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Teoh SC, Sim CY, Chuah SL, Kok V, Teh CL. Pyoderma gangrenosum and cobalamin deficiency in systemic lupus erythematosus: a rare but non fortuitous association. BMC Rheumatol 2021; 5:7. [PMID: 33653418 PMCID: PMC7927254 DOI: 10.1186/s41927-021-00177-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is an uncommon, idiopathic, ulcerative neutrophilic dermatosis. In many cases, PG is associated with a wide variety of different disorders but SLE in association with PG is relatively uncommon. In this article we present the case of a middle aged patient with PG as the initial clinical presentation of SLE. We also provide a brief review of cobalamin deficiency which occurred in our patient and evidence-based management options. CASE PRESENTATION A 35 years old man presented with a 5 month history of debilitating painful lower limb and scrotal ulcers. This was associated with polyarthralgia and morning stiffness involving both hands. He also complained of swallowing difficulties. He had unintentional weight loss of 10 kg and fatigue. Physical examination revealed alopecia, multiple cervical lymphadenopathies, bilateral parotid gland enlargement and atrophic glossitis. There was Raynaud's phenomenon noted over both hands and generalised hyper-pigmented fragile skin. Laboratory results disclosed anaemia, leukopenia, hyponatraemia and hypocortisolism. Detailed anaemic workup revealed low serum ferritin and cobalamin level. The autoimmune screen showed positive ANA, anti SmD1, anti SS-A/Ro 52, anti SSA/Ro 60, anti U1-snRNP with low complement levels. Upper gastrointestinal endoscopy with biopsies confirmed atrophic gastritis and duodenitis. Intrinsic factor antibodies and anti-tissue transglutaminase IgA were all negative. Punch biopsies of the leg ulcer showed neutrophilic dermatosis consistent with pyoderma gangrenosum. Based on the clinical findings and positive immunologic studies, he was diagnosed as systemic lupus erythematosus. His general condition improved substantially with commencement of corticosteroids, immunosuppressants and vitamin supplements. CONCLUSIONS We report a case of PG as the first manifestation of SLE which was treated successfully with immunosuppressants and vitamin supplements. Our report highlighted the need to consider connective tissue diseases such as SLE in a patient presenting with PG in order for appropriate treatment to be instituted thereby achieving a good outcome.
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Affiliation(s)
- Sing Chiek Teoh
- Department of Medicine, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Chun Yang Sim
- Faculty of Medicine and Health Sciences, University Malaysia Sarawak, Jalan Datuk Mohammad Musa, 94300, Kota Samarahan, Sarawak, Malaysia.
| | - Seow Lin Chuah
- Department of Medicine, Rheumatology Unit, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Victoria Kok
- Department of Medicine, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Cheng Lay Teh
- Department of Medicine, Rheumatology Unit, Sarawak General Hospital, Kuching, Sarawak, Malaysia
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Magdoud O, Souissi A, Chelly I, Haouet S, Mokni M. [Pyoderma gangrenosum and systemic lupus erythematosus: A rare association]. Rev Med Interne 2019; 41:54-57. [PMID: 31495525 DOI: 10.1016/j.revmed.2019.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/03/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Pyoderma gangrenosum (PG) is a neutrophilic dermatosis that is traditionally associated with systemic disorders such as chronic inflammatory bowel diseases, rheumatoid arthritis and malignant hematologic disorders. Its association with systemic lupus erythematosus (SLE) is rare and not well known. We report a case of this association with a review of the literature. CASE REPORT A 43-year-old female patient, followed for 4 years for SLE, presented a deep ulceration of the anterior face of the left thigh with inflammatory borders, an ulcerated nodule of the right shoulder and four small ulcerations of the back of the right hand. The biopsy of the ulceration of the left thigh concluded to PG. The patient was treated by corticosteroids with complete healing of lesions. CONCLUSION The prognosis of lupus does not seem to be aggravated by PG and the treatments of a SLE flare are usually enough for treating associated PG.
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Affiliation(s)
- O Magdoud
- Dermatology department, La Rabta Hospital, Tunis, Tunisia.
| | - A Souissi
- Dermatology department, La Rabta Hospital, Tunis, Tunisia
| | - I Chelly
- Pathology department, La Rabta Hospital, Tunis, Tunisia
| | - S Haouet
- Pathology department, La Rabta Hospital, Tunis, Tunisia
| | - M Mokni
- Dermatology department, La Rabta Hospital, Tunis, Tunisia
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Lebrun D, Robbins A, Hentzien M, Toquet S, Plee J, Durlach A, Bouaziz JD, Bani-Sadr F, Servettaz A. Two case reports of pyoderma gangrenosum and systemic lupus erythematosus: A rare but nonfortuitous association? Medicine (Baltimore) 2018; 97:e11933. [PMID: 30142811 PMCID: PMC6112963 DOI: 10.1097/md.0000000000011933] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
RATIONALE Pyoderma gangrenosum (PG), like other neutrophilic dermatosis, may be associated with a variety of systemic disorders including inflammatory bowel diseases, rheumatoid arthritis, and hematologic disorders. Conversely, the association between PG and systemic lupus erythematosus (SLE) has rarely been reported. PATIENT CONCERNS We report here 2 cases of this association. DIAGNOSES The first case involves a 32-year-old woman who developed, 1 year after SLE diagnosis, 3 painful nodular lesions of PG on her face, and cervical area. The second case was observed in a 37-year-old woman referred for ulcerative nodular papules of PG on her legs, whereas she had been diagnosed with SLE 10 years before. SLE was inactive in the first case, whereas PG occurred during a lupus flare up in the second one. INTERVENTIONS We found 23 previous cases of SLE and PG in the literature with most cases (12/20) occurring during a lupus flare. OUTCOMES Although rare, this association may be supported by common innate immunity dysregulation and abnormal neutrophil activation. LESSONS PG and other neutrophilic diseases reported in patients with SLE may be added to the large clinical spectrum of cutaneous lesions observed in SLE.
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Affiliation(s)
- Delphine Lebrun
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
- Department of Internal Medicine and Infectious Diseases, Manchester Hospital, Charleville-Mézières
| | - Ailsa Robbins
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
| | - Maxime Hentzien
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
| | - Ségolène Toquet
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
| | - Julie Plee
- Department of Dermatology, Robert Debré Hospital
| | - Anne Durlach
- Laboratory of Pathology, Maison Blanche Hospital, University Hospital, Reims
| | | | - Firouzé Bani-Sadr
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
| | - Amélie Servettaz
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
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Hau E, Vignon Pennamen MD, Battistella M, Saussine A, Bergis M, Cavelier-Balloy B, Janier M, Cordoliani F, Bagot M, Rybojad M, Bouaziz JD. Neutrophilic skin lesions in autoimmune connective tissue diseases: nine cases and a literature review. Medicine (Baltimore) 2014; 93:e346. [PMID: 25546688 PMCID: PMC4602621 DOI: 10.1097/md.0000000000000346] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The pathophysiology of neutrophilic dermatoses (NDs) and autoimmune connective tissue diseases (AICTDs) is incompletely understood. The association between NDs and AICTDs is rare; recently, however, a distinctive subset of cutaneous lupus erythematosus (LE, the prototypical AICTD) with neutrophilic histological features has been proposed to be included in the spectrum of lupus. The aim of our study was to test the validity of such a classification. We conducted a monocentric retrospective study of 7028 AICTDs patients. Among these 7028 patients, a skin biopsy was performed in 932 cases with mainly neutrophilic infiltrate on histology in 9 cases. Combining our 9 cases and an exhaustive literature review, pyoderma gangrenosum, Sweet syndrome (n = 49), Sweet-like ND (n = 13), neutrophilic urticarial dermatosis (n = 6), palisaded neutrophilic granulomatous dermatitis (n = 12), and histiocytoid neutrophilic dermatitis (n = 2) were likely to occur both in AICTDs and autoinflammatory diseases. Other NDs were specifically encountered in AICTDs: bullous LE (n = 71), amicrobial pustulosis of the folds (n = 28), autoimmunity-related ND (n = 24), ND resembling erythema gyratum repens (n = 1), and neutrophilic annular erythema (n = 1). The improvement of AICTDS neutrophilic lesions under neutrophil targeting therapy suggests possible common physiopathological pathways between NDs and AICTDs.
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Affiliation(s)
- Estelle Hau
- From the Dermatology Department (EH, AS, MJ, FC, MarB, MR, JDB) and Pathology Department (MDVP, MaxB, BCB), Paris Diderot University, Sorbonne Paris Cité, AP-HP, Saint Louis Hospital, Paris, France
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González-Moreno J, Ruíz-Ruigomez M, Callejas Rubio JL, Ríos Fernández R, Ortego Centeno N. Pyoderma gangrenosum and systemic lupus erythematosus: a report of five cases and review of the literature. Lupus 2014; 24:130-7. [PMID: 25199808 DOI: 10.1177/0961203314550227] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pyoderma gangrenosum (PG) is an uncommon, distinctive cutaneous ulceration which is usually idiopathic, but may be associated with many systemic disorders. The etiopathogenesis of PG is still not well understood. PG is part of the spectrum of the neutrophilic dermatoses and it has been proposed as a prototype of cutaneous autoinflammatory disease. PG usually has a good outcome under immunosuppressive treatment. Although PG has been associated with several systemic diseases, it has rarely been reported in association with systemic lupus erythematosus (SLE). In this article we report five cases of SLE-related PG and review the literature. Our findings support the possible relationship between active SLE and PG, although the mechanism remains unclear. Clinical manifestations, used treatments and outcomes of SLE-related PG do not differ from the described for the general population.
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Affiliation(s)
- J González-Moreno
- Internal Medicine Department, Hospital Son Llàtzer, Spain Autoimmune Diseases Unit, Internal Medicine Department, Hospital Clínico San Cecilio, Spain
| | - M Ruíz-Ruigomez
- Autoimmune Diseases Unit, Internal Medicine Department, Hospital Clínico San Cecilio, Spain
| | - J L Callejas Rubio
- Autoimmune Diseases Unit, Internal Medicine Department, Hospital Clínico San Cecilio, Spain
| | - R Ríos Fernández
- Autoimmune Diseases Unit, Internal Medicine Department, Hospital Clínico San Cecilio, Spain
| | - N Ortego Centeno
- Autoimmune Diseases Unit, Internal Medicine Department, Hospital Clínico San Cecilio, Spain
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Molecular basis of hereditary C1q deficiency--revisited: identification of several novel disease-causing mutations. Genes Immun 2011; 12:626-34. [PMID: 21654842 DOI: 10.1038/gene.2011.39] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
C1q is the central pattern-recognition molecule in the classical pathway of the complement system and is known to have a key role in the crossroads between adaptive and innate immunity. Hereditary C1q deficiency is a rare genetic condition strongly associated with systemic lupus erythematosus and increased susceptibility to bacterial infections. However, the clinical symptoms may vary. For long, the molecular basis of C1q deficiency was ascribed to only six different mutations. In the present report, we describe five new patients with C1q deficiency, present the 12 causative mutations described till now and review the clinical spectrum of symptoms found in patients with C1q deficiency. With the results presented here, confirmed C1q deficiency is reported in 64 patients from at least 38 families.
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