Rowell's syndrome revisited: report of two cases from India

Targetoid-like lesions and chilblain-like erythema manifested on hands and feet: A case of Rowell syndrome from China

BACKGROUND

Rowell syndrome (RS) is an uncommon condition characterized by erythema multiforme (EM)-like lesions and lupus erythematosus. It is more common in females, and EM may be the first manifestation of the disease with positive autoantibodies, such as antinuclear antibody (ANA), SSA, SSB and rheumatoid factor. The pathogenesis of RS is unknown and is likely caused by drug induction, ultraviolet exposure and infection.

METHOD

We describe a case of RS from China which presented as characteristic targetoid-like lesions and chilblain-like erythema on hands and feet. This is a case of RS in a female patient from the inpatient department of dermatology.

RESULTS

A 41-year-old female with systemic lupus erythematosus exhibited chilblain-like erythema and characteristic EM lesions on her extremities. She tested positive for serum ANA (1:320) and anti-double-stranded DNA, as well as other autoantibodies. Systemic glucocorticoids and hydroxychloroquine worked effectively for her.

CONCLUSION

The present case met diagnostic criteria of RS. Notably, there was a co-occurrence of facial butterfly erythema, chilblain-like erythema and EM lesions distributed on the limbs in this case.

Utilization of Rituximab for Refractory Rowell Syndrome

Rowell syndrome describes the occurrence of erythema multiforme-like lesions in patients with cutaneous lesions of lupus erythematosus. The clinical picture of atypical erythema multiforme-like lesions, presence of chilblains, speckled ANA pattern, anti-Ro/SSA, or anti-La/SSB antibodies, and absence of infectious or pharmacologic triggers in a patient with systemic lupus erythematosus are some of the classic clinical and serologic features. Histopathologic and serologic findings can help differentiate this process from erythema multiforme. We present a case of young woman with systemic lupus erythematosus, end-stage renal disease due to lupus nephritis, and a remote history of Steven–Johnson syndrome due to sulfa allergy who presented to the hospital with a recurrent, progressive, targetoid erythematous rash involving more than 60% of her body surface area. Our patient had several hospitalizations in the recent past for this erythematous rash and had failed oral therapy with prednisone 1 mg/kg and hydroxychloroquine. In view of the minimal improvement and increasing severity and patient exhibiting early features of mast cell activation syndrome, the patient was treated with pulse intravenous glucocorticoids followed by rituximab with an excellent response. We highlight a unique case report of progressive Rowell syndrome refractory to standard of care with an excellent response to rituximab.

Rowell-Syndrom bei subakut-kutanem Lupus erythematodes

Wir berichten über einen 77-jährigen Patienten mit akut aufgetretenen, kokardenartig anmutenden Hautveränderungen bei vorbekanntem subakut-kutanem Lupus erythematodes.

Aufgrund der Befundkonstellation mit fein-gesprenkelten antinukleären Antikörpern, Antikörpern gegen Ro/SSA und La/SSB und einem positiven Rheumafaktor wurde in Zusammenschau mit der Histologie die Diagnose eines Rowell-Syndroms gestellt. Das Rowell-Syndrom beschreibt das Auftreten Erythema-exsudativum-multiforme-artiger Hautveränderungen bei Patienten mit vorbekanntem Lupus erythematodes.

Die diagnostischen Herausforderungen bei der Diagnosestellung des Rowell-Syndroms in Abgrenzung zur Koinzidenz von Lupus erythematodes mit einem Erythema exsudativum multiforme werden anhand einer weiteren Fallbeschreibung einer 44-jährigen Patientin mit vorbekanntem subakut-kutanem Lupus erythematodes veranschaulicht.

Neuropsychiatric manifestations in an adolescent male with Rowell syndrome

A 15-year-old boy presented with fever, skin, and oral lesions for 4 weeks. The cutaneous lesions were suggestive of subacute cutaneous lupus erythematosus and erythema multiforme. His clinical, histopathological, and immunological features were indicative of Rowell syndrome and he satisfied the diagnostic criteria of Rowell syndrome proposed by Zeitouni et al. He subsequently developed neurological manifestations and was diagnosed to have neuropsychiatric systemic lupus erythematosus. We report this case for the unusual occurrence of a rare entity like Rowell syndrome in an adolescent male with co-existence of neuropsychiatric systemic lupus erythematosus.

The First Case of Rowell Syndrome with Lupus Nephritis and Lobar Pneumonia in a Male Child Reported in Pakistan

Rowell syndrome (RS) is a rare entity that presents with lupus erythematosus (LE), erythema multiforme (EM) like lesions and characteristic immunological findings including positive rheumatoid factor (RF), speckled antinuclear antibody (ANA) and positive anti-Ro or anti-La antibodies in the serum. Only a few cases have been reported in the literature, mostly in middle-aged women. Our case is about an 11-year-old male child who had a history of pustular rashes over the whole body with scattered targetoid lesions for the past few months and later developed respiratory distress and swelling of the body. He was extensively investigated and confirmed on specific positive immunochemistry markers as RS along with lobar pneumonia (LP) and lupus nephritis. The co-existence of lobar pneumonia in our patient was a unique feature that has not been previously reported.

Rowell's syndrome in an Indian male and review of the literature

Lupus erythematosus (LE) with erythema multiforme-like lesions with its characteristic serological picture had been described in 1963. We report a 33-year-old married male who presented with skin lesions of various morphology on different body parts since four months. The skin lesions ranged from lupus-specific tumid LE to Rowell's syndrome and discoid LE. Histopathology of skin biopsy from all representative sites showed different forms of lupus erythematosus. Antinuclear and anti-double-stranded DNA was positive; however, serology for anti-SSA and anti-SSB was negative. There were no symptoms specific for organ involvement. It is unusual to document various morphological types in a single patient of lupus erythematosus. We document this case as all forms of cutaneous LE including Rowell's syndrome were evident in a single male patient.

Rowell syndrome

Rowell syndrome is a rare disease consisting of erythema multiforme-like lesions associated with lupus erythematosus. The syndrome occurs mostly in middle-aged women. The authors describe the syndrome in a 15-year-old boy who responded well to systemic steroids and hydroxychloroquine.

The last word on the so-called 'Rowell's syndrome'?

To date, 71 patients having the so-called 'Rowell's syndrome' (RS) have been reported in the literature. However, most of them did not show all the clinical and serological features first described by Rowell and co-workers in 1963. Moreover, since then, subacute cutaneous lupus erythematosus (SCLE) has been identified and the diagnostic criteria as well as the clinical features of erythema multiforme (EM) defined. Accordingly several authors have questioned the existence of RS over the past years. In the present paper, the main clinical, histopathological and immunopathological features of both SCLE and EM are described and all of the cases of RS reported in the literature are also reviewed in depth. A real association between discoid LE and EM was present only in a minority of cases and could be considered a mere coincidence. As for other associations, e.g. those between CLE and lichen planus or psoriasis, the coexistence of CLE and EM does not justify the framing of a separate syndrome as suggested by Rowell et al.