Erythema Elevatum Diutinum in the Setting of Connective Tissue Disease and Chronic Bacterial Infection

Atypical Presentation of Erythema Elevatum Diutinum in a Patient With Hashimoto's Disease

Erythema elevatum diutinum (EED) is a cutaneous vasculitis that is characterized by histopathologic findings of neutrophilic infiltration, vessel fibrosis, and leukocytoclasia. It most often presents as papules, plaques, and nodules on the extensor surfaces of the extremities. Herein, we present a case of a 44-year-old woman with Hashimoto's disease with an atypical presentation of EED on the palmar surface of the thumb, in addition to the classic appearance on the elbow. Diseases associated with EED, including autoimmune conditions, are discussed.

Atypical Palmar Involvement with Erythema Elevatum Diutinum as a Sole Manifestation: A Report of Two Cases

Erythema elevated diutinum (EED) is a rare distinctive form of cutaneous leukocytoclastic vasculitis. EED typically presents with asymptomatic symmetrical erythematous-brown papules, nodules or plaques which favor the extensor aspect of extremities while distinctly sparing the palms. We report two cases of EED with a rare presentation limited to the palms.

Erythema elevatum et diutinum as a systemic disease

Erythema elevatum et diutinum (EED) is a rare, chronic dermatosis. It has been associated with extracutaneous findings, including arthralgias, scleritis, panuveitis, peripheral ulcerative keratitis, oral and penile ulcers, and neuropathy. Additionally, EED is connected with various systemic diseases, including HIV, IgA paraproteinemia, myelomas, neutrophilic dermatoses, and inflammatory bowel diseases. The presence of such extracutaneous manifestations in EED patients suggests that EED may be a multiorgan entity. Extracutaneous manifestations in EED may involve deposition of circulating immune complexes; thus, patients with EED should be evaluated for systemic manifestations to ensure targeted management.

Erythema elevatum diutinum: a case report and review of literature

Erythema elevatum diutinum (EED) is a rare cutaneous leukocytoclastic vasculitis thought to be related to increased levels of circulating antibodies. It has been shown to be associated with HIV infection, tuberculosis, as well as various autoimmune diseases. A retrospective review of all cases of EED indexed in PubMed between 1990 and 2014 was performed. Inclusion criteria for articles was availability of full text in English and a biopsy-confirmed diagnosis of EED. All other articles were excluded. Cases were stratified by age and anatomic location of the lesions. Treatment response was coded as "complete," "partial," and "none." A total of 133 cases of EED with 381 lesions detailed in case reports and case series were included. Twenty-one cases were associated with HIV. Of 47 patients with reported paraproteinemias, IgA paraproteinemia was found in 57.45%, IgG paraproteinemia in 29.8%, IgM paraproteinemia in 10.6%, and IgD paraproteinemia in 2.1% of cases. Of 40 (30.1%) patients with reported comorbid autoimmune disease, rheumatoid arthritis was associated with 10 cases. Cancer was found to be associated with 9.77% of cases. Seventy-five patients were treated with dapsone, with 36 (48%) achieving complete treatment response, 24 (32%) achieving partial response, and seven (9.3%) achieving no response. Keeping the clinical associations of EED in mind, especially malignancy, is critical in management of the disease. More structured studies need to take place in order to fully define the mechanisms and strength of these associations.

[Erythema elevatum diutinum associated with pyoderma gangrenosum in an HIV-positive patient]

BACKGROUND

Erythema elevatum diutinum (EED) is a very rare form of chronic dermatosis clinically characterised by reddish-violet papular nodules extending to the surfaces of the limbs and extremities. Histologically, there are classically two phases of progression initially involving associated neutrophilic dermatosis and leucocytoclastic vasculitis, which is later followed by fibrosis of characteristic appearance. We report the association of EED and pyoderma gangrenosum in a patient infected with HIV.

PATIENTS AND METHODS

A 53-year-old male seen since 1989 for HIV infection had been presenting firm bilateral and symmetrical nodules on the feet for 6 months. Histological analysis of one of these nodules resulted in diagnosis of chronic erythema elevatum diutinum and treatment with dapsone was initiated. Three months later, despite regression of the EED lesions under dapsone, two large pustules appeared on the outer aspect of the right leg; they were confluent and progressed towards a superficial ulcer with rounded edges with a clinical appearance evocative of pyoderma gangrenosum (PG). Histopathological analysis demonstrated a massive dermal infiltrate beneath the ulcer comprising neutrophils with evidence of leucocytoclasia, all of which militated in favour of the diagnosis of pyoderma gangrenosum.

DISCUSSION

We report for the first time the association of two forms of neutrophilic dermatosis, EED and PG, in an HIV-positive patient. This case report and certain data in the literature suggest that the various forms of neutrophilic dermatosis tend to result in a range of lesions rather than in clearly distinct entities.

Erythema elevatum diutinum in systemic lupus erythematosus

Erythema elevatum diutinum (EED) is a rare chronic form of leukocytoclastic vasculitis with unknown etiology. EED has been described in association with hematological malignancies, infections and a number of rheumatological diseases. We report a patient with systemic lupus erythematosus (SLE) who presented with intermittent attacks of tender nodules and plaques on the shins and ankles for 6 months. Skin biopsy confirmed the diagnosis of EED. Treatment with dapsone resulted in complete resolution of the skin lesions. EED is rarely reported in SLE, and its presentation and treatment is reviewed.

[Medium and large vessel vasculitis]

Vasculitis comprises a broad group of syndromes characterized by inflammation and necrosis on the walls of blood vessels, resulting in narrowing or occlusion of the lumen. The distribution of involved blood vessel varies considerably and serves as the basis for one classification of vasculitic syndromes: large vessels (Takayasu arteritis, giant cell arteritis); medium and small muscular arteries (polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, vasculitis in rheumatic diseases); and small vessels ("hypersensitivity" vasculitis, Henoch-Schonlein purpura, microscopic polyangiitis, cryoglobulinemia). This article reviews medium and large vessel vasculitis and current treatment options; it also presents a comprehensive approach to diagnosing and treating patients with suspected cutaneous vasculitis.

The development of erythema elevatum diutinum in a patient with juvenile idiopathic arthritis under treatment with abatacept

In this case report, we present the first report of erythema elevatum diutinum after treatment of juvenile idiopathic arthritis with abatacept. Although it could also be coincidental, in our case, the appearance of vasculitis was not blocked by the simultaneous administration of a stimulation inhibitor, and alerts to the fact that as effective as a abatacept may be to control of the inflammatory articular symptoms, this might not translate into control of the disease.

Cutaneous Vasculitis Update: Small Vessel Neutrophilic Vasculitis Syndromes

A broad and diverse spectrum of vasculitic syndromes exists. These syndromes affect the skin with varying levels of associated systemic manifestations, running the gamut from a self-limited, localized, cutaneous phenomenon to rapidly progressive, multiorgan disease. The majority of cases of cutaneous vasculitis will show a neutrophilic small vessel vasculitis that can be either a primary (idiopathic) disorder (eg, cutaneous leukocytoclastic angiitis) or a secondary disorder that is associated with drugs, infection (eg, streptococcal infection, viral hepatitis), or underlying disease (eg, connective tissue disease, malignancy). Biopsy is the gold standard for the diagnosis of cutaneous vasculitis and also necessary for the detection of cutaneous vascular immune complexes by direct immunofluorescence. Based on the type of vessel disrupted by inflammation (small and/or muscular), the distribution of vasculitis in the dermis and subcutis, and predominate inflammatory cell-type mediating vessel wall damage, a list of relevant differential diagnoses can be generated. This histologic information coupled with extravascular findings such as tissue eosinophilia, tissue neutrophilia, and/or granulomas, plus pathophysiologic markers such as direct immunofluorescent examination for immune complexes and serologic evaluation for antineutrophil cytoplasmic antibodies allows for more accurate diagnosis of specific vasculitic entities. Herein, we review both primary and secondary vasculitic syndromes that affect the skin and show a small vessel neutrophilic mediated vasculitis.