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Gunawan H, Zulfan Z. Toxocariasis and Strongyloidiasis as Triggering Factors for Wells' Syndrome. Clin Cosmet Investig Dermatol 2024; 17:1687-1693. [PMID: 39071846 PMCID: PMC11277892 DOI: 10.2147/ccid.s464192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 07/14/2024] [Indexed: 07/30/2024]
Abstract
Wells' syndrome is a rare inflammatory skin disease characterized by pruritic erythematous lesions and cutaneous edema, often accompanied by eosinophilia. Parasitic infestations, such as toxocariasis and strongyloidiasis, can serve as triggers. However, Wells' syndrome associated with toxocariasis and strongyloidiasis has not been reported previously in Indonesia. Herein, we present a case of a 27-year-old male with a chief complaint of recurrent, pruritic, and painful erythematous rash on the right lower leg for 6 months, accompanied by fever and diarrhea. Physical examination showed cutaneous edema with erythematous macules and bullae on the affected leg. Peripheral blood eosinophilia was noted, and the histopathological analysis demonstrated flame figures, confirming the diagnosis of Wells' syndrome. A stool culture identified Strongyloides stercoralis, confirming strongyloidiasis, and serological testing was positive for toxocariasis immunoglobulin G antibodies. The patient was treated with albendazole 400 mg twice daily for 3 weeks resulted in clinical improvement observed by the 14th day. The diverse clinical features of Wells' syndrome present a challenge to clinicians in making an accurate diagnosis, which typically hinges on histopathological assessment and identifying flame figures. Therefore, clinicopathological correlation is important to establish an accurate diagnosis.
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Affiliation(s)
- Hendra Gunawan
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Zulfan Zulfan
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin Hospital, Bandung, Indonesia
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Cain CL, Bradley CW, Mauldin EA. Clinical and histologic features of acute-onset erythroderma in dogs with gastrointestinal disease: 18 cases (2005–2015). J Am Vet Med Assoc 2017; 251:1439-1449. [DOI: 10.2460/javma.251.12.1439] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Wells syndrome has been described as an inflammatory disorder based on typical clinical appearance combined with the histopathological presence of eosinophilic infiltrates and flame figures in the absence of vasculitis. Churg-Strauss syndrome, on the other hand, is primarily a diffuse, necrotizing vasculitis but is also typically displaying eosinophils and flame figures. Despite several parallels, the present understanding of these two diseases excludes any pathogenetic relationship. METHODS We describe the clinical course and histopathological appearance of three patients who had initially been diagnosed with Wells syndrome that developed into Churg-Strauss syndrome during the course of their disease. RESULTS The clinical presentation of all three patients led to the diagnosis of Wells syndrome by independent specialists. Histopathology showed an eosinophilic infiltrate and flame figures next to features of leukocytoclastic vasculitis. Detailed examination revealed asthma bronchiale and additional symptoms indicating Churg-Strauss syndrome. The initial diagnosis of Wells syndrome had to be revised to Churg-Strauss syndrome. CONCLUSION We conclude that Wells syndrome could be the starting point of a pathogenetic process that might reach its maximum in Churg-Strauss syndrome. As a clinical consequence, patients with Wells syndrome should be evaluated and followed for Churg-Strauss syndrome.
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Affiliation(s)
- Gudrun Ratzinger
- Department of Dermatology and Venereology, Medical University Innsbruck, Anichstrasse 35, Innsbruck, Austria.
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El-Khalawany M, Al-Mutairi N, Sultan M, Shaaban D. Eosinophilic annular erythema is a peculiar subtype in the spectrum of Wells syndrome: a multicentre long-term follow-up study. J Eur Acad Dermatol Venereol 2012; 27:973-9. [PMID: 22731886 DOI: 10.1111/j.1468-3083.2012.04616.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVE Eosinophilic annular erythema (EAE) was proposed to describe annular skin lesions associated with tissue eosinophilia, however, its relation to Well's syndrome (WS) remains a source of controversy. We studied a series of patients to increase awareness of this entity and to clarify its relation to WS. METHODS A multicentre study in which the clinical records, histological findings, laboratory results, therapeutic responses and follow-up of 10 patients were demonstrated. RESULTS The study included seven women and three men with age ranging from 31 to 54 years. The duration of the disease ranged from 3 to 28 months. All patients showed involvement of trunk and extremities. Early lesions were manifested as erythematous plaques, which progressed to well-developed figurate lesions and ended as large annular lesions with pigmented centre and elevated border. Flame figures were only observed in well-developed and long-standing lesions. Blood eosinophilia was found in all patients with different grades. Associated disorders included chronic gastritis, diabetes mellitus, chronic hepatitis-C virus infection and chronic kidney disease. The disease showed chronic course with high relapse rate and resistance to various therapeutic modalities including systemic steroid alone and in combination with hydroxychloroquine and cyclosporine. CONCLUSION We believe that EAE is a peculiar clinical variant in the spectrum of WS, which is characterized by a chronic course, resistance to treatment and high relapse rate. The diagnosis and evaluation of this condition need a close monitoring with repeated clinical, histological and laboratory assessment.
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Affiliation(s)
- M El-Khalawany
- Department of Dermatology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
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Cutaneous manifestations of human toxocariasis. J Am Acad Dermatol 2008; 59:1031-42. [DOI: 10.1016/j.jaad.2008.06.031] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 06/15/2008] [Accepted: 06/24/2008] [Indexed: 11/22/2022]
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Bassukas ID, Gaitanis G, Zioga A, Boboyianni C, Stergiopoulou C. Febrile "migrating" eosinophilic cellulitis with hepatosplenomegaly: adult toxocariasis - a case report. CASES JOURNAL 2008; 1:356. [PMID: 19038064 PMCID: PMC2621125 DOI: 10.1186/1757-1626-1-356] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Accepted: 11/28/2008] [Indexed: 11/22/2022]
Abstract
Background Eosinophilic cellulitis (Wells' syndrome) is a polyetiologic clinical entity with still obscure pathogenesis. Clinically overt toxocariasis is uncommon in adults, yet helminthozoonoses, including toxocariasis have been occasionally implicated in the pathogenesis of eosinophilic cellulitis. Case representation A 55-year-old female patient presented with a skin biopsy verified recurring febrile eosinophilic cellulitis, blood eosinophilia (42%), slight anaemia (Hct 35%), hepatosplenomegaly and positive specific anti-Toxocara canis antibodies. Toxocariasis-associated eosinophilic cellulitis was diagnosed. Already two weeks after treatment with thiabendazole the skin lesions resolved, T. canis antibody titre normalized eight months after treatment and no recurrences of eosinophilic cellulitis have been observed (for meanwhile three years). Conclusion The clinical characteristics (relapsing skin lesions, fever, hepatosplenomegaly), the laboratory features (blood eosinophilia, modest anemia, positive T. canis serology) and the clinical course after treatment, all support a causal relationship between Toxocara infection and the disease of this patient. We propose that in this context eosinophilic cellulitis must be interpreted as the leading symptom of a "skin-predominant" form of overt adult toxocariasis out of a spectrum of toxocariasis-associated febrile, "migrating-relapsing", organotropic eosinophilic inflammatory syndromes.
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Affiliation(s)
- Ioannis D Bassukas
- Dept, of Skin & Venereal Diseases, Univ, Ioannina Medical School and Univ, Hospital, Ioannina, Greece.
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Zeeli T, Feinmesser M, Segal R, David M. Insect-bite-like Wells' syndrome in association with mantle-zone lymphoma. Br J Dermatol 2007; 155:614-6. [PMID: 16911290 DOI: 10.1111/j.1365-2133.2006.07345.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Wells' syndrome is a multifaceted dermatosis with a wide morphological spectrum, ranging from characteristic cellulitis-like erythema and wheals to an unusual presentation of vesicles and bullae. We describe a patient in whom Wells' syndrome presented as an insect-bite-like eruption and was associated with underlying mantle-cell lymphoma. We recommend meticulous investigation of patients diagnosed with Wells' syndrome manifesting as an insect-bite-like eruption.
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Affiliation(s)
- T Zeeli
- Department of Dermatology, Rabin Medical Center, Beilinson Campus, Petah Tiqwa 49100, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Mauldin EA, Palmeiro BS, Goldschmidt MH, Morris DO. Comparison of clinical history and dermatologic findings in 29 dogs with severe eosinophilic dermatitis: a retrospective analysis. Vet Dermatol 2006; 17:338-47. [PMID: 16961820 DOI: 10.1111/j.1365-3164.2006.00538.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The medical records and histopathological sections of 29 dogs diagnosed with a unique eosinophilic dermatitis resembling Wells' syndrome were reviewed in an attempt to elucidate the pathogenesis of this syndrome. The medical records were reviewed for information on dermatological lesion appearance, systemic signs in other organ systems, clinical analyte abnormalities, and drug therapy. Histological sections of dogs with moderate to severe eosinophilic dermatitis without folliculitis and furunculosis were reviewed and evaluated for the presence of collagen flame figures. Three categories of patients were found. Category 1 consisted of 17 dogs treated for vomiting and/or diarrhoea (often haematochezia or haematemesis) prior (mean: 4.6 days) to the onset of skin lesions. Fourteen category 1 dogs had erythematous lesions (macules, papules or plaques) that were most pronounced on the abdomen. Sixteen of the 17 dogs received multiple classes of drugs, and 59% were hypoalbuminemic. Category 2 consisted of five dogs that had skin lesions and gastrointestinal signs at presentation and four of these dogs were hypoalbuminemic. Category 3 included seven dogs without enteric illness. A positive drug score was found in six category 1 dogs and one each from categories 2 and 3. Eighteen cases had eosinophilic dermatitis without flame figures, seven cases had early flame figures and four had well-developed flame figures. These changes did not correlate with the categories of clinical presentation. More than 50% of the dogs developed eosinophilic dermatitis following treatment for severe gastrointestinal disease. The authors propose that this represents a unique syndrome that may have causal drug association.
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Affiliation(s)
- Elizabeth A Mauldin
- Department of Clinical Studies, University of Pennsylvania, School of Veterinary Medicine, Philadelphia, Pennsylvania 19104-6051, USA.
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Affiliation(s)
- Paul B Bloom
- Allergy and Dermatology Clinic for Animals, 31205 Five Mile Road, Livonia, MI 48158, USA.
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Gilliam AE, Bruckner AL, Howard RM, Lee BP, Wu S, Frieden IJ. Bullous "cellulitis" with eosinophilia: case report and review of Wells' syndrome in childhood. Pediatrics 2005; 116:e149-55. [PMID: 15995016 DOI: 10.1542/peds.2004-2273] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 1-year-old girl presented with acute onset of edematous erythematous plaques associated with bullae on her extremities and accompanied by peripheral eosinophilia. She was afebrile, and the skin lesions were pruritic but not tender. The patient was treated with intravenously administered antibiotics for presumed cellulitis, without improvement. However, the lesions responded rapidly to systemic steroid therapy. On the basis of lesional morphologic features, peripheral eosinophilia, and cutaneous histopathologic features, a diagnosis of Wells' syndrome was made. Wells' syndrome is extremely rare in childhood, with 27 pediatric cases reported in the literature. Because it is seen so infrequently, there are no specific guidelines for evaluation and management of Wells' syndrome among children. The diagnosis should be considered for children with presumed cellulitis and eosinophilia who fail to respond to antibiotics. Evaluation should include a directed history, physical examination, complete blood count, and stool testing for ova and parasites, to identify potential triggers. Treatment is with systemic steroid therapy unless disease is limited, in which case medium/high-potency topical steroids may be indicated. If systemic features are prominent or disease is chronic (lasting >6 months), then a referral to hematology/oncology should be considered.
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Affiliation(s)
- Amy E Gilliam
- Department of Dermatology, University of California, 1701 Divisadero St, 3rd Floor, San Francisco, CA 94115, USA.
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Attout H, Séris P, Guez S, Seriès C. [Toxocariasis and cutaneous vasculitis]. Rev Med Interne 2004; 25:940-3. [PMID: 15582180 DOI: 10.1016/j.revmed.2004.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Accepted: 07/20/2004] [Indexed: 11/30/2022]
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Rossini MS, de Souza EM, Cintra ML, Pagnano KB, Chiari AC, Lorand-Metze I. Cutaneous adverse reaction to 2-chlorodeoxyadenosine with histological flame figures in patients with chronic lymphocytic leukaemia. J Eur Acad Dermatol Venereol 2004; 18:538-42. [PMID: 15324388 DOI: 10.1111/j.1468-3083.2004.00969.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION 2-Chlorodeoxyadenosine (cladribine or 2-CdA) is a purine analogue that has been used successfully in hairy cell leukaemia (HCL). Moreover, it has been increasingly used to treat chronic lymphoproliferative syndromes and paediatric acute myeloid leukaemia. Cutaneous side-effects associated with this drug have seldom been described in cases of HCL. PATIENTS AND METHODS We describe three patients with chronic lymphocytic leukaemia that presented generalized skin eruptions after treatment with 2-CdA. RESULTS All patients had advanced disease, receiving 2-CdA as a second or third line chemotherapy. Skin lesions were severe and chemotherapy had to be discontinued. Histological examination of skin biopsies showed an eosinophil-rich infiltrate with flame figures, similar to what is observed in Wells' syndrome (eosinophilic cellulitis). Corticosteroids were effective to control the eruptions. CONCLUSIONS Cutaneous adverse reactions associated with 2-CdA have seldom been observed in the treatment of HCL. However, as this purine analogue has been used in more advanced cases these may be more frequent and severe. The pathophysiology of these lesions is unclear, but it is probably related to drug-induced change in T-cell imbalance in severely immunosuppressed patients.
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Affiliation(s)
- M S Rossini
- Hematology-Hemotherapy Center, State University of Campinas, Sao Paulo, Brazil
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Abstract
A collagenolytic or necrobiotic non-infectious granuloma is one in which a granulomatous infiltrate develops around a central area of altered collagen and elastic fibers. The altered fibers lose their distinct boundaries and exhibit new staining patterns, becoming either more basophilic or eosinophilic. Within the area of altered collagen, there may be deposition of acellular substances such as mucin (blue) or fibrin (red), or there may be neutrophils with nuclear dust (blue), eosinophils (red), or flame figures (red). These color distinctions can be used as a simple algorithm for the diagnosis of collagenolytic granulomas, i.e. 'blue' granulomas vs. 'red' granulomas. Eight diagnoses are included within these two groupings, which are discussed in this two-part article. In the previously published first part, the clinical presentation, pathogenesis and histologic features of the 'blue' collagenolytic granulomas were discussed. These are the lesions of granuloma annulare, Wegener's granulomatosis, and rheumatoid vasculitis. In this second half of the series, the 'red' collagenolytic granulomas are discussed; these are the lesions of necrobiosis lipoidica, necrobiotic xanthogranuloma, rheumatoid nodules, Churg-Strauss syndrome, and eosinophilic cellulitis (Well's Syndrome).
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Affiliation(s)
- Jane M Lynch
- Departments of Dermatology and Pathology, Virginia Commonwealth University Medical Center, Richmond, VA, USA.
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Ludwig RJ, Grundmann-Kollmann M, Holtmeier W, Wolter M, Glas J, Podda M, Kaufmann R, Zollner TM. Herpes simplex virus type 2-associated eosinophilic cellulitis (Wells' syndrome). J Am Acad Dermatol 2003; 48:S60-1. [PMID: 12734477 DOI: 10.1067/mjd.2003.20] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Eosinophilic cellulitis (Wells' syndrome) is a recurrent inflammatory dermatosis characterized by massive infiltration of eosinophils into the skin. Drugs and pathogens have been recognized causes of eosinophilic cellulitis. We report the repeated association of eosinophilic cellulitis with herpes simplex virus type 2 infections. Antiviral therapy led to a complete remission of eosinophilic cellulitis, indicating that causative treatment of underlying diseases can be effective in controlling eosinophilic cellulitis.
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Affiliation(s)
- Ralf J Ludwig
- Department of Dermatology, University of Frankfurt, Frankfurt am Main, Germany
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Abstract
Wells' syndrome, or eosinophilic cellulitis, is characterized clinically by an acute dermatitis resembling cellulitis, which evolves into violaceous plaques that resolve spontaneously without scarring. The histopathologic features are dynamic, starting with dermal edema and infiltration of eosinophils, the development of "flame figures," and finishing with the appearance of phagocytic histiocytes. We present the clinical and histopathologic features of seven cases of eosinophilic cellulitis.
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Affiliation(s)
- Meena Moossavi
- Department of Dermatology, Wayne State University, Detroit, Michigan, USA
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Abstract
We present a 15-year-old girl who has had a persisting extensive annular erythematous eruption since birth. Otherwise, she is healthy and developmentally normal. Multiple investigations throughout the years have been normal or negative. Numerous treatments have been tried, but with little success. Both clinical and histological examination fit no known classification. It is most consistent with annular erythema of infancy but could be the first reported case of a new entity. A review of other causes of annular erythema in infancy is presented.
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Affiliation(s)
- Li-Chuen Wong
- Department of Dermatology, The Children's Hospital at Westmead, New South Wales, Australia.
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Canonne D, Dubost-Brama A, Segard M, Piette F, Delaporte E. Wells' syndrome associated with recurrent giardiasis. Br J Dermatol 2000; 143:425-7. [PMID: 10951158 DOI: 10.1046/j.1365-2133.2000.03675.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Wells' syndrome (WS) is a rare, recurrent, inflammatory dermatosis of uncertain pathogenesis, although a hypersensitivity response to different stimuli has been postulated. Several cases in association with parasitic infections have been described. We present a patient with WS associated with recurrent giardiasis. The course of the dermatosis was strictly related to the course of the parasitic infection. Both diseases disappeared with antiparasitic treatment. To our knowledge, this association is here reported for the first time.
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Affiliation(s)
- D Canonne
- Department of Dermatology, University Hospital, Lille, France
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