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Kögel J, Berneburg M, Karrer S, Drexler K, Niebel D. [Multilocular pyoderma gangrenosum : Association with primary manifestation of primary biliary cholangitis]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00105-023-05161-2. [PMID: 37326669 DOI: 10.1007/s00105-023-05161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/17/2023]
Abstract
A 16-year-old female patient with previously diagnosed acne vulgaris was transferred to our clinic in reduced general condition with rapidly progressive and extremely painful ulcerations. In the laboratory exam, inflammatory parameters were highly elevated, but she was normothermic. Based on the findings, we diagnosed multilocular pyoderma gangrenosum. Further investigations established the diagnosis of primary biliary cholangitis as the underlying condition. Treatment with systemic corticosteroids was initiated and we started therapy with ursodeoxycholic acid. This led to improvement within a few days. PAPA-syndrome (pyogenic arthritis, pyoderma gangrenosum and acne vulgaris) could be ruled out by genetic analysis.
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Affiliation(s)
- Julian Kögel
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Mark Berneburg
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Sigrid Karrer
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Konstantin Drexler
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Dennis Niebel
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
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Martinelli VF, Martinelli Barbosa P, Dantas de Oliveira LS, de Melo LDALV, Casa Nova JM, de Brito CAA. Atypical Forms of Pyoderma Gangrenosum in Inflammatory Bowel Disease: Report of Four Cases and Literature Review. Int Med Case Rep J 2022; 15:449-456. [PMID: 36051090 PMCID: PMC9427006 DOI: 10.2147/imcrj.s376915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background Cutaneous involvement is the second-most frequent extraintestinal manifestation of inflammatory bowel disease, with pyoderma gangrenosum (PG) a particularly relevant form because of its frequency, morbidity, and recurrence. The limited number of clinical trials involving PG increases the challenge to gastroenterologists in the management of this condition. Case Presentation Four cases of atypical presentations of PG are reported. A 25-year-old patient with ulcerative colitis presented an extensive chronic ulcerative lesion on her left leg that was associated with significant bleeding; the intestinal disease was in remission under the use of azathioprine. The patient was on long-term use of 60 mg corticosteroid with no improvement in the skin disease; however, initiation of cyclosporine induced remission. In the second case, a 52-year-old woman was a carrier of Crohn’s disease, with a history of partial colectomy. The patient’s skin condition had evolved with a cutaneous lesion localized in the perineal region, buttocks, and colostomy pouch, simulating a case of impetigo, and this had been treated with antibiotic cycles without improvement. Lesion biopsy suggested a diagnosis of PG. Consequently, the patient was started on biological therapy with infliximab, and the PG regressed. In the third case, a 38-year-old woman with a history of pancolitis presented a picture of PG with an extensive and deep ulcerative lesion in the right breast. The lesion regressed after treatment with oral corticosteroid. The final case was a 44-year-old woman with Crohn’s disease suffering from Crohn’s disease pancolitis. The patient’s condition evolved with a mixed pattern with pustules, bullae, and ulcerative lesions in the vulva, oral cavity, gluteus, right auricular region, scalp, and left flank, and was resolved by administration of adalimumab. Conclusion PG is an important and frequent manifestation of inflammatory bowel disease, with a spectrum of clinical variants, significant morbidity, and requiring a variety of therapeutic approaches.
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Affiliation(s)
- Valéria Ferreira Martinelli
- Department of Gastroenterology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil
- Department of Gastroenterology, Member of Organização Brasileira de Doença de Crohn e Retocolite – GEDIIB, São Paulo, Brazil
| | - Pedro Martinelli Barbosa
- Department of Internal Medicine, Medical Sciences Center, Pernambucana of Health College, Recife, Pernambuco, Brazil
| | | | | | - João Manoel Casa Nova
- Department of Gastroenterology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Carlos Alexandre Antunes de Brito
- Department of Gastroenterology, Member of Organização Brasileira de Doença de Crohn e Retocolite – GEDIIB, São Paulo, Brazil
- Department of Internal Medicine, Center of Medical Sciences of Federal University of Pernambuco, Pernambuco, Brazil
- Department of Immunology, Autoimune Research Institute, Recife, Pernambuco, Brazil
- Correspondence: Carlos Alexandre Antunes de Brito, Department of Immunology, Autoimune Research Institute, Avenue Rui Barbosa 715, Recife, Pernambuco, 52011-040, Brazil, Tel +55 81 31480101, Email
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Ackerman D, Phan C, Kuroki M, Helm M, Jeganathan NA. A Case Report of Necrotizing Neutrophilic Dermatosis: A Sheep in Wolf's Clothing. Cureus 2022; 14:e26498. [PMID: 35923500 PMCID: PMC9339259 DOI: 10.7759/cureus.26498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
Neutrophilic dermatosis (ND) is a category of diseases characterized by trauma-induced, autoinflammatory cutaneous eruption. Comorbid systemic disease is common with a predilection for malignancy, inflammatory bowel disease, and rheumatologic disease. Rarely, it can manifest with aseptic shock, an entity referred to as necrotizing neutrophilic dermatosis (NND). NND may occur in the postoperative setting and is often misdiagnosed as a necrotizing soft tissue infection. Unfortunately, the treatment for a necrotizing soft tissue infection, namely, wide debridement, is often detrimental in the setting of NND. We present the case of a woman with underlying myelodysplastic syndrome who developed episodic postoperative hemodynamic collapse followed by delayed necrotic peristomal ulceration following colonic diversion for complicated diverticulitis. Infectious workup and operative re-exploration were unrevealing. Pathologic assessment of affected skin tissue showed changes consistent with ND, ultimately leading to the diagnosis of NND. Her clinical course dramatically improved with the initiation of immunosuppressive therapy. The mimicry of NND to a potentially lethal necrotizing soft-tissue infection creates a grave diagnostic dilemma in the postoperative period. A general lack of knowledge of NND among non-dermatologic specialists produces an opportunity for misdiagnosis and inappropriate surgical interventions, namely, serial debridement. Several clinical cues may aid in the earlier recognition of NND. The cornerstone of treatment involves systemic corticosteroid therapy with adjunctive therapy for refractory cases. NND must be considered in the differential diagnosis of necrotizing soft tissue infection as early recognition may result in the avoidance of deleterious surgical interventions.
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Affiliation(s)
- Devon Ackerman
- College of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Chandat Phan
- College of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Marcos Kuroki
- General Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Matthew Helm
- Dermatology, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Nimalan A Jeganathan
- Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Neutrophilic Dermatoses in a Clinical Practice of Wound Care Professionals. Adv Skin Wound Care 2022; 35:1-8. [PMID: 35703854 DOI: 10.1097/01.asw.0000826832.69141.e4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Diagnosing and treating neutrophilic dermatoses (NDs) in clinical practice can be challenging because of various presentations and stubborn treatment responses. Establishing a diagnosis is necessary, though, because many NDs are associated with underlying conditions, including malignancy. In this article, the authors provide information about Sweet syndrome, pyoderma gangrenosum, and other NDs and describe their clinical presentation, pathophysiology, diagnostic criteria, and associated conditions. The authors also present a case report describing the coexistence of two NDs and hidradenitis suppurativa in one patient and review the treatment modalities for those conditions.
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Hegde S, Saep M, Saldanha P, Shenoy M. Lesions of pyoderma gangrenosum mimicking sweet's syndrome; A diagnostic dilemma. Indian Dermatol Online J 2021; 12:920-922. [PMID: 34934736 PMCID: PMC8653741 DOI: 10.4103/idoj.idoj_815_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 04/11/2021] [Accepted: 04/23/2021] [Indexed: 11/04/2022] Open
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Maller B, Bigness A, Moiño D, Greene J. Sweet's syndrome associated with hematological malignancies. Leuk Res 2020; 99:106461. [PMID: 33099235 DOI: 10.1016/j.leukres.2020.106461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Sweet's syndrome, or acute febrile neutrophilic dermatosis, is often mistaken for a skin infection given its similar clinical presentation. OBJECTIVE To describe the clinical presentations and management of a rare dermatologic condition associated with hematological malignancies. METHODS Case series; Chart review of patients at Moffitt Cancer Center between 2017 and 2020. RESULTS The subjects are a 79 year-old man (Patient 1) with Myelodysplastic Syndrome (MDS), a 66 year-old woman (Patient 2) with Acute Myeloid Leukemia (AML), a 56 year-old man (Patient 3) with AML, and a 69 year-old man (Patient 4) with MDS. Patient 1 was initially misdiagnosed with neutropenic fever. Patient 2 was incidentally discovered to have erythematous skin lesions prior to initiating chemotherapy. Before starting second line chemotherapy, patient 3 developed pathergy at the site of a PICC line. Patient 4 developed erythema around a newly placed port before initiating chemotherapy. Only patients 1 and 3 received glucocorticoids. Patients 2, 3, and 4 were able to initiate chemotherapy without further complications. LIMITATIONS Heterogeneity of subjects in terms of prognostic factors, stage at diagnosis, and treatment strategies. CONCLUSION Early recognition and treatment of malignancy-associated Sweet's syndrome is imperative to limit patient morbidity and expeditiously provide anti-cancer treatments.
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Affiliation(s)
- Bradley Maller
- VCU Health, Department of Internal Medicine, 1101 E Marshall St Sanger Hall Suite 1-030 Richmond, VA, 23298, United States.
| | - Alec Bigness
- USF Health Morsani College of Medicine, 12901 Bruce B Downs Blvd Tampa, FL, 33612, United States.
| | - Daniela Moiño
- USF Health Morsani College of Medicine, 12901 Bruce B Downs Blvd Tampa, FL, 33612, United States.
| | - John Greene
- Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr Tampa, FL, 33612, United States.
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Gowda A, Christensen L, Polly S, Barlev D. Necrotizing neutrophilic dermatosis: A diagnostic challenge with a need for multi-disciplinary recognition, a case report. Ann Med Surg (Lond) 2020; 57:299-302. [PMID: 32874559 PMCID: PMC7452005 DOI: 10.1016/j.amsu.2020.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/18/2020] [Accepted: 07/18/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction Necrotizing neutrophilic dermatoses can clinically resemble necrotizing fasciitis and therefore pose a diagnostic and therapeutic challenge. Given their similar presentations, misdiagnosis and inappropriate or delayed treatments are possible. Presentation of case We discuss the case of a woman with acute myeloid leukemia who presented with fevers, chills, cough, and a leg wound. She underwent amputation of her lower extremity after she was presumed to have necrotizing fasciitis; however, symptoms persisted. She was ultimately diagnosed with and treated for necrotizing Sweet's syndrome with notable clinical improvement. Discussion Both, necrotizing neutrophilic dermatoses and necrotizing fasciitis, grossly affect the skin and are associated with rapidly progressing systemic features including fevers, chills, leukocytosis, and elevated inflammatory markers. Recent literature in dermatology addresses these similarities and the appropriate approach to management; however, it is critical that medical and surgical subspecialties have an understanding of necrotizing neutrophilic dermatoses and their clinical presentations, diagnostic approaches, as well as therapeutic interventions. Familiarity with this entity can mitigate the risk of misdiagnosis, morbidity, and mortality. Conclusion With this report, we seek to review the features that are suggestive of and aid in the diagnosis of necrotizing neutrophilic dermatoses to help prevent significant and avoidable morbidity. Necrotizing neutrophilic dermatoses are a rare skin condition that can easily be misdiagnosed as necrotizing fasciitis. Providers from specialties like internal medicine, oncology, and surgery may encounter necrotizing neutrophilic dermatosis. Familiarity with the management of necrotizing neutrophilic dermatoses can reduce avoidable morbidity.
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Shah M, Sachdeva M, Gefri A, Jfri A. Paraneoplastic pyoderma gangrenosum in solid organ malignancy: a literature review. Int J Dermatol 2019; 59:154-158. [DOI: 10.1111/ijd.14637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/27/2019] [Accepted: 08/08/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Monica Shah
- Faculty of Medicine University of Toronto Toronto ON Canada
| | | | - Amnah Gefri
- Department of Dermatology Al‐Noor Specialist Hospital Makkah Saudi Arabia
| | - Abdulhadi Jfri
- Division of Dermatology McGill University Health Centre Montreal QC Canada
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Abate MS, Battle LR, Emerson AN, Gardner JM, Shalin SC. Dermatologic Urgencies and Emergencies: What Every Pathologist Should Know. Arch Pathol Lab Med 2019; 143:919-942. [PMID: 30785787 DOI: 10.5858/arpa.2018-0239-ra] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Fatal dermatologic diseases and ones with high morbidity can occur in the inpatient setting. In such cases, prompt and accurate assessment of a bedside skin biopsy is required. This may be challenging for many pathologists who are not familiar with the complexity of skin pathology and skin terminology within the fields of dermatopathology and dermatology. OBJECTIVE.— To provide the pathologist with a practical, up-to-date, and "must-know" reference guide on dermatologic urgencies and emergencies from a real-world perspective, highlighting diagnostic pearls, diagnostic pitfalls, and commonly encountered practice gaps. This review will focus on key diseases with which every pathologist should be familiar, including angioinvasive fungal infections, Stevens-Johnson syndrome/toxic epidermal necrolysis, staph-scalded-skin syndrome, acute graft-versus-host disease, bullous pemphigoid, calciphylaxis, Sweet syndrome and its histiocytoid variant, pyoderma gangrenosum, and leukocytoclastic vasculitis, as well as those in their clinical and histopathologic differential. DATA SOURCES.— This review is based on peer-reviewed literature and our personal experiences with these diseases at major academic institutions, including one where a large number of stem cell transplants are performed. This review is unique as it represents collaborative expert opinion from both a dermatopathology and a dermatology standpoint. CONCLUSIONS.— This review outlines the critical role that the pathologist plays in the outcomes of patients with dermatologic urgencies and emergencies. Improved patient care will result from prompt and accurate histopathologic diagnoses as well as an open line of communication with the dermatologist.
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Affiliation(s)
- Mallory S Abate
- From the Department of Dermatology, Saint Louis University, St Louis, Missouri (Dr Abate); the Departments of Dermatology (Dr Battle), and Pathology (Drs Gardner and Shalin), University of Arkansas for Medical Sciences, Little Rock; and the Department of Dermatology, University of Mississippi Medical Center, Jackson (Dr Emerson)
| | - Laura R Battle
- From the Department of Dermatology, Saint Louis University, St Louis, Missouri (Dr Abate); the Departments of Dermatology (Dr Battle), and Pathology (Drs Gardner and Shalin), University of Arkansas for Medical Sciences, Little Rock; and the Department of Dermatology, University of Mississippi Medical Center, Jackson (Dr Emerson)
| | - Ashley N Emerson
- From the Department of Dermatology, Saint Louis University, St Louis, Missouri (Dr Abate); the Departments of Dermatology (Dr Battle), and Pathology (Drs Gardner and Shalin), University of Arkansas for Medical Sciences, Little Rock; and the Department of Dermatology, University of Mississippi Medical Center, Jackson (Dr Emerson)
| | - Jerad M Gardner
- From the Department of Dermatology, Saint Louis University, St Louis, Missouri (Dr Abate); the Departments of Dermatology (Dr Battle), and Pathology (Drs Gardner and Shalin), University of Arkansas for Medical Sciences, Little Rock; and the Department of Dermatology, University of Mississippi Medical Center, Jackson (Dr Emerson)
| | - Sara C Shalin
- From the Department of Dermatology, Saint Louis University, St Louis, Missouri (Dr Abate); the Departments of Dermatology (Dr Battle), and Pathology (Drs Gardner and Shalin), University of Arkansas for Medical Sciences, Little Rock; and the Department of Dermatology, University of Mississippi Medical Center, Jackson (Dr Emerson)
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Tartey S, Gurung P, Samir P, Burton A, Kanneganti TD. Cutting Edge: Dysregulated CARD9 Signaling in Neutrophils Drives Inflammation in a Mouse Model of Neutrophilic Dermatoses. THE JOURNAL OF IMMUNOLOGY 2018; 201:1639-1644. [PMID: 30082320 DOI: 10.4049/jimmunol.1800760] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/19/2018] [Indexed: 11/19/2022]
Abstract
Mice homozygous for the Y208N amino acid substitution in the carboxy terminus of SHP-1 (referred to as Ptpn6spin mice) spontaneously develop a severe inflammatory disease resembling neutrophilic dermatosis in humans. Disease in Ptpn6spin mice is characterized by persistent footpad swelling and suppurative inflammation. Recently, in addition to IL-1α and IL-1R signaling, we demonstrated a pivotal role for RIPK1, TAK1, and ASK1 in promoting inflammatory disease in Ptpn6spin mice. In the current study we have identified a previously unknown role for CARD9 signaling as a critical regulator for Ptpn6spin-mediated footpad inflammation. Genetic deletion of CARD9 significantly rescued the Ptpn6spin-mediated footpad inflammation. Mechanistically, enhanced IL-1α-mediated signaling in Ptpn6spin mice neutrophils was dampened in Ptpn6spinCard9-/- mice. Collectively, this study identifies SHP-1 and CARD9 cross-talk as a novel regulator of IL-1α-driven inflammation and opens future avenues for finding novel drug targets to treat neutrophilic dermatosis in humans.
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Affiliation(s)
- Sarang Tartey
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN 38105; and
| | - Prajwal Gurung
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN 38105; and.,Inflammation Program, University of Iowa, Iowa City, IA 52241
| | - Parimal Samir
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN 38105; and
| | - Amanda Burton
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN 38105; and
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Tartey S, Gurung P, Dasari TK, Burton A, Kanneganti TD. ASK1/2 signaling promotes inflammation in a mouse model of neutrophilic dermatosis. J Clin Invest 2018; 128:2042-2047. [PMID: 29629899 DOI: 10.1172/jci98446] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/27/2018] [Indexed: 12/12/2022] Open
Abstract
Mice homozygous for the Tyr208Asn amino acid substitution in the carboxy terminus of Src homology region 2 (SH2) domain-containing phosphatase 1 (SHP-1) (referred to as Ptpn6spin mice) spontaneously develop a severe inflammatory disease resembling neutrophilic dermatosis in humans. Disease in Ptpn6spin mice is characterized by persistent footpad swelling and suppurative inflammation. Recently, in addition to IL-1α and IL-1R signaling, we demonstrated a pivotal role for several kinases such as SYK, RIPK1, and TAK1 in promoting inflammatory disease in Ptpn6spin mice. In order to identify new kinases involved in SHP-1-mediated inflammation, we took a genetic approach and discovered apoptosis signal-regulating kinases 1 and 2 (ASK1 and ASK2) as novel kinases regulating Ptpn6-mediated footpad inflammation. Double deletion of ASK1 and ASK2 abrogated cutaneous inflammatory disease in Ptpn6spin mice. This double deletion further rescued the splenomegaly and lymphomegaly caused by excessive neutrophil infiltration in Ptpn6spin mice. Mechanistically, ASK regulates Ptpn6spin-mediated disease by controlling proinflammatory signaling in the neutrophils. Collectively, the present study identifies SHP-1 and ASK signaling crosstalk as a critical regulator of IL-1α-driven inflammation and opens future avenues for finding novel drug targets to treat neutrophilic dermatosis in humans.
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Affiliation(s)
- Sarang Tartey
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Prajwal Gurung
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Inflammation Program, University of Iowa, Iowa City, Iowa, USA
| | - Tejasvi Krishna Dasari
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Amanda Burton
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Gupta AS, Greiling TM, Ortega-Loayza AG. A systematic review of pyoderma gangrenosum with pulmonary involvement: clinical presentation, diagnosis and management. J Eur Acad Dermatol Venereol 2018; 32:e295-e297. [PMID: 29377399 DOI: 10.1111/jdv.14828] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A S Gupta
- School of Medicine, Virginia Commonwealth University, 1101 E Marshall St, 23284-2512, Richmond, VA, USA
| | - T M Greiling
- Department of Dermatology, Oregon Health & Sciences University, 3303 SW Bond Avenue, CHD 16D, Portland, OR, 97239, USA
| | - A G Ortega-Loayza
- Department of Dermatology, Oregon Health & Sciences University, 3303 SW Bond Avenue, CHD 16D, Portland, OR, 97239, USA
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Postsurgical Pyoderma Gangrenosum Versus Necrotizing Fasciitis: Can We Spot the Difference? Ann Plast Surg 2018; 78:582-586. [PMID: 28379857 DOI: 10.1097/sap.0000000000001070] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pyoderma gangrenosum is a rare noninfectious cutaneous disease characterized by expanding areas of skin ulceration around necrotic centers with purulent debris. Exceptionally, it can be precipitated by surgery alone, and this entity has been described as postsurgical pyoderma gangrenosum (PSPG). Cases of PSPG in the literature are rare. METHODS We performed a retrospective review of the current literature on PSPG and highlight some observed differences between these conditions. We also present our experience of PSPG imitating an infectious process post reduction mammoplasty. RESULTS Although PSPG can demonstrate fever, malaise, systemic signs, and serology that mimic the sepsis of necrotizing fasciitis, we identify some features that can aid diagnosis of pyoderma gangrenosum in the absence of pathergy (which is pathognomonic). These include premorbid inflammatory bowel disease, hematological malignancy, or inflammatory polyarthritis; the exquisite and disproportionate pain associated (in particular within surrounding normal skin); symmetrical changes on both breasts; specific histopathological changes with absence of microorganisms; cutaneous wounds demonstrating an ulcerated, violaceous, and undermined edge; and, in this case, bilaterally spared nipple-areola complexes suggesting progression within continuous skin up to but not across incision lines. CONCLUSIONS We hope that, in encouraging a higher index of suspicion, prompt diagnosis, and accurate treatment, a better outcome for both patient and surgeon can be achieved in future cases.
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Vanbrabant PRA, De Turck BJG, Petrick M. Sweet's or not: a cutaneous presentation of a severe disease. Acta Clin Belg 2016; 71:114-6. [PMID: 26231970 DOI: 10.1179/2295333715y.0000000058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Philip R A Vanbrabant
- a Department of Emergency Medicine , AZ Sint Lucas General Hospital , Groenebriel 1, 9000 Ghent , Belgium
| | - Bruno J G De Turck
- a Department of Emergency Medicine , AZ Sint Lucas General Hospital , Groenebriel 1, 9000 Ghent , Belgium
| | - Marjan Petrick
- b Department of Oncology and Radiotherapy , AZ Sint Lucas General Hospital , Groenebriel 1, 9000 Ghent , Belgium
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Abstract
Cutaneous complications are common in patients with leukemia. However, the cause is not always immediately clear, as there are often numerous potential etiologies. Thrombocytopenia or coagulopathy can result in ecchymoses or petechiae, whereas extramedullary (EM) involvement by leukemia can present as a rash. Leukemia can also result in skin manifestations via indirect means, including several types of paraneoplastic phenomena. Moreover, various agents routinely used to treat leukemia-most notably cytarabine (cytosine arabinoside)-can precipitate quite profound skin eruptions. Finally, infections, including fungal invasion of the skin, can be responsible for rashes, as can the vast array of antimicrobials that are administered to leukemia patients.
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Affiliation(s)
| | | | - Raghava Induru
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC
| | - Jonathan M Gerber
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC.
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Ajili F, Souissi A, Bougrine F, Boussetta N, Abdelhafidh NB, Sayhi S, Louzir B, Doss N, Laabidi J, Othmani S. Coexistence of pyoderma gangrenosum and sweet's syndrome in a patient with ulcerative colitis. Pan Afr Med J 2015; 21:151. [PMID: 26327988 PMCID: PMC4546795 DOI: 10.11604/pamj.2015.21.151.6364] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 06/19/2015] [Indexed: 01/03/2023] Open
Abstract
Pyoderma gangrenosum (PG) and Sweet's Syndrome (SS) are inflammatory skin diseases caused by the accumulation of neutrophils in the skin and, rarely, in internal organs. These neutrophilic dermatosis (NDs) are distinguished by the existence of forms of transition or overlap. They are frequently associated to systemic diseases especially hematologic and gastrointestinal ones. We report a case of a patient with ulcerative colitis (UC) who successively developed two types of NDs: PG then SS. A 66 years old patient with a history of UC consulted in July 2012 for an erythematous swelling of the back of the right hand treated with antibiotics without improvement. At that time, bacteriological samples were negative. In October 2012, he was hospitalized for polyarthralgia and impaired general condition. In physical examination, he had vesiculobullous plaque of 10 cm long of the right hand and wrist, infiltrated erythematous plaque on the right leg and another topped with a large pustule at the left ankle. Skin biopsy showed at the back of the right hand an aspect of PG and at the infiltrated plaques of the ankle an aspect of SS. Prednisone was started with improvement of the skin lesions and a recovery condition. The combination of PG and SS has already been described in cases of hematologic malignancy and rarely in UC. There is also the notion of passage from a neutrophilic dermatosis to another. Indeed, a typical lesion initially of SS can evolve to a future PG. This case demonstrates that neutrophilic dermatoses form a continous spectrum of entities that may occur in UC.
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Affiliation(s)
- Faida Ajili
- Department of Internal Medicine, Military Hospital of Tunis, 1008 Montleury, Tunisie
| | - Asmahan Souissi
- Department of Dermatology, Military Hospital of Tunis, 1008 Montleury, Tunisie
| | - Fathi Bougrine
- Department of Anatomopathology, Military Hospital of Tunis, 1008 Montleury, Tunisie
| | - Najah Boussetta
- Department of Internal Medicine, Military Hospital of Tunis, 1008 Montleury, Tunisie
| | - Nadia Ben Abdelhafidh
- Department of Internal Medicine, Military Hospital of Tunis, 1008 Montleury, Tunisie
| | - Sameh Sayhi
- Department of Internal Medicine, Military Hospital of Tunis, 1008 Montleury, Tunisie
| | - Bassem Louzir
- Department of Internal Medicine, Military Hospital of Tunis, 1008 Montleury, Tunisie
| | - Nejib Doss
- Department of Dermatology, Military Hospital of Tunis, 1008 Montleury, Tunisie
| | - Janet Laabidi
- Department of Internal Medicine, Military Hospital of Tunis, 1008 Montleury, Tunisie
| | - Salah Othmani
- Department of Internal Medicine, Military Hospital of Tunis, 1008 Montleury, Tunisie
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Dasanu CA, Bockorny B, Alexandrescu DT. Pyoderma gangrenosum due to lenalidomide use for multiple myeloma. J Oncol Pharm Pract 2014; 21:471-3. [PMID: 24986794 DOI: 10.1177/1078155214541975] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pyoderma gangrenosum has been described in association with multiple myeloma and usually affects patients with active/untreated disease. This dermatologic condition was shown to resolve after successful anti-myeloma therapy. We report herein occurrence of pyoderma gangrenosum involving bilateral knees in a patient with multiple myeloma responding to lenalidomide therapy. Previous papers claimed usefulness of thalidomide and its newer derivatives for the therapy of this neutrophilic dermatosis. Occurrence of pyoderma gangrenosum in a myeloma patient responding to lenalidomide would argue against its effectiveness in treating this skin condition. Moreover, the clinical setting suggested that lenalidomide either induced or contributed to the occurrence of pyoderma gangrenosum in our patient. If our hypothesis is correct, we expect more reports of pyoderma gangrenosum with the use of this class of pharmaceuticals.
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Affiliation(s)
| | - Bruno Bockorny
- Department of Medicine, University of Connecticut, Farmington, CT, USA
| | - Doru T Alexandrescu
- Department of Dermatology, Health Care Partners Medical Group, Mission Hills, CA, USA
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Affiliation(s)
- S. Ratnagobal
- School of Medicine, Faculty of Health Science, University of Tasmania, Australia
| | - S. Sinha
- School of Medicine, Faculty of Health Science, University of Tasmania, Australia
- Wound Clinic, Royal Hobart Hospital, Tasmania, Australia
- University of Notre Dame Australia, School of Medicine Sydney, Australia
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Grillo MA, Cavalheiro TT, da Silva Mulazani M, Rocha JLL, Semchechen D, da Cunha CA. Postsurgical pyoderma gangrenosum complicating reduction mammaplasty. Aesthetic Plast Surg 2012; 36:1347-52. [PMID: 23052384 DOI: 10.1007/s00266-012-9981-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 07/17/2012] [Indexed: 11/30/2022]
Abstract
UNLABELLED Reduction mammaplasty is one of the most common surgeries performed by plastic surgeons. It relieves back and neck pain and improves the aesthetic contour of the ptotic breast. Postsurgical pyoderma gangrenosum (PSPG) is an unusual inflammatory disorder leading to rapidly progressive skin necrosis that can occur after any surgical procedure. The skin lesions have the characteristic appearance of ulcers with a purple-colored border and erythematous halo. Clinically, the patient has a low fever and severe local pain. In the majority of cases this disease is misdiagnosed as severe infection leading to improper debridement, exacerbating the problem. The mainstay of therapy for PSPG is still nonoperative and focuses on immunosuppressive medications and local wound care, which allows healing in the majority of the cases. It is important for plastic surgeons and infectologists to be cognizant of this entity, as a delay in diagnosis and management can be life-threatening and lead to considerable tissue loss and disfigurement of the breast. The authors report a case of reduction mammaplasty complicated with PSPG and its treatment. LEVEL OF EVIDENCE V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Marcos Artigas Grillo
- Clínica de Cirurgia Plástica Dr. Marcos Grillo, Avenida Sete de Setembro, Curitiba, PR, 4848, Brazil.
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de Moya MA, Wong JT, Kroshinsky D, Robbins GK, Shenoy-Bhangle AS, Gimbel DC. Case records of the Massachusetts General Hospital. Case 28-2012. A 30-year-old woman with shock and abdominal-wall necrosis after cesarean section. N Engl J Med 2012; 367:1046-57. [PMID: 22970948 DOI: 10.1056/nejmcpc1208146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Marc A de Moya
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, USA
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21
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Pellicer Z, Santiago JM, Rodriguez A, Alonso V, Antón R, Bosca MM. Management of cutaneous disorders related to inflammatory bowel disease. Ann Gastroenterol 2012; 25:21-26. [PMID: 24713996 PMCID: PMC3959344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 10/28/2011] [Indexed: 11/16/2022] Open
Abstract
Almost one-third of patients with inflammatory bowel disease (IBD) develop skin lesions. Cutaneous disorders associated with IBD may be divided into 5 groups based on the nature of the association: specific manifestations (orofacial and metastatic IBD), reactive disorders (erythema nodosum, pyoderma gangrenosum, pyodermatitis-pyostomatitis vegetans, Sweet's syndrome and cutaneous polyarteritis nodosa), miscellaneous (epidermolysis bullosa acquisita, bullous pemphigoid, linear IgA bullous disease, squamous cell carcinoma-Bowen's disease, hidradenitis suppurativa, secondary amyloidosis and psoriasis), manifestations secondary to malnutrition and malabsorption (zinc, vitamins and iron deficiency), and manifestations secondary to drug therapy (salicylates, immunosupressors, biological agents, antibiotics and steroids). Treatment should be individualized and directed to treating the underlying IBD as well as the specific dermatologic condition. The aim of this review includes the description of clinical manifestations, course, work-up and, most importantly, management of these disorders, providing an assessment of the literature on the topic.
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Affiliation(s)
- Zaira Pellicer
- Dermatology Department of the University Clinic Hospital of Valencia (Zaira Pellicer, Vicent Alonso)
| | - Jesus Manuel Santiago
- Inflammatory Bowel Disease Unit of the Gastroenterology and Hepatology Department of the University Clinic Hospital of Valencia (Jesus Manuel Santiago, Rosario Antón, Marta Maia Bosca)
| | - Alejandro Rodriguez
- Inflammatory Bowel Disease Unit of the Gastroenterology and Hepatology Department of the University Clinic Hospital of Valencia (Jesus Manuel Santiago, Rosario Antón, Marta Maia Bosca)
| | - Vicent Alonso
- Dermatology Department of the University Clinic Hospital of Valencia (Zaira Pellicer, Vicent Alonso)
| | - Rosario Antón
- Inflammatory Bowel Disease Unit of the Gastroenterology and Hepatology Department of the University Clinic Hospital of Valencia (Jesus Manuel Santiago, Rosario Antón, Marta Maia Bosca)
| | - Marta Maia Bosca
- Inflammatory Bowel Disease Unit of the Gastroenterology and Hepatology Department of the University Clinic Hospital of Valencia (Jesus Manuel Santiago, Rosario Antón, Marta Maia Bosca),
Correspondence to: Marta Maia Bosca, Gastroenterology and Hepatology Department, Investigation Foundation of the University Clinic Hospital, University Clinic Hospital of Valencia, Avda. Blasco Ibañez 17, 46010 Valencia, Spain, Tel: 0034-963862600, extension 51255, e-mail:
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Goshtasby PH, Chami RG, Johnson RM. A novel approach to the management of pyoderma gangrenosum complicating reduction mammaplasty. Aesthet Surg J 2010; 30:186-93. [PMID: 20442095 DOI: 10.1177/1090820x10366011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Reduction mammaplasty is a common procedure performed by plastic and reconstructive surgeons to relieve chronic back and neck pain associated with macromastia, with the added benefit of an improvement in the aesthetic contour of the ptotic breast. Complications related to this procedure are fortunately uncommon, but include hematoma, infection, and wound breakdown. The authors report an interesting case of reduction mammaplasty complicated postoperatively by pyoderma gangrenosum (PG), which is a rare inflammatory disorder leading to progressive skin necrosis. The destructive process, which involved both breast incisions, was managed successfully with immunosuppressive therapy and intensive wound care, followed by a novel method of coverage with a dermal regeneration template and subsequent epidermal autograft that led to stable coverage of the open wounds. PG is frequently misdiagnosed as a necrotizing infection, leading to improper debridement with exacerbation of the disease process. The mainstay of therapy for PG is still nonoperative and focuses on immunosuppressive medications and local wound care, which allows healing in most cases. However, there are a few indications for surgical intervention, including significantly large wounds that are refractory to medical management. It is important for plastic surgeons and other clinicians to be cognizant of this entity, as a delay in diagnosis and management of PG can lead to serious consequences, with considerable soft tissue loss and disfigurement of the breast.
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Affiliation(s)
- Parviz H Goshtasby
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Wright State University-Boonshoft School of Medicine, Dayton, OH 45409, USA.
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Abstract
Neutrophilic dermatoses are a spectrum of diseases with varying presentations and similar clinical and histologic features. The association of neutrophilic dermatosis with celiac disease has not previously been described. We report a 43-year-old man with a history of diverticulitis who presented with mildly pruritic, ulcerating pustules of the dorsal hands, face, elbow, and neck, clinico-pathologically consistent with the neutrophilic dermatosis Sweet syndrome. Remission was achieved with prednisone taper, dapsone, and a gluten-free diet.
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Affiliation(s)
- Abigail Fogo
- Dermatology Department, King's College Hospital, London.
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25
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Abstract
We report on an 18-month-old boy with a typical presentation of Sweet syndrome following an upper respiratory tract illness. No evidence of hematologic malignancy was found and he was successfully treated with oral prednisolone. A comprehensive literature review has summarized the features of pediatric Sweet syndrome from 66 reported cases. Cases occurring under the age of 3 years had a male predominance and no association with malignancy, whereas cases over the age of 3 years had an equal sex distribution and were strongly associated with myeloid line hematologic malignancies. Identified complications were serious with an overall mortality of 9% rising to 40% with cardiovascular involvement.
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Affiliation(s)
- James Halpern
- Department of Dermatology, University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom.
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Acute febrile neutrophilic dermatosis (Sweet's syndrome) in childhood and adolescence: two new patients and review of the literature on associated diseases. Eur J Pediatr 2009; 168:1-9. [PMID: 18830624 DOI: 10.1007/s00431-008-0812-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2008] [Accepted: 08/04/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The objectives of this study were to analyse the literature on Sweet's syndrome in childhood focussing on associated diseases and to suggest possible screening procedures for this group of patients. Furthermore, two new patients with Sweet's syndrome are reported. METHODS A literature search was performed on Pub med using search terms "sweet* syndrome*" and neutrophil* dermatos*. Patients were subdivided into the following groups: classic/idiopathic, paraneoplastic, and parainflammatory Sweet's syndrome. RESULTS The literature search revealed 64 patients (including our two patients) who were diagnosed with Sweet's syndrome in childhood and adolescence; 27 (42%) patients were categorized as "classic/idiopathic Sweet's syndrome". In 37 patients (58%) chronic associated diseases were reported. Out of these, 21 (33%) patients were categorized as "parainflammatory Sweet's syndrome" including chronic recurrent multifocal osteomyelitis, vasculitis with aortitis, recurrent infections due to immunodeficiencies, arthritis, and systemic lupus erythematosus. Sixteen (25%) patients were categorized as "paraneoplastic Sweet's syndrome" comprising both malignant and premalignant diseases like leukemia, aplastic anaemia, and Fanconi anaemia. As all five (8%) patients treated with drugs (granulocyte-colony stimulating factor, retinoid acid) suffered from malignant, premalignant, or parainflammatory diseases, these patients were categorized according to the underlying disease. Two new children with Sweet's syndrome and associated diseases are presented here, one of them suffering from recurrent infections and trisomy 21, while the other was diagnosed with CNS vasculitis 5(1/2) years after the primary diagnosis. CONCLUSIONS Sweet's syndrome should be considered in differential diagnosis of prolonged fever with cutaneous involvement. As most cases of pediatric Sweet's syndrome are associated with other diseases we suggest careful screening and monitoring of these patients especially concerning malignant/premalignant diseases, immunodeficiencies, cardiovascular involvement, autoimmune diseases, and drug associations.
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27
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Magro CM, Kiani B, Li J, Crowson AN. Clonality in the setting of Sweet's syndrome and pyoderma gangrenosum is not limited to underlying myeloproliferative disease. J Cutan Pathol 2007; 34:526-34. [PMID: 17576331 DOI: 10.1111/j.1600-0560.2006.00654.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The neutrophilic dermatoses encompass, among others, Sweet's syndrome (SS) and pyoderma gangrenosum (PG), which are associated with underlying systemic diseases including myeloid dyscrasias. METHODS On skin biopsies from 16 patients with biopsy-proven SS and/or PG, we performed an X-inactivation assay to detect clonal restriction of neutrophils. There were two patient categories based on known diseases at the time of diagnosis: patients with myeloproliferative disease and patients without myeloproliferative disease. RESULTS Among seven patients with acute myelogenous leukemia and two with myelodysplastic syndrome, clonal restriction was found in five; three were homozygous, precluding analysis. Among the seven control patients, infiltrates were clonally restricted in five; one was polyclonal and the other was homozygous for the allele, precluding analysis. Of the five patients with clonally restricted infiltrates, one was subsequently diagnosed with myelodysplasia, one had unexplained neutropenia and an additional patient developed breast cancer. Overall, the incidence of clonality in both groups was the same, averaging 81%. CONCLUSION These findings suggest that clonality in neutrophilic dermatoses, while characteristic of underlying myeloid dyscrasia, is not observed exclusively in the setting of myeloproliferative diseases. The significance of clonal neutrophilic infiltrates unassociated with myeloproliferative disease is unclear, but it may have some implications regarding the pathogenesis of sterile neutrophilic infiltrates. Clonality is well described in the setting of lymphomatoid hypersensitivity, reflecting an overzealous response to antigenic stimuli. One could speculate a similar mechanism operational in cases of apparently reactive SS/PG associated with monoclonality; a localized form of cutaneous neutrophilic dyscrasia is also possible.
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Affiliation(s)
- Cynthia M Magro
- Department of Pathology and Laboratory Medicine, Weill Medical College of Cornell University, New York, NY 10021, USA.
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Sanft T, Barrett TA, Barr WG, Jones MP. Henoch-Schönlein Purpura Presenting as Terminal Ileitis: Case Report and Review of Unusual Causes of Ileitis. Gastroenterol Hepatol (N Y) 2006; 2:375-378. [PMID: 28289341 PMCID: PMC5338191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | | | - Walter G. Barr
- Division of Rheumatology, Feinberg School of Medicine, Northwestern University, Chicago, Ill.
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29
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Affiliation(s)
- Patrizia Zappasodi
- Division of Hematology and Department of Dermatology, University of Pavia, IRCCS Policlinico San Matteo, Italy.
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Abstract
Paraneoplastic syndromes are a group of clinical manifestations associated with a malignancy, but not directly related to the primary tumor itself or to its metastases. Characteristically, they follow a course parallel to the tumor, resolve with successful treatment of the primary tumor, and tend to recur with its relapse or the onset of metastases. The mechanism by which they occur is not well understood, but may be related to the production of bioactive substances by or in response to the tumor, such as polypeptide hormones, hormone-like peptides, antibodies or immune complexes, cytokines, or growth factors.
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Affiliation(s)
- Isabelle Thomas
- Department of Dermatology, New Jersey Medical School, Newark, 07103-2714, USA
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31
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Affiliation(s)
- Cindy Berthelot
- University of Texas Southwestern Medical School, Dallas, USA
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32
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Abstract
Since its first description in 1930, the pathogenesis of pyoderma gangrenosum (PG) has remained obscure even as an ever-widening array of systemic diseases has been described in association with it. The histopathologic distinction of PG from other ulcerative processes with dermal neutrophilia is challenging and at times impossible. In consequence, when confronted with a biopsy from such a lesion, the pathologist has an obligation to obtain a full and detailed clinical history. In short, as a diagnosis of PG does not hinge exclusively upon the biopsy findings in isolation from other studies, a solid knowledge of the clinical features, the systemic disease associations and the differential diagnosis will help the pathologist to avoid diagnostic pitfalls or the generation of a report which is non-contributory to patient care. In this review, we describe in detail the different clinicopathologic forms of PG, summarize the diseases associated with this process in the literature and in our experience, and briefly review the treatment options.
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Affiliation(s)
- A Neil Crowson
- Department of Dermatology, University of Oklahoma, Tulsa, OK, USA.
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33
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 14-2001. A 47-year-old woman with diabetes, Crohn's colitis, and a painful swelling of the foot. N Engl J Med 2001; 344:1461-6. [PMID: 11346812 DOI: 10.1056/nejm200105103441908] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Hagman JH, Carrozzo AM, Campione E, Romanelli P, Chimenti S. The use of high-dose immunoglobulin in the treatment of pyoderma gangrenosum. J DERMATOL TREAT 2001; 12:19-22. [PMID: 12171682 DOI: 10.1080/095466301750163527] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Immunosuppressive medications such as corticosteroids and cyclosporin are the most commonly employed therapies in pyoderma gangrenosum. We describe a patient with multiple ulcers of pyoderma gangrenosum on the lower extremities in whom immunosuppressive therapy caused serious side effects and had to be discontinued but who was subsequently treated successfully with high dose intravenous immunoglobulin (IVIG). METHODS IVIG was given intravenously at a dose of 400 mg/kg per day for 5 consecutive days. After 1 week there was an arrest in the progression of the ulcers and a marked reduction in pain. Two weeks later clinical improvement of the ulcers was observed. Subsequently, IVIG was given at a dose of 1 g/kg per day for 2 consecutive days. RESULTS The treatment induced a dramatic clinical improvement of one ulcer and healing of the others. Side effects were minimal and well tolerated, and consisted of chills and a slight fever, which resolved with the administration of acetaminophen. CONCLUSION We feel that IVIG can be used in patients with pyoderma gangrenosum in whom conventional therapies are ineffective or produce serious side effects.
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Affiliation(s)
- J H Hagman
- University of Rome 'Tor Vergata', Department of Dermatology, Rome, Italy
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35
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Abstract
Medical specialists who care for patients with pyoderma gangrenosum have been reluctant traditionally to consult plastic surgeons. This is the result of previous negative experience with debridement and skin grafting. However, a new understanding of the pathophysiology of the disease process, and better therapeutic options for control have emerged. Very few studies report the results of surgical therapy of this disease, and fewer yet report successful outcome. The authors present their limited experience at the American University of Beirut with 4 patients who were controlled medically followed by skin grafting their large wounds, thus decreasing their morbidity and hospital stay. A review of the literature together with insights on the rationale and timing of surgery in this particular small group of patients are discussed.
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Affiliation(s)
- I L Kaddoura
- Department of Surgery, American University Medical Center, Beirut, Lebanon
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Galaria NA, Junkins-Hopkins JM, Kligman D, James WD. Neutrophilic dermatosis of the dorsal hands: pustular vasculitis revisited. J Am Acad Dermatol 2000; 43:870-4. [PMID: 11050599 DOI: 10.1067/mjd.2000.109286] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An entity termed "pustular vasculitis of the hands" was recently described. Patients with this condition presented with low-grade fevers and erythematous plaques, pustules, and bullae limited to the dorsal hands and fingers, which were characterized histologically by a dense neutrophilic infiltrate and leukocytoclastic vasculitis. We describe patients with a similar clinical presentation, but who lacked vasculitis on biopsy findings. We describe 3 otherwise asymptomatic patients with hemorrhagic bullae, plaques, and pustules solely on the dorsal hands. Biopsy specimens showed a neutrophilic infiltrate and leukocytoclasis, but no necrotizing vasculitis, and were reminiscent of Sweet's neutrophilic dermatoses. In our patients, corticosteroids or dapsone led to clearing of the lesions, and small maintenance doses of dapsone prevented their recurrence. Our 3 patients had clinical lesions similar to those termed pustular vasculitis of the hands, but which lacked leukocytoclastic vasculitis on biopsy findings. Because of histologic findings and a therapeutic response more characteristic of Sweet's syndrome, we propose the term neutrophilic dermatosis of the dorsal hands. In addition, low-dose dapsone is proposed as a possible first-line therapy in this condition, especially in those with recurrent disease.
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Affiliation(s)
- N A Galaria
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA
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37
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Pharis DB, Cerenko D, Caughman SW. Sweet's syndrome in a patient with idiopathic progressive bilateral sensorineural hearing loss. J Am Acad Dermatol 2000; 42:932-5. [PMID: 10767709 DOI: 10.1016/s0190-9622(00)90276-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Acute febrile neutrophilic dermatosis, or Sweet's syndrome, was first described in 1964 and consists of a triad of erythematous cutaneous plaques infiltrated by neutrophils in association with fever and leukocytosis. Sweet's syndrome has been reported to be associated with conditions ranging from upper respiratory tract infections to inflammatory bowel disease to rheumatoid arthritis. We report a patient with a 2-year history of Sweet's syndrome in whom idiopathic progressive bilateral sensory neural hearing loss (IPBSNHL) developed. IPBSNHL is a suspected immunologically mediated hearing loss first described by McCabe in 1979. On the basis of this association, hearing evaluation should be considered in the initial and subsequent examinations of the patient with Sweet's syndrome.
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Affiliation(s)
- D B Pharis
- Department of Dermatology and the Emory Skin Diseases Research Center, Atlanta, Georgia, USA
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38
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Affiliation(s)
- C D Hensley
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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39
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Vannucci SA, Mitchell WM, Stratton CW, King LE. Pyoderma gangrenosum and Chlamydia pneumoniae infection in a diabetic man: pathogenic role or coincidence? J Am Acad Dermatol 2000; 42:295-7. [PMID: 10642692 DOI: 10.1016/s0190-9622(00)90145-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chlamydia Pneumoniae is not a known cause of skin infections, but unusual pathogens cause chronic infections in diabetic patients. Multiple idiopathic pyoderma gangrenosum-like (PG-like) lesions were refractory to multiple therapeutic agents in a diabetic patient who had C pneumoniae identified by serologic tests and polymerase chain reaction. Based on complete resolution by prolonged anti-chlamydial antibiotic therapy and concomitant decrease in serologic and titers determined by polymerase chain reactions, the PG-like lesions were presumed to be due to C pneumoniae.
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Affiliation(s)
- S A Vannucci
- Department of Medicine, Division of Dermatology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-5227, USA
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40
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Matsumura T, Sato-Matsumura KC, Ota M, Yokota T, Arita K, Kodama K, Inokuma D, Kobayashi H. Two cases of pyoderma gangrenosum complicated with nasal septal perforation. Br J Dermatol 1999; 141:1133-5. [PMID: 10606868 DOI: 10.1046/j.1365-2133.1999.03220.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report two patients with pyoderma gangrenosum complicated with nasal septal perforation. An 18-year-old woman and a 65-year-old man had typical lesions of pyoderma gangrenosum on the legs that responded well to oral prednisolone. Both patients complained of mild nasal discharge, and nasal fibroscopy revealed nasal septal perforation. Biopsy of the nasal lesions showed an active inflammatory infiltrate, mainly of neutrophils. Systemic investigations failed to show any pulmonary or renal lesions of Wegener's granulomatosis. Cytoplasmic immunofluorescent pattern antineutrophil cytoplasmic antibody was negative. In both cases, intense neutrophilic infiltration was observed not only in skin lesions but also in nasal lesions, which may indicate that the nasal lesions had a pathogenesis in common with the skin lesions.
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Affiliation(s)
- T Matsumura
- Department of Dermatology, Hokkaido University School of Medicine, Japan.
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Brady RC, Morris J, Connelly BL, Boiko S. Sweet's syndrome as an initial manifestation of pediatric human immunodeficiency virus infection. Pediatrics 1999; 104:1142-4. [PMID: 10545563 DOI: 10.1542/peds.104.5.1142] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We report a 3-month-old infant in whom Sweet's syndrome was a presenting manifestation of pediatric human immunodeficiency virus infection. Although rare in children, Sweet's syndrome may be associated with certain infections and malignancies. The diagnosis of Sweet's syndrome in a child should always prompt a thorough evaluation to assess for an associated systemic disease.
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Affiliation(s)
- R C Brady
- Division of Pediatric Infectious Diseases, Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA
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Darben T, Savige J, Prentice R, Paspaliaris B, Chick J. Pyoderma gangrenosum with secondary pyarthrosis following propylthiouracil. Australas J Dermatol 1999; 40:144-6. [PMID: 10439526 DOI: 10.1046/j.1440-0960.1999.00346.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The association of pyoderma gangrenosum and arthritic symptoms is well documented. We present a rarely reported variant of this in a 44-year-old woman with pyoderma gangrenosum and bilateral large purulent effusions of her knees. She had no evidence of underlying rheumatoid arthritis or a specific seronegative spondyloarthropathy. Of note she had a history of Graves' disease for which she had been treated with propylthiouracil for 3 years and on investigation at this presentation had a markedly elevated perinuclear antineutrophil cytoplasm antibody (P-ANCA) level with specificities for IgM myeloperoxidase, IgG elastase and IgG lactoferrin. We believe this patient had pyoderma gangrenosum with secondary sterile pyarthrosis and a P-ANCA precipitated by propylthiouracil.
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Affiliation(s)
- T Darben
- Department of Dermatology, Royal Brisbane Hospital, Herston, Queensland, Australia
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Wilson DM, John GR, Callen JP. Peripheral ulcerative keratitis--an extracutaneous neutrophilic disorder: report of a patient with rheumatoid arthritis, pustular vasculitis, pyoderma gangrenosum, and Sweet's syndrome with an excellent response to cyclosporine therapy. J Am Acad Dermatol 1999; 40:331-4. [PMID: 10025862 DOI: 10.1016/s0190-9622(99)70479-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The term peripheral ulcerative keratitis represents a spectrum of inflammatory diseases, characterized by cellular infiltration, corneal thinning, and ulceration. Neutrophilic dermatoses are rarely associated with peripheral ulcerative keratitis. To date, peripheral ulcerative keratitis has only been reported in patients with pyoderma gangrenosum. Separate episodes of pyoderma gangrenosum, Sweet's syndrome, and pustular vasculitis developed in a 60-year-old patient with rheumatoid arthritis over an 8-year period. Over the past 2 years, 3 episodes of peripheral ulcerative keratitis occurred. Cyclosporine (4 mg/kg/d) treatment was started on confirmation of pyoderma gangrenosum. Over the ensuing 2 years, it became evident that the activity of her ocular and skin diseases, as well as her arthritis, paralleled the administration or cessation of cyclosporine therapy. Dermatologists should be aware of the association of Sweet's syndrome, pyoderma gangrenosum, and pustular vasculitis with peripheral ulcerative keratitis. This rare ocular manifestation and the serious sequelae when left untreated make recognition crucial. Cyclosporine proved to be a very effective treatment for all of our patient's diseases.
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Affiliation(s)
- D M Wilson
- Department of Medicine, University of Louisville School of Medicine, Kentucky, USA
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