Retrospective analysis of adult patients with cutaneous leukocytoclastic vasculitis

Cutaneous leukocytoklastic vasculitis in a patient with ankylosing spondylitis: A case report

Extra-articular manifestations (EAMs) in ankylosing spondylitis (AS) are common and most extra-articular manifestations such as acute iritis and inflammatory bowel disease are positively correlated with disease activity of AS. Vasculitis is an extra-articular manifestation of AS. However cutaneous leukocytoclastic vasculitis (CLV) is uncommon in AS patients. In this article, we report a case of a 66-year-old female patient who has had AS for long time. Although the patient's articular manifestations were stable, the aortic aneurysm and CLV continued to occur sequentially. This article reminds clinicians that even AS patients with stable articular manifestations should be followed up regularly. All extra-articular manifestations of AS patients should be taken seriously and treated as soon as possible under the guidance of rheumatoid immunologists.

A rare adverse event of atorvastatin inducing leukocytoclastic vasculitis with ANCA-negative (Anti-Neutrophil cytoplasmic antibody) case report and literature review

Leukocytoclastic vasculitis is an entity associated with drugs, infections, cryoglobulinemia, and connective tissue diseases but can also be idiopathic, systemic, or organ localized. Moreover, LCV associated with drugs is a rare disorder. When it is present usually has an elevation of anti-neutrophil cytoplasmic antibody, most likely anti-myeloperoxidase, which can be helpful to orient the diagnosis. We are presenting a 55-year-old female with a past medical history of diabetes mellitus (DM) and hyperlipidemia (HLD) who presented with a painful and pruritic rash localized in the abdomen and lower extremities that started 1 week after initiated atorvastatin for management of hyperlipidemia. This is the first case ever reported of leukocytoclastic vasculitis ANCA negative associated with atorvastatin, to our best knowledge.

Systemic disease in leukocytoclastic vasculitis: a focus on direct immunofluorescence findings

BACKGROUND

Direct immunofluorescence (DIF) panels are usually ordered for clinically suspected cutaneous vasculitis, but their positivity rate is variable, and their prognostic significance is not clear to date.

OBJECTIVE

The study aims to investigate the systemic involvement rate in leukocytoclastic vasculitis (LCV) patients and the potential clinical and laboratory associations with systemic involvement, including DIF findings.

METHODS

A retrospective study of patients with histopathologically proven cutaneous LCV examined in the dermatology department between 2013 and 2017 was performed.

RESULTS

Of the 81 patients (mean age, 50.6 years), 42 (52%) were male. The mean time between the appearance of skin lesions and biopsy was 23.1 days, ranging from 2 to 180 days. DIF showed overall positivity of 90.1%, and C3 was the most frequent immunoreactant (82.7%). Any kind of extracutaneous involvement was present in 47 (58%) of patients, with renal involvement being the most frequent (53.1%), followed by articular (18.5%) and gastrointestinal (11.1%) involvement. The presence of renal disease was associated with the detection of IgG in the lesional skin (p = 0.017), and with the absence of IgM in the lesional skin (p = 0.032). There was a significant association between C3 deposition and joint involvement (p = 0.05).

STUDY LIMITATIONS

This is a single-center study with a retrospective design.

CONCLUSION

DIF seems to be a useful ancillary diagnostic tool in the evaluation of cutaneous vasculitis, but the relationship between DIF findings and systemic involvement needs to be further elucidated due to contradictory data in the current literature.

Leukocytoclastic Vasculitis of the Foot and Ankle: A Case Report With Over Five-Year Follow-Up

The estimated incidence of leukocytoclastic vasculitis of any etiology is between 15 and 30 people per million per year. Despite being a rare pathologic entity, leukocytoclastic vasculitis has many documented etiologies. Here, we report on a case of a 47-year-old man with liver cirrhosis who was admitted to our institution for diffuse palpable purpura of the distal lower extremities. Workup was largely negative for infectious and systemic causes. The patient received multiple days of intravenous antibiotics and consultations with infectious disease, dermatology, and podiatry. Skin biopsies confirmed a diagnosis of idiopathic leukocytoclastic vasculitis. A steroid taper was prescribed, and the patient had clinical resolution and healing of skin lesions. After 5.5 years after the vasculitic episode, the patient remained free of cutaneous lower extremity lesions. Medication-induced leukocytoclastic vasculitis and associations with systemic illness or malignancy were ruled out. In the lower extremities, misdiagnosis of cellulitis for noninfectious dermatologic conditions is common. Clinicians must have a wide differential and take a multidisciplinary approach to similar types of cases to reduce unnecessary antibiotic usage.

A Cross-Sectional Study to Correlate Serum Complement C3 and C4 Levels With Clinical and Pathological Severity in Cutaneous Small-Vessel Vasculitis

Introduction

The role of serum C3 and C4 levels as a marker of disease activity in cutaneous small-vessel vasculitis (CSVV) has been sparsely studied, especially in India. The primary objective was to determine the correlation between clinico-histopathological severity and serum C3 and C4 levels in CSVV. The secondary objective was to determine the association between direct immunofluorescence (DIF) findings and serum C3 and C4 levels and clinico-histopathological findings.

Method

This prospective cross-sectional study included all the clinically diagnosed cases of CSVV that satisfied the pathological criteria for CSVV. A clinical disease activity grade and a histopathological severity grade were calculated in all patients (N=50).

Results

Serum C3 and C4 levels (n=44) were diminished in 4.5% of cases. There was no significant correlation between the serum C3 and C4 levels and the clinical and histopathological severity. DIF was positive in 60.0% of cases (n=45), and IgA was the predominant immune deposit (46.7%). No significant association was detected between the DIF findings and the serum C3 and C4 levels, histopathological severity, and clinical disease activity grade. Positive DIF findings were significantly associated with palpable purpura and cutaneous necrosis. A significant association was detected between gastrointestinal involvement and IgA positivity.

Conclusion

In CSVV, serum C3 and C4 may not be used as markers of disease severity, and a positive DIF finding may indicate an underlying gastrointestinal involvement.

Localized Forms of Vasculitis

Purpose of Review

To provide an updated review on epidemiology, clinical manifestations, diagnostic assessment, treatment, and prognosis of localized vasculitis, following the 2012 Revised International Chapel Hill Consensus Conference Nomenclature on single-organ vasculitis.

Recent Findings

Localized, single-organ vasculitides encompass a group of rare conditions in which there is no evidence of concomitant systemic vasculitis. Most data on this topic derives from case reports and small case series. Although some aspects of these diseases, such as clinical manifestations and histologic findings, have already been extensively investigated, there is still a lack of robust data concerning the pathogenesis, epidemiology, and treatment.

Summary

Localized vasculitides may have a wide range of clinical features depending on the organ affected. The inflammatory process may have a multifocal/diffuse or unifocal distribution. Diagnosis is usually based on histopathology findings and exclusion of systemic vasculitis, which may frequently pose a challenge. Further research on treatment is warranted.

Cutaneous leukocytoclastic vasculitis secondary to COVID-19 infection: A case report

COVID-19 is a novel disease that mostly affects the respiratory system but as the number of cases is rising significantly around the world, more extra-respiratory manifestations are being reported among which are various dermatologic manifestations.

Update on vasculitis: overview and relevant dermatological aspects for the clinical and histopathological diagnosis - Part II

Vasculitis is a group of several clinical conditions in which the main histopathological finding is fibrinoid necrosis in the walls of blood vessels. This article assesses the main dermatological aspects relevant to the clinical and laboratory diagnosis of small- and medium-vessel cutaneous and systemic vasculitis syndromes. The most important aspects of treatment are also discussed.

Update on vasculitis: an overview and dermatological clues for clinical and histopathological diagnosis - part I

The term vasculitis refers to the inflammation of vessel walls. It may range in severity from a self-limited disorder in one single organ to a life-threatening disease due to multiple organ failure. It has many causes, although they result in only a few histological patterns of vascular inflammation. Vessels of any type and in any organ can be affected, a fact that results in a broad variety of signs and symptoms. Different vasculitides with indistinguishable clinical presentations have quite different prognosis and treatments. This condition presents many challenges to physicians in terms of classification, diagnosis, appropriate laboratory workup, and treatment. Moreover, it compels a careful follow-up. This article reviews the Chapel-Hill 2012 classification, etiology, recent insights in pathophysiology, some important dermatological clues for the diagnosis and summarizes treatment of some of these complex vasculitis syndromes.

Early diagnosis and treatment of Leukocytoclastic Vasculitis: case report

A 46-year-old female patient presented at the emergency department of a Municipal University Hospital with necrotic lesions in lower limbs associated with wasting syndrome. She was diagnosed with leukocytoclastic vasculitis after physical examination and history-taking in a fast and cost-effective manner, using an algorithm specifically for primary vasculitis, enabling early and appropriate treatment. The good clinical outcome demonstrates the need to quickly make a definitive diagnosis and start treatment.

Dermatologic Aspects of Systemic Vasculitis

Systemic and localized vasculitis affects the skin and subcutis, due to large vascular beds and hemodynamic factors, such as stasis in lower extremities, and environmental influences, as occur in cold exposure. Initial cutaneous manifestations of vasculitides include diverse and dynamic patterns of discoloration, swelling, hemorrhage, and necrosis. One-half of affected patients present with localized, self-limited disease to the skin without any known trigger or associated systemic disease, known as idiopathic cutaneous leukocytoclastic vasculitis. Skin biopsy and dermatopathology contribute relevant information; however, they require correlation with clinical history, physical examination, and laboratory findings to reach an accurate diagnosis.

Leukocytoclastic vasculitis secondary to clozapine

Leukocytoclastic vasculitis (LCV) may be secondary to drugs, underlying infection, collagen vascular disorders, or malignancy. Drug-induced vasculitis contributes to 10% of vasculitic skin lesions cases usually developing within 7-21 days of treatment initiation. The present case highlights a report of LCV in a 59-year-old male with a history of paranoid schizophrenia on clozapine therapy. The report upsurges the need to promote awareness and expedite diagnosis and treatment of drug-induced LCVs.

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.

Tenofovir-induced Leukocytoclastic Vasculitis

Tenofovir, a nucleotide analog, is one of the first-line medications recommended for the treatment of active chronic hepatitis B virus infection (CHB) and as a primary prophylaxis to prevent hepatitis B reactivation in cases of immunosuppression. We report the first case of tenofovir-induced leukocytoclastic vasculitis (LCV). A 43-year-old obese woman, who was known to have inactive CHB, was diagnosed with chronic immune thrombocytopenic purpura (ITP). She was treated with corticosteroid therapy and was put on tenofovir to prevent hepatitis B virus reactivation. A month later, she developed a skin rash, described as non-blanchable well-defined erythematous to violaceous papules and targetoid patches in her lower extremities. A skin biopsy showed features of LCV. The rash resolved completely within few days after replacing tenofovir with entecavir.

[Cutaneous leukocytoclastic vasculitis: about 85 cases]

La présentation clinique, les étiologies et l'évolution des Vascularites leucocytoclasiques sont peu étudiées. L'objectif de notre travail est d'étudier les particularités épidémiologiques, cliniques, étiologiques et évolutives de cette entité. Nous avons mené une étude transversale portant sur 85 patients ayant une vascularite leucocytoclasique colligés dans le service de dermatologie de l'hôpital Farhat Hached de Sousse entre Janvier 2000 et Décembre 2013. Pour chaque patient, une fiche des données épidémiologiques, cliniques, paracliniques et étiologiques a été remplie. L'âge moyen de nos patients était de 47,65 ans avec des extrêmes allant de 10 à 78 ans. Cinquante trois femmes et 32 hommes étaient recensés (sexe ratio = 0,6). Les manifestations cutanées étaient dominées par le purpura vasculaire (88,2%). Les étiologies les plus fréquentes étaient les maladies systémiques (51%), les infections (20%) et les dermatoses neutrophiliques (14,5%). Les autres étiologies retrouvées étaient : les causes médicamenteuses (9,1%) et les hémopathies malignes (5,4%). Chez 30 patients (35,3%), l'étiologie n'a pas été retrouvée. Deux facteurs prédictifs à l'évolution aigue étaient retenus : la présence d'une infection récente (p= 0,014) et d'une prise médicamenteuse précédant l'éruption cutanée (p= 0,013). L'évolution chronique était corrélée positivement aux anticorps antinucléaires (p= 0,009), et à la cryoglobulinémie (p=0,025). Notre étude illustre la multitude des étiologies de vascularites leucocytoclasiques. La recherche d'une maladie sous-jacente est impérative afin de garantir une meilleure prise en charge thérapeutique.

Demographic characteristics, aetiology, and assessment of treatment options in leukocytoclastic vasculitis

Introduction

Vasculitides are a heterogeneous group of diseases characterized by inflammation of the blood vessel walls. Etiological factors include infections, drugs, connective tissue diseases, and malignancies.

Aim

To examine the demographic characteristics, etiological factors, and treatment options in 75 patients with leukocytoclastic vasculitis.

Material and methods

The study included 75 patients diagnosed with leukocytoclastic vasculitis at our clinic. The patients’ medical records were reviewed to determine their age, sex, presence of systemic symptoms, possible etiological factors, laboratory results, types of cutaneous lesions, locations of the lesions, treatment options, and disease course.

Results

There were 43 women and 32 men. Cutaneous lesions affected only the lower limbs in 60 of the 75 patients (80%) and usually presented as palpable purpura (64%, n = 48). Arthralgia (26.7%, n = 20) was the most frequent extracutaneous symptom. Of the patients with secondary vasculitis, the most common causes were infections and drugs. The mean age of the patients with Henoch-Schönlein purpura was 26.8 years. There was no significant association between age and renal, gastrointestinal, or joint involvement.

Conclusions

The most common form of vasculitis in our study was cutaneous leukocytoclastic vasculitis. In most of the patients it appeared to be idiopathic. Among drugs, antibiotics were the most common etiological factor. In 4 patients, the cutaneous leukocytoclastic vasculitis behaved like the paraneoplastic syndrome.

Leukocytoclastic vasculitis in children: clinical characteristics, subtypes, causes and direct immunofluorescence findings of 56 biopsy-confirmed cases

BACKGROUND

Leukocytoclastic vasculitis (LCV) in children is a complex group of conditions.

OBJECTIVES

This study presents the demographics, clinical features, direct immunofluorescence (DIF) results and suspected aetiologies of 56 biopsy-confirmed cases of leukocytoclastic vasculitis in children.

METHODS

Retrospective review of 56 children seen at Mayo Clinic in Rochester, Minnesota, from 1993 to 2013 with clinical features and cutaneous biopsy consistent with LCV.

RESULTS

Twenty-seven (48%) cases were found to be due to IgA vasculitis (Henoch-Schonlein purpura). The remaining cases were found to be due to cutaneous small-vessel vasculitis (n = 19, 34%), urticarial vasculitis (n = 5, 9%), ANCA-associated vasculitis (n = 4, 7%) and acute haemorrhagic oedema of infancy (n = 1, 2%). IgA vasculitis was found to be associated with abdominal pain (P = 0.008), whereas the non-IgA vasculitis group was associated with headache (P = 0.052). Children with IgA vasculitis had palpable purpura (P = <0.001), petechia (P = 0.057), vesicles (P = 0.009) and involvement of the buttock (P = 0.004) more frequently than the non-IgA vasculitis group. On DIF, perivascular IgA was positive in IgA vasculitis compared to non-IgA vasculitis cases (P = <0.001), the other conjugates were similar between the two groups.

CONCLUSION

The most common subtype of biopsy-confirmed LCV in children is IgA vasculitis. Clinical features, exam characteristics and DIF results can be helpful in determining the subtype of cutaneous vasculitis in children.

Etiologies and prognostic factors of leukocytoclastic vasculitis with skin involvement: A retrospective study in 112 patients

In this study, outcomes of patients with leukocytoclastic vasculitis (LCV) were analyzed focusing on clinical, histopathology and laboratory findings, relapses, and survival.Data from patients with cutaneous vasculitis diagnosed between January 1, 2000, and December 31, 2010, at Dijon University Hospital (France) were retrospectively reviewed. LCV was defined as perivascular neutrophilic infiltrate, endothelial cell nuclear swelling, extravasation of red blood cells, and/or fibrin deposition in vessels. Patients were classified according to the 2012 Chapel Hill Consensus Conference. Relapses were defined as the recurrence of vasculitis symptoms after a period of remission >1 month. Time to relapse and/or death was calculated from the date of diagnosis. Univariate and multivariate (Cox model) analyses were performed.A total of 112 patients (57 males and 55 females), with a mean age of 60 ± 19 (18-98) years, were analyzed. Overall follow-up was 61 ± 38 months. At diagnosis, all patients had skin lesions, purpura being the most common (n = 83). Lesions were associated with systemic involvement in 55 (51%) patients. Only 41 (36.6%) patients received specific treatment: glucocorticoids in 29 of 41 (70.7%) and immunosuppressants in 9 of 41 (22%). Sixty-two patients (55%) had LCV due to underlying causes, 29 (25.9%) had single-organ cutaneous small vessel vasculitis (SoCSVV), and 21 (18.8%) had unclassifiable LCV. Twenty patients of the cohort (18%) experienced relapse, 14 ± 13 (1-40) months after the diagnosis of LCV. None of the 29 patients with SoCSVV relapsed. Independent risk factors for relapse were vascular thrombosis in the biopsy [hazard ratio (HR) = 4.9; P = 0.017], peripheral neuropathy (HR = 9.8; P = 0.001), hepatitis (HR = 3.1; P = 0.004), and positive antineutrophil cytoplasm antibodies (ANCA, HR = 5.9 P = 0.005). In contrast, SoCSVV was a protective factor for relapse (HR = 0.12; P = 0.043).The 1-, 3-, and 6-year overall survival rates were 99%, 83%, and 71%, respectively, with no difference between relapsers and nonrelapsers (P = 0.960) or between SoCSVV and unclassifiable LCV (P = 0.588).This study demonstrates that global survival for LCV patients is good but relapses remain frequent, especially when the cutaneous biopsy shows vascular thrombosis, or in patients with peripheral neuropathy or hepatitis. Conversely, SoCSVV is a protective factor for relapse.

Nimesulide induced leukocytoclastic vasculitis and hepatitis: a case report

Background

Nimesulide is a non-steroidal anti-inflammatory drug with antipyretic and analgesic properties, which is still used in many countries despite its known hepatotoxicity. Along with hepatotoxicity it has also been associated with several other Adverse Drug Reactions (ADRs) including leukocytoclastic vasculitis (LCV).

Case description

A 38 year-old female presented with history of acute onset fever for which she took tablet nimesulide and paracetamol combination (100 mg Nimesulide + 500 mg paracetamol tablet), 1 tab three times daily for 4 days, following which she developed rash all over the body. She also had clinical and biochemical evidence of acute hepatitis. Histopathological examination of the skin rash documented the presence of LCV. She was managed symptomatically with anti-inflammatory and supportive therapy and was not further exposed to nimesulide.

Discussion and evaluation

Our case demonstrates occurrence of acute hepatitis and LCV associated with nimesulide intake. The case meets the defining criteria for the diagnosis of LCV preceded by history of nimesulide intake. There was also clinical and biochemical evidence of hepato-cellular damage which supports the concurrent development of hepatitis along with the development of LCV following nimesulide use. To the best of our knowledge there is no previous published report of LCV and hepatitis occurring concurrently in the same patient following nimesulide intake. Nimesulide should be added to the list of agents associated with these serious adverse drug reactions.

Conclusions

Nimesulide has been a contentious drug over many years. Under such evidence of serious ADRs the scientific community should consider ensuring strict pharmacovigilance with respect to its use especially in the developing countries where such monitoring systems are inadequate.

Incidence of leukocytoclastic vasculitis, 1996 to 2010: a population-based study in Olmsted County, Minnesota

OBJECTIVE

To determine the population-based incidence of leukocytoclastic vasculitis (LCV).

PATIENTS AND METHODS

This is a retrospective population-based study of all Olmsted County, Minnesota, residents with a skin biopsy-proven diagnosis of LCV from January 1, 1996, through December 31, 2010.

RESULTS

A total of 84 patients (mean age at diagnosis, 48.3 years) with newly diagnosed skin biopsy-proven LCV (43 women and 41 men) were identified. The incidence rate (age and sex adjusted to the 2000 US white population) was 4.5 per 100,000 person-years (95% CI, 3.5-5.4). The incidence of LCV increased significantly with age at diagnosis (P<.001) and did not differ between female and male patients. Subtypes of LCV were cutaneous small-vessel vasculitis (CSVV), 38 patients (45%); IgA vasculitis, 25 (30%); urticarial vasculitis, 10 (12%); cryoglobulinemic vasculitis, 3 (4%); and antineutrophil cytoplasmic antibody-associated vasculitis, 8 (10%). LCV was idiopathic in 29 of 38 patients with CSVV (76%) and 24 of 25 patients with IgA vasculitis (96%). Thirty-nine of 84 patients (46%) had systemic involvement, with the renal system most commonly involved (17 of 39 [44%]). Twenty-four of 80 patients (30%) with follow-up data available had recurrent disease. Compared with the Minnesota white population, observed survival in the incident LCV cohort was significantly poorer than expected (P<.001), including the subset of patients with idiopathic CSVV (P=.03).

CONCLUSION

The incidence of LCV was higher than that reported in previously published studies. Idiopathic LCV was more common in our population-based cohort than that described previously. Overall survival was significantly poorer (P<.001) and should be explored further in future studies.

Cutaneous vasculitis: a rheumatologist perspective

Cutaneous vasculitis (CV) comprises a wide spectrum of diseases and displays a variety of clinical lesions, the most common being a palpable purpura. CV may be a process confined exclusively to the skin or be a manifestation of a more widespread entity associated to a variable grade of visceral involvement. In this regard, CV may occur as part of the clinical spectrum of primary systemic vasculitis, autoimmune diseases or less commonly as presenting manifestation of cancer or severe infections. An adequate clinical approach is required to establish optimal management of this condition.

Vasculitic neuropathy

Vasculitis is a primary phenomenon in autoimmune diseases such as polyarteritis nodosa, Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and essential mixed cryoglobulinemia. As a secondary feature vasculitis may complicate, for example, connective tissue diseases, infections, malignancies, and diabetes. Vasculitic neuropathy is a consequence of destruction of the vessel wall and occlusion of the vessel lumen of small epineurial arteries. Sometimes patients present with nonsystemic vasculitic neuropathy, i.e., vasculitis limited to peripheral nerves and muscles with no evidence of further systemic involvement. Treatment with corticosteroids, sometimes in combination with other immunosuppressants, is required to control the inflammatory process and prevent further ischemic nerve damage.

An aetiological & clinicopathological study on cutaneous vasculitis

BACKGROUND & OBJECTIVES

Cutaneous vasculitis has protean clinical manifestations. It may be idiopathic or associated with a spectrum of conditions such as infections, drugs, etc. Skin is involved in both small vessel vasculitis (SVV) and medium vessel vasculitis (MVV). Overlapping features are seen between SVV and MVV. The histopathological features may not always relate with the clinical lesions. The aim of the present study was to evaluate the aetiological factors and clinicopathological association in patients with cutaneous vasculitis.

METHODS

In this cross-sectional study, detailed history and clinical examination were done on patients with biopsy proven cutaneous vasculitis. Two skin biopsies were taken from each patient for routine histopathology and direct immunofluorescence.

RESULTS

Of the 61 patients studied, hypersensitivity vasculitis (HSV) [23 (37.7%)] and Henoch Schonlein purpura (HSP) [16 (26.2%)] were the two most common forms. Systemic involvement was seen in 32 (52.45%) patients. Drugs were implicated in 12 (19.7%) cases, infections in 7 (11.4%) and connective tissue disorders in 4 (6.5%) cases. Histologically SVV was the most common pattern, seen in all the clinically diagnosed patients with SVV (47), and in 12 of the 14 clinically diagnosed patients with MVV. Direct immunofluorescence showed positivity for at least one immunoreactant in 62 per cent of the patients and the most common deposit was C3 followed by IgG, IgA and IgM.

INTERPRETATION & CONCLUSIONS

Majority of our patients with cutaneous vasculitis were idiopathic. Histologically, SVV was seen in most of our patients. No association was seen between history of drug intake and tissue eosinophilia and also between histologically severe vasculitis and clinical severity. The presence of immunoreactant IgA was not specific for HSP.

The histological assessment of cutaneous vasculitis

Vasculitis is defined as inflammation directed at vessels, which compromises or destroys the vessel wall leading to haemorrhagic and/or ischaemic events. Skin biopsy is the gold standard for the diagnosis of cutaneous vasculitis, whose manifestations include urticaria, infiltrative erythema, petechiae, purpura, purpuric papules, haemorrhagic vesicles and bullae, nodules, livedo racemosa, deep (punched out) ulcers and digital gangrene. These varied morphologies are a direct reflection of size of the vessels and extent of the vascular bed affected, ranging from a vasculitis affecting few superficial, small vessels in petechial eruptions to extensive pan-dermal small vessel vasculitis in haemorrhagic bullae to muscular vessel vasculitis in lower extremity nodules with livedo racemosa. Skin biopsy, extending to subcutis and taken from the earliest, most symptomatic, reddish or purpuric lesion is crucial for obtaining a high-yielding diagnostic sample. Based on histology, vasculitis can be classified on the size of vessels affected and the dominant immune cell mediating the inflammation (e.g. neutrophilic, granulomatous, lymphocytic, or eosinophilic). Disruption of small vessels by inflammatory cells, deposition of fibrin within the lumen and/or vessel wall coupled with nuclear debris allows for the confident recognition of small vessel, mostly neutrophilic vasculitis (also known as leukocytoclastic vasculitis). In contrast, muscular vessel vasculitis can be identified solely by infiltration of its wall by inflammatory cells. Extravasation of red blood cells (purpura) and necrosis are supportive, but not diagnostic of vasculitis as they are also seen in haemorrhagic and/or vaso-occlusive disorders (pseudovasculitis). Vasculitic foci associated with extravascular granulomas (palisaded neutrophilic and granulomatous dermatitis), tissue eosinophilia, or tissue neutrophilia signal the risk for, or co-existence of systemic disease. This essential histological information coupled with direct immunofluorescence and anti-neutrophil cytoplasmic data and clinical findings enables more precise and accurate diagnosis of localized and systemic vasculitis syndromes.

Skin Infection by Coagulase Negative Staphylococci as a Potential Triggering Factor for Cutaneous Leukocytoclastic Vasculitis

Introduction

Leukocytoclastic vasculitis (LV) is a necrotising vasculitis of the small dermal blood vessels, clinically presented as palpable purpura. It is a heterogeneous disorder often limited to the skin but which may involve other organs. LV might be a serious drug reaction, caused by bacterial and viral infections, or less commonly a manifestation of systemic vasculitic syndromes.

Case Reports

Three patients were admitted to our institution with petechiae and palpable purpura. The cutanous lesions were affecting the lower limbs and in one patient also the upper extremities and the trunk. The diagnosis of leukocytoclastic vasculitis was made based on clinical and histopathological findings. Systemic involvement was excluded, as was connective tissue disease. Clinical examination revealed ulcers on the legs of each patient. Smears from those ulcers were taken and investigated for micro organisms. Culture results showed infection with coagulase negative staphylococci. Systemic signs of sepsis were absent; therefore the infections were treated locally. Two patients developed necrotic blisters during the first week of hospitalisation. To avoid further vasculitic complications steroids were administered parenterally and LV lesions diminished in all patients within ten days.

Conclusion

Drugs and connective tissue disease were ruled out as triggering factors of LV in the patients reported on. Therefore, it was concluded that superantigens produced by the coagulase negative staphylococci were responsible for LV.

Spectrum of cutaneous vasculitis in adult patients from the Farwaniya region of Kuwait

OBJECTIVE

To determine the clinical profile, etiologic factors, disease associations, and the laboratory profile of adult patients with cutaneous leukocytoclastic vasculitis (LV) presenting to the Dermatology Department at Farwaniya Hospital, Kuwait.

SUBJECTS AND METHODS

The medical records of 57 adult patients (>18 years) with biopsy-proven cutaneous LV from January 2004 to June 2006 at Farwaniya Hospital were reviewed.

RESULTS

Of the 57 patients studied, 21 (36.8%) were classified as having primary cutaneous small vessel vasculitis. The most common type of skin lesions found was palpable purpura seen in 29 (50.9%) patients. No possible cause for the cutaneous vasculitis could be identified in 21 patients. Extracutaneous involvement was seen in 32 (56.1%) patients of which 29 had joint involvement. The most frequent laboratory abnormality was an elevated erythrocyte sedimentation rate (ESR). Altered laboratory evaluation in the form of leukocytosis, raised antistreptolysin O titers and urine abnormalities were found in association with systemic vasculitis. IgA deposits were present in 33 patients. Risk factors for chronicity of cutaneous LV were female sex, advanced age, unidentified etiology, absence of fever and presence of joint involvement.

CONCLUSION

The commonest type of LV in Kuwait is primary cutaneous small vessel vasculitis. The most frequent laboratory abnormality associated with LV was increased ESR.