Wells' syndrome in children: varicella infection as a precipitating event

Granuloma Annulare-like Wells Syndrome in a Child - A Case Report

Wells syndrome (WS) is a rare inflammatory skin disease of unknown etiology. Possible triggers for WS include insect bites/stings, infections, medications, malignancies, and vaccination. Most cases have been reported in adults, but WS may also occur in children.

We report a case of idiopathic WS in a 12-year-old boy, who presented with pruritic papulonodular and granuloma annulare-like lesions on his legs. The patient had an excellent response to topical and systemic corticosteroids.

WS may present as plaque, granuloma annulare-like, urticaria-like, papulovesicular, bullous, papulonodular, or fixed drug eruption-like lesions. Erythematous annular lesions are most common in adults, while plaques are mostly found in children. The histopathologic features are dynamic, starting with dermal edema and infiltration of eosinophils, then flame figures develop, and finishing with the appearance of histiocytes and giant cells.

Our patient represents a rare pediatric case with granuloma annulare-like WS syndrome.

Treatment of eosinophilic cellulitis (Wells syndrome) - a systematic review

Eosinophilic cellulitis (Wells syndrome) is a rare inflammatory skin disease defined by erythematous, tender, sometimes urticarial plaques, possibly with vesicles and bullae, and granulomatous eosinophilic infiltrates in the dermis. Usually the disease has a benign course with spontaneous remission within a few weeks. Nevertheless, recurrences are quite frequent and may occur for several years. The objective of this study was to review the so far reported treatment options for Wells syndrome in a systematic manner. This systematic review is based on a search on Medline, Embase and Cochrane Central Register for English and German articles from 1970 to 2015. Advices on the treatment of Wells syndrome are limited predominately to case reports or to small case series. There are no randomized controlled trials, and control groups are missing. A variety of treatment options for Wells syndrome were reported including topical and systemic corticosteroids, antihistamines, cyclosporine, dapsone, azathioprine, griseofulvin, doxycycline, minocycline, antimalarial medications, oral tacrolimus/topical tacrolimus, sulfasalazine, interferon alpha and gamma, TNF alpha inhibitors, colchicine and PUVA therapy. As well-designed, randomized controlled trials are missing, no guidelines for the treatment of this disease can be given. Due to the small number of patients and the frequent misdiagnosis of this clinical entity, the aim of this systematic overview is to call attention to this rare condition and to help clinicians to diagnose and treat Wells syndrome effectively. Due to the good prognosis and tendency to resolve, systemic treatment should be limited to cases resistant to local therapy or with widespread lesions.

[Wells Syndrome in children and atopy: Retrospective study of 11 cases and review of the literature]

BACKGROUND

Well's syndrome, or eosinophilic cellulitis, is rare in childhood, with fewer than 40 pediatric cases being reported since 1979. The physiopathology is unknown.

PATIENTS AND METHODS

In February 2012, members of the research group of the Department of Pediatric Dermatology Society submitted their case of Wells' syndrome in children aged 0-15 years. Details of clinical, biological and histological features and of therapeutic strategies were collected by physicians using a standardized questionnaire. Pictures were reviewed by the authors.

RESULTS

Eleven patients were included (average age: 6 years), with a strong prevalence of atopy (63%). Two types of clinical manifestation were noted: single or multiple cellulitis associated or not with vesiculobullous lesions and fixed urticaria. Eighty-two percent of patients had pruritus and 73% had eosinophilia. For all patients, histological examination of skin biopsies showed an eosinophilic infiltrate extending in the dermis with associated Sweet-like neutrophilic infiltrate being seen in 2 patients. The course of the disease was protracted (mean duration: 8 months) with flare-ups. Treatment varied depending on the doctors (topical or systemic steroids, tacrolimus and dapsone).

DISCUSSION

Our study confirms some of the data in the literature concerning the clinical, histological features and course of Well's syndrome in children. The key information is the high prevalence of atopic children hitherto unreported. In a setting of insect bites, vaccination, infection or traumatism, this unusual background could explain the onset of inflammatory reaction with eosinophils. Oral or topical steroids appear to be the first-line treatment in children when necessary.

CONCLUSION

Well's syndrome in children is rare and characterized by its polymorphism. We report for the first time in a series of patients a high prevalence of atopy, which raises new perspectives in understanding these rare diseases. We propose topical steroids as first-line therapy in children with superficial lesions, with oral steroids being given for cellulitic lesions or where topical therapy fails.

Insect-bite-like Wells' syndrome in association with mantle-zone lymphoma

Wells' syndrome is a multifaceted dermatosis with a wide morphological spectrum, ranging from characteristic cellulitis-like erythema and wheals to an unusual presentation of vesicles and bullae. We describe a patient in whom Wells' syndrome presented as an insect-bite-like eruption and was associated with underlying mantle-cell lymphoma. We recommend meticulous investigation of patients diagnosed with Wells' syndrome manifesting as an insect-bite-like eruption.

Bullous "cellulitis" with eosinophilia: case report and review of Wells' syndrome in childhood

A 1-year-old girl presented with acute onset of edematous erythematous plaques associated with bullae on her extremities and accompanied by peripheral eosinophilia. She was afebrile, and the skin lesions were pruritic but not tender. The patient was treated with intravenously administered antibiotics for presumed cellulitis, without improvement. However, the lesions responded rapidly to systemic steroid therapy. On the basis of lesional morphologic features, peripheral eosinophilia, and cutaneous histopathologic features, a diagnosis of Wells' syndrome was made. Wells' syndrome is extremely rare in childhood, with 27 pediatric cases reported in the literature. Because it is seen so infrequently, there are no specific guidelines for evaluation and management of Wells' syndrome among children. The diagnosis should be considered for children with presumed cellulitis and eosinophilia who fail to respond to antibiotics. Evaluation should include a directed history, physical examination, complete blood count, and stool testing for ova and parasites, to identify potential triggers. Treatment is with systemic steroid therapy unless disease is limited, in which case medium/high-potency topical steroids may be indicated. If systemic features are prominent or disease is chronic (lasting >6 months), then a referral to hematology/oncology should be considered.

Cutaneous adverse reaction to 2-chlorodeoxyadenosine with histological flame figures in patients with chronic lymphocytic leukaemia

INTRODUCTION

2-Chlorodeoxyadenosine (cladribine or 2-CdA) is a purine analogue that has been used successfully in hairy cell leukaemia (HCL). Moreover, it has been increasingly used to treat chronic lymphoproliferative syndromes and paediatric acute myeloid leukaemia. Cutaneous side-effects associated with this drug have seldom been described in cases of HCL.

PATIENTS AND METHODS

We describe three patients with chronic lymphocytic leukaemia that presented generalized skin eruptions after treatment with 2-CdA.

RESULTS

All patients had advanced disease, receiving 2-CdA as a second or third line chemotherapy. Skin lesions were severe and chemotherapy had to be discontinued. Histological examination of skin biopsies showed an eosinophil-rich infiltrate with flame figures, similar to what is observed in Wells' syndrome (eosinophilic cellulitis). Corticosteroids were effective to control the eruptions.

CONCLUSIONS

Cutaneous adverse reactions associated with 2-CdA have seldom been observed in the treatment of HCL. However, as this purine analogue has been used in more advanced cases these may be more frequent and severe. The pathophysiology of these lesions is unclear, but it is probably related to drug-induced change in T-cell imbalance in severely immunosuppressed patients.

Herpes simplex virus type 2-associated eosinophilic cellulitis (Wells' syndrome)

Eosinophilic cellulitis (Wells' syndrome) is a recurrent inflammatory dermatosis characterized by massive infiltration of eosinophils into the skin. Drugs and pathogens have been recognized causes of eosinophilic cellulitis. We report the repeated association of eosinophilic cellulitis with herpes simplex virus type 2 infections. Antiviral therapy led to a complete remission of eosinophilic cellulitis, indicating that causative treatment of underlying diseases can be effective in controlling eosinophilic cellulitis.

Wells' syndrome: a clinical and histopathologic review of seven cases

Wells' syndrome, or eosinophilic cellulitis, is characterized clinically by an acute dermatitis resembling cellulitis, which evolves into violaceous plaques that resolve spontaneously without scarring. The histopathologic features are dynamic, starting with dermal edema and infiltration of eosinophils, the development of "flame figures," and finishing with the appearance of phagocytic histiocytes. We present the clinical and histopathologic features of seven cases of eosinophilic cellulitis.

Wells' syndrome associated with recurrent giardiasis

Wells' syndrome (WS) is a rare, recurrent, inflammatory dermatosis of uncertain pathogenesis, although a hypersensitivity response to different stimuli has been postulated. Several cases in association with parasitic infections have been described. We present a patient with WS associated with recurrent giardiasis. The course of the dermatosis was strictly related to the course of the parasitic infection. Both diseases disappeared with antiparasitic treatment. To our knowledge, this association is here reported for the first time.

Familial eosinophilic cellulitis, dysmorphic habitus, and mental retardation

BACKGROUND

Eosinophilic cellulitis is a polymorphous, chronic disease characterized by eosinophil infiltration and granulomatous inflammation.

OBJECTIVE

Our purpose was to describe the clinical, histologic, and immunohistologic findings in three family members who have had eosinophilic cellulitis since childhood associated with mental retardation and abnormal body habitus.

METHODS

Family members were evaluated. Multiple skin biopsy specimens were obtained and examined after hematoxylin-and-eosin staining, by immunofluorescence and by electron microscopy. Blood specimens were analyzed by immunoassays for eosinophil granule proteins and eosinophil active cytokines.

RESULTS

Three short-statured, mentally retarded family members with abnormal body habitus in at least two generations had recurrent eosinophilic cellulitis. Peripheral blood and bone marrow eosinophilia was present. Plasma eosinophil granule major basic protein and eosinophil-derived neurotoxin levels were elevated with normal plasma eosinophil cationic protein levels. Eosinophil survival in culture was increased by patients' plasma and was blocked with monoclonal interleukin-5 antibody. The level of plasma interleukin-5 was elevated. Lesional skin biopsy specimens showed massive staining for three eosinophil granule proteins. Electron microscopy showed eosinophil disruption.

CONCLUSION

Eosinophilic cellulitis, mental retardation, and abnormal body habitus were likely inherited as a dominant syndrome in this family in which eosinophil involvement was striking.

Congenital Wells syndrome

We describe a girl with eosinophilic cellulitis (Wells syndrome) in whom the disease appeared immediately after birth with subcutaneous nodules on the scalp and trunk, followed by the characteristic skin swelling and erythema at the age of 6 months. The lesions disappeared after a few weeks, but recurred several times. The mother had consumed large quantities of medications during the pregnancy, including iron, vitamins, and "natural remedies." Based on time of onset, this may be regarded as a unique case of congenital Wells syndrome. Its relation to the medications taken by the mother remains speculative. Subcutaneous nodules may be the presenting sign of Wells syndrome in children.

Wells' syndrome in childhood: case report and review of the literature

We report a severe case of Wells' syndrome, or eosinophilic cellulitis, after a bee sting in a 4-year-old girl. The patient had a widespread, painful, blistering eruption that was subsequently complicated by Pseudomonas aeruginosa superinfection and septicemia, hypoalbuminemia, anemia, and neutropenia. The skin lesions responded to systemic steroid therapy. There was residual scarring alopecia of the scalp. There have been 17 previous reports of childhood Wells' syndrome. We believe that this disorder is a distinct entity that should be considered in the differential diagnosis of blistering diseases in children.

Eosinophilic cellulitis case report: treatment options

Eosinophilic cellulitis in a 56 year old woman is described. The patient responded well to oral prednisolone, but attempts to withdraw the corticosteroid resulted in relapses. Remission was achieved with a combination of dapsone, antihistamine and alternate-day prednisolone.