Erythema gyratum repens. A case studied with immunofluorescence, immunoelectron microscopy and immunohistochemistry

Cutaneous manifestations of internal malignancy

Skin lesions associated with internal malignancy may present as cutaneous metastases or as typical lesions occurring in the context of certain cancer-associated genetic syndromes. Paraneoplastic syndromes, on the other hand, are only indirectly associated with an underlying malignancy and are not malignant per se. Historically, a distinction has been made between "obligate" and "facultative" paraneoplastic disorders, depending on the likelihood with which they are potentially associated with malignancy. In addition, there are nonspecific cutaneous manifestations that are only rarely associated with an underlying malignancy. Another possible classification is based on the pathophysiological mechanisms underlying the cutaneous lesions. In everyday practice, it is essential that dermatologists recognize potentially cancer-associated dermatoses, as this will frequently contribute to the initial diagnosis of an underlying neoplasm.

Autoimmune paraneoplastic syndromes associated to lung cancer: A systematic review of the literature: Part 2: Hematologic, cutaneous and vascular syndromes

The development of new immune treatment in oncology and particularly for lung cancer may induce new complications, particularly activation or reactivation of auto-immune diseases. In this context, a systematic review on the auto-immune paraneoplastic syndromes associated with lung cancer appears useful. This article is the second of a series of five and deals with hematologic, cutaneous and vascular syndromes.

Erythema Gyratum Repens Associated with Transitional Cell Carcinoma of the Bladder

Background:

Erythema gyratum repens (EGR) is a gyrate erythema found in association with underlying malignancy, most commonly that of the lung, esophagus, and breast. Since 1952, there have been 51 cases of this condition reported.

Objective:

Only one case of EGR associated with transitional cell carcinoma of the bladder (TCCB) has been previously reported.

Methods:

The second case of EGR is the subject of a case report presentation.

Results:

An elderly patient presented with EGR and subsequent work-up revealed the presence of malignancy of the bladder.

Conclusion:

Erythema gyratum repens can be found in association with a variety of malignancies, including TCCB.

Cutaneous manifestations of internal malignancy: diagnosis and management

An association between systemic malignancy and cutaneous manifestations has long been recognized. The cutaneous features that can occur are numerous and heterogeneous, and many different etiologic mechanisms are represented - from direct tumor invasion of skin or distant metastases to a wide variety of inflammatory dermatoses that may occur as paraneoplastic phenomena. In addition, there are a number of inherited syndromes that carry an increased risk of cutaneous as well as internal malignancies. While some of these inherited syndromes and paraneoplastic phenomena are exceedingly rare, all clinicians will be aware of the common cutaneous manifestations of advanced malignant disease such as generalized xerosis and pruritus. This review classifies these wide-ranging cutaneous manifestations of internal malignancy into five basic groups and provides practical advice regarding diagnosis and screening of patients who initially present with a cutaneous complaint. Also included is up-to-date information on two rapidly expanding and exciting areas of research that are likely to have far-reaching clinical implications: (i) clarification of underlying humoral mechanisms, for example, in the malignant carcinoid syndrome; and (ii) identification of an increasing number of specific genetic defects that confer a susceptibility to malignancy.Increased clinician awareness regarding the associations between these lesions and internal malignancy or inherited syndromes will facilitate screening and early diagnosis.

Life-threatening paraneoplastic cutaneous syndromes

Paraneoplastic syndromes are diseases or symptom complexes associated with malignancy, usually internal. In dermatology, we modify the definition to refer to dermatoses associated with internal malignancy. In this article, we discuss the link between malignancy and such dermatologic disorders as acanthosis nigricans, acrokeratosis paraneoplastica of Bazex, dermatomyositis, erythema gyratum repens, necrolytic migratory erythema (glucagonoma syndrome), and paraneoplastic pemphigus and discuss, where such information is known, the mechanism by which these paraneoplastic diseases occur.

Is the Skin an Excitable Medium? Pattern Formation in Erythema Gyratum Repens

Erythema gyratum repens (EGR) is a rare, inflammatory dermatosis of unknown aetiology. The morphology of the eruption is striking and displays rapidly evolving circinate and gyrate bands of erythematous and scaly skin. Although the aetiology of the pattern is unknown, it has previously been noted that the eruption shares morphologic features with the patterns of spatio-temporal chemical concentration profiles observed in the Belusov-Zhabotinski (BZ) reaction. Yet this morphologic correspondence has not been investigated further. Here we apply a simple non-linear reaction–diffusion model, previously used to describe the BZ reaction, as a template for pattern formation in EGR, and show how the mechanism may provide a biochemical basis for many of the dynamic and morphologic features of the rash. These results are supported by the results of a cellular automaton simulation approximating the dynamics of oscillatory chemical systems—the Hodgepodge machine—where the spatio-temporal patterns developed show astonishing similarities to the morphology of EGR.

Erythema gyratum repens responding to cetirizine hydrochloride

We report a case of erythema gyratum repens (EGR) in a 59-year-old man with inoperable pancreatic cancer and liver metastasis. The patient had a widespread erythema with concentric marginal band spreading in waves over the trunk and extremities. Numerous vesicles were seen on the margin of the erythema. The skin lesions were severely pruritic, and his peripheral blood showed marked eosinophilia. He also had palmoplantar hyperkeratosis. A biopsy specimen of the erythema disclosed spongiosis, microvesicles filled with eosinophils, infiltration of eosinophils into the epidermis, and a perivascular infiltrate in the dermis. The skin lesions and pruritus cleared quickly after the administration of cetirizine hydrochloride.

Erythema Gyratum Repens

BACKGROUND

Erythema gyratum repens is a rare, clinically specific, and distinctive paraneoplastic syndrome. It is associated with internal malignancy in 82% of patients.

OBJECTIVE

A 58-year-old man with erythema gyratum repens is described. On diagnosis of his eruption, a malignancy work-up revealed a 9-mm pulmonary adenocarcinoma. Removal of the carcinoma resulted in clearing of the erythema.

RESULTS

Erythema gyratum repens is most commonly associated with bronchial, esophageal, and breast cancer. It has also rarely been reported in patients without evidence of malignancy. The histopathologic findings are nonspecific. Direct immunofluorescence has sometimes revealed C3, C4, or immunoglobulin G at the basement membrane zone.

CONCLUSION

The etiology of erythema gyratum repens is unknown, although an immune response is postulated. Treatment involves treating the underlying malignancy.

Erythema gyratum repens-like psoriasis

A 28-year-old man was admitted to our department for investigation in 1992. He presented with a red, scaly, centrifugally spreading eruption, which had appeared in 1990, beginning on the neck and thorax, and later extending to the trunk and limbs. The cutaneous lesions, located mainly on the trunk and proximal upper limbs, were arranged in rings, with a slightly raised prominent scaling edge (Fig. 1a). The characteristic feature was the presence of rings or waves within already existing rings, whereas the central part was flattened, with the texture of normal skin. The concentric figurate lesions resembled a wood grain pattern (Fig. 1b). The clinical picture was strikingly similar to tinea imbricata; there was, however, no itching, and repeated mycologic studies did not disclose Trichophyton concentricum. The histology was not characteristic. The epidermis, which was slightly edematous, was covered with a heavy crust. In the dermis, a sparse inflammatory infiltrate, somewhat more pronounced in the subpapillary areas, was composed of lymphocytes with some eosinophils. Periodic acid-Schiff (PAS) and other stains for mycotic infection were negative. The general condition was not affected and laboratory studies did not show any abnormalities, except for low serum protein (5.1 g/L) and decreased gamma globulins (10.5%). Cell-mediated immunity was preserved. Immunofluorescence studies (direct and indirect) were negative. In spite of repeatedly negative mycotic examinations and due to the striking similarity to tinea imbricata, we applied various antimycotic therapies (terbinafine, itraconazole), with no effect. The figurate pattern, with normal skin in between, altered from day to day, while new concentric rings appeared within the cleared skin. The migrating rate was about 2-3 cm per 2 weeks. The patient had undergone a thorough search for internal malignancy. During the follow-up period of 1992-98, cutaneous involvement slowly became almost generalized (1996), and the confluent lesions formed large plaques, but still with pronounced concentric rings. Transitional blood eosinophilia (27% in 1993 and 11% in 1996) regressed with no therapy. Since 1995, antibodies to HBs and HBc have been present with no clinical symptoms of liver disease. The blood proteins increased to 7.0 g/L, and gamma globulins to 17.2% (normal). The histology, studied repeatedly, started to display some signs of psoriasis from 1996 and, in 1998, was already consistent with the disease (Fig. 2). RE-PUVA (0.8 mg/kg acitretin and UVA 0.8 J/cm2 ) was applied for 2 weeks before the patient interrupted the therapy. In spite of this, there was further improvement and, in 1999, the patient was almost free of lesions with some abortive rings left. From time to time, single vesicles appeared within the elevated borders of the rings. The histology of such vesicles was consistent with abortive pustular psoriasis (Fig. 3).

A prospective study of 200 women with dermatoses of pregnancy correlating clinical findings with hormonal and immunopathological profiles

In 1994 we set up a specialist clinic for pregnancy dermatoses, both to improve the management of pregnant women with skin problems and to enhance our general understanding of the pregnancy dermatoses. This clinic has provided a large database of 200 women which has formed the basis for a prospective study over a 2-year period. In each case the dermatological diagnosis was clearly defined on clinical criteria, with additional help from histopathology and direct immunofluorescence of the skin where appropriate. We have included a number of patients who presented with relatively trivial diagnoses, as this reflects the referral patterns of our midwives, general practitioners and obstetricians within our hospital and local population. Our results show that all patients with specific dermatoses of pregnancy conformed well to the classification established by Holmes and Black in 1983. The role of the sex hormones [oestradiol, human chorionic gonadotrophin (hCG) and cortisol] in polymorphic eruption (PEP) and prurigo of pregnancy was studied in 125 cases and compared with 138 normal healthy pregnant controls. For pruritic folliculitis (PF), serum androgens were measured to establish if these were elevated. Nearly all patients were followed up postpartum, with respect to both maternal and fetal prognosis (some were unfortunately lost to follow-up). Many patients were primiparous (47%) and presented in their third trimester (49%). This study shows a surprisingly high prevalence of eczema during pregnancy. It is possible that earlier cases in the literature termed prurigo of pregnancy may in fact have been eczema, thus explaining the low incidence of prurigo in this study. Hormonal analysis showed a significant reduction in serum cortisol levels in patients with PEP compared with normal pregnant controls (P = 0.03), although hCG and oestradiol showed no differences. Serum androgens were not significantly elevated in patients with PF compared with controls. Birthweight (analysed by the individualized birthweight ratio) was significantly reduced in both the PF and pemphigoid gestationis groups. In the PEP and PF groups there was a male/female infant ratio of 2 : 1, not noted in previous studies. In all cases studied there were no adverse effects either on maternal or fetal outcome as a result of the pregnancy dermatosis. This study indicates that all patients fulfilled the criteria of the previous classification of the specific dermatoses of pregnancy, although we also now highlight the frequency of eczema in pregnancy and speculate as to possible causes. There were no cases of papular dermatitis of pregnancy. We feel that the specialist clinic is an important service which has improved the management of these women and identified areas for further research.

Erythema Gyratum Repens an Immunological Paraneoplastic Dermatosis

The authors present a patient with erythema gyratum repens who had a bronchogenic carcinoma. Autoantibodies and complement at the basement membrane zone of the skin was found which suggest that erythema gyratum repens may have an immunological pathogenesis but the nature of the antigen should be further characterised.