1
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Rubin L, Talmon A, Ribak Y, Lavie D, Nechushtan H, Caplan N, Lotem M, Shamriz O, Adini I, Tal Y. Targeted inhibition of the IL5 axis for immune checkpoint inhibitors eosinophilic-induced adverse events. J Immunother Cancer 2024; 12:e009658. [PMID: 39395838 PMCID: PMC11474678 DOI: 10.1136/jitc-2024-009658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 09/23/2024] [Indexed: 10/14/2024] Open
Abstract
Given the broad implementation of immune checkpoint inhibitors (ICI) for cancer therapy, we encounter a variety of immune-related adverse events (irAE) including immune-related blood eosinophilia. Eosinophilia demonstrated a potential positive predictive marker for a beneficial clinical response to ICI. However, there are reports of eosinophil-induced adverse events (Eo-irAE) with organ dysfunction requiring initiation of oral glucocorticoid therapy and discontinuation of ICI.We aim to assess the efficacy and safety of interleukin (IL) 5-axis inhibition in Eo-irAE secondary to ICI therapy.We present three cases of Eo-irAE referred to our allergy and clinical immunology unit at Hadassah Hebrew University Medical Center following therapy with pembrolizumab and nivolumab, monoclonal antibodies that target the programmed cell death 1 (PD-1) receptor, for two cases of melanoma and one metastatic non-small cell lung carcinoma. Following informed consent and committee approval, two patients were treated with 1-3 doses of mepolizumab, 100 mg, monoclonal IgG1 kappa anti-IL-5 antibody, and one patient received up-to-date 9 doses of benralizumab, 30 mg, monoclonal IgG1 kappa antibody directed against the alpha chain of the interleukin-5 receptor, both administered subcutaneously. Patients were carefully followed and treatment response was assessed by physical examinations and laboratory tests.Hypereosinophilia at the level of 2300-8000 K/UL was observed 8-12 months following therapy accompanied by symptoms of dyspnea, arthralgia, myalgia, fasciitis, 'morphea'-like lesions, fatigue, abdominal discomfort, pruritus, and chest pain. ICI discontinuation did not improve symptoms, two patients were resistant to glucocorticoids and therefore biological treatment was initiated to inhibit the IL5 axis. Patients demonstrated rapid clinical response and a decrease in peripheral blood eosinophil levels with long-term symptoms remission. There were no signals of negative impacts, such as tumor progression following IL5 axis inhibition.Eosinophilia secondary to ICI therapy can lead to organ dysfunction. Discontinuation of ICI might not be effective and symptoms may be refractory to steroid therapy hence targeted inhibition of the IL5 axis should be considered.
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Affiliation(s)
- Limor Rubin
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah University Medical Center Division of Internal Medicine, Jerusalem, Israel
| | - Aviv Talmon
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah University Medical Center Division of Internal Medicine, Jerusalem, Israel
| | - Yaarit Ribak
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah University Medical Center Division of Internal Medicine, Jerusalem, Israel
| | - David Lavie
- Department of Hematology, Hadassah University Medical Center, Jerusalem, Israel
| | - Hovav Nechushtan
- Oncology, Hadassah Medical Center, Jerusalem, Israel
- Hebrew University, Jerusalem, Israel
| | - Nadia Caplan
- Department of Radiology, Hadassah University Medical Center, Jerusalem, Israel
| | - Michal Lotem
- Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Oded Shamriz
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah University Medical Center, Jerusalem, Israel
- Institute of Medical Research Israel-Canada, Faculty of Medicine, Hebrew University The Lautenberg Center for Immunology and Cancer, Jerusalem, Israel
| | - Irit Adini
- Department of Surgery, Center for Engineering in Medicine and Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Yuval Tal
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah University Medical Center Division of Internal Medicine, Jerusalem, Israel
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2
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Barajas-McGahan M, Tuckfield L, Rice K, Patel R. Atypical Case of Toe-Walking and Hyperpigmented Rash in a 9-year-old Boy. Pediatr Rev 2024; 45:e19-e23. [PMID: 38821902 DOI: 10.1542/pir.2022-005761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/07/2023] [Accepted: 08/30/2023] [Indexed: 06/02/2024]
Affiliation(s)
- Maria Barajas-McGahan
- Valley Children's Pediatric Residency Program affiliated with Stanford School of Medicine, Madera, CA
- Valley Children's Healthcare, Madera, CA
| | - Lynnia Tuckfield
- Valley Children's Pediatric Residency Program affiliated with Stanford School of Medicine, Madera, CA
- Valley Children's Healthcare, Madera, CA
| | - Kerrilynn Rice
- Valley Children's Pediatric Residency Program affiliated with Stanford School of Medicine, Madera, CA
- Valley Children's Healthcare, Madera, CA
| | - Reshma Patel
- Valley Children's Pediatric Residency Program affiliated with Stanford School of Medicine, Madera, CA
- Valley Children's Healthcare, Madera, CA
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3
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Cherim A, Bastian AE, Popp CG, Mihon MI, Efrem IC, Vreju AF, Ionescu RA. Eosinophilic fasciitis: unraveling the clinical tapestry of a rare case and review of literature. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2024; 65:341-347. [PMID: 39020550 PMCID: PMC11384037 DOI: 10.47162/rjme.65.2.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
Eosinophilic fasciitis (EF) remains a diagnostic challenge due to its rarity and resemblance to scleroderma. This case report aims to provide a cohesive exploration of EF's clinical nuances, emphasizing the importance of accurate diagnosis and effective management. A 52-year-old male developed bilateral forearm and calf hardening, along with erythema, pruritus, and pain four months prior to the presentation in our Clinic. The symptoms initially debuted bilaterally in the forearms and progressed to involve the calves, distal arms, and thighs. Clinical examination revealed symmetrical plaques on forearms and calves, featuring erythematous, hyper, and hypopigmented elements extending proximally, a positive "groove sign" and a moderate difficulty in knee joint flexion. Despite these findings, the patient was generally in good condition, without any other notable clinical signs. Initial laboratory findings showed slightly increased percentual eosinophil levels, elevated C-reactive protein (CRP), normal erythrocyte sedimentation rate (ESR), and negative antinuclear and scleroderma specific antibodies. Magnetic resonance imaging (MRI) demonstrated enhanced fascial signal and thickening while the fascia-muscle biopsy revealed marked edema and inflammatory lymphoplasmacytic infiltrate, consistent with the diagnosis of EF. The patient showed a favorable response to systemic corticosteroids. EF predominantly affects males aged 30 to 60 and is characterized by a sudden onset and unclear etiological factors. Differential diagnosis requires careful exclusion of scleroderma and other mimicking conditions. Diagnostic modalities such as skin-muscle biopsy and MRI reveal characteristic findings like inflammatory infiltrate and fascial thickening. Accurate diagnosis and differentiation from scleroderma are crucial, with early intervention involving glucocorticoids and immunosuppressive agents improving long-term outcomes.
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Affiliation(s)
- Aifer Cherim
- Department of Internal Medicine - Medical Semiology, Faculty of Dentistry, University of Medicine and Pharmacy of Craiova, Romania; ,
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4
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Shahriari N, Mazori DR, Shahriari M, Taylor D, Shaw K, LaChance AH, Femia AN, Vleugels RA. Utility of magnetic resonance imaging in the diagnosis of eosinophilic fasciitis: A multicenter retrospective cohort study. J Am Acad Dermatol 2023; 89:1313-1315. [PMID: 37659455 DOI: 10.1016/j.jaad.2023.08.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/09/2023] [Accepted: 08/23/2023] [Indexed: 09/04/2023]
Affiliation(s)
- Neda Shahriari
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Daniel R Mazori
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, NYU Langone Health, New York, New York
| | - Mona Shahriari
- Central Connecticut Dermatology, Cromwell, Connecticut; Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Dustin Taylor
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katharina Shaw
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Avery H LaChance
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alisa N Femia
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, NYU Langone Health, New York, New York
| | - Ruth Ann Vleugels
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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5
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Desai V, Vokey S, Vaughan S, Somayaji R. Necrotizing Soft-Tissue Infections: A Case-Based Review. Adv Skin Wound Care 2023; 36:571-577. [PMID: 37861662 DOI: 10.1097/asw.0000000000000060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
GENERAL PURPOSE To review the assessment and management of necrotizing fasciitis. TARGET AUDIENCE This continuing-education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant will:1. Identify the etiologic pathogens for necrotizing fasciitis.2. Summarize assessment guidelines for patients who present with signs of necrotizing fasciitis.3. Explain recommended treatment protocols for patients who have necrotizing fasciitis.
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Chen Z, Wasti B, Shang Y, Jia A, Xiang X, Ouyang R. Clinical characteristics and risk factors of patients with eosinophilic fasciitis associated with pleural effusion. Sci Rep 2023; 13:5452. [PMID: 37012347 PMCID: PMC10070614 DOI: 10.1038/s41598-023-32678-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
To investigate the risk factors of eosinophilic fasciitis (EF) associated with pleural effusion (PE). A retrospective analysis was performed on 22 patients with EF diagnosed by skin biopsy in our hospital, and they were divided into EF-PE and EF according to chest computed tomography examination. The clinical characteristics, clinical manifestations, comorbidities and laboratory test indicators of the two groups were collected and compared, and the risk factors for occurring PE in patients with EF were determined by multivariate logistic regression analysis. Among 22 patients with EF, 8 had PE. The age, course of disease, incidence of fever, weight loss, cough and shortness of breath, pulmonary infection, hypothyroidism, hydronephrosis and kidney stone, swelling rate of small vascular endothelial cells, consolidation shadows, C-reactive protein and thyroid stimulating hormone in EF-PE group were higher than those in EF group, while free triiodothyronine and thyroxine were lower than those in EF group. Age, fever, shortness of breath, C-reactive protein, ESR, thyroid stimulating hormone, pulmonary infection, hypothyroidism, hydronephrosis, kidney stones, swollen small vascular endothelial cells and chest CT consolidation shadows were identified as risk factors for happening PE in patients with EF, while free triiodothyronine and free thyroxine were identified as protective factors against PE in patients with EF. The incidence of EF-PE was 36.36% in this study. Advanced age, high C-reactive protein, ESR, thyroid stimulating hormone, incidence of fever, shortness of breath, pulmonary infection, hydronephrosis, kidney stones, swollen small vascular endothelial cells, chest CT consolidation shadows, and low free triiodothyronine and thyroxine suggest that patients with EF are significantly at increased risk of PE.
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Affiliation(s)
- Zhifeng Chen
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011, Hunan, China
| | - Binaya Wasti
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011, Hunan, China
| | - Yulin Shang
- Ophthalmology and Otorhinolaryngology, Zigui County Traditional Chinese Medicine Hospital, 30 Pinghu Avenue, Zigui, 443600, Hubei, China
| | - Aijun Jia
- Department of the Third Emergency of Yuelushan Hospital District, Hunan Provincial People's Hospital, No.90 Pingchuan Road, Changsha, 410006, Hunan, China
| | - Xudong Xiang
- Department of Emergency, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011, Hunan, China
| | - Ruoyun Ouyang
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011, Hunan, China.
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7
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Kim J, Lee LH. Diagnostic Utility of Magnetic Resonance Imaging in Eosinophilic Fasciitis: A Case Report and Review of Literature. Cureus 2023; 15:e37899. [PMID: 37214068 PMCID: PMC10199750 DOI: 10.7759/cureus.37899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 05/23/2023] Open
Abstract
Eosinophilic fasciitis (EF), also known as Shulman syndrome, is a rare scleroderma-like disorder that is characterized by an acute onset of induration, swelling, erythema, and tenderness of the skin and deep fascia, often affecting all four limbs. We report a case of eosinophilic fasciitis in a 51-year-old female patient, whose diagnosis of EF was made based on the findings from clinical evaluation and magnetic resonance imaging (MRI) but without skin biopsy. She was treated with a combination therapy of prednisolone and methotrexate, and her response to therapy was assessed via clinical assessment and MRI. MRI may be a useful non-invasive diagnostic tool for not only supporting but also confirming the clinical diagnosis of EF when a skin-to-muscle biopsy is not available or cannot be performed, as well as for monitoring disease activity and response to therapy. Further prospective studies should be conducted to evaluate the precise sensitivity and specificity of MRI in diagnosing EF and also to create more structured protocols to guide the diagnosis and management of EF.
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Affiliation(s)
- Jiwon Kim
- General Medicine, Goulburn Valley Health, Shepparton, AUS
| | - Lit Hiang Lee
- General Medicine, Goulburn Valley Health, Shepparton, AUS
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8
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Okuyama S, Satomi H, Ishikawa R, Shishido T, Sato K, Ueki T, Sumi M, Kobayashi H. Eosinophilic Fasciitis with Hypereosinophilia as the Initial Clinical Manifestation of Peripheral T-Cell Lymphoma, Not Otherwise Specified. Intern Med 2022; 61:3425-3429. [PMID: 35491131 PMCID: PMC9751711 DOI: 10.2169/internalmedicine.9300-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A 58-year-old man presented with painful edema of the extremities, and a diagnosis of eosinophilic fasciitis (EF) was confirmed. He also met the criteria for hypereosinophilic syndrome (HES), but there were no findings suggestive of malignancies or hematologic neoplasms despite a close examination. He was started on steroid therapy but subsequently developed severe liver dysfunction, hemophagocytic lymphohistiocytosis, hepatosplenomegaly, and renal involvement. The diagnosis of peripheral T-cell lymphoma, not otherwise specified was finally established by a bone marrow reexamination and liver biopsy. In cases of eosinophilia, EF, and/or HES, it is important to suspect an intrinsic abnormality, including potential T-cell lymphoma.
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Affiliation(s)
- Shuhei Okuyama
- Department of Hematology, Nagano Red Cross Hospital, Japan
| | | | - Ryuto Ishikawa
- Department of Hematology, Nagano Red Cross Hospital, Japan
| | | | - Keijiro Sato
- Department of Hematology, Nagano Red Cross Hospital, Japan
| | | | - Masahiko Sumi
- Department of Hematology, Nagano Red Cross Hospital, Japan
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9
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Amrane K, Le Meur C, Thuillier P, Alemany P, Niel C, Renault D, Abgral R. Case report: Eosinophilic fasciitis induced by pembrolizumab with high FDG uptake on 18F-FDG-PET/CT. Front Med (Lausanne) 2022; 9:1078560. [PMID: 36606046 PMCID: PMC9807755 DOI: 10.3389/fmed.2022.1078560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Eosinophilic fasciitis (EF) is a rare connective tissue disorder causing inflammation and fibrosing of fascia. In this study, we present a very rare case of an immune checkpoint inhibitor (ICI)-induced EF revealed by 18F-fluorodesoxyglucose positron emission tomography (FDG-PET/CT) 20 months after the initiation of Pembrolizumab treatment of a relapsed non-small cell lung cancer (NSCLC). This study presents a 52-year-old Caucasian woman clinically presenting asthenia, inflammatory muscle, and joint pain associated with subcutaneous nodules and symmetrical edema of the lower limbs. Iterative 18FDG-PET/CT scans allow us to guide the therapeutic strategy due to this atypical ICI adverse event.
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Affiliation(s)
- Karim Amrane
- Department of Oncology, Centre Hospitalier des Pays de Morlaix, Morlaix, France.,Institut National de la Santé et de la Recherche Médicale UMR 1227, Lymphocytes B et Autoimmunité, Univ. Brest, Institut National de la Santé et de la Recherche Médicale, LabEx IGO, Brest, France
| | - Coline Le Meur
- Department of Oncology, Centre Hospitalier des Pays de Morlaix, Morlaix, France
| | - Philippe Thuillier
- Institut National de la Santé et de la Recherche Médicale UMR 1304 GETBO, University of Western Brittany, Brest, France.,Department of Endocrinology, University Hospital of Brest, Brest, France
| | - Pierre Alemany
- Department of Pathology, Ouest Pathologie, Brest, France
| | - Clémence Niel
- Department of Pneumology, Centre Hospitalier des Pays de Morlaix, Morlaix, France
| | - David Renault
- Department of Pneumology, Centre Hospitalier des Pays de Morlaix, Morlaix, France
| | - Ronan Abgral
- Department of Endocrinology, University Hospital of Brest, Brest, France.,Department of Nuclear Medicine, University Hospital of Brest, Brest, France
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10
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Primitivo A, Madeira N, Lopez D, Afonso D. Eosinophilic fasciitis (Shulman disease) with clinical, imaging and pathological correlation. BMJ Case Rep 2021; 14:e246151. [PMID: 34969795 PMCID: PMC8719132 DOI: 10.1136/bcr-2021-246151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 11/04/2022] Open
Abstract
Eosinophilic fasciitis (EF) is a rare subacute fibrosing disorder of unknown aetiology, characterised by thickening of the muscular fascia and subcutaneous tissue, leading to swelling of limbs and trunk and sparing fingers and toes. Eosinophilic infiltration and degranulation may prompt tissue damage and consequent fibrosis due to the accumulation of collagen and extracellular matrix proteins. MRI is the best imaging modality for diagnosis, depicting fascial thickening and enhancement. MRI may also have a significant role in excluding alternative diagnosis and guiding the skin-muscle biopsy.We report a case of EF with clinical and pathological correlation, highlighting the diagnostic value of MRI for early diagnosis and further treatment.
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Affiliation(s)
- Ana Primitivo
- Radiology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Nathalie Madeira
- Reumatology, Instituto Português de Reumatologia, Lisboa, Lisboa, Portugal
| | - Dolores Lopez
- Anatomical Pathology, Centro Hospitalar Lisboa Norte EPE, Lisboa, Lisboa, Portugal
| | - Diana Afonso
- Department of Radiology, Hospital da Luz, Lisboa, Lisboa, Portugal
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Sehgal R, Ernste FC, Eckloff S. Dr. Sehgal et al reply. J Rheumatol 2021; 49:547. [PMID: 34911806 DOI: 10.3899/jrheum.211190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We appreciate the interest of Wang et al1 in our case.2 We agree with several of their comments and would like to clarify a few details here.
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Affiliation(s)
- Rahul Sehgal
- Department of Medicine, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA. R. Sehgal passed away on November 10, 2021. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. F. Ernste, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Floranne C Ernste
- Department of Medicine, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA. R. Sehgal passed away on November 10, 2021. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. F. Ernste, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Sara Eckloff
- Department of Medicine, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA. R. Sehgal passed away on November 10, 2021. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. F. Ernste, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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12
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Mourad AI, Lehman JS, Mydlarski PR. Groove Sign in Eosinophilic Fasciitis. Mayo Clin Proc 2021; 96:2184. [PMID: 34353471 DOI: 10.1016/j.mayocp.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/07/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ahmed I Mourad
- Division of Dermatology, University of Calgary, Calgary, Alberta, Canada
| | | | - P Régine Mydlarski
- Division of Dermatology, University of Calgary, Calgary, Alberta, Canada.
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Abstract
This case report describes a rare case of progressive muscle weakness in a patient treated for eosinophilic fasciitis (EF) for many years before being diagnosed with a second autoimmune disease: dermatomyositis. Our case is a report of a 65-year-old male diagnosed with eosinophilic fasciitis 7 years before being evaluated in our service at Mayo Clinic in Jacksonville, Florida, due to progressive muscle weakness despite the chronic treatment with methotrexate. Contrast-enhanced magnetic resonance imaging of the lower extremity showed enhancement throughout the thigh musculature, which led us to pursue biopsies of the fascia and muscle in order to confirm the diagnosis of EF associated with myopathy. This case illustrates the need to consider the possibility of myopathy in patients diagnosed with EF whenever muscle weakness is more prominent than expected.
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Affiliation(s)
- Razvan Chirila
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States of America
| | | | - Monica Roxana Purcarea
- Department of Nephrology, "Carol Davila" Clinical Nephrology Hospital, Bucharest, Romania
| | - Laura Carina Tribus
- Department of Gastroenterology, Bucharest Emergency University Hospital.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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14
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Kaushik A, Mahajan R, De D, Handa S. Paediatric morphoea: a holistic review. Part 2: diagnosis, measures of disease activity, management and natural history. Clin Exp Dermatol 2020; 45:679-684. [PMID: 32449205 DOI: 10.1111/ced.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 12/01/2022]
Abstract
Paediatric morphoea is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Defining optimum management strategies in paediatric morphoea remains an ongoing challenge, owing to the varied presentations and a relative paucity of paediatric-specific studies. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected and results analysed before summarizing them. In Part 1 of this review, we described the epidemiology, aetiopathogenesis and clinical classification; in this part, we discuss the diagnosis, markers of disease activity, management and natural history in paediatric morphoea.
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Affiliation(s)
- A Kaushik
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - R Mahajan
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - D De
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Handa
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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15
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Sturdy A, Stratton R, Perez-Machado M, Lamb L. Case of eosinophilic fasciitis during military training in a Nepalese British infantry soldier. BMJ Mil Health 2020; 166:277-278. [PMID: 32139410 DOI: 10.1136/jramc-2019-001273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/26/2019] [Accepted: 07/27/2019] [Indexed: 12/15/2022]
Abstract
We present the case of a Nepalese British soldier with peripheral oedema and a significantly raised eosinophil count. After extensive investigation looking for a parasitic cause of his illness, he was diagnosed with eosinophilic fasciitis, a connective tissue disorder, often triggered by heavy exertion and responsiveness to immunosuppression. In a military setting, in which clinicians are likely to encounter patients who have spent time in tropical areas, it is important to still consider non-infectious causes of eosinophilia.
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Affiliation(s)
- Ann Sturdy
- Department of Infection, Royal Free Hospital, London, UK
| | - R Stratton
- Department of Rheumatology, Royal Free Hospital, London, UK
| | - M Perez-Machado
- Department of Cellular Pathology, Royal Free Hospital, London, UK
| | - L Lamb
- Department of Infection, Royal Free Hospital, London, UK.,Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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16
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Ou Yang O, Crepaldi BE, Berger A. Eosinophilic Fasciitis - Beware of the Rare Form of Hand Contracture. J Hand Surg Asian Pac Vol 2020; 25:129-132. [PMID: 32000611 DOI: 10.1142/s2424835520720054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Eosinophilic fasciitis (EF) is a rare form of fibrosing disorder associated with peripheral eosinophilia with scleroderma-like skin induration and fasciitis in the extremities resulting in painful swelling, erythema and progressive contracture. We present a case report of EF and a literature review to raise awareness of this unusual condition and also highlight key features in its management.
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Affiliation(s)
- Owen Ou Yang
- Victorian Hand Surgery Associates, Hand Unit, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Bruno E Crepaldi
- Victorian Hand Surgery Associates, Hand Unit, St. Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Anthony Berger
- Victorian Hand Surgery Associates, Hand Unit, St. Vincent's Hospital Melbourne, Fitzroy, Australia
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Mango RL, Bugdayli K, Crowson CS, Drage LA, Wetter DA, Lehman JS, Peters MS, Davis MD, Chowdhary VR. Baseline characteristics and long-term outcomes of eosinophilic fasciitis in 89 patients seen at a single center over 20 years. Int J Rheum Dis 2019; 23:233-239. [PMID: 31811710 DOI: 10.1111/1756-185x.13770] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/20/2019] [Accepted: 11/20/2019] [Indexed: 11/27/2022]
Abstract
AIM Eosinophilic fasciitis (EF) is a rare, fibrosing disorder of skin and subcutaneous tissue. This study was undertaken to describe its clinical and laboratory features and identify prognostic factors associated with outcome. METHODS We conducted a retrospective review of all EF patients evaluated at our institution from 1 January1997 to 30 December 2016. Kaplan-Meier methods were used to determine treatment response rates over time. Potential associations between baseline characteristics and complete response were examined using Cox models adjusted for age and sex. Time-dependent covariates were used to examine treatment effects. RESULTS We identified 89 EF patients, with a female-to-male ratio of 1:1. Clinical features included groove sign in 26 (29%), peau d'orange/dimpling in 22 (25%), inflammatory arthritis in 9 (10%) and muscle weakness in 9 (10%). Aldolase was elevated in 11/36 (31%). Complete response rate was 60% (95% confidence interval [CI]: 35-75) at 3 years. Diagnostic delay was inversely associated with treatment response (hazards ratio: 0.84 per 1 month increase; 95% CI: 0.73-0.98). No baseline characteristics correlated with treatment response, but a trend toward positive association of elevated aldolase, hypergammaglobulinemia and presence of hematologic disorders was noted. Methotrexate was the most commonly used immunosuppressant in 79%, hydroxychloroquine in 45%, mycophenolate mofetil in 18% and azathioprine in 8%. No single immunosuppressant agent was associated with a superior response during treatment. CONCLUSIONS EF is characterized by relatively high response rates. Consensus diagnostic criteria, standardized management algorithms, and large prospective multi-center cohorts are needed to develop an evidence-directed approach to this challenging condition.
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Affiliation(s)
| | | | - Cynthia S Crowson
- Division of Rheumatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.,Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Lisa A Drage
- Department of Dermatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - David A Wetter
- Department of Dermatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic College of Medicine, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Margot S Peters
- Department of Dermatology, Mayo Clinic College of Medicine, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Mark D Davis
- Department of Dermatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Vaidehi R Chowdhary
- Section of Rheumatology, Allergy and Immunology, Yale University School of Medicine, New Haven, CT, USA
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Cabral C, Novais A, Araujo D, Mosca A, Lages A, Knock A. Eosinophilic fasciitis: an atypical presentation of a rare disease. ACTA ACUST UNITED AC 2019; 65:326-329. [PMID: 30994827 DOI: 10.1590/1806-9282.65.3.326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 08/27/2018] [Indexed: 11/22/2022]
Abstract
Eosinophilic fasciitis, or Shulman's disease, is a rare disease of unknown etiology. It is characterized by peripheral eosinophilia, hypergammaglobulinemia, and high erythrocyte sedimentation rate. The diagnosis is confirmed by a deep biopsy of the skin. The first line of treatment is corticotherapy. We present a rare case of eosinophilic fasciitis in a 27-year-old woman with an atypical presentation with symmetrical peripheral edema and a Groove sign. The patient responded well to treatment with corticosteroids at high doses and, in this context, was associated with hydroxychloroquine and azathioprine. After two and a half years, peripheral eosinophilia had increased, and more of her skin had hardened. At that time, the therapy was modified to include corticoids, methotrexate, and penicillamine. It is of great importance to publicize these cases that allow us to gather experience and better treat our patients.
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Affiliation(s)
- Catia Cabral
- Internal Medicine Service, Centro Hospitalar Tondela-Viseu, Viseu, Portugal.,Internal Medicine Service, Hospital de Braga, Braga, Portugal
| | - António Novais
- Internal Medicine Service, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - David Araujo
- Internal Medicine Service, Hospital de Braga, Braga, Portugal
| | - Ana Mosca
- Internal Medicine Service, Hospital de Braga, Braga, Portugal
| | - Ana Lages
- Internal Medicine Service, Hospital de Braga, Braga, Portugal
| | - Anna Knock
- Internal Medicine Service, Hospital de Braga, Braga, Portugal
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Abstract
PURPOSE OF REVIEW The purpose of this review article is to highlight the current role of diagnostic imaging in the assessment of inflammatory myopathies. RECENT FINDINGS Recent research demonstrates that imaging plays an important role in evaluating patients with symptoms of an inflammatory myopathy. In general, MRI is the pivotal imaging modality for assessing inflammatory myopathies, revealing precise anatomic details because of changes in the signal intensity of the muscles. Whole-body MR imaging has become increasingly important over the last several years. US is also a valuable imaging modality for scanning muscles. Together with the clinical history, familiarity with the imaging features of inflammatory myopathies is essential for formulating an accurate diagnosis.
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Kirchgesner T, Demondion X, Stoenoiu M, Durez P, Nzeusseu Toukap A, Houssiau F, Galant C, Acid S, Lecouvet F, Malghem J, Vande Berg B. Fasciae of the musculoskeletal system: normal anatomy and MR patterns of involvement in autoimmune diseases. Insights Imaging 2018; 9:761-771. [PMID: 30159858 PMCID: PMC6206374 DOI: 10.1007/s13244-018-0650-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/08/2018] [Accepted: 07/16/2018] [Indexed: 12/19/2022] Open
Abstract
Abstract The fascial system is a three-dimensional continuum of connective tissues present everywhere throughout the body, from the head to the toes and from the skin to the bone. The current article aims to review the normal anatomy of the fasciae of the musculoskeletal system with macroscopic and microscopic correlations and to describe their appearance at MRI in normal subjects and in patients with autoimmune diseases of the musculoskeletal system. Key Points • The fascial system is a three-dimensional continuum of connective tissues. • It is present everywhere throughout the body, from the head to the toes and from the skin to the bone. • The normal fascial system is barely visible at MRI. • MR patterns of fascial involvement in autoimmune diseases reflect the complex anatomy of the fasciae of the musculoskeletal system.
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Affiliation(s)
- Thomas Kirchgesner
- Department of Radiology - Musculoskeletal Imaging Unit, Cliniques universitaires Saint-Luc / Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium.
| | - Xavier Demondion
- Department of Radiology and Musculoskeletal Imaging, CHRU Lille / Laboratory of Anatomy, Faculty of Medicine of Lille, Lille, France
| | - Maria Stoenoiu
- Department of Rheumatology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Patrick Durez
- Department of Rheumatology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | | | - Frédéric Houssiau
- Department of Rheumatology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Christine Galant
- Department of Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Souad Acid
- Department of Radiology - Musculoskeletal Imaging Unit, Cliniques universitaires Saint-Luc / Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Frédéric Lecouvet
- Department of Radiology - Musculoskeletal Imaging Unit, Cliniques universitaires Saint-Luc / Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Jacques Malghem
- Department of Radiology - Musculoskeletal Imaging Unit, Cliniques universitaires Saint-Luc / Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Bruno Vande Berg
- Department of Radiology - Musculoskeletal Imaging Unit, Cliniques universitaires Saint-Luc / Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
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21
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Jinnin M, Yamamoto T, Asano Y, Ishikawa O, Sato S, Takehara K, Hasegawa M, Fujimoto M, Ihn H. Diagnostic criteria, severity classification and guidelines of eosinophilic fasciitis. J Dermatol 2018; 45:881-890. [PMID: 29235676 DOI: 10.1111/1346-8138.14160] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/06/2017] [Indexed: 11/28/2022]
Abstract
We established diagnostic criteria and severity classification of eosinophilic fasciitis because there is no established diagnostic criteria or widely accepted severity classification of the disease. Also, there has been no clinical guideline for eosinophilic fasciitis, so we established its clinical guideline ahead of all over the world. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of eosinophilic fasciitis.
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Affiliation(s)
- Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Toshiyuki Yamamoto
- Department of Dermatology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yoshihide Asano
- Department of Dermatology, The University of Tokyo Hospital, Tokyo, Japan
| | - Osamu Ishikawa
- Department of Dermatology, Graduate School of Medicine, Gunma University, Gunma, Japan
| | - Shinichi Sato
- Department of Dermatology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Minoru Hasegawa
- Department of Dermatology Division, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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22
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Kastsianok L, Ranganathan P. Skin Induration in a Patient With Aplastic Anemia. Arthritis Care Res (Hoboken) 2018; 70:1095-1100. [DOI: 10.1002/acr.23524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 01/23/2018] [Indexed: 11/10/2022]
Affiliation(s)
| | - Prabha Ranganathan
- Washington University School of Medicine in St. Louis; St. Louis Missouri
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25
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Abstract
Morphea, also known as localized scleroderma, encompasses a group of idiopathic sclerotic skin diseases. The spectrum ranges from relatively mild phenotypes, which generally cause few problems besides local discomfort and visible disfigurement, to subtypes with severe complications such as joint contractures and limb length discrepancies. Eosinophilic fasciitis (EF, Shulman syndrome) is often regarded as belonging to the severe end of the morphea spectrum. The exact driving mechanisms behind morphea and EF pathogenesis remain to be elucidated. However, extensive extracellular matrix formation and autoimmune dysfunction are thought to be key pathogenic processes. Likewise, these processes are considered essential in systemic sclerosis (SSc) pathogenesis. In addition, similarities in clinical presentation between morphea and SSc have led to many theories about their relatedness. Importantly, morphea may be differentiated from SSc based on absence of sclerodactyly, Raynaud’s phenomenon, and nailfold capillary changes. The diagnosis of morphea is often based on characteristic clinical findings. Histopathological evaluation of skin biopsies and laboratory tests are not necessary in the majority of morphea cases. However, full-thickness skin biopsies, containing fascia and muscle tissue, are required for the diagnosis of EF. Monitoring of disease activity and damage, especially of subcutaneous involvement, is one of the most challenging aspects of morphea care. Therefore, data harmonization is crucial for optimizing standard care and for comparability of study results. Recently, the localized scleroderma cutaneous assessment tool (LoSCAT) has been developed and validated for morphea. The LoSCAT is currently the most widely reported outcome measure for morphea. Care providers should take disease subtype, degree of activity, depth of involvement, and quality-of-life impairments into account when initiating treatment. In most patients with circumscribed superficial subtypes, treatment with topical therapies suffices. In more widespread disease, UVA1 phototherapy or systemic treatment with methotrexate (MTX), with or without a systemic corticosteroid combination, should be initiated. Disappointingly, few alternatives for MTX have been described and additional research is still needed to optimize treatment for these debilitating conditions. In this review, we present a state-of-the-art flow chart that guides care providers in the treatment of morphea and EF.
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26
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Lamback EB, Resende FSS, Lenzi TCR. Eosinophilic fasciitis. An Bras Dermatol 2017; 91:57-59. [PMID: 28300895 PMCID: PMC5324994 DOI: 10.1590/abd1806-4841.20164683] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 11/03/2015] [Indexed: 11/22/2022] Open
Abstract
Eosinophilic fasciitis is a rare sclerodermiform syndrome of unknown etiology. It
is characterized by the thickening of the muscular fascia and subcutaneous
tissue, with a variable infiltration of eosinophils. Peripheral eosinophilia,
poly or monoclonal hypergammaglobulinemia and increased erythrocyte
sedimentation rate can be seen. Clinical features begin acutely, with local
edema and a painful and symmetrical stiffening of the limbs, progressing rapidly
to fibrosis, which can limit joint movements. Some cases have a history of
strenuous physical exercise or trauma. The diagnosis is confirmed by a deep skin
biopsy. Glucocorticoids in high doses is the treatment of choice. We report a
typical eosinophilic fasciitis case with peripheral eosinophilia and dramatic
response to pulse therapy with methylprednisolone.
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27
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Focal myositis: a rare case report. Turk J Phys Med Rehabil 2017; 63:181-184. [PMID: 31453449 DOI: 10.5606/tftrd.2017.78466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 05/20/2015] [Indexed: 11/21/2022] Open
Abstract
Focal myositis is an uncommon, self-limiting, benign skeletal muscle disease, which is generally determined as an inflammatory pseudotumor. The etiology is not fully known, although it has been suggested that subclinical damage may play a role. As it leads to a tumoral mass it may be confused with several diseases leading to incorrect evaluations. Definitive diagnosis is made by biopsy of the skeletal muscle. In radiologic diagnosis, magnetic resonance imaging is the most important modality. In this paper we presented the imaging findings of a 58-year-old female patient with focal myositis who was admitted with complaints of forearm swelling.
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28
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Whitlock JB, Dimberg EL, Selcen D, Rubin DI. Eosinophilic fasciitis with subjacent myositis. Muscle Nerve 2016; 56:525-529. [PMID: 27875630 DOI: 10.1002/mus.25492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2016] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Eosinophilic fasciitis (EF) is a rare disorder that can present with muscle symptoms that mimic other neuromuscular diseases. METHODS We report the case of a 43-year-old woman with chronic muscle aches, tightness, and stiffness with hypertrophied, well-defined muscles despite physical inactivity, and thickened skin with reduced elasticity and discoloration. RESULTS Except for mild peripheral eosinophilia, laboratory studies, including blood count, electrolytes, paraneoplastic panel, muscle enzymes, thyroid function, and serum protein electrophoresis, were normal. Nerve conduction studies and needle electromyography were normal. Magnetic resonance imaging of the thighs demonstrated superficial and deep fascial thickening with T2 hyperintensity and post-gadolinium enhancement. Fascial and muscle biopsy demonstrated an inflammatory exudate in the perimysium and endomysium with fragmented perimysial connective tissue and thickened, inflamed fascia. EF was diagnosed. The patient was treated with methotrexate and prednisone followed by improvement of muscle stiffness and tightness. CONCLUSION EF should be considered when patients present with muscle pain or enlarged muscles. Muscle Nerve 56: 525-529, 2017.
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Affiliation(s)
- Julia B Whitlock
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida, 32224, USA
| | - Elliot L Dimberg
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida, 32224, USA
| | - Duygu Selcen
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Devon I Rubin
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida, 32224, USA
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29
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Suyama Y, Kishimoto M, Nozaki T, Nishimoto K, Okada M. Man With Swelling in Legs and Forearms. Ann Emerg Med 2016; 68:e57-8. [PMID: 27451311 DOI: 10.1016/j.annemergmed.2016.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Yasuhiro Suyama
- Immuno-Rheumatology Center, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Immuno-Rheumatology Center, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
| | - Taiki Nozaki
- Department of Radiology, St. Luke's International University, Tokyo, Japan
| | | | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
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30
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Sène D. [Eosinophilic fasciitis (Shulman's disease): Diagnostic and therapeutic review]. Rev Med Interne 2015; 36:738-45. [PMID: 26385125 DOI: 10.1016/j.revmed.2015.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 08/01/2015] [Accepted: 08/03/2015] [Indexed: 11/16/2022]
Abstract
Eosinophilic fasciitis (EF) is a rare connective tissue disease characterized by symmetrical and painful swelling with a progressive induration and thickening of the skin and soft tissues. The diagnosis of EF is often based on the association of characteristic skin or subcutaneous abnormalities and a thickened fascia with an inflammatory infiltration, mostly composed of lymphocytes and eosinophils. A peripheral eosinophilia is frequently present (60-90%) but is not mandatory for the EF diagnosis. At the onset, the morphological diagnosis might be helped by a muscle magnetic resonance imaging, which typically may evidence an increased signal intensity within the fascia and marked fascia enhancement after gadolinium administration at the acute phase of the disease. Differential diagnoses include eosinophilia-myalgia syndrome after L-tryprophane ingestion, hypereosinophilic syndromes (HES), systemic sclerosis, eosinophilic granulomatosis with polyangeitis, and peripheral T cell lymphomas with cutaneous involvement. There is no consensual therapeutic strategy. However, oral corticosteroids, with or without methylprednisolone pluses, remain the mainstay treatment with a significant improvement for the majority of patients. It might be associated to an immunosuppressive drug, mainly methotrexate, in patients with morphea-like lesions or an unsatisfactory response to corticosteroids alone.
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Affiliation(s)
- D Sène
- Université Paris-Cité Sorbonne Paris-Diderot, 75013 Paris, France; Service de médecine interne, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France.
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Alolabi B, Lesieur M, Smilovici B, Koo K, El Bahtimi R, Jenkinson RJ. Forearm compartment syndrome as a result of eosinophilic fasciitis: case report. J Hand Surg Am 2015; 40:707-10. [PMID: 25747740 DOI: 10.1016/j.jhsa.2015.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 01/08/2015] [Accepted: 01/08/2015] [Indexed: 02/02/2023]
Abstract
Eosinophilic fasciitis is an uncommon scleroderma-like connective tissue disease, usually characterized by symmetrical and painful swelling and induration of the skin and thickened fascia infiltrated with lymphocytes and eosinophils. A middle-aged woman with follicular lymphoma being treated with chemotherapy presented with acute onset atraumatic forearm swelling and severe pain. The history, physical examination, and pressure measurements were consistent with compartment syndrome. Intraoperative biopsy of the forearm fascia confirmed eosinophilic fasciitis.
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Affiliation(s)
- Bashar Alolabi
- Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada; Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Department of Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
| | - Martin Lesieur
- Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada; Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Department of Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Brian Smilovici
- Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada; Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Department of Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Kevin Koo
- Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada; Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Department of Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Reem El Bahtimi
- Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada; Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Department of Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Richard J Jenkinson
- Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada; Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Department of Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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Kirchgesner T, Dallaudière B, Omoumi P, Malghem J, Vande Berg B, Lecouvet F, Houssiau F, Galant C, Larbi A. Eosinophilic fasciitis: Typical abnormalities, variants and differential diagnosis of fasciae abnormalities using MR imaging. Diagn Interv Imaging 2015; 96:341-8. [DOI: 10.1016/j.diii.2014.06.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/11/2014] [Accepted: 06/23/2014] [Indexed: 01/14/2023]
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Abstract
OBJECTIVE The purpose of this article is to review the imaging features of necrotizing fasciitis and its potential mimics. Key imaging features are emphasized to enable accurate and efficient interpretation of variables that are essential in appropriate management. CONCLUSION Necrotizing fasciitis is a medical emergency with potential lethal outcome. Dissecting gas along fascial planes in the absence of penetrating trauma (including iatrogenic) is essentially pathognomonic. However, the lack of soft-tissue emphysema does not exclude the diagnosis. Mimics of necrotizing fasciitis include nonnecrotizing fasciitis (eosinophilic, paraneoplastic, inflammatory (lupus myofasciitis, Churg-Strauss, nodular, or proliferative), myositis, neoplasm, myonecrosis, inflammatory myopathy, and compartment syndrome. Necrotizing fasciitis is a clinical diagnosis, and imaging can reveal nonspecific or negative findings (particularly during the early course of disease). One should be familiar with salient clinical and imaging findings of necrotizing fasciitis to facilitate a more rapid and accurate diagnosis and be aware that its diagnosis necessitates immediate discussion with the referring physician.
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35
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Berianu F, Cohen MD, Abril A, Ginsburg WW. Eosinophilic fasciitis: clinical characteristics and response to methotrexate. Int J Rheum Dis 2014; 18:91-8. [DOI: 10.1111/1756-185x.12499] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
| | - Marc D. Cohen
- Department of Rheumatology; Mayo Clinic; Jacksonville Florida USA
| | - Andy Abril
- Department of Rheumatology; Mayo Clinic; Jacksonville Florida USA
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Nashel J, Steen V. The use of an elevated aldolase in diagnosing and managing eosinophilic fasciitis. Clin Rheumatol 2014; 34:1481-4. [PMID: 25245261 DOI: 10.1007/s10067-014-2777-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/30/2014] [Accepted: 09/07/2014] [Indexed: 11/30/2022]
Abstract
Eosinophilic fasciitis (EF) is a rare localized fibrosing disorder of the fascia whose diagnosis is often suspected based on clinical findings and laboratory values. These lab abnormalities can be transient in early disease and may not always be present. We have reviewed a case series of patients to assess the utility of the various laboratory abnormalities in diagnosing EF. We performed a retrospective review of EF patients seen at Georgetown University Hospital in the Division of Rheumatology during 2009 and 2013. This review included 15 adult patients with EF with a mean age at diagnosis of 45 years (range 18 to 77 years). The majority of patients 13/15 had classic skin thickening documented on all four extremities Only eight patients had peripheral eosinophilia ranging between 8 and 38 %. In these patients, the peripheral eosinophilia was an early but transient finding. Inflammatory markers including the erythrocyte sedimentation rate (ESR) was elevated in 5/14 and C-reactive Protein (CRP) was elevated in 7/11. At disease presentation, only one of eleven patients checked had an elevated creatine phosphokinase (CPK). Aldolase levels were available for 12 of the 15 patients, and they were increased in 11 out of 12 patients. We have found that in this case series, aldolase was more likely to be abnormal than peripheral eosinophilia, hypergammaglobulinemia, and ESR particularly after starting treatment. Aldolase should be measured in all patients suspected of having EF, and may also play a useful role in following disease activity.
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[Eosinophilic fasciitis, morphea and vitiligo in a single patient]. Ann Dermatol Venereol 2014; 141:598-602. [PMID: 25288063 DOI: 10.1016/j.annder.2014.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 04/26/2014] [Accepted: 06/19/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Fasciitis with eosinophilia (FE), or Shulman syndrome, is a rare disease of unknown origin for which the nosological profile has not been clearly defined. It is clinically characterised by oedema and induration of the limbs with hypereosinophilia. It may be associated with morphea, in which case it carries a poor prognosis, or other diseases, particularly autoimmune conditions. Herein, we report a case of fasciitis associated with eosinophilia, morphea and vitiligo. PATIENT AND METHODS A 45-year-old male patient followed up for vitiligo for 20 years had been presenting swelling and induration of the skin on all 4 limbs for the previous 7 months associated with morphea on the trunk. Treatment consisting of systemic corticosteroids and methotrexate was initiated and displayed a certain degree of efficacy. DISCUSSION The association of morphea/fasciitis with eosinophilia is a classical finding; the presence of vitiligo raises the question of possible association between these different disorders.
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Lese AB, Dodds SD. Eosinophilic fasciitis: case report. J Hand Surg Am 2013; 38:2204-7. [PMID: 24206984 DOI: 10.1016/j.jhsa.2013.08.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 02/02/2023]
Abstract
A 16-year-old healthy boy presented with an acute claw hand and signs of flexor tenosynovitis or possible necrotizing fasciitis of all 4 fingers in 1 hand. After an operative incision and drainage and treatment with antibiotic, the patient improved; cultures were negative. He relapsed shortly after completing the 10-day course of antibiotics. A second incision and drainage was performed. Cultures from the second operation also revealed no infectious agent. The pathological report indicated a diagnosis of eosinophilic fasciitis. Our patient improved on antibiotics and nonsteroidal anti-inflammatory medication and has since had no further relapse. Eosinophilic fasciitis should be considered in the setting of acute claw hand and physical examination findings consistent with necrotizing fasciitis in which no infection is identified. One should consider biopsies as well as cultures during operative intervention in cases that clinically mimic serious infection but do not have purulence.
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Affiliation(s)
- Andréa B Lese
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, Connecticut..
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Radiology–pathology conference: neutrophilic fasciitis and panniculitis of the feet (Sweet's syndrome). Clin Imaging 2013; 37:608-12. [DOI: 10.1016/j.clinimag.2012.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 08/01/2012] [Indexed: 11/18/2022]
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Ton E, Kruize AA. When and how to perform biopsies in a patient with a (suspected) connective tissue disease. Best Pract Res Clin Rheumatol 2013; 27:209-36. [DOI: 10.1016/j.berh.2013.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lebeaux D, Sène D. Eosinophilic fasciitis (Shulman disease). Best Pract Res Clin Rheumatol 2012; 26:449-58. [DOI: 10.1016/j.berh.2012.08.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 08/06/2012] [Indexed: 10/27/2022]
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Orthopedic considerations with eosinophilic fasciitis: a case report and literature review. Case Rep Orthop 2012; 2012:865360. [PMID: 23227395 PMCID: PMC3504250 DOI: 10.1155/2012/865360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 04/23/2012] [Indexed: 11/28/2022] Open
Abstract
Eosinophilic fasciitis (EF) or Shulman's disease is a very rare condition first described in 1974 by Dr. Shulman in patients with diffuse fasciitis and eosinophilia. Fewer than 300 cases have been reported worldwide in the past 35 years. The current understanding of the disease in the medical community relies only on a few large case series and multiple case reports. The proposed etiology, pathological mechanisms, and consensus for therapy are obscure or lacking. The presentation of the disease is variable, but certain signs and symptoms have been associated with EF. The extreme rarity of the disease, the large constellation of signs and symptoms, as well as the lack of knowledge about eosinophilic fasciitis and make this disease difficult to recognize and treat. Through the review of the literature, there is only one other case by Yamanishi where recurrent asthma has been seen to be associated with eosinophilic fasciitis. To the knowledge of the authors of this paper this patient represents the second recorded incident. The case described by the authors of this paper demonstrated an initial biopsy of mixed cell fasciitis including eosinophils, compared to the eosinophil-rich sample taken at a later date. This could be a unique aspect to the pathology of the disease not previously discovered. Similar scenarios were not noted in a review of the literature. A change in the pathological findings as shown in this case from non-eosinophil-rich sample to one rich in eosinophils is unique in a patient actively suffering from EF. The authors of this paper propose that an allergic reaction (at the patient's puncture site) occurred, which initially caused the left hand symptoms that led to the patient's first presentation to the hospital. This is a unique causative agent, not found in the review of the literature. Through a review of the literature and the presentation of this patient, the authors propose an underlying dysregulation of the immune system, leading to the initiation or synergistic perpetuation of EF. This is a unique outlook on the disease pathology, not explained much in the medical literature.
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Hamdi W, Haouel M, Chaabouni S, Chelli Bouaziz M, Ghannouchi MM, Ladeb MF, Kchir MM. Syndrome de Shulman de l’enfant. Arch Pediatr 2012. [DOI: 10.1016/j.arcped.2011.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Cheriet S, Chastan M, Levesque H, Marie I. Positron emission tomography in the diagnosis of eosinophilic fasciitis. QJM 2011; 104:987-8. [PMID: 21081565 DOI: 10.1093/qjmed/hcq218] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- S Cheriet
- Département de Médecine interne, CHU Rouen, 1 rue de Germont, 76031 Rouen Cedex, France
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MRI findings of neutrophilic fasciitis in a patient with acute febrile neutrophilic dermatosis (Sweet's syndrome). Skeletal Radiol 2011; 40:779-82. [PMID: 21298430 DOI: 10.1007/s00256-011-1104-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 12/19/2010] [Accepted: 01/13/2011] [Indexed: 02/02/2023]
Abstract
Acute febrile neutrophilic dermatosis (Sweet's syndrome) is a clinical condition that is histopathologically characterized by infiltration of the dermis with mature neutrophils with or without vessel wall destruction. Frequently, an extracutaneous systemic disease can be seen. We report magnetic resonance imaging (MRI) findings of neutrophilic fasciitis in a 62-year-old man with Sweet's syndrome and musculoskeletal involvement. The musculoskeletal system is rarely involved in Sweet's syndrome and, to our knowledge, no previous report of MRI findings of neutrophilic fasciitis with myofascial involvement exists in the literature.
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Mujer de 47 años con disnea progresiva, tumefacción cutánea y pérdida de fuerza. Med Clin (Barc) 2011; 136:495-500. [DOI: 10.1016/j.medcli.2010.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Accepted: 10/19/2010] [Indexed: 11/29/2022]
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Servy A, Clérici T, Malines C, Le Parc JM, Côté JF. Eosinophilic fasciitis: a rare skin sclerosis. PATHOLOGY RESEARCH INTERNATIONAL 2010; 2011:716935. [PMID: 21151540 PMCID: PMC2995928 DOI: 10.4061/2011/716935] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 10/15/2010] [Accepted: 11/03/2010] [Indexed: 11/20/2022]
Abstract
Eosinophilic fasciitis (Schulman's syndrome) is a rare disease with specific clinical symptoms such as the groove sign which facilitate diagnosis. We report a typical case of eosinophilic fasciitis in an otherwise healthy 49-year-old man who presented with “prayer and groove signs”. Histological analysis showed sclerosis and eosinophilic infiltration of the fascia. The patient was successfully treated with systemic corticotherapy and Cyclosporine. A short review of the clinicopathological features of the lesions is presented.
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Affiliation(s)
- Amandine Servy
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Ambroise Paré, AP-HP, Université de Versailles Saint-Quentin-en-Yvelines, 9 Avenue Charles de Gaulle, 92104 Boulogne-Billancourt Cedex, France
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Desvignes-Engelbert A, Saulière N, Loeuille D, Blum A, Chary-Valckenaere I. Polymyalgia revealing eosinophilic fasciitis in a young male: Contribution of magnetic resonance imaging. Joint Bone Spine 2010; 77:367-8. [DOI: 10.1016/j.jbspin.2010.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2010] [Indexed: 10/19/2022]
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