Imaging modalities revealed a thin-walled cavitary lesion in the right lung apex and scattered nodular opacities. Acid fast bacilli (AFB) were found in sputum and subsequently identified by culture as Mycobacterium avium-intracellulare (MAI). Punch biopsies of her skin lesions yielded a histological diagnosis of small-to-medium vessel vasculitis. Stains and cultures for organisms were negative. Her skin lesions resolved quickly after the initiation of antimicrobial therapy for MAI. Hypersensitivity vasculitis associated with an atypical mycobacterial infection is unusual. The postulated underlying mechanism is the deposit of immune complexes and not the bacillus itself. While cutaneous leukocytoclastic vasculitis (CLV) due to MAI is certainly a rare entity, it should be entertained in patients with vasculitic skin lesions and a concomitant pulmonary disease.

Cutaneous leukocytoclastic vasculitis revealing multifocal tuberculosis

Cutaneous leukocytoclastic vasculitis (CLV) is an inflammatory vascular disorder rarely reported to be associated with tuberculosis. The following report describes the case of a young man with multifocal tuberculosis revealed by CLV. Diagnosis was confirmed by the presence of tuberculoid granuloma with caseous necrosis on pleural and perianal biopsy, and a rapid improvement in anti-tuberculous quadritherapy. Although rarely seen, Mycobacterium tuberculosis should be considered as a potential cause of CLV.

Skin Infection by Coagulase Negative Staphylococci as a Potential Triggering Factor for Cutaneous Leukocytoclastic Vasculitis

Introduction

Leukocytoclastic vasculitis (LV) is a necrotising vasculitis of the small dermal blood vessels, clinically presented as palpable purpura. It is a heterogeneous disorder often limited to the skin but which may involve other organs. LV might be a serious drug reaction, caused by bacterial and viral infections, or less commonly a manifestation of systemic vasculitic syndromes.

Case Reports

Three patients were admitted to our institution with petechiae and palpable purpura. The cutanous lesions were affecting the lower limbs and in one patient also the upper extremities and the trunk. The diagnosis of leukocytoclastic vasculitis was made based on clinical and histopathological findings. Systemic involvement was excluded, as was connective tissue disease. Clinical examination revealed ulcers on the legs of each patient. Smears from those ulcers were taken and investigated for micro organisms. Culture results showed infection with coagulase negative staphylococci. Systemic signs of sepsis were absent; therefore the infections were treated locally. Two patients developed necrotic blisters during the first week of hospitalisation. To avoid further vasculitic complications steroids were administered parenterally and LV lesions diminished in all patients within ten days.

Conclusion

Drugs and connective tissue disease were ruled out as triggering factors of LV in the patients reported on. Therefore, it was concluded that superantigens produced by the coagulase negative staphylococci were responsible for LV.

A Case of Henoch-Schönlein Purpura Nephritis in Pulmonary Tuberculosis

A 38-year-old man with pulmonary tuberculosis developed purpura over both lower extremities and renal disturbance after starting antituberculosis treatment. A renal biopsy and skin biopsy were performed to diagnose the new clinical manifestations, and leukocytoclastic vasculitis with IgA and C3 deposition were detected. Henoch-Schönlein purpura nephritis (HSPN) was diagnosed on the basis of the clinical and pathologic findings, and prednisolone therapy was added. The skin lesions disappeared in 7 days after starting steroid therapy, and renal function gradually improved. These results suggested that the pathogenesis of HSPN might be the consequence of the deposition of the circulating immune complexes. The treatment of HSPN has been not established yet. We should consider how to use steroid therapy for HSPN and call attention to the recurrences of renal disturbance and pulmonary tuberculosis. It is thus recommended to follow patients with HSPN in tuberculosis for long periods.

Cutaneous leukocytoclastic vasculitis with cervical tuberculous lymphadenitis: a case report and literature review

Cutaneous leukocytoclastic vasculitis (CLV) is a small-vessel vasculitis localized to the skin. Many possible causes exist for this pathological condition, including drugs, infection, collagen vascular disease, and malignancy. However, Mycobacterium tuberculosis is rarely reported to be associated with CLV. Here, we report a 49-year-old male patient that presented with fever, myalgia, and multiple palpable purpura on both of his legs. The biopsy from the purpura yielded a histologic diagnosis of leukocytoclastic vasculitis. The patient had several enlarged lymph nodes on his right neck, and the biopsy revealed tuberculous lymphadenitis. There were no signs of vasculitis present in the internal organs. After anti-tuberculosis treatment, his fever declined and the skin purpura were completely resolved. Although incidence is rare, tuberculosis should be considered as a possible cause of CLV.

Cutaneous leukocytoclastic vasculitis in a child with interleukin-12 receptor beta-1 deficiency

We report a patient with complete interleukin-12 receptor beta-1 deficiency associated with cutaneous leukocytoclastic vasculitis. The patient experienced Bacille Calmette Guérin, Mycobacterium chelonae, and Salmonella enteritidis infection. Vasculitis affecting both small arteries and postcapillary venules due to deposition of immune complexes was probably caused by S. enteritidis and/or M. chelonae infection.

Successive development of cutaneous polyarteritis nodosa, leucocytoclastic vasculitis and Sweet's syndrome in a patient with cervical lymphadenitis caused by Mycobacterium fortuitum

Mycobacterium fortuitum is a rapidly growing mycobacterium found in soil and water throughout the world. It can cause diseases in immunocompetent patients, usually resulting in localized skin and soft tissue infections. Cervical lymphadenitis caused by M. fortuitum is rare. We report a 46-year-old woman in whom skin lesions of cutaneous polyarteritis nodosa, leucocytoclastic vasculitis and Sweet's syndrome had successively developed before the diagnosis of cervical lymphadenitis caused by M. fortuitum was made. The skin lesions responded to colchicine and systemic corticosteroids but recurred intermittently. After establishment of the diagnosis, she received treatment with clarithromycin and ciprofloxacin. The cervical lymph nodes decreased in size 6 months later and no more new skin lesions were found.

Henoch-Schönlein purpura associated with pulmonary Mycobacterium avium-intracellulare complex

A 57-year-old woman presented with bloody sputum and high grade fever. She had been treated for Mycobacterium avium-intracellulare complex (MAC). High grade fever slightly decreased and bloody sputum disappeared after two weeks, but low grade fever persisted. After 3 days of recurrence of bloody sputum, she suddenly complained of palpable pururitic lesions on the bilateral lower extremities with bilateral gonalgia. Although there are some reports of direct skin lesions due to MAC, there are no reports of hypersensitivity vasculitis, Henoch-Schönlein purpura, in MAC. It is necessary to consider MAC infection as a potential cause of Henoch-Schönlein purpura.

Orbital inflammatory pseudotumor due to hypersensitivity vasculitis and mononeuritis multiplex in a patient with atypical, cANCA-positive Wegener's granulomatosis

OBJECTIVE

We report on a 60-year-old woman with a retro-orbital pseudotumor and polyneuropathy. The retro-orbital inflammation was histologically diagnosed as hypersensitivity vasculitis (HV). As cytoplasmatic antineutrophilic cytoplasmatic antibody (cANCA) and anti-proteinase-3 antibody were detected, the differential diagnosis also included atypical Wegener's granulomatosis. Hypersensitivity vasculitis is defined as small-vessel vasculitis mediated by the deposition of immune complexes (Arthus reaction) after exposure to various agents such as drugs, toxins, and infections. Since an inflammatory retro-orbital pseudotumor due to HV has not previously been reported, the following case is presented.

METHODS AND MAIN OUTCOME MEASURES

Magnetic resonance imaging (MRI) revealed retro-orbital infiltrate without granuloma. Histology from an orbital biopsy confirmed HV. Electromyography was used for the diagnosis of polyneuropathy. Serum investigation indicated erythrocyte sedimentation rate (ESR) >100 mm/h, C-reactive protein (CRP) 223 mg/l, antinuclear antibodies 1:80, and cANCA 100 U/ml.

RESULTS

The bilateral orbital pseudotumor, polyneuropathy, and serum levels of inflammation reactants (ESR and CRP) improved from therapy with corticosteroids (1 g of methylprednisolone initially) and azathioprine (150 mg/day).

CONCLUSIONS

Because of cANCA and anti-proteinase-3 antibody positivity, this case can be viewed more as an atypical Wegener's granulomatosis than a systemic HV. The causal variety of inflammatory orbital pseudotumor, including HV and different therapeutic consequences, requires histological differentiation from usual orbital pseudotumors.