Possible pathogenetic mechanisms in allergic cutaneous vasculitis

Use of granulocyte and monocyte adsorption apheresis in dermatology (Review)

Adsorptive granulocyte and monocyte apheresis (GMA) is an extracorporeal treatment that selectively removes activated myeloid lineage leukocytes from peripheral blood. This technique consists of a column with cellulose acetate beads as absorptive leukocytapheresis carriers, and was initially used to treat ulcerative colitis. A literature search was conducted to extract recently published studies about the clinical efficacy of GMA in patients with different skin disorders, reporting information on demographics, clinical symptoms, treatment and clinical course. Dermatological diseases, in which GMA has been performed, include generalized pustular psoriasis, pyoderma gangrenosum, palmoplantar pustular psoriasis, Behcet's disease, Sweet's syndrome, adult-onset Still's disease, impetigo herpetiformis, reactive arthritis, acne and hidradenitis suppurativa syndrome, cutaneous allergic vasculitis and systemic lupus erythematosus. In most patients, GMA was started after the failure of conventional therapeutic options and it was helpful in the majority of cases. Based on the information summarized, GMA could be considered a valid non-pharmacological treatment option for patients with several dermatological conditions, which are difficult to treat with other pharmacological preparations.

Leukocytoclastic Vasculitis Related to Ustekinumab in a Crohn's Disease Patient: First Case Report and Literature Review

Leukocytoclastic vasculitis is a single-organ, skin-isolated small vessel vasculitis. It can be a side effect of many common drugs, including biological agents. Unlike with other drugs, leukocytoclastic vasculitis induced by biological agents may have a prolonged latency period. We report the first case of ustekinumab-induced leukocytoclastic vasculitis in a patient with inflammatory bowel disease.

Multiple myeloma presenting as cutaneous leukocytoclastic vasculitis and eosinophilia disclosing a T helper type 1/T helper type 2 imbalance: a case report

Background

Multiple myeloma is a very heterogeneous disease comprising a number of genetic entities that differ from each other in their evolution, mode of presentation, response to therapy, and prognosis. Due to its more chronic nature and cumulative toxicities that patients develop from multiple lines of treatments, a number of symptoms are associated with multiple myeloma. However, the mechanisms responsible for the relationship between these symptoms and multiple myeloma currently remain unclear.

Case presentation

An 85-year-old Japanese woman exhibited the rare presentation of multiple myeloma (immunoglobulin kappa chain type) with leukocytoclastic vasculitis and eosinophilia. The serum level of interferon-γ was decreased; however, serum levels of interleukin-4, interleukin-5, interleukin-6, interleukin-10, and tumor growth factor-β levels were elevated. She received a bortezomib, lenalidomide, and dexamethasone regimen. After one course of the treatment, the cutaneous manifestation rapidly improved and laboratory tests showed decrease of eosinophil cell count. Serum concentrations of immunoglobulin G decreased and plasma cells in bone marrow decreased. The serum level of interferon-γ was elevated and serum levels of interleukin-4, interleukin-5, interleukin-6, interleukin-10, and tumor growth factor-β decreased.

Conclusions

It is the first case of leukocytoclastic vasculitis and eosinophilia in multiple myeloma that was associated with a T helper type 1/T helper type 2 imbalance and T regulatory cells, and was successfully treated with bortezomib, lenalidomide, and dexamethasone. The present case reinforces the value of early evaluations for paraneoplastic symptoms in order to reach a diagnosis and allow for the prompt initiation of appropriate treatments and achieve successful therapeutic management.

A Unique Case Report on Hypersensitivity Vasculitis as an Allergic Reaction to the Herpes Zoster Vaccine

Hypersensitivity vasculitis (HV) or leukocytoclastic vasculitis is a rare small-vessel vasculitis that may occur as a manifestation of the body's extreme allergic reaction to a drug, infection, or other foreign substance. Characterized by the presence of inflammatory neutrophils in vessel walls, HV results in inflammation and damage to blood vessels, primarily in the skin. Histologically, when neutrophils undergo leukocytoclasia and release nuclear debris into the vasculature, vascular damage manifests as palpable purpura. The incidence of HV is unknown and its relationship and interaction with certain vaccinations is rare and poorly understood. Affected patients with HV generally have a good prognosis; however, fatality may occur if organs such as the central nervous system, heart, lungs, or kidneys are involved. We report a unique case of a 60-year-old man who presented with a serious case of HV after receiving the herpes zoster vaccine. A thorough literature review yielded only one similar case of vascular reaction to the varicella vaccine that was reported in the Annals of Internal Medicine in 1997; however, no other reported cases with regard to the herpes zoster vaccine have been found. Our case presents a rare glimpse into HV that may result from varicella vaccine administration.

Fatal paraneoplastic systemic leukocytoclastic vasculitis as a presenting feature of chronic lymphocytic leukemia

BACKGROUND

The most common paraneoplastic vasculitis is leukocytoclastic vasculitis (LCV),(1) 75% of which are caused by hematological malignancies. Chronic lymphocytic leukemia (CLL) is associated with a multitude of auto-immune paraneoplastic syndromes. Data on LCV in association with CLL is restricted to isolated case reports,(3,4) none of which had systemic LCV. We present a unique case of fatal paraneoplastic, systemic LCV as an initial presentation of CLL in an elderly male with multiple co-morbidities.

CASE

A 71-year-old man presented with a palpable, symmetric, purpuric rash on the lower extremities and an absolute lymphocytosis (white blood cell count 26.9; 23% lymphocytes). His co-morbidities included coronary artery disease, congestive heart failure, and new critical aortic stenosis. Flow cytometry of peripheral blood demonstrated an abnormal population of B-cells, positive for CD5, CD19, and CD23, consistent with CLL. The skin biopsy specimen revealed neutrophilic inflammation in vessel walls indicative of LCV. Acute renal failure (creatinine 2 mg/dL), urinary red cell casts, and hypocomplementemia were concerning for a systemic vasculitis. The antinuclear antibody, cryoglobulin titer, antineutrophil cytoplasmic antibody, serum protein electrophoresis, viral serologies were negative. On hospital day 6, he developed acute hepatocellular injury and acute respiratory failure. Continuous veno-venous hemodialysis was begun for worsening acidemia and hyperkalemia. Two days later he became obtunded on hospital day 8 and had an elevated lactic acid level with generalized abdominal tenderness worrisome for bowel ischemia. The same day he needed intubation with cardiopulmonary resuscitation for a brief episode of asystole. Despite aggressive treatment with high-dose steroids and plasmapheresis, he suffered worsening renal failure and shock. His family sought withdrawal of care on hospital day 11. Autopsy revealed diffuse LCV of the stomach, distal ileum, integument and alveoli with petechial hemorrhages, fibrin thrombi, and gangrenous patchy necrosis.

CONCLUSION

Paraneoplastic LCV is a rare syndrome and seldom occurs in association with CLL. This is the first reported case of fatal systemic paraneoplastic LCV from B-cell CLL. Dermatologic involvement is universal with LCV, and may portend systemic disease. More data on its pathogenesis in CLL is warranted.

Severe leukocytoclastic vasculitis secondary to the use of a naproxen and requiring amputation: a case report

INTRODUCTION

Leukocytoclastic vasculitis (also known as hypersensitivity vasculitis and cutaneous necrotizing vasculitis) can present with various manifestations, which often delays the diagnosis and treatment. In order to show the importance of the early recognition of leukocytoclastic vasculitis, we present a case which occurred secondary to the use of a common pharmaceutical, naproxen. We were unable to find a case of leukocytoclastic vasculitis secondary to naproxen in the literature.

CASE PRESENTATION

We present the case of a 33-year-old African American woman with below the knee and bilateral digital gangrene from hypersensitivity vasculitis secondary to the non-steroidal anti-inflammatory medication naproxen.

CONCLUSION

This is an original case report focusing on the rheumatologic management of leukocytoclastic vasculitis. However, other specialties, such as internal medicine, dermatology, infectious disease, general surgery and pathology, can gain valuable information by reviewing this case report. Reporting a case of leukocytoclastic vasculitis secondary to treatment with naproxen will advance our understanding of this disease etiology by adding yet another non-steroidal anti-inflammatory drug to the list of potential causes of leukocytoclastic vasculitis.

Vasculite cutânea de pequenos vasos: etiologia, patogênese, classificação e critérios diagnósticos - Parte I

Vasculite é a inflamação da parede dos vasos. Pode variar em gravidade desde doença autolimitada de um único órgão até doença grave com risco de morte por falência de múltiplos órgãos. Existem várias causas, embora só se apresente por poucos padrões histológicos de inflamação vascular. Vasos de qualquer tipo e em qualquer órgão podem ser afetados, resultando em ampla variedade de sinais e sintomas. Diferentes vasculites com apresentações clínicas indistinguíveis têm evolução e tratamento muito diferentes. Essa condição representa desafio para o médico, incluindo classificação, diagnóstico, exames laboratoriais pertinentes, tratamento e seguimento adequado. Neste artigo são revistos a classificação, a etiologia, a patogênese e os critérios diagnósticos das vasculites cutâneas.

Mast cells in cutaneous allergic vasculitis: a case report

BACKGROUND

The mechanism of cutaneous allergic vasculitis still remains unclear, and to the best of our knowledge, no case has been reported in the literature in which the number of mast cells was examined.

METHODS

A 33-year-old woman, with a past history of allergic rhinitis due to Japanese cedar and Phleum pratense (timothy), presented with a chief complaint of palpable papules on both lower legs in December 2002. On blood examination, peripheral blood eosinophilia was present, but all other examinations for immunologic diseases were negative, including specific IgE. We suspected cutaneous allergic vasculitis and performed skin biopsy.

RESULTS

In December 2002, histological examination of biopsy specimens of the skin lesions showed leukocytoclastic vasculitis. The diagnosis of cutaneous allergic vasculitis was made based on the clinical symptoms and the pathological findings of biopsy specimens. Immunohistochemical staining for human mast cell tryptase using monoclonal antibody against human mast cell tryptase showed an accumulation of mast cells. Treatment with oral corticosteroid resulted in the disappearance of clinical symptoms, and the steroid tapered. A second skin biopsy was performed in June 2005 after informed consent was obtained. Histological examination showed no findings of leukocytoclastic vasculitis, and the number of mast cells had decreased. She has been well without treatment.

CONCLUSIONS

Mast cells may increase in the skin lesion of cutaneous allergic vasculitis.

Leukocytoclastic (small vessel) vasculitis in multiple myeloma

The hallmark of leukocytoclastic vasculitis (LCV) is palpable purpura. Histologically, there is a neutrophilic, angiocentric, segmental inflammation with endothelial cell injury and fibrinoid necrosis of the blood vessel walls. Leukocytoclastic vasculitis has many associations, including, rarely, multiple myeloma (MM). A total of 2357 patients with a diagnosis of MM were reviewed to retrieve cases that had developed leukocytoclastic vasculitis. Eight patients with MM and LCV showed a predominance of immunoglobulin G (IgG) myeloma paralleling the immunoglobulin secretion seen overall. Overexpression of interleukin 6, which is necessary for myeloma cell growth and survival, may contribute to the pathogenesis of LCV in the setting of MM.

Cutaneous small-vessel vasculitis

Cutaneous small-vessel vasculitis (CSVV) refers to a group of disorders usually characterized by palpable purpura; it is caused by leukocytoclastic vasculitis of postcapillary venules. CSVV can be idiopathic or can be associated with a drug, infection, or underlying systemic disease. Initially, the pathogenesis of CSVV is immune complex related, but in its later stages different pathogenetic mechanisms may intensify the reaction and lymphocytes may predominate in the infiltrate. Cure requires elimination of the cause (ie, drugs, chemicals, infections, food allergens) when possible, as well as therapy with nonsteroidal antiinflammatory agents, corticosteroids, dapsone, potassium iodide, fibrinolytic agents, aminocaproic acid, immunosuppressive agents (ie, cyclophosphamide, azathioprine, methotrexate, cyclosporine) or even monoclonal antibodies, depending on disease severity.

Possible pathogenic role of IgE in Henoch-Schönlein purpura

The incidences of clinical and biological markers of atopy were investigated in 16 children with IgA nephropathy (IgAN) (group A) and in 22 with Henoch-Schönlein purpura nephritis (HSPN) (group B). The incidence of increased plasma IgE levels according to age-matched normal values was significantly higher in group B (17/22, 77%) than in group A (7/16, 44%) (P < 0.05). Although not significant, the incidences of positive RAST tests and of a history of typical atopic symptoms were also higher in group B [10/22 (45%) and 11/22 (50%), respectively] than in group A [4/16 (25%) and 5/16 (31%), respectively]. Moreover, IgE deposits were demonstrated by a peroxidase/anti-peroxidase method on cutaneous Langerhans and mast cells in 4 of 6 patients with HSPN. Thus immunoallergy might account, in some cases, for the cutaneous, intestinal and pulmonary signs observed in HSPN, but not in IgAN. We postulate stimulation of IgE-sensitized mast cells by specific antigens in the presence of IgA circulating immune complexes (CIC), release of vasoactive substances, increased capillary permeability and perivascular deposition of IgA CIC.

Immune complex assays: diagnostic and clinical application

The presence of circulating immune complexes have been described in many different human disease states but the significance of their presence has always been a subject for debate. Improvements in the methods of detecting immune complexes have demonstrated a wide degree of heterogeneity, which accounts for the difficulty in obtaining accurate and reproducible measurements, even in the same individual. Techniques for isolating individual complexes, characterizing their pathophysiological properties, and biochemically analyzing the nature of the complexed antigen are now being used to provide data that is helping to clarify the role of immune complexes in the pathogenesis of disease. In addition, such studies are also providing data which is proving that immune complexes have a potential role in immune regulation.