Sweet's syndrome: a review of current treatment options

A Rare Case of Drug-Induced Sweet Syndrome After Pembrolizumab Therapy

Sweet syndrome is an uncommon inflammatory disorder characterized by the abrupt appearance of painful, erythematous papules, plaques, or nodules on the skin. Fever and leukocytosis frequently accompany the cutaneous lesions. In addition, involvement of the eyes, musculoskeletal system, and internal organs may occur. Sweet syndrome has been associated with a broad range of disorders. There are three subtypes: classical Sweet syndrome, malignancy-associated Sweet syndrome, and drug-induced Sweet syndrome. Classical Sweet syndrome is not associated with malignancy or drugs. It is essentially associated with an upper respiratory infection, gastrointestinal infection, inflammatory bowel disease, and pregnancy. Malignancy-associated Sweet syndrome is associated with hematologic malignancy more than solid malignancy, most commonly with acute myeloid leukemia. Drug-induced Sweet syndrome usually develops approximately two weeks after drug exposure, in patients who lack a prior history of exposure to the inciting drug. Here we are discussing our patient, a 68-year-old male who presented eight weeks after starting chemotherapy with pemetrexed, carboplatin, and pembrolizumab for left lung adenocarcinoma with macular rash. On further investigation with biopsy was found to have neutrophilic dermatitis, hence being diagnosed with drug-induced Sweet syndrome. Histopathology revealed a dermis with infiltration of neutrophils with lekocytoclasia.

Sweet Syndrome and Neutrophilic Dermatosis of the Dorsal Hands

Sweet syndrome is a rare cutaneous condition with a broad clinical differential diagnosis. It can be classified into 3 subtypes: classic, malignancy-associated, and drug-induced. There are numerous associated disorders and provoking medications. Uncommonly, it can present as a multiorgan disease and cause significant morbidity. Systemic corticosteroids are the gold standard of treatment and yield rapid improvements in both lesions and symptoms. Nonsteroidal therapies may be effective alternatives, although high-quality comparative data are lacking. Some treatments for Sweet syndrome have paradoxically been implicated in the induction of disease.

Pulmonary coccidioidomycosis mimicking malignancy associated with Sweet's syndrome (acute febrile neutrophilic dermatosis)

A suspicious malignant lung nodule with cutaneous reaction is not always cancer, especially in low risk for malignancy patients. A lung biopsy should be taken into consideration. The associated cause of Sweet's syndrome directs the treatment in each patient.

An uncommon culprit of neutropenic fever: a case of Sweet syndrome following induction therapy for acute myeloid leukemia

Sweet syndrome (SS) is a rare inflammatory disorder characterized by the rapid onset of a characteristically tender rash, fever, and other systemic symptoms. These manifestations are often mistaken for an infection that is not responding to antimicrobials, especially in immunocompromised hosts. We present the case of a 44-year-old woman who developed SS following induction chemotherapy for newly diagnosed acute myeloid leukemia (AML). She exhibited a painful rash on the anterior chest, which spread centrifugally, along with neutropenic fever unresponsive to broad-spectrum antimicrobials. Biopsy of the rash revealed a dense neutrophilic infiltrate within the dermis, confirming the diagnosis of SS. The patient was subsequently treated with systemic steroids with prompt resolution of fevers and improvement of her rash. This case highlights that SS can manifest with a robust neutrophilic infiltrate, even in the context of neutropenia stemming from chemotherapy. SS serves as a crucial consideration in hematologic malignancies, particularly AML, when patients present with fever and cutaneous eruptions. Prompt recognition followed by systemic steroid therapy often leads to symptom resolution.

A Not-So-Sweet Syndrome: A Case Report of a Male Presenting With Acute Febrile Neutrophilic Dermatosis

Physicians often encounter patients who present with a chief complaint of skin changes or lesions in both acute and primary care settings. Early initiation of appropriate treatment and pharmacotherapy in patients who present with rash is crucial to prevent decompensation, morbidity, and further downstream utilization of hospital resources. Acute febrile neutrophilic dermatosis, more commonly known as Sweet syndrome, is a rare and highly symptomatic inflammatory skin condition. Early recognition of Sweet syndrome is important as it requires specific treatment considerations and often can be a sign of an underlying pro-inflammatory condition, malignancy, or reaction to new medication that must be identified. This article discusses the presentation and management of a 50-year-old male who presented with a classic presentation of Sweet syndrome.

Unique challenges to diagnosing sweet syndrome following induction chemotherapy for relapsed Acute Myeloid Leukemia (AML): A case and brief-review

Background

Sweet Syndrome (SS) is a rare inflammatory skin condition characterized by the sudden appearance of tender, erythematous or violaceous papules, plaques, and nodules typically found on the face, neck, shoulder, upper extremities, and trunk. Often, SS is difficult to diagnose because of its various non-specific manifestations, including fever, arthralgia, myalgia and ocular involvement. In most cases described in literature, cutaneous and pulmonary symptoms of SS present in a concomitant manner. Several reported cases of pulmonary SS have shown that if left untreated, acute respiratory distress syndrome can ensue and progress to fatal respiratory failure.

Case report

A 58-year-old female with acute myeloid leukemia (AML) secondary to chronic lymphocytic leukemia (CLL) presented with new nodular lesions, dyspnea, and fevers. Chest X-ray revealed pulmonary infiltrates. The patient developed new facial lesions and worsening hypoxic respiratory failure. Further infectious workup was negative. She was found to have SS with pulmonary involvement and initiated on high-dose intravenous (IV) steroids with marked clinical improvement.

Conclusions

Major and minor criteria for the diagnosis of lung-associated SS should be carefully evaluated, especially when a biopsy is unavailable. The following case report describes the clinical course and outcomes from treatment for this patient.

Dermatologic complications in transplantation and cellular therapy for acute leukemia

Adoptive cellular immunotherapy, mainly hematopoietic stem cell transplant and CAR-T cell therapy have revolutionized treatment of patients with acute leukemia. Indications and inclusion criteria for these treatments have expanded in recent years. While these therapies are associated with significant improvements in disease response and overall survival, patients may experience adverse events from associated chemotherapy conditioning, engraftment, cytokine storm, supportive medications, and post-transplant maintenance targeted therapies. Supportive oncodermatology is a growing specialty to manage cutaneous toxicities resulting from the anti-cancer therapies. In this review, we summarize diagnosis and management of the common cutaneous adverse events including drug eruptions, graft-versus-host disease, neoplastic and paraneoplastic complications in patients undergoing cellular therapies.

Sweet syndrome unresponsive to corticosteroid therapy managed with ayurveda medication: A case report

BACKGROUND

Sweet syndrome (SS) is characterized by sudden appearance of multiple, painful erythematous, papular-nodular skin lesions accompanied by a fever and myalgia. SS resembles Visphota (Bullous eruption disorders) in Ayurveda. SS is a scarcerare skin condition, and Ayurvedic management of this condition is not reported. Therefore, this case report is prepared after taking informed consent from the patient.

CASE PRESENTATION

A 34-year-old male patient presented with a complaint of the appearance of multiple blisters over the upper and lower extremities, forehead, and chest with mild fever, congestion of the eye, joint pain, and muscular stiffness for the last two weeks. He has been on oral prednisolone for ten weeks by a dermatologist. The patient has no history of taking drugs in the previous four months before the onset of the skin lesions. The patient was prescribed Nagaradi Kasya (Amrttam Kasaya), Siddha Makardwaja (Plain), Kaisara Guggulu (KG), Ashwagandha ghana vati, and Avipatikar Churna in recommended dose for two weeks. Fifty percentage lesions disappear along systemic symptoms within seven days and complete remission of lesions in fifteen days. The medication was stopped after fifteen days and observed for one year. There is a significant reduction of inflammatory markers like-erythrocyte sedimentation rate (ESR), Total Leucocyte Count (TLC), and C Reactive protein (CRP) after the treatment compared to the baseline also.

CONCLUSION

Ayurvedic modalities may be a better treatment option in rare skin conditions like sweet syndrome, where corticosteroid usage failed to improve. More evidence of the usefulness of the Ayurvedic therapeutic approach must be gathered.

Dermatological manifestations of hematologic neoplasms. Part II: nonspecific skin lesions/paraneoplastic diseases

Cutaneous manifestations occur in the course of hematologic malignancies and precede, accompany or occur late in relation to the diagnosis. They result from paraneoplastic phenomena, tumor infiltrations, immunosuppression resulting from the hematologic disease itself or its treatment. The dermatologist must be aware of these conditions that may be helpful both in the diagnosis of the underlying disease and in reducing patient morbidity. This review (part II) addresses the paraneoplastic dermatological changes associated with systemic hematologic malignancies.

Neutrophilic dermatoses

Neutrophilic dermatoses (ND) are a group of inflammatory skin conditions characterized by a neutrophilic infiltrate on histopathology with no evidence of infection. ND are classified based upon the localization of neutrophils within the skin and clinical features. Recent findings suggest that ND are due to two main mechanisms: i) a polyclonal hereditary activation of the innate immune system (polygenic or monogenic); or ii) a clonal somatic activation of myeloid cells such as encountered in myelodysplastic syndrome or VEXAS syndrome. ND belong to internal medicine as a great number of patients with ND suffer from an underlying condition (such as hematological malignancy, inflammatory bowel disease, auto-immune and auto-inflammatory diseases). ND are diagnoses of exclusion and physicians should always consider differential diagnoses, particularly skin infections. Here, we review the pathophysiology and classification of the main ND (i.e., subcorneal pustular dermatosis (Sneddon-Wilkinson Disease) and Intercellular IgA dermatoses, aseptic pustulosis of the folds, Sweet syndrome, neutrophilic eccrine hidradenitis, pyoderma gangrenosum, erythema elevatum diutinum, neutrophilic urticarial dermatosis and neutrophilic panniculitis), their clinical and histopathological features, and we highlight the investigations that are useful to identify ND-associated diseases and to exclude the differential diagnoses.

New Practical Aspects of Sweet Syndrome

Sweet syndrome (SS), or acute febrile neutrophilic dermatosis, is an inflammatory, non-infectious skin reaction characterized clinically by tender, erythematous papules/plaques/pustules/nodules commonly appearing on the upper limbs, trunk, and head and neck; histologically, SS is characterized by dense neutrophilic infiltrate in the dermis. SS is accompanied by fever; an elevation of inflammatory markers (e.g., erythrocyte sedimentation rate, C reactive protein) in serum may also be observed. Although most cases of SS are idiopathic, SS also occurs in the setting of malignancy or following administration of an associated drug. SS has also been reported in association with pregnancy and a burgeoning list of infectious (most commonly upper respiratory tract infections) and inflammatory diseases; likewise, the litany of possible iatrogenic triggers has also grown. Over the past several years, a wider spectrum of SS presentation has been realized, with several reports highlighting novel clinical and histological variants. Corticosteroids continue to be efficacious first-line therapy for the majority of patients with SS, although novel steroid-sparing agents have been recently added to the therapeutic armamentarium against refractory SS. New mechanisms of SS induction have also been recognized, although the precise etiology of SS still remains elusive. Here, we catalogue the various clinical and histological presentations of SS, summarize recently reported disease associations and iatrogenic triggers, and review treatment options. We also attempt to frame the findings of this review in the context of established and emerging paradigms of SS pathogenesis.

A Rare Case of Midostaurin-Associated Sweet’s Syndrome

Acute febrile neutrophilic dermatosis which is referred as Sweet's syndrome (SS) is a dermatological condition characterized by fever, erythematous rash, and leukocytosis. SS can be idiopathic or associated with malignancies or medications. We present a rare case of SS which developed shortly after starting midostaurin in a patient with acute myelogenous leukemia (AML).

Cutaneous Manifestations of Inflammatory Bowel Disease: A Basic Overview

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal (GI) tract that is subdivided into Crohn's disease (CD) and ulcerative colitis (UC). CD is characterized by involvement of the entire GI tract, while UC mainly affects the distal GI tract. Moreover, both CD and UC can present with extraintestinal manifestations (EIMs) of the disease affecting multiple organ systems including the hepatobiliary tract, kidney, bones, eyes, joints, and skin. These complications can cause significant morbidity and negatively impact the quality of life for IBD patients. Although the pathogenesis of EIMs is not clearly elucidated, it is postulated that the diseased GI mucosa similarly stimulates excess immune responses at the extraintestinal sites. Cutaneous EIMs occur in up to 15% of patients with IBD, often predating their IBD diagnosis. They are categorized into (1) specific, (2) reactive, (3) associated, and (4) treatment-induced. Here, we review the epidemiological, clinical, diagnostic, and histologic features of the most commonly described cutaneous EIMs of IBD along with their respective treatment options.

Cutaneous manifestations of monoclonal gammopathy

Monoclonal gammopathy associated with dermatological manifestations are a well-recognized complication. These skin disorders can be associated with infiltration and proliferation of a malignant plasma cells or by a deposition of the monoclonal immunoglobulin in a nonmalignant monoclonal gammopathy. These disorders include POEMS syndrome, light chain amyloidosis, Schnitzler syndrome, scleromyxedema and TEMPI syndrome. This article provides a review of clinical manifestations, diagnostics criteria, natural evolution, pathogenesis, and treatment of these cutaneous manifestations.

Sweet's Syndrome: A Case Report of a Rare Extraintestinal Manifestation of Ulcerative Colitis

Sweet’s syndrome is a neutrophilic dermatosis of unknown etiology and a rare extraintestinal manifestation of ulcerative colitis.

Classically, it is more common in women with active inflammatory bowel disease (IBD). This syndrome typically presents in patients with acute-onset painful tender erythematous skin lesions and is usually accompanied by fever, arthralgia, and elevated inflammatory markers. Histological examination is characterized by diffuse dense dermal neutrophilic infiltrate with leukocytoclasia, without vasculitis.

The treatment goals are to reduce morbidity and complications, and the most effective therapy is systemic corticosteroids. Early recognition of this syndrome is essential to improve our diagnostic and therapeutic abilities.

We report a case of a 59-year-old female with ulcerative colitis, which presented with manifestations of Sweet’s syndrome.

Not So Sweet Sweet’s Syndrome: A Case of Acute Febrile Neutrophilic Dermatosis in the Treatment of Ovarian Carcinoma

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Sweet’s Syndrome presents with dermal lesions, pyrexia, and specific histology.

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This case exemplifies the drug-induced sub-type of Sweet’s Syndrome.

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Sweet’s Syndrome has rarely been discussed in context of gynecologic malignancies.

Background

Acute febrile neutrophilic dermatosis, or Sweet’s Syndrome (SS), was first characterized by Dr. Robert Sweet in 1964 with eight cases of fever, neutrophilic polymorphonuclear leukocytosis, dermatological lesions, and histological evidence of dense dermal infiltration by mature neutrophils. SS presents in three settings: idiopathic, malignancy-associated, and drug-induced. In 1996, Walker and Cohen outlined the current diagnostic criteria for drug-induced SS with abrupt onset of painful lesions, dermal histology showing dense neutrophilic infiltrate, pyrexia > 38 °C, temporal relationship of drug administration to clinical presentation, and symptom resolution following drug withdrawal or systemic corticosteroid treatment. SS has rarely been reported in association with gynecologic malignancies.

Method

Case Report.

Case

A 41-year-old female receiving neoadjuvant chemotherapy for advanced high-grade serous ovarian carcinoma presented for evaluation of cyclic fevers with dermatologic lesions following treatment with Carboplatin and Taxol, with Pegfilgrastim. On days 11–17 of treatment she reported fevers ranging from 101°F-104°F (38 °C- 40 °C) with subsequent eruption of truncal erythematous, pustular, and painful coalescing plaques. Lesion biopsies confirmed histologic presence of dense neutrophilic infiltration. The patient was initiated on oral corticosteroid therapy with symptom improvement.

Discussion

This case represents an example of SS in a patient receiving therapy with the most commonly implicated medication class, granulocyte colony-stimulating factor (GCSF). In drug-induced SS, there’s often a temporal relationship between medication administration and symptom development. In this case, all criteria for drug-induced SS were met with a GCS-F as the likely causative agent. This case illustrates a rare diagnosis in the context of gynecologic cancer treatment and will expand available reports of SS in the Gynecologic Oncology literature. We hope to elicit more prompt recognition and diagnosis of SS from practitioners to minimize patient morbidity and long-term sequelae.

Sweet's Syndrome: An Update

Sweet's syndrome is a serious dermatological disorder characterized by a rapid onset of tender plaques or nodules, fever, joint pain, headache, and oral and genital lesions. According to the clinical features and underlying causes, Sweet's syndrome is divided into three categories, i.e., classical (or idiopathic), malignancy-associated Sweet's syndrome, and drug-induced Sweet's syndrome. It is multifactorial in etiology, and the exact cause is still undetermined. The diagnosis can be confirmed by the routine histopathologic evaluation of skin biopsy from the lesions. The first-line treatment options are topical and systemic steroids. Multiple databases, like Medline/PubMed, Scopus, and Google, were used to identify resources for this literature review. The relevant information was collected from various case reports, case series, reviews, meta-analyses, and large clinical trials reporting clinical description, etiology, diagnosis, and management of Sweet's syndrome. This narrative review aimed to discuss recent understandings related to Sweet's syndrome, both in terms of clinical presentation and management approach.

Multiple painful plaques and the Sweet's syndrome

We present a rare case of Sweet's syndrome. A 39-year-old woman with subjective fevers, polyarthralgia, and malaise presented with worsening painful erythematous plaques on the trunk, arms, and legs. Further examination with biopsy revealed a diagnosis of acute febrile neutrophilic dermatosis, or Sweet's syndrome. Diagnosis by skin biopsy is crucial, and onset requires prompt evaluation for serious associated disorders such as leukemias, inflammatory bowel disease, thyroid disease, sarcoidosis, and infectious etiologies. In general, symptoms and cutaneous manifestations of Sweet syndrome respond rapidly to treatment with systemic corticosteroids or potassium iodide.

Sweet syndrome after Oxford-AstraZeneca COVID-19 vaccine (AZD1222) in an elderly female

Vaccination for COVID19 infection is in full swing all around the world and while the vaccines are considered overall safe, many cutaneous and extracutaneous adverse effects have been reported after their use. Local injection-site reactions are the commonest adverse effect described with the use of these vaccines. We describe a case of Sweet syndrome in an elderly female after the first dose of Oxford-AstraZeneca COVID-19 vaccine (AZD1222).

Necrotising Sweet's syndrome: a rare presentation of Sweet's syndrome with unilateral painful swelling of the neck

This case describes the first documented clinical presentation of Sweet's syndrome with unilateral swelling of the neck, severe pain and fever. The clinical and radiological manifestation resembled necrotising fasciitis and the patient underwent acute neck dissection. The patient was ultimately diagnosed with a new subtype of Sweet's syndrome called necrotising Sweet's syndrome, and quickly recovered after treatment with intravenous administration of prednisolone.

Diagnosis of Sweet's syndrome in otolaryngology

Sweet's syndrome (acute febrile neutrophilic dermatosis) consists of acute onset of painful cutaneous erythematous lesions, mostly found in the upper extremities followed by the head and neck region, particularly in patients with underlying malignancies. We describe the case of a woman in her mid-30s, who was treated for acute myeloid leukaemia and presented with a severe painful and progressive erythematous lesion of the retroauricular skin. Clinical features, laboratory tests, blood cultures and histological biopsy yielded a diagnosis of Sweet's syndrome. The treatment consisted of oral and topical corticosteroids and her signs and symptoms resolved within 1 week. Although Sweet's syndrome is uncommon, awareness among otolaryngologists is crucial to ensure a prompt diagnosis, cure and referral to an oncologist (if not already involved) for patients with Sweet's syndrome in the head and neck area.

Midostaurin-induced Sweet syndrome in a patient with FLT3-ITD-positive AML

Sweet syndrome (SS), also referred as acute febrile neutrophilic dermatosis, is an inflammatory process characterised by the abrupt appearance of erythematous papules or nodules with predominant neutrophilic infiltration in the dermis. Fever and neutrophilia are common presenting features. However, extracellular manifestations, including ocular and musculoskeletal, may occur. SS is divided into three subtypes: classical (or idiopathic), malignancy associated and drug induced. Medication-induced subtype accounts for up to 26% of cases. In recent years, emerging evidence has showed that SS may also occur in neutropenic patients who underwent induction for acute myeloid leukemia (AML). The identification of FMS-like tyrosine kinase 3 (FLT3) gene mutation in approximately 30% of patients with AML has promoted the targeted therapy with FLT3-internal tandem duplication (ITD) inhibitors. Midostaurin, a recently Food and Drug Administration-approved medication for FLT3-ITD-positive AML, was reported once as cause for SS. We report a midostaurin-induced SS with neutropenia in a patient following induction chemotherapy of AML.

Colchicine in coronary artery disease

Coronary artery disease (CAD) is a major cause of morbidity and mortality worldwide. Inflammation has been seen to be a key feature of atherosclerosis and CAD, with a raised C-reactive protein being a marker of poor prognosis. Thus, the role of anti-inflammatory agents has been investigated in CAD. Colchicine is a well-known, inexpensive drug with marked anti-inflammatory effects. Here, we discuss the role of colchicine in stable CAD and post-acute coronary syndrome. We suggest that colchicine may play a key role in prevention of cardiovascular events in patients with stable and unstable CAD as colchicine is associated with a reduction in the rate of myocardial infarction and other major cardiovascular outcomes.

Sweet syndrome as an adverse reaction to tyrosine kinase inhibitors: A review

Tyrosine kinase inhibitors are a class of targeted anticancer drugs that inhibit cancer cell proliferation by inactivating proteins involved in signal transduction cascades. Various cutaneous adverse events have been observed after tyrosine kinase inhibitor administration, including Sweet syndrome. We queried the PubMed database to identify 14 cases of Sweet syndrome thought to be secondary to tyrosine kinase inhibitors. Tyrosine kinase inhibitor-induced Sweet syndrome had a median of 2 months latency following drug administration. All cases but one had morphologic features classic for Sweet syndrome (erythematous and tender papules, plaques, or nodules). All cases also had classic histopathologic findings (dermal neutrophilic infiltrate without vasculitis or necrosis). Using diagnostic criteria for drug-induced Sweet syndrome and the Naranjo Drug Reaction Probability Scale for a drug-induced cutaneous eruption, we found that six cases favored a drug-induced etiology over malignancy, two cases favored a malignancy-associated Sweet syndrome, and the remaining eight met drug-induced Sweet syndrome criteria but had low Naranjo scores. Nine cases resulted in medication discontinuation, while five cases continued anticancer therapy and were treated only with corticosteroids with quick resolution of skin lesions. Dermatologists should be aware of this adverse cutaneous reaction to tyrosine kinase inhibitors and should treat on a case-by-case basis, though limited evidence in this review suggests that oncologic therapy may safely be continued with prompt corticosteroid treatment.

Sweet's syndrome associated with hematological malignancies

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.

Neutrophilic drug reactions

Neutrophilic drug reactions are unique eruptions that can affect hospitalized patients and share a common pathophysiology with neutrophils as the key mediators of inflammation. They range in clinical presentation from papules and plaques to bullae and erosions to pustules. Although there is some overlap in presentation, each has distinguishing features that aid the clinician in differentiation from one another and from other drug hypersensitivity reactions. Much of the data on these reactions are from case reports and series or retrospective review studies. There are limited prospective observational studies dedicated to these adverse drug reactions. We review the more common and life-threatening neutrophilic drug reactions, their proposed mechanism of action, and their management.

Giant cellulitis-like Sweet syndrome: An underrecognized clinical variant mimicking skin and soft tissue infection

A new clinical variant of Sweet syndrome, called giant cellulitis-like Sweet syndrome, can masquerade as cellulitis because the patients present with an acute onset of large erythematous plaques, fever, and leukocytosis with neutrophil predominance. This case describes a 90-year-old female with a history of invasive ductal carcinoma of the breast who presented with 3 days of erythema of the right chest and right leg. Physical examination was notable for well-demarcated, blanching erythematous rashes involving the right chest and right lower extremity. Laboratory data was notable for neutrophilic leukocytosis. A clinical diagnosis of cellulitis was made initially, and intravenous cefazolin was initiated. The rash had only partially improved with antibiotics. Skin biopsy revealed a dense neutrophilic infiltrate, which was consistent with Sweet syndrome. Based on the widespread plaques, this case was considered a “giant cellulitis-like” variant of Sweet syndrome. Clinicians should have a high index of suspicion for Sweet syndrome when assessing a patient with fever, neutrophilia and erythematous skin plaques atypical of cellulitis because this condition does not respond to antimicrobial therapy and requires systemic glucocorticoid therapy.

[Neutrophilic and pustular dermatoses : New autoinflammatory diseases and syndromes]

This article reviews noninfectious inflammatory dermatoses with mainly neutrophilic infiltrates and the formation of pustules. The infiltrate containing neutrophils may either be mild as in urticaria or very dense, even with leukocytoclasia, as in Sweet syndrome or pyoderma gangrenosum. Neutrophilic infiltrates and pustular eruptions are caused by different noninfectious immunomechanisms. For some of them, mutations have been found (e.g. NLRC4 mutation in cryopyrin-associated periodic syndromes (CAPS) leading to activation of the inflammasome; IL36RN mutation in pustular psoriasis resulting in uncontrolled IL36 signaling). Neutrophilic dermatoses are of high interest, as they may be the cause of underlying benign or malignant conditions. In recent years, efficient targeted therapies have been developed.

Sweet syndrome in a patient with Hidradenitis Suppurativa

Neutrophilic Dermatoses should be considered in the differential diagnosis, if a patient with abrupt onset of painful erythematous plaques/nodules and elevated erythrocyte sedimentation rate is not responding to antibiotics.

Recurrent Idiopathic Sweet Syndrome - Case Report and Literature Review

INTRODUCTION

Sweet syndrome (SS), also denominated as acute febrile neutrophilic dermatosis, is a rare disease characterized by the sudden onset of painful, erythematous, firm skin lesions (papules, plaques, and nodules) which show, upon histologic examination, the presence of a diffuse infiltrate of mature neutrophils. The cutaneous manifestation typically involves the face, neck, trunk, and upper limbs and is associated with fever, general malaise, arthralgia.

CASE REPORT

A female patient, 60 years old, attended the Dermatology Clinic due to the appearance of violaceous erythematous-oedematous infiltrated plaques, located on the face, neck, upper limbs, trunk and knees. The onset of the cutaneous manifestation had occurred 2 months prior, accompanied by pain, chills, flares of fever and arthralgia. The onset coincided with the surgical treatment of an umbilical hernia. From the medical history we note that the patient was diagnosed in 2014 with histiocytoid SS. She followed a treatment with methylprednisolone, with positive response, but had many relapses after the discontinuation of treatment. In 2017, due to a new episode, the histopathological examination was repeated, which revealed classical SS. She received treatment with Disulone and Colchicine. She had not been administered any treatment throughout the previous year. Laboratory tests revealed leukocytosis with neutrophils, increased ESR, elevated C4, hyperglycemia. The current histopathological examination revealed lymphocytic SS. Under treatment with methylprednisolone 32mg/day, the evolution was favorable.

DISCUSSIONS

The first case of SS was described by Robert Douglas Sweet in 1964. As known aetiological factors there have been described gastrointestinal and urinary tract infections, pregnancy, inflammatory bowel disease, drugs or malignancies. There have been described cases of SS that appeared after surgical treatment, as in our case, which registered a new outbreak following the umbilical hernia treatment. The histopathological variants of SS described in the literature are: subcutaneous, eosinophilic, histiocytoid, lymphocytic type. The first line-therapy consists in systemic corticosteroids, which induce a fast remission of lesions and general symptoms. Recurrence may occur in approximately 50% of patients and is common in idiopathic or paraneoplastic cases.

CONCLUSIONS

In addition to the neutrophilic infiltrate that is typical for Sweet syndrome, different types of histological manifestations have been described in the literature: subcutaneous, eosinophilic, histiocytoid, lymphocytic. In our case, we noted that the histological profile changed over time, from a histiocytoid SS recorded in 2014, to a classical SS in 2017, followed by the appearance of lymphocytic SS in 2019. Due to the fact that SS can be associated with a numerous other disorders, our patient requires regular monitoring with a view to eliminate them, and potentially to make a diagnosis and initiate early specific treatment.

Allergic and Immunologic Perspectives of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic immune-mediated inflammatory condition primarily involving the gastrointestinal tract. It includes Crohn's disease (CD), ulcerative colitis (UC), and a less common phenotype-indeterminate colitis. It is thought to result from a complex interplay of environmental, microbial, and host factors including genetic factors, although the exact mechanism is not known. Dietary factors have been shown to play a role in the pathogenesis of IBD and can potentially alter the intestinal microbiota as well as disrupt the immune function in the gut. CD is characterized by transmural inflammation, sometimes associated with granulomatous lesions, and involves the entire gastrointestinal tract but often spares the rectum. UC is characterized by mucosal inflammation typically confined to the colon and rectum. Although IBD is mostly seen in western world, recent data suggests that the incidence and prevalence are increasing worldwide. Enteral nutrition has been shown to be effective in inducing remission in pediatric population with CD; however, there is mixed data in adult population. Nutritional deficiencies such as vitamin D and zinc deficiency are often noted in IBD patients. Several extraintestinal manifestations are noted in patients with IBD. Some of them parallel with the disease activity and others are independent of the disease course. Assessment of IBD disease activity clinically, radiologically, if indicated, biochemically and endoscopically is important to guide therapy in IBD. To ensure comprehensive care, it is important to assess associated conditions such as nutritional and psychological well-being, as well as age appropriate health maintenance status prior to starting treatment for IBD. Several biologic agents including anti-tumor necrosis factor alpha (anti-TNF-α) drugs, anti-integrins, and antibodies to the p40 subunit of IL12/23 are approved for induction and maintenance of remission of IBD. Steroids are also often used for induction. Anti-metabolites and thiopurines are also useful either as monotherapy or in combination regimens. Potential side effects of anti-TNF-α drugs such as serious infections, malignancy, worsening of heart failure, and infusion-related reactions should be considered prior to starting these drugs. Anti-TNF-α drugs with or without immunomodulators (azathioprine, 6-mercaptopurine, methotrexate) are often used for the induction and maintenance of remission. Treating to target of endoscopic and clinical remission provides the best long-term outcomes. Our knowledge and understanding of IBD has grown significantly. However, there are several unanswered questions on pathogenesis, disease behavior, and drivers of inflammation in various patient subgroups which require further research.

Recurrent soft tissue inflammation, necrotizing fascitis or Sweet syndrome, diagnostic dilemma

Necrotizing Sweet syndrome is a recently described entity that can pose significant challenges for management. Although necrotizing fasciitis can be rapidly fatal in the absence of prompt surgical management, necrotizing Sweet syndrome may actually be worsened by any surgical intervention. Authors want to emphasize and increase awareness of this rare presentation.

Insights Into the Pathogenesis of Sweet's Syndrome

Sweet's syndrome, also known as Acute Febrile Neutrophilic Dermatosis, is a rare inflammatory condition. It is considered to be the prototype disease of neutrophilic dermatoses, and presents with acute onset dermal neutrophilic lesions, leukocytosis, and pyrexia. Several variants have been described both clinically and histopathologically. Classifications include classic Sweet's syndrome, malignancy associated, and drug induced. The cellular and molecular mechanisms involved in Sweet's syndrome have been difficult to elucidate due to the large variety of conditions leading to a common clinical presentation. The exact pathogenesis of Sweet's syndrome is unclear; however, new discoveries have shed light on the role of inflammatory signaling, disease induction, and relationship with malignancy. These findings include an improved understanding of inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic contributions. Continued investigations into effective treatments and targeted therapy will benefit patients and improve our molecular understanding of inflammatory diseases, including Sweet's syndrome.

An atypical presentation of Sweet's syndrome in a myelofibrosis patient

A 46-year-old man with no significant medical history presented to haematology with symptoms of fatigue, dyspnoea on exertion and weight loss. Physical examination revealed a lesion on the right shin and splenomegaly. Labs were significant for leucocytosis with immature components, thrombocytosis and 3% peripheral blasts on smear. A bone marrow biopsy confirmed a diagnosis of myelofibrosis (MF). Dynamic International Prognosis Scoring system was 2. He was started on ruxolitnib, with decitabine added subsequently prior to definitive therapy with an allogenic haematopoietic stem cell transplant. His course with decitabine was complicated with febrile neutropaenia with multiple tender erythematous plaques unresponsive to antibacterial and antifungal coverage. A skin biopsy showed neutrophilic dermatitis, consistent with a diagnosis of Sweet's syndrome (SS) and empirical treatment with glucocorticoids was initiated resulting in resolution of symptoms. This report reviews the literature for cases of SS in the setting of MF.

Recurrent Sweet's syndrome in a patient with multiple myeloma

We report on a case of Sweet's syndrome associated with multiple myeloma, as harbinger for disease relapse.

Neutrophilic dermatoses: Pathogenesis, Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease

Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The first article in this continuing medical education series explores the pathogenesis of neutrophilic dermatoses and reviews the epidemiology, clinical and histopathologic features, diagnosis, and management of Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease.

Potassium iodide in refractory, recurrent pediatric Sweet syndrome: Guidance in dosing and monitoring

We describe a 5-month-old boy with clinical and histopathologic presentation of Sweet syndrome. He responded to systemic corticosteroids, with multiple flares on tapering; potassium iodide was added, which provided complete resolution of Sweet syndrome. Potassium iodide has been used in only a few cases, and no standard dosage has been established in children. We discuss calculation of a pediatric dosage for potassium iodide in Sweet syndrome.

A Sweet Case of Mycoplasma

Sweet syndrome, also known as acute febrile neutrophilic dermatosis, is an uncommon inflammatory disorder marked by fever and swelling of the skin that can be very painful. It is especially rare in the pediatric population. Infection is a well-known trigger for Sweet syndrome, but this entity has, to our knowledge, never been described after Mycoplasma infection. Herein, we describe the first pediatric case of febrile neutrophilic dermatosis associated with Mycoplasma infection.

Sweet's syndrome in a patient with chronic lymphocytic leukaemia

Bullous Sweet's syndrome is a rare variant of the inflammatory neutrophilic dermatosis characterised by painful bullous skin lesions, fever, leukocytosis and a neutrophilic infiltrate of the dermis. The condition may be classified according to aetiology into classical (idiopathic), malignancy-associated and drug-induced. Neutrophilic infiltration occurs in response to a systemic insult. A punch biopsy for histology and culture is necessary due to its close resemblance to infection. Characteristic histology features a dense infiltration of neutrophils in the upper and mid dermis, oedema in the superficial dermis and endothelial swelling. Treatment with systemic glucocorticosteroids typically results in a dramatic clinical response. This case report illustrates a rare case of bullous Sweet syndrome associated with chronic lymphocytic leukaemia in a 53-year-old man.

Sweet syndrome presenting as a febrile rash in a returning traveller

Sweet syndrome was discovered in 1964 and is now well described in the dermatology literature. Knowledge of this unique febrile and painful dermatosis is important for the emergency physician because the syndrome can be readily identified and is extremely responsive to oral steroid therapy. Early diagnosis can greatly improve patient satisfaction and avoid days of ineffective treatment. An accurate and timely diagnosis of Sweet syndrome is also important to guide investigation into a number of associated diseases.

Sweet Syndrome: Clinical Features, Histopathology, and Associations of 83 Cases

BACKGROUND

Sweet syndrome (SS) is an infrequent skin disease characterised by sudden onset of fever, leukocytosis, neutrophilia, and tender erythematous plaques infiltrated by neutrophils. Multiple conditions have been associated with this syndrome.

OBJECTIVES

The aim of this study was to evaluate the clinical, epidemiological, laboratory, and histopathological findings and associations of patients with SS.

METHODS

We conducted a retrospective study of 83 patients with SS followed between January 1, 2006, and January 31, 2015.

RESULTS

Of the patients, 82% were female; the mean age at onset was 48 years. Clinical presentation was mainly characterised by erythematous and edematous plaques, mostly on upper extremities and trunk. Fever was observed in 32%; 60% presented leukocytosis and 39% neutrophilia. On histopathological examination, neutrophilic and lymphohistiocytic infiltrate and edema were the most frequent findings. Fourteen percent of patients had malignancy or hematologic disorders, 26% were classified as having drug-induced SS, and 24% noted recent infection. Only 2 cases occurred during pregnancy. Systemic corticosteroid was the most common choice of treatment, with excellent response. In malignancy-associated SS, the mean hemoglobin level was lower ( P = .01) and the erythrocyte sedimentation rate (ESR) was higher ( P = .04) in comparison to classic and drug-induced SS. Leukocytoclasia was associated with higher risk of recurrence ( P = .01).

CONCLUSION

All patients with SS deserve careful investigation of possible underlying conditions. Higher ESR and lower hemoglobin levels might reinforce the need of malignancy screening. Also, leukocytoclasia appears to be a potential marker of higher recurrence rate, demanding closer and longer follow-up.