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Al-Obaidi AD, Sabeeh SK, Mohammed MJ, Othman A, Algburi YA, Hashim HT, Alhatemi AQM, Al Hilali Z, Al-Attabi BRT, Al-Awad A. Negative Results, Positive Outcome: A Case of Primary Livedoid Vasculopathy With an Elusive Laboratory Workup. J Investig Med High Impact Case Rep 2024; 12:23247096241266090. [PMID: 39068597 DOI: 10.1177/23247096241266090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024] Open
Abstract
Livedoid vasculopathy (LV) is a chronic, recurrent thrombotic vasculopathy characterized by painful ulcerations on the lower extremities, which heal slowly and leave atrophic white scars known as "atrophie blanche." This report presents the case of a 31-year-old woman with a 4-year history of recurrent painful ulcerations on her legs and feet. A skin biopsy revealed findings consistent with LV, and an exhaustive laboratory workup ruled out secondary causes such as thrombophilia, malignancies, autoimmune diseases, and peripheral arterial disease. The patient showed remarkable improvement with a treatment regimen of pentoxifylline, nifedipine, and warfarin, resulting in complete ulcer resolution and sustained remission over 5 months. Our case highlights the importance of a comprehensive diagnostic approach and a multidisciplinary treatment strategy in managing primary LV to achieve remission and prevent recurrence of skin ulcerations.
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Eswaran H, Chaturvedi S, Brodsky RA, Gerber GF, Pan XZ, Moll S. Evaluating complement dysregulation in livedoid vasculopathy using a functional assay. Blood Adv 2023; 7:6604-6607. [PMID: 37722353 PMCID: PMC10641098 DOI: 10.1182/bloodadvances.2022009142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 08/31/2023] [Accepted: 09/10/2023] [Indexed: 09/20/2023] Open
Affiliation(s)
- Harish Eswaran
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Shruti Chaturvedi
- Divison of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert A. Brodsky
- Divison of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gloria F. Gerber
- Divison of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiang-Zuo Pan
- Divison of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephan Moll
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
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3
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Palanisamy N, Chinnappan J, Bachuwa G. Pain Management Options in a Patient with Livedoid Vasculopathy and Peripheral Neuropathy. Eur J Case Rep Intern Med 2023; 10:003727. [PMID: 36819654 PMCID: PMC9930874 DOI: 10.12890/2023_003727] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/12/2023] [Indexed: 02/01/2023] Open
Abstract
Livedoid vasculopathy (LV) is a rare clinical condition presenting as painful lesions mostly on the lower extremities. We present a case of LV with peripheral neuropathy in a young man initially misdiagnosed and treated for cellulitis. He was started on aspirin, pentoxifylline and apixaban immediately after the diagnosis of LV. However, pain management was a real challenge for the clinicians. Hence, he was later treated with epoprostenol and amlodipine for vasodilation, steroids for any possible inflammation, and antibiotics to treat superimposed infection. Irrespective of all the above, his pain was uncontrollable, and he finally received ketamine infusions along with narcotics, achieving better pain control. Various studies support the use of intravenous immunoglobulin and anti-TNF agents for pain relief in idiopathic and secondary LV. Intermittent low-dose dabigatran has also been found to be effective in the maintenance of remission in LV. However, no large studies have yet been conducted to confirm the efficacy of these medications. LEARNING POINTS Early initiation of treatment with antiplatelets and anticoagulants is recommended to prevent the progression of livedoid vasculopathy (LV).Anti-TNF agents can be tried in refractory LV for rapid relief of pain.Intravenous immunoglobulin has been shown to be effective for the resolution of pain and improvement of neuropathic symptoms especially in LV refractory to immunosuppressive agents.
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Affiliation(s)
- Nageshwari Palanisamy
- Department of Internal Medicine, Michigan State University, Hurley Medical Center, Flint, MI, USA
| | - Justine Chinnappan
- Department of Internal Medicine, Michigan State University, Hurley Medical Center, Flint, MI, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Michigan State University, Hurley Medical Center, Flint, MI, USA
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Eswaran H, Googe P, Vedak P, Marston WA, Moll S. Livedoid vasculopathy: A review with focus on terminology and pathogenesis. Vasc Med 2022; 27:593-603. [PMID: 36285834 PMCID: PMC9732787 DOI: 10.1177/1358863x221130380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Livedoid vasculopathy (LV) is a rare thrombotic vasculopathy of the dermis characterized by painful, relapsing ulcers over the lower extremities. Diagnosis is challenging due to the overlap in clinical appearance and nomenclature with other skin disorders. Treatment selection is complicated by poor understanding of the pathogenesis of LV and lack of robust clinical trials evaluating therapy efficacy. The terminology and pathophysiology of LV are reviewed here, along with its epidemiology, clinical and histologic features, and treatment options. A diagnostic pathway is suggested to guide providers in evaluating for comorbidities, referring to appropriate specialists, and choosing from the available classes of therapy.
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Affiliation(s)
- Harish Eswaran
- Department of Medicine, Division of
Hematology, University of North Carolina School of Medicine, Chapel Hill, NC,
USA
| | - Paul Googe
- Department of Dermatology, University
of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Priyanka Vedak
- Department of Dermatology, University
of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - William A Marston
- Department of Surgery, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Stephan Moll
- Department of Medicine, Division of
Hematology, University of North Carolina School of Medicine, Chapel Hill, NC,
USA
- Blood Research Center, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
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5
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Soulages A, Maisonobe T, Auzou P, Petit A, Allenbach Y, Barète S, Skopinski S, Ribeiro E, Jullié ML, Lamant L, Brevet F, Soulages X, Vallat JM, Martin-Négrier ML, Solé G, Duval F, Carla L, Le Masson G, Mathis S. Peripheral neuropathy and livedoid vasculopathy. J Neurol 2022; 269:3779-3788. [PMID: 35166926 DOI: 10.1007/s00415-022-11007-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/24/2021] [Accepted: 02/02/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Livedoid vasculopathy (LV) is a chronic dermatosis associated with micro-thrombosis of the vessels of the dermis, leading to ischemic lesions and painful skin ulcerations of the lower limbs. This thrombosing occlusive vasculopathy, clearly distinct from 'classical vasculitis' (not related to alteration of vessel walls), may lead to peripheral neuropathy. OBJECTIVE To clarify the main clinical, electrophysiological and pathological characteristics of peripheral neuropathy linked to LV. METHOD We presented a series of personal cases of peripheral neuropathy due to LV. We also conducted a review of the literature (since the first description of LV in 1974) using multiple combinations of keywords from 'PubMed', 'Google Scholar' and 'ScienceDirect' databases according to the 'Preferred Reporting Items for Systematic reviews and Meta-Analyses' guidelines. RESULTS We identified 16 patients (6 personal cases and 10 cases from the medical literature). Our personal cases were five females and one male, with a median age (at the onset of cutaneous signs of LV) of 38 (range 25-62). Several types of skin lesions of the lower limbs were observed. Median age at the onset of peripheral neuropathy symptoms was 48 years (range 29-66), with a main clinical and electrophysiological pattern of mononeuropathy multiplex. DISCUSSION We observed a typical pattern of peripheral neuropathy, mostly mononeuropathy multiplex, whose pathophysiology might be related to occlusions of the small vessels of the nerves, as seen in the dermis. Moreover, LV may also be associated with other types of peripheral neuropathies (sometimes of autoimmune etiology) not directly related to the skin lesions. CONCLUSION The 'ischemic form' of peripheral neuropathy linked to LV is mainly responsible for sensory disturbances (with multifocal distribution), sometimes for motor disturbances. This type of peripheral neuropathy has to be distinguished from 'classical vasculitic neuropathies' which are usually treated with antithrombotic therapies.
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Affiliation(s)
- Antoine Soulages
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Thierry Maisonobe
- Department of Clinical Neurophysiology, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Pascal Auzou
- Department of Neurology, CHR Orléans, Orléans, France
| | - Antoine Petit
- Department of Dermatology, AP-HP, Saint-Louis Hospital, Paris, France
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Stéphane Barète
- Department of Dermatology, Sorbonne Université (UPMC Paris-6), Paris, France
| | - Sophie Skopinski
- Department of Vascular Medicine, University Hospital of Bordeaux (CHU Bordeaux, Saint-André Hospital), Bordeaux, France
| | - Emmanuel Ribeiro
- Department of Internal Medicine and Tropical Diseases, University Hospital of Bordeaux (CHU Bordeaux, Saint-André Hospital), Bordeaux, France
| | - Marie-Laure Jullié
- Department of Pathology, University Hospital of Bordeaux (CHU Bordeaux, Haut-Lévêque Hospital), Pessac, France
| | - Laurence Lamant
- Department of Pathology, Institut Universitaire du Cancer de Toulouse, Oncopole (IUC-T), Toulouse, France
| | | | - Xavier Soulages
- Neurology Office, 23 Boulevard de la République, Rodez, France
| | - Jean-Michel Vallat
- Department of Neurology, University Hospital of Limoges (Dupuytren Hospital), Limoges, France
| | - Marie-Laure Martin-Négrier
- Department of Pathology, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Guilhem Solé
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Fanny Duval
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Louis Carla
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Gwendal Le Masson
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Stéphane Mathis
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France.
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6
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Weishaupt C, Strölin A, Kahle B, Kreuter A, Schneider SW, Gerss J, Eveslage M, Drabik A, Goerge T. Characteristics, risk factors and treatment reality in livedoid vasculopathy - a multicentre analysis. J Eur Acad Dermatol Venereol 2019; 33:1784-1791. [PMID: 31009111 DOI: 10.1111/jdv.15639] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Livedoid vasculopathy (LV) is a rare cutaneous thrombotic disease. It is characterized by occlusion of dermal vessels resulting in livedo racemosa, ulceration and atrophie blanche. Clear guidelines for diagnosis and treatment are missing. OBJECTIVE The purpose of this study was to better characterize epidemiology, clinical appearance and treatment reality of LV in a well-defined patient cohort. METHODS The cohort was allocated within a prospective, multicentre, phase IIa trial that investigated the effect of rivaroxaban in LV. RESULTS Analysis of 27 patients revealed that LV patients had an increased Body Mass Index (BMI; 11/27), hypertension (19/27) and increased levels of lipoprotein (a) (5/12) and homocysteine (10/12) in the blood. The female-to-male ratio was 2.1 : 1, and the median age was 53.0 years [interquartile range (IQR) 40.5-68]. Investigation of the clinical appearance found that 82% of patients had livedo racemosa, and the ankle region was most likely to be affected by ulceration (56-70%). The analysis of patient treatment history showed that heparin was most effective (12/17), while anti-inflammatory regimens were, although often used (17/24), not effective (0/17). CONCLUSION We add clinical clues for a data supported diagnosis of LV, and we provide evidence that anticoagulants should be administered in monotherapy first line (EudraCT number 2012-000108-13-DE).
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Affiliation(s)
- C Weishaupt
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany
| | - A Strölin
- Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - B Kahle
- Department of Dermatology, University Hospital Luebeck, Luebeck, Germany
| | - A Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Hospital Oberhausen, University Witten/Herdecke, Oberhausen, Germany
| | - S W Schneider
- Department of Dermatology, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
| | - J Gerss
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - M Eveslage
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - A Drabik
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany
| | - T Goerge
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany
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7
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Abstract
ZusammenfassungFallbericht: Wir beschreiben den Fall eines 42-jährigen adipösen Mannes, der sich mit fibrinös belegten Ulcera crurum in unserer Klinik vorstellte. Die Ulcera waren umgeben von Hyperpigmentierungen und einer initialen Dermatolipofasziosklerose. Duplexsonographisch zeigte sich eine Stammvarikosis der V. saphena magna am linken Bein. Am rechten Bein waren jedoch weder venöse Insuffizienzen noch Obstruktionen nachweisbar. Hinweise für eine periphere arterielle Verschlusskrankheit, ein Lymphödem oder Infektzei-chen fehlten.Ergebnisse: Durch eine lokale Wundbehand-lung mit Polyurethan-Wundauflagen in Kombination mit einer Kompressionstherapie mit einem 2-lagigen Kompressionssystem konnte nach 8 Monaten eine vollständige Abheilung der Ulcera am rechten Bein erzielt werden. In Zusammenschau mit dem klinischen Bild stellten wir die Diagnose Ulcera crurum bei Adipositas-assoziiertem Dependency-Syndrom.Diskussion: Das Adipositas-assoziierte Dependency Syndrom stellt eine Ursache für hydrostatische Ulcera ohne Vorhandensein von Klappeninsuffizienzen oder Obstruktionen dar und kann als funktionelle Veneninsuffizienz verstanden werden. Pathogenetisch liegt ein andauerndes Herabhängenlassen der Beine aufgrund von eingeschränkter Mobilität zugrunde. Zudem wurde eine Kompression der Beinvenen durch die abdominelle Fettschürze beschrieben. Therapeutisch stehen neben einer konsequenten Kompressionstherapie eine Remobilisierung der Patienten und eine Gewichtsreduktion im Vordergrund.English version available at: www.phlebologieonline.de
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8
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Abstract
Livedoid vasculopathy (atrophie blanche) is a form of thrombotic vasculopathy. It is characterized by small ulcers that become crusted, and heal after several months to produce white atrophic scars. The most commonly affected sites are the lower legs, in particular the dorsum of the feet and ankles. To date, the dermoscopic features of livedoid vasculopathy have not been clearly described in the literature. In this observational study, we sought to evaluate the dermoscopic patterns of livedoid vasculopathy and determine whether the dermoscopic features are associated with certain histopathological characteristics. We evaluated 9 patients with livedoid vasculopathy by dermoscopy. Skin biopsy specimens were stained with hematoxylin and eosin for histopathologic examination, and dermoscopic features were correlated with histopathological characteristics. In the majority of patients with livedoid vasculopathy, examination with dermoscopy revealed central crusted ulcers or ivory white areas associated with peripheral pigmentation in a reticular pattern. In addition, increased vascular structures including linear and glomerular vessels were found. On histopathological examination, the central ivory white areas correlated with dermal fibrosis, the reticular pigmentation corresponded to epidermal basal layer hyperpigmentation or melanin within melanophages in the dermal papillae, and the vascular structures correlated with dilatation and proliferation of capillaries in the upper dermis. In summary, the most common dermoscopic features of livedoid vasculopathy identified in this study were central crusted ulcers or ivory white scar-like areas associated with peripheral reticular pigmentation and increased vascular structures. The characterization of dermoscopic criteria for livedoid vasculopathy may improve the accuracy in the clinical diagnosis and follow-up of this disease.
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Affiliation(s)
- Stephen Chu-Sung Hu
- Department of Dermatology, College of Medicine, Kaohsiung Medical University
- Department of Dermatology, Kaohsiung Medical University Hospital
| | - Gwo-Shing Chen
- Department of Dermatology, College of Medicine, Kaohsiung Medical University
- Department of Dermatology, Kaohsiung Medical University Hospital
| | - Chi-Ling Lin
- Department of Dermatology, Kaohsiung Medical University Hospital
- Department of Dermatology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung
| | - Yang-Chun Cheng
- Department of Dermatology, Kaohsiung Medical University Hospital
| | - Yung-Song Lin
- Department of Otolaryngology, Chi Mei Medical Center
- Center of General education, Southern Taiwan University of Technology, Tainan City
- Department of Otolaryngology, School of Medicine, Taipei Medical University, Taipei, Taiwan
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9
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Provenza JR, Pedri LE, Provenza GM. Livedoid vasculopathy. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:554-556. [PMID: 27914604 DOI: 10.1016/j.rbre.2016.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 09/25/2015] [Indexed: 11/30/2022] Open
Affiliation(s)
- José Roberto Provenza
- Pontifícia Universidade Católica de Campinas, Hospital e Maternidade Celso Pierro, Serviço de Reumatologia, Campinas, SP, Brazil
| | - Lucas Eduardo Pedri
- Pontifícia Universidade Católica de Campinas, Hospital e Maternidade Celso Pierro, Serviço de Reumatologia, Campinas, SP, Brazil.
| | - Gabriel Mesquita Provenza
- Pontifícia Universidade Católica de Campinas, Hospital e Maternidade Celso Pierro, Serviço de Radiologia, Campinas, SP, Brazil
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10
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Provenza JR, Pedri LE, Provenza GM. Livedoid vasculopathy. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:S0482-5004(16)00027-9. [PMID: 26952873 DOI: 10.1016/j.rbr.2015.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 08/26/2015] [Accepted: 09/25/2015] [Indexed: 11/16/2022] Open
Abstract
Livedoid vasculopathy is a chronic and painful skin disease that progresses to ulceration. Due to its uncertain pathogenesis, there is no single effective treatment for this condition, and current therapeutic options are based on isolated case reports, or on case series. We report a case of a female patient with livedoid vasculopathy, which achieved excellent healing of lower limb ulcers after using an anti-TNF agent.
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Affiliation(s)
- José Roberto Provenza
- Serviço de Reumatologia, Hospital e Maternidade Celso Pierro, Pontifícia Universidade Católica de Campinas, Campinas, SP, Brasil
| | - Lucas Eduardo Pedri
- Serviço de Reumatologia, Hospital e Maternidade Celso Pierro, Pontifícia Universidade Católica de Campinas, Campinas, SP, Brasil.
| | - Gabriel Mesquita Provenza
- Serviço de Radiologia, Hospital e Maternidade Celso Pierro, Pontifícia Universidade Católica de Campinas, Campinas, SP, Brasil
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11
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Criado P, Espinell D, Barreto P, Di Giacomo T, Sotto M. Lipoprotein(a) and livedoid vasculopathy: A new thrombophilic factor? Med Hypotheses 2015; 85:670-4. [DOI: 10.1016/j.mehy.2015.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/29/2015] [Accepted: 08/13/2015] [Indexed: 11/25/2022]
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12
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Allenbach Y, Tourte M, Stenzel W, Goebel HH, Maisonobe T, Frances C, Barete S, Benveniste O. Expanding the spectrum of livedoid vasculopathy: peculiar neuromuscular manifestations. Neuropathol Appl Neurobiol 2015; 41:849-52. [DOI: 10.1111/nan.12243] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/28/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Yves Allenbach
- Department of Neuropathology; Charité - Universitätsmedizin; Berlin Germany
- Department of Internal Medicine and Clinical Immunology; Hospital University Department: Inflammation, Immunopathology and Biotherapy (DHU i2B); Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière University Hospital; Paris France
- Inflammatory Muscle Team; Inserm U974; Sorbonne Université; Paris France
| | - Maylis Tourte
- Department of Internal Medicine and Clinical Immunology; Hospital University Department: Inflammation, Immunopathology and Biotherapy (DHU i2B); Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière University Hospital; Paris France
- Inflammatory Muscle Team; Inserm U974; Sorbonne Université; Paris France
| | - Werner Stenzel
- Department of Neuropathology; Charité - Universitätsmedizin; Berlin Germany
| | - Hans-Hilmar Goebel
- Department of Neuropathology; Charité - Universitätsmedizin; Berlin Germany
| | - Tierry Maisonobe
- Assistance Publique-Hôpitaux de Paris; Department of Neuropathology; Pitié-Salpêtrière University Hospital; Paris France
| | - Camille Frances
- Assistance Publique - Hôpitaux de Paris; Tenon University Hospital; Department of Dermatology; Sorbonne University; Paris France
| | - Stephane Barete
- Assistance Publique - Hôpitaux de Paris; Tenon University Hospital; Department of Dermatology; Sorbonne University; Paris France
- Assistance Publique - Hôpitaux de Paris; Pitié-Salpêtrière University Hospital; Dermatology unit; Sorbonne University; University Pierre et Marie-Curie-Paris 6; Paris France
| | - Olivier Benveniste
- Department of Internal Medicine and Clinical Immunology; Hospital University Department: Inflammation, Immunopathology and Biotherapy (DHU i2B); Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière University Hospital; Paris France
- Inflammatory Muscle Team; Inserm U974; Sorbonne Université; Paris France
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13
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Malaguti MC, Cavallaro T, Speziali L, Zorzi MG, Marangoni S, Morini A. Mononeuritis multiplex associated with primary livedoid vasculopathy: Neuropathological evidence of ischemic nerve damage. J Neurol Sci 2015; 351:214-215. [DOI: 10.1016/j.jns.2015.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/18/2015] [Accepted: 03/05/2015] [Indexed: 11/28/2022]
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14
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Alix JJ, Hadjivassiliou M, Ali R, Slater D, Messenger AG, Rao DG. Sensory ganglionopathy with livedoid vasculopathy controlled by immunotherapy. Muscle Nerve 2014; 51:296-301. [DOI: 10.1002/mus.24452] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2014] [Indexed: 12/26/2022]
Affiliation(s)
- James J.P. Alix
- Department of Clinical Neurophysiology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield S10 2JF
| | - Marios Hadjivassiliou
- Department of Neurology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield England
| | - Rokiahmah Ali
- Department of Histopathology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield England
| | - David Slater
- Department of Histopathology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield England
| | - Andrew G. Messenger
- Department of Dermatology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield England
| | - D. Ganesh Rao
- Department of Clinical Neurophysiology; Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield S10 2JF
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15
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Zhou Q, Yang D, Ombrello AK, Zavialov AV, Toro C, Zavialov AV, Stone DL, Chae JJ, Rosenzweig SD, Bishop K, Barron KS, Kuehn HS, Hoffmann P, Negro A, Tsai WL, Cowen EW, Pei W, Milner JD, Silvin C, Heller T, Chin DT, Patronas NJ, Barber JS, Lee CCR, Wood GM, Ling A, Kelly SJ, Kleiner DE, Mullikin JC, Ganson NJ, Kong HH, Hambleton S, Candotti F, Quezado MM, Calvo KR, Alao H, Barham BK, Jones A, Meschia JF, Worrall BB, Kasner SE, Rich SS, Goldbach-Mansky R, Abinun M, Chalom E, Gotte AC, Punaro M, Pascual V, Verbsky JW, Torgerson TR, Singer NG, Gershon TR, Ozen S, Karadag O, Fleisher TA, Remmers EF, Burgess SM, Moir SL, Gadina M, Sood R, Hershfield MS, Boehm M, Kastner DL, Aksentijevich I. Early-onset stroke and vasculopathy associated with mutations in ADA2. N Engl J Med 2014; 370:911-20. [PMID: 24552284 PMCID: PMC4193683 DOI: 10.1056/nejmoa1307361] [Citation(s) in RCA: 544] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND We observed a syndrome of intermittent fevers, early-onset lacunar strokes and other neurovascular manifestations, livedoid rash, hepatosplenomegaly, and systemic vasculopathy in three unrelated patients. We suspected a genetic cause because the disorder presented in early childhood. METHODS We performed whole-exome sequencing in the initial three patients and their unaffected parents and candidate-gene sequencing in three patients with a similar phenotype, as well as two young siblings with polyarteritis nodosa and one patient with small-vessel vasculitis. Enzyme assays, immunoblotting, immunohistochemical testing, flow cytometry, and cytokine profiling were performed on samples from the patients. To study protein function, we used morpholino-mediated knockdowns in zebrafish and short hairpin RNA knockdowns in U937 cells cultured with human dermal endothelial cells. RESULTS All nine patients carried recessively inherited mutations in CECR1 (cat eye syndrome chromosome region, candidate 1), encoding adenosine deaminase 2 (ADA2), that were predicted to be deleterious; these mutations were rare or absent in healthy controls. Six patients were compound heterozygous for eight CECR1 mutations, whereas the three patients with polyarteritis nodosa or small-vessel vasculitis were homozygous for the p.Gly47Arg mutation. Patients had a marked reduction in the levels of ADA2 and ADA2-specific enzyme activity in the blood. Skin, liver, and brain biopsies revealed vasculopathic changes characterized by compromised endothelial integrity, endothelial cellular activation, and inflammation. Knockdown of a zebrafish ADA2 homologue caused intracranial hemorrhages and neutropenia - phenotypes that were prevented by coinjection with nonmutated (but not with mutated) human CECR1. Monocytes from patients induced damage in cocultured endothelial-cell layers. CONCLUSIONS Loss-of-function mutations in CECR1 were associated with a spectrum of vascular and inflammatory phenotypes, ranging from early-onset recurrent stroke to systemic vasculopathy or vasculitis. (Funded by the National Institutes of Health Intramural Research Programs and others.).
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Affiliation(s)
- Qing Zhou
- The authors' affiliations are listed in the Appendix
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Alavi A, Hafner J, Dutz JP, Mayer D, Sibbald RG, Criado PR, Senet P, Callen JP, Phillips TJ, Romanelli M, Kirsner RS. Livedoid vasculopathy: An in-depth analysis using a modified Delphi approach. J Am Acad Dermatol 2013; 69:1033-1042.e1. [DOI: 10.1016/j.jaad.2013.07.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 07/16/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
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Song HB, Woo SJ, Jung CK, Lee YJ, Ahn J, Park KH, Kwon OK. Acute central retinal artery occlusion associated with livedoid vasculopathy: a variant of Sneddon's syndrome. KOREAN JOURNAL OF OPHTHALMOLOGY 2013; 27:376-80. [PMID: 24082777 PMCID: PMC3782585 DOI: 10.3341/kjo.2013.27.5.376] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 02/02/2012] [Indexed: 11/23/2022] Open
Abstract
Livedoid vasculopathy (LV) is characterized by a long history of ulceration of the feet and legs and histopathology indicating a thrombotic process. We report a case of acute central retinal artery occlusion in a 32-year-old woman who had LV. She showed no discernible laboratory abnormalities such as antiphospholipid antibodies and no history of cerebrovascular accidents. Attempted intra-arterial thrombolysis showed no effect in restoring retinal arterial perfusion or vision. The central retinal artery occlusion accompanied by LV in this case could be regarded as a variant form of Sneddon's syndrome, which is characterized by livedo reticularis and cerebrovascular accidents.
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Affiliation(s)
- Hyun Beom Song
- Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea. ; Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, Korea
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Bounfour T, Bouaziz JD, Bézier M, Petit A, Viguier M, Rybojad M, Bagot M. Intravenous immunoglobulins in difficult-to-treat ulcerated livedoid vasculopathy: five cases and a literature review. Int J Dermatol 2013; 52:1135-9. [DOI: 10.1111/j.1365-4632.2012.05826.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Touda Bounfour
- Department of Dermatology; AP-HP; Saint Louis Hospital and Paris 7 Diderot Sorbonne University; Paris; France
| | - Jean-David Bouaziz
- Department of Dermatology; AP-HP; Saint Louis Hospital and Paris 7 Diderot Sorbonne University; Paris; France
| | - Maud Bézier
- Department of Dermatology; AP-HP; Saint Louis Hospital and Paris 7 Diderot Sorbonne University; Paris; France
| | - Antoine Petit
- Department of Dermatology; AP-HP; Saint Louis Hospital and Paris 7 Diderot Sorbonne University; Paris; France
| | - Manuelle Viguier
- Department of Dermatology; AP-HP; Saint Louis Hospital and Paris 7 Diderot Sorbonne University; Paris; France
| | - Michel Rybojad
- Department of Dermatology; AP-HP; Saint Louis Hospital and Paris 7 Diderot Sorbonne University; Paris; France
| | - Martine Bagot
- Department of Dermatology; AP-HP; Saint Louis Hospital and Paris 7 Diderot Sorbonne University; Paris; France
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Gan EY, Tang MBY, Tan SH, Chua SH, Tan AWH. A Ten-Year Retrospective Study on Livedo Vasculopathy in Asian Patients. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2012. [DOI: 10.47102/annals-acadmedsg.v41n9p400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: This study aims to analyse the clinico-epidemiological characteristics of Asian patients diagnosed with livedo vasculopathy (LV). Materials and Methods: We performed a retrospective analysis of all patients diagnosed with LV from 1997 to 2007 at our centre. Results: Seventy patients were diagnosed with LV with a mean age of 39 years, female: male ratio of 3:1 and no racial predilection. Most cases remained purely cutaneous, presenting with painful leg ulcers and atrophie blanche. Peripheral neuropathy was the only extra-cutaneous complication (9%). In patients who were screened, associations included hepatitis B (7%) and hepatitis C (4%), positive anti-nuclear antibody (14%), positive anti-myeloperoxidase antibody (5%), positive anti-cardiolipin antibodies (7%) and positive lupus anticoagulant (2%). In 49 patients who achieved remission, 55% required combination therapy, most commonly with colchicine, pentoxifylline and prednisolone. In those treated successfully with monotherapy, colchicine was effective in 59% followed by prednisolone (17.5%), pentoxifylline (17.5%) and aspirin (6%). Mean follow-up period was 50 months. Conclusion: LV in Asian patients is a high morbidity, chronic relapsing ulcerative skin condition. Most patients require induction combination therapy for remission. As further evidence emerges to support a procoagulant pathogenesis, a standardised protocol is needed to investigate for prothrombotic disorders during diagnosis.
Key words: Atrophie blanche, Livedo reticularis, Livedoid vasculitis
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Painless Livedoid Vasculopathy in a Patient with G20210A Prothrombin Gene Mutation. Case Rep Med 2012; 2012:910231. [PMID: 22988463 PMCID: PMC3440924 DOI: 10.1155/2012/910231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 08/09/2012] [Accepted: 08/09/2012] [Indexed: 12/03/2022] Open
Abstract
87 year old Caucasian female with chronic painless non-healing ulcers over malleoli was admitted to the hospital. On a physical examination, there were two bilateral and laterally located malleoli ulcers with no discharge. A thorough work up was done: lower extremities venous and arterial Doppler ultrasound did not show any evidence of venous and arterial disease respectively. Heterozygous G20210A Prothrombin gene mutation was found, and the patient was started on anticoagulation. This case reports highlights a possibility of a painless livedoid vasculopathy presentation in a patient without significant past thrombotic events. Therefore, it is important to consider livedoid vasculopathy in the differential in a patient with painless ulcerative, atrophic and/or nodular skin lesions over the shins and malleoli.
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21
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Vascular disease in systemic lupus erythematosus. Autoimmune Dis 2012; 2012:876456. [PMID: 22957213 PMCID: PMC3432322 DOI: 10.1155/2012/876456] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 08/03/2012] [Indexed: 01/09/2023] Open
Abstract
Vascular disease, either as a direct complication of the disease or developing as an accompanying comorbidity impairs significantly the quality of life of patients with SLE and represents the most frequent cause of death in established lupus. This paper aims to give an overview of the prevalence of the different forms of vasculopathy that can be encountered in a lupus patient, describe their pathogenesis, and address their impact on disease severity and outcome.
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22
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Mir-Bonafé JM, Román-Curto C, Santos-Briz Á, Cañueto J, Fernández-López E, Unamuno P. Gemcitabine-associated livedoid thrombotic microangiopathy with associated sclerema neonatorum-like microscopic changes. J Cutan Pathol 2012; 39:707-11. [DOI: 10.1111/j.1600-0560.2012.01918.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abou Rahal J, Ishak RS, Otrock ZK, Kibbi AG, Taher AT. Livedoid vasculopathy in a patient with lupus anticoagulant and MTHFR mutation: treatment with low-molecular-weight heparin. J Thromb Thrombolysis 2012; 34:541-4. [DOI: 10.1007/s11239-012-0743-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kim JE, Park SY, Sinn DI, Kim SM, Hong YH, Park KS, Sung JJ, Lee KW. Ischemic neuropathy associated with livedoid vasculitis. J Clin Neurol 2011; 7:233-6. [PMID: 22259622 PMCID: PMC3259500 DOI: 10.3988/jcn.2011.7.4.233] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 10/19/2010] [Accepted: 10/19/2010] [Indexed: 11/17/2022] Open
Abstract
Background Livedoid vasculitis is a chronic dermatological problem with an unclear etiology. Clinical findings are petechiae with painful ulcers in both lower extremities, which heal to become hyperpigmented and porcelain-white satellite lesions. There are only a few reported cases of livedoid vasculitis presenting in combination with peripheral neuropathy. Case Report We report the first case of a Korean patient presenting with mononeuritis multiplex combined with livedoid vasculitis, which was confirmed by electrophysiological and pathological studies. Conclusions Our report supports the possible vaso-occlusive etiology of livedoid vasculitis in multifocal ischemic neuropathy.
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Affiliation(s)
- Jee-Eun Kim
- Department of Neurology, Seoul Medical Center, Seoul, Korea
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25
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El Khoury J, Taher A, Kurban M, Kibbi AG, Abbas O. Livedoid vasculopathy associated with sickle cell trait: significant improvement on aspirin treatment. Int Wound J 2011; 9:344-7. [PMID: 22044499 DOI: 10.1111/j.1742-481x.2011.00882.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Livedoid vasculopathy (LV) is a chronic, recurrent, painful cutaneous disease manifesting as longstanding distal lower extremity ulcers that scar leaving stellate atrophic lesions known as 'atrophie blanche'. A significant number of cases have been associated with thrombophilic abnormalities. In this study, we describe, to the best of our knowledge, the first report of LV only associated with sickle cell trait with significant improvement on aspirin.
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Affiliation(s)
- Jinane El Khoury
- Dermatology Department, American University of Beirut Medical Center, Beirut, Lebanon
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Zemtsov A, Omueti-Ayoade K, Zemtsov R, Yang M. Livedo reticularis as an initial clinical manifestation of gemcitabine-induced hemolytic uremic syndrome. J Dermatol 2011; 39:487-9. [PMID: 21906135 DOI: 10.1111/j.1346-8138.2011.01353.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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27
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Vasconcelos R, Criado P, Belda W. Livedoid vasculopathy secondary to high levels of lipoprotein(a). Br J Dermatol 2011; 164:1111-3. [DOI: 10.1111/j.1365-2133.2011.10216.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
New clinical indications for rituximab seem to appear every day. This review will trace the use of this monoclonal antibody from lymphoid malignancy, to classic autoimmune disease, and specifically severe autoimmune skin diseases. The history leading to different dosing schema with associated pharmacokinetic data will be discussed. A case of livedoid vasculopathy (atrophie blanche) responding to rituximab will illustrate how the response to therapy can help to elucidate previously obscure pathophysiology.
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Affiliation(s)
- Daniel D Bennett
- Department of Dermatology, Division of Hematology and Oncology, Scott and White Healthcare, Texas A&M Health Science Center College of Medicine. Temple, TX, USA
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