Sweet's syndrome evolved from recurrent erythema nodosum in a patient with myelodysplastic syndrome

Insights Into the Pathogenesis of Sweet's Syndrome

Sweet's syndrome, also known as Acute Febrile Neutrophilic Dermatosis, is a rare inflammatory condition. It is considered to be the prototype disease of neutrophilic dermatoses, and presents with acute onset dermal neutrophilic lesions, leukocytosis, and pyrexia. Several variants have been described both clinically and histopathologically. Classifications include classic Sweet's syndrome, malignancy associated, and drug induced. The cellular and molecular mechanisms involved in Sweet's syndrome have been difficult to elucidate due to the large variety of conditions leading to a common clinical presentation. The exact pathogenesis of Sweet's syndrome is unclear; however, new discoveries have shed light on the role of inflammatory signaling, disease induction, and relationship with malignancy. These findings include an improved understanding of inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic contributions. Continued investigations into effective treatments and targeted therapy will benefit patients and improve our molecular understanding of inflammatory diseases, including Sweet's syndrome.

Myelodysplastic syndrome with neutrophilic panniculitis: A report of two cases and a literature review

Myelodysplastic syndrome (MDS) associated with neutrophilic panniculitis (NP) is rare. To the best of our knowledge, there are only five previously reported cases of MDS associated with NP, consisting of four adults and a young male. The present study reviews the literature of the previously reported cases and presents two case reports of adult male patients who were initially diagnosed as MDS. The two patients presented with a sudden onset of fever without infection and erythematous indurated papules. The patients were diagnosed with NP by skin biopsy and their symptoms disappeared completely following treatment with systemic corticosteroids. NP may be an independent high-risk factor for MDS. However, due to the rarity of such cases, the exact pathogenesis of NP associated with MDS requires further investigation.

Characteristics of Sweet Syndrome in patients with acute myeloid leukemia

INTRODUCTION

Sweet syndrome (SS) is associated with hematologic malignancies including acute myeloid leukemia (AML).

PATIENTS AND METHODS

Records of patients with AML treated at our institution were reviewed to identify those with SS. Patient characteristics, laboratory values, and cytogenetic and molecular abnormalities were retrospectively reviewed.

RESULTS

We identified 21 of 2178 (1%) AML patients who demonstrated clinical signs and symptoms, and histological features consistent with SS. Eleven patients (52%) were classified as AML with myelodysplasia-related features and 3 patients had therapy-related AML. Three patients had received treatment with granulocyte colony stimulation factor, 1 patient liposomal all-trans-retinoic acid, and 2 patients received hypomethylating agents before development of SS. Cytogenetic analysis revealed diploid karyotype in 7 patients (33%); -5/del(5q) in 8 patients (38%): 3 patients had -5/del(5q) as the sole abnormality and 5 patients had -5/del(5q) as part of complex cytogenetics; and complex cytogenetics in 5 patients (24%). Gene mutations in FMS-related tyrosine kinase-3 (FLT3) gene were identified in 7 of 18 evaluable patients (39%), including FLT3-internal tandem duplication in 4 patients and FLT3-D835 tyrosine kinase domain mutation in 3 patients.

CONCLUSION

SS occurs in 1% of AML patients; -5/del(5q) karyotype, FLT3 mutations, and AML with myelodysplasia-related features were more frequent among patients with SS.

Multiclinical experiences in erythema nodosum: rheumatology clinics versus dermatology and infection diseases clinics

Erythema nodosum (EN) is the most common cause of inflammatory nodules and usually affects the lower extremities and especially pretibial regions. EN may be idiopathic or associated with a wide spectrum of conditions including systemic diseases, infection, treatment with various drugs, pregnancy, and exceptionally with malignancies. The purpose of this study is to investigate the EN patients with different etiologies and laboratory features admitted to the rheumatology department and to compare them with other EN patients admitted to different departments including dermatology and infectious diseases. Totally, 107 patients diagnosed with EN (male/female: 37/70) were enrolled in the study. Of the 107 EN patients, 37 participants who were categorized as primary (idiopathic) EN (34.6 %) had not any underlying diseases or precipitating events. Majority of the participants were women (male/female: 12/25; mean age: 42.9 ± 9.2 years). Precisely, 70 EN (secondary EN) patients (65.4 %) had an underlying disease (male/female: 25/45; mean age: 36.1 ± 10.1). Behçet's disease (BD) was the foremost (n = 40, 37.4 %), followed by sarcoidosis (n = 17, 15.9 %), post-streptococcal (n = 9, 8.4 %), and other rheumatologic disease (one patient temporal arthritis, one patient Sjögren's syndrome, 1.9 %). Consequently, it is observed that BD, sarcoidosis, and post-streptococcal infection were found as the main etiologies of EN patients treated in our rheumatology department. These diseases should be kept in mind as an etiological factor in the management of EN.

Panniculitis as the presenting sign of a myelodysplastic syndrome in an adolescent boy

Panniculitis is an uncommon condition in childhood and may prove difficult to diagnose both clinically and histologically. The clinical spectrum is similar to that in adults and has been associated with many primary diseases. Noninfectious causes are less common in children than in adults. The pathogenesis remains uncertain in a significant number of children. In some it may be a malignant, unremitting disease which can be fatal. We present a boy aged 13 years with panniculitis of the right foot as presenting sign for the ultimate diagnosis myelodysplasia-acute myeloid leukemia. To our knowledge this is the first report on a young boy.

Sweet's syndrome--a comprehensive review of an acute febrile neutrophilic dermatosis

Sweet's syndrome (the eponym for acute febrile neutrophilic dermatosis) is characterized by a constellation of clinical symptoms, physical features, and pathologic findings which include fever, neutrophilia, tender erythematous skin lesions (papules, nodules, and plaques), and a diffuse infiltrate consisting predominantly of mature neutrophils that are typically located in the upper dermis. Several hundreds cases of Sweet's syndrome have been published. Sweet's syndrome presents in three clinical settings: classical (or idiopathic), malignancy-associated, and drug-induced. Classical Sweet's syndrome (CSS) usually presents in women between the age of 30 to 50 years, it is often preceded by an upper respiratory tract infection and may be associated with inflammatory bowel disease and pregnancy. Approximately one-third of patients with CSS experience recurrence of the dermatosis. The malignancy-associated Sweet's syndrome (MASS) can occur as a paraneoplastic syndrome in patients with an established cancer or individuals whose Sweet's syndrome-related hematologic dyscrasia or solid tumor was previously undiscovered; MASS is most commonly related to acute myelogenous leukemia. The dermatosis can precede, follow, or appear concurrent with the diagnosis of the patient's cancer. Hence, MASS can be the cutaneous harbinger of either an undiagnosed visceral malignancy in a previously cancer-free individual or an unsuspected cancer recurrence in an oncology patient. Drug-induced Sweet's syndrome (DISS) most commonly occurs in patients who have been treated with granulocyte-colony stimulating factor, however, other medications may also be associated with DISS. The pathogenesis of Sweet's syndrome may be multifactorial and still remains to be definitively established. Clinical and laboratory evidence suggests that cytokines have an etiologic role. Systemic corticosteroids are the therapeutic gold standard for Sweet's syndrome. After initiation of treatment with systemic corticosteroids, there is a prompt response consisting of dramatic improvement of both the dermatosis-related symptoms and skin lesions. Topical application of high potency corticosteroids or intralesional corticosteroids may be efficacious for treating localized lesions. Other first-line oral systemic agents are potassium iodide and colchicine. Second-line oral systemic agents include indomethacin, clofazimine, cyclosporine, and dapsone. The symptoms and lesions of Sweet's syndrome may resolved spontaneously, without any therapeutic intervention; however, recurrence may follow either spontaneous remission or therapy-induced clinical resolution.

Sweet's syndrome associated with skin methicillin-resistant Staphylococcus epidermidis infection

A 53-year-old Chinese man presented with fever, a painful exudative plaque around his left eye and subsequent multiple tender plaques and nodules on his bilateral face, neck and back. He had a 12-year history of refractory anemia, a subtype of myelodysplastic syndrome. Repeated bacterial cultures of exudates from the lesion of the left zygomatic area showed growth of methicillin-resistant Staphylococcus epidermidis. A biopsy of a plaque on the back showed edema of the papillary dermis and marked neutrophilic infiltrates in the upper dermis. The patient was diagnosed with Sweet's syndrome (SS), and responded well to combination therapy of amoxycilline/sulbactam and corticosteroids. To our knowledge, this is the first reported case of SS associated with skin S. epidermidis infection.

A case of erythema nodosum and serositis associated with myelodysplastic syndrome

Myelodysplastic syndrome (MDS) is a heterogenous group of stem cell disorders usually characterized by progressive refractory cytopenias, which could progress to acute myeloid leukemia. MDS may be associated with a wide spectrum of skin lesions, including neoplastic cell infiltration, Sweet's syndrome, pyoderma gangrenosum, erythema elevatum diutinum, vasculitis, and panniculitis. However, erythema nodosum is rarely associated with MDS. Unusual rheumatologic manifestations in patients with MDS also have been reported, which range from asymptomatic serological abnormalities to classic connective tissue disorders such as Sjögren's syndrome, relapsing polychondritis, systemic lupus erythematosus, rheumatoid arthritis and mixed connective tissue disease. However, concurrent erythema nodosum and serositis has rarely been reported. We describe a case of MDS with erythema nodosum and immune-mediated pericardial effusion in a 34-year-old woman.