Clinical study on single-organ cutaneous small vessels vasculitis: a retrospective observational study

OBJECTIVE

Single-organ cutaneous small-vessel vasculitis (SoCSVV) is an inflammatory skin-limited vascular disease affecting the dermal and/or hypodermal vessel wall. Pathogenetically, idiopathic forms are described, as well as the induction from different triggers, such as infections, drugs, and vaccines. Following the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic outbreak, cases of cutaneous vasculitis induced by both COVID-19 and COVID-19 vaccinations have been reported in literature. The aim of this study is to provide the most recent evidence on new etiological factors, clinical features, and management of the SoCSVV.

PATIENTS AND METHODS

We included 42 patients (22 women, 20 men) with SoCSVV and no systemic involvement in the study. The mean age of the patients was 57.3 years. Palpable purpura was the most frequent clinical manifestation (38 cases-90.4%). All patients were diagnosed with leukocytoclastic vasculitis by skin biopsy.

RESULTS

The etiological factors were as follows: idiopathic in 9 (21%) patients, drug-related in 19 (45%) patients, COVID-19 infection-related in 5 (12%) patients, post-COVID-19 vaccination in 5 (12%) patients, paraneoplastic in 2 (5%) patients, and drug and infection and sepsis in 1 patient each. Among the drug-related cases, 16 (84%) were antibiotic-related, and most of them were beta-lactam antibiotics. Eosinophilia was present in skin biopsy in the cases related to vaccination and drugs, while intense necrosis and vascular damage in the skin were observed in the cases related to COVID-19 infection, unlike the others. A rapid resolution was observed with the cessation of drugs and short-term steroid treatment for the precipitating factors.

CONCLUSIONS

SoCSVV is usually associated with drugs, preceding infections, and vaccines. COVID-19 infection and COVID-19 vaccinations have been reported as new etiological factors. SoCSVV indicates that the disease seems to be a mild, self-limiting illness with a good clinical result.

Cutaneous Manifestations of Diabetes Mellitus and Prediabetes

Diabetes is a serious, chronic disease with a rising prevalence worldwide. Its complications are a major cause of morbidity and mortality and contribute substantially to health care costs. In this article the authors review the most common and sensitive skin manifestations that can be present on patients with diabetes and prediabetes. The prompt recognition of these frequently underestimated entities is extremely important as it may trigger not only an adequate metabolic evaluation but also a timely referral and appropriate treatment, minimizing the secondary effects of long-term diabetes and improving the prognosis of diabetic patients.

Diffuse dermal angiomatosis

Diffuse dermal angiomatosis (DDA) is a benign and rare acquired, cutaneous, reactive, vascular disorder. We report a rare case of a 43-year-old man who presented with a large (15-cm diameter), indurated, hyperpigmented plaque covering the left buttock for 6 years. This report further discusses DDA with a review of the literature, including its classification, epidemiology, pathophysiology, etiology, histopathology, differential diagnosis, and current therapeutic approaches.

Cutaneous vasculitis in a patient with ankylosing spondylitis: A case report

RATIONALE

Cutaneous vasculitis is usually found in patients with rheumatoid arthritis (RA) as an extra-articular manifestation, but rare in patients with ankylosing spondylitis (AS). In this case, we describe an AS patient who developed large skin lesions, of which the histological findings were consistent with cutaneous vasculitis.

PATIENT CONCERNS

A 22-year-old male who was diagnosed as HLA-27 positive AS for 5 years. However, in the last year, he suffered a recurrent skin lesion in both lower extremities especially the dorsum of feet, accompanying with intense pruritus.

DIAGNOSIS

The originally diagnosis of the skin lessons was dermatitis, and then a skin biopsy pathology showed it was consistent with cutaneous vasculitis.

INTERVENTION

At first he was treated with gentamycin and ethacridine for nearly 2 weeks, the symptoms were relieved. But then he suffered severe cutaneous lesions with swell at the ulcerous margin in his dorsum of right foot. The patient was treated with dexamethasone 10 mg intravenous drip daily for 2 weeks, and followed by methylprednisolone 160 mg oral administration daily after discharge. The skin lesions were gradually healed in several months OUTCOMES:: This patient was followed up at 1-month, 5-month, and 10-month after discharged, the skin lessons was gradually healed and never occurred.

LESSONS

This case indicated that cutaneous vasculitis might be an extra-articular manifestation of AS in which IgA may plays a pathogenic part. All this may be associated with the damage of cytokines and autoantibodies to vascular endothelial wall caused by active inflammatory phase.

Herpes zoster presenting as unilateral vasculitis

Vasculitis can be a primary disorder or a cutaneous manifestation of a viral infection. The present case describes an atypical localized cutaneous varicella-zoster virus infection inducing a small vessel vasculitis in a patient with multisystem sarcoidosis. Additionally, we discuss the differential diagnoses and treatment options. Varicella-Zoster infection occurs more frequently in immunosuppressed populations and can present with uncharacteristic clinical manifestations complicating the diagnosis as in the present case.

ANCA Associated with Behçet's Disease

Behçcet's disease is a multisystem disorder affecting primarily mucocutaneous and ocular sites although the gastrointestinal, cardiovascular, central nervous and respiratory systems may also be involved. Hulusi Behçet, a Turkish dermatologist, first described Behçet's disease in 1937 and suggested a possible infectious aetiology1. The pathogenesis of this condition still remains unclear although it is likely that infection acts as a trigger in genetically susceptible individuals.

We report a patient with unusual cutaneous manifestations of Behçet's disease and antineutrophil cytoplasmic antibodies (ANCA) directed against the cytotoxic protein, bactericidal/permeability-increasing protein (BPI). This is the first report of Behçet's disease associated with this autoantibody.

Histopathologic differences between cutaneous vasculitis associated with severe bacterial infection and cutaneous vasculitis secondary to other causes: study of 52 patients

OBJECTIVES

To determine if cutaneous vasculitis (CV) associated with severe infection has some histopathologic findings that may help us to differentiate patients with this condition from other patients with CV.

METHODS

We reviewed the skin biopsy specimens of patients with leukocytoclastic CV associated with a severe bacterial infection. Histopathologic findings of these patients were compared with those observed in leukocytoclastic CV secondary to other causes. Biopsy-proven leukocytoclastic CV were stratified as follows: group a): CV associated with severe underlying bacterial infection; group b): CV without severe bacterial infection but with systemic involvement; group c): CV without systemic involvement. Slides were reviewed by expert pathologists that were blind to the clinical information. The severity of vascular lesions was measured according to a semiquantitative scale (Hodge index). A comparative study between group a) and the other groups was conducted.

RESULTS

group a) included 12 patients (2 women/10 men), mean age± SD 56±15 years; group b) 21 patients (10 women/11 men), 52±18 years; and group c) 19 patients (12 women/7 men), 59±24 years. Presence of neutrophilia was significantly increased in biopsies from group a) when compared with the other two groups. Also, a trend to higher frequency of pustular dermatosis was found in patients from group a). Hodge index, degree of inflammatory infiltrate and deep arterioles involvement were similar in all groups.

CONCLUSIONS

Neutrophilia is common in skin biopsies of patients with CV associated with severe bacterial infection. No other histopathological findings help us to establish the presence of a severe underlying infection.

Cutaneous and ocular manifestations of neurocutaneous syndromes

Neurocutaneous syndromes are a heterogeneous group of congenital and hereditary disorders with manifestations in the skin and the nervous system, usually together with ocular features that represent diagnostic clues and potential sources of morbidity. Dermatologists and ophthalmologists often need to work together in identifying and managing patients with these conditions; herein, we focus on classic and under-recognized neurocutaneous syndromes. We begin with autosomal dominant genodermatoses characterized by hamartomas and tumors in the skin, eyes, and central nervous system: neurofibromatosis type 1, tuberous sclerosis complex, and PTEN hamartoma-tumor syndrome. This is followed by a discussion of two mosaic disorders, Sturge-Weber syndrome and neurocutaneous melanocytosis. In addition to providing an update on clinical presentations and evaluation of patients with these conditions, we review recent insights into their pathogenesis, drawing attention to relationships among the diseases on a molecular level and implications regarding treatment. We also highlight the major features of other neurocutaneous syndromes that have ocular findings plus pigmentary, vascular, hyperkeratotic, adnexal, connective tissue, photosensitive, and inflammatory manifestations in the skin.

Cutaneous vasculitis and inflammatory bowel diseases

Extraintestinal manifestations occur in up to 40% of patients living with inflammatory bowel disease (IBD) and may precede the onset of gastrointestinal symptoms by many years. Vasculitides are considered rare cutaneous manifestations, but they often represent an important cause of morbidity and a relevant diagnostic issue in IBD. In addition, the increasing use of biological therapies for IBD may also play a pivotal role in the development of vascular disorders of different type. Hence, we provide a complete and in-depth review of the main features of cutaneous vasculitides observed in IBD, with a specific focus on their clinical presentation and possible pathophysiological mechanisms.

Vasculitis associated with connective tissue diseases

Vasculitis in connective tissue disease (CTD) is quite rare, it is reported in approximately 10% of patients with CTD; systemic lupus erythematosus (SLE) shows the highest association rate. Vessels of any size may be involved, but mainly small vessels vasculitis is reported. At present the classification of these vasculitis is unsatisfactory. According to the 2012 revised International Chapel Hill Consensus Conference, vasculitides secondary to CTD are a well identified entity and are classified under the category of "vasculitis associated with systemic disease". However only lupus vasculitis and rheumatoid vasculitis are explicitly listed, while the remaining are generically included under the heading "others". Petechiae, purpura, gangrene and ulcers are the most frequent cutaneous manifestations that should investigated in order to rule out potentially dangerous systemic involvement, especially if cryoglobulinemic or necrotizing vasculitis are suspected. This review will focus on the cutaneous involvement in CTD associated vasculitis.

Cutaneous vasculitis associated with severe bacterial infections. A study of 27 patients from a series of 766 cutaneous vasculitis

OBJECTIVES

To assess the clinical spectrum of severe bacterial infections presenting as cutaneous vasculitis (CV) in a defined population.

METHODS

Unselected series of 766 patients with CV diagnosed at a single university referral center.

RESULTS

An underlying severe bacterial infection was diagnosed in 27 (22 men/5 women; mean age ± standard deviation [SD]: 53 ± 18 years) of 766 cases presenting with CV (3.5%). These infections were: pneumonia (n=8), endocarditis (n=6), meningitis (n=4), intra-abdominal infections (n=3), septic arthritis (n=2), septicaemia (n=2), septic bursitis (n=1), and urinary tract infection (n=1). All the patients were admitted for suspected CV. The median delay from admission to the diagnosis of infection was 4 days. A typical palpable purpura without relevant visceral vasculitic involvement was the main clinical manifestation. Patients with severe bacterial infections were older, with male predominance, had more frequently fever, constitutional symptoms, focal infectious features, and leukocytosis with left shift and anaemia than the remaining patients with CV. Although antibiotics were prescribed in all the patients, seven also required the use of low-dose corticosteroids to achieve complete resolution of the cutaneous lesions. Most patients experienced full recovery but two of them underwent prosthetic cardiac valve replacement, and another two died due to infection-related complications.

CONCLUSIONS

CV may be the presenting manifestation of a severe underlying bacterial infection. Physicians should keep in mind this fact to make an early diagnosis of infection and, consequently, prevent life-threatening complications.

Tobacco differentially affects the clinical-biological phenotypes of ANCA-associated vasculitides

OBJECTIVES

To describe the clinical-biological phenotype of ANCA-associated vasculitides (AAV) according to tobacco consumption.

METHODS

We conducted a descriptive study to describe that phenotype at diagnosis according to tobacco use. AAV patients entered in the French Vasculitis Study Group database with data on smoking habits were analysed. The clinical-biological phenotypes at diagnosis were compared according to current tobacco use (current smokers) or not (including previous and never smokers).

RESULTS

AAV diagnoses were: granulomatosis with polyangiitis (GPA) for 583 (50%), eosinophilic granulomatosis with polyangiitis (EGPA) for 326 (28%) and microscopic polyangiitis (MPA) for 256 (22%). Among them, 973 patients (84%) never smoked, 116 (10%) were previous smokers and only 76 (6%) were current smokers. Current smokers were younger age (p=0.01), male gender (p=0.004), less frequently EGPA (p=0.017) and MPA (p=0.036), and had less frequent kidney involvement (p=0.10). Among GPA patients, current smokers, compared to non-current smokers, were younger age (p=0.02), male gender (p=0.08), more frequent skin involvement (p=0.03) and less frequent ENT involvement (p=0.06). Among EGPA patients, current smokers, compared to non-current smokers, were also younger (p=0.028) and had less frequent constitutional symptoms (p=0.02), arthralgias (p=0.04), renal involvement (p=0.025) and MPO-ANCA (p=0.02). Finally, analysis of MPA patients was impossible because only 6 (2%) were current smokers.

CONCLUSIONS

These results suggest that tobacco use could differentially affect GPA and EGPA clinical-biological phenotypes, and support the role of environmental exposures in AAV development and its phenotype.

[Calcific uremic arteriolopathy (Calcyphilaxis): a rare disease? Report of three cases]

INTRODUCTION

Calcific uremic arteriolopathy (CUA; CALCYPHILAXIS) is a syndrome that occurs prevalently in patients with chronic kidney disease on dialysis. It is characterized by the medial calcification of skin small arteries leading to necrotic lesions. Several risk factors have been identified: obesity, female gender, diabetes mellitus, hyperphosphatemia, inflammation, treatment with vitamin D, calcium-based phosphate binders and warfarin.

MATERIALS AND METHODS

We report three cases of CUA observed from October 2011 to September 2014.

RESULTS

The mean age at diagnosis was 56 years (range 33-68). Biochemistry showed: mean levels of PTH=1277 pg/ml (range 1000-1696), serum calcium =10.2 mg/dl (range 9.4-11.1), phosphorus=4.5 mg/dl (range 3.4-5.5). All patients were taking vitamin D, two patients were on warfarin therapy. Following actions were undertaken: interruption of calcium-based phosphate binders, vitamin D and warfarin therapy, initiation of cinacalcet and sodium thiosulfate therapy, use of dialysate with lowest available calcium concentration (1.25 mmol/l), Hyperbaric Oxygen Therapy, surgical dressings of skin lesions three times a week. Significant improvement was observed in mean levels of PTH (331 pg/ml, range 200-465), serum calcium (8.3 mg/dl, range 7.4-9.6) and phosphorus (3.4 mg/dl, range 2.6-3.8). In two out of three patients complete healing of ulcerative lesions was obtained.

CONCLUSIONS

These cases underline the importance of early diagnosis of CUA especially in patients with concomitant risk factors and careful clinical monitoring, being CUA characterized by a rapid evolution and high mortality.

Cutaneous decompression sickness

A probable case of decompression illness with associated cutis marmorata is presented, which regressed over a few hours with oxygen breathing and after intravenous methylprednisolone and fluid resuscitation without recompression. He was eventually transferred for hyperbaric treatment some 10 hours post dive. Cutaneous decompression illness is not associated with high mortality per se, but prompt and accurate recognition is warranted, as it may represent a prodromal feature of potentially life-threatening complications. However, in this case, as differential diagnosis, an allergic reaction remains possible.

[Chromametry, a promising technique for the quantification of skin changes in chronic venous disorders]

OBJECTIVE

The development and validation of new clinimetric tools is essential for the progress of clinical research in the field of chronic venous insufficiency. Chromametry is a simple, quick and non-invasive technique that measures the color of the skin. The aim of this study was to evaluate the ability of this technique to quantify skin pigmentation as a marker of severity of chronic venous disease and to assess the variability of measurements obtained in this condition.

METHODS

Chomametry was performed on three different sites on each lower limb in 42 patients undergoing a spa treatment in La Léchère (Savoie) for chronic venous disorders (CVD). Four series of measurements were taken by two investigators for each patient, at two sessions two to four days apart.

RESULTS

The chromameter readily measured the pigmentation index (PI). The PI increased with higher clinical class (CEAP classification) for measurements made at the malleolar level (r=0.48; P<0.001) and the supra-malleolar area (r=0.55; P<0.001), but not at the level of the anterior tibial tuberosity (r=-0.09; P=0.45). The repeatability and the intra- and inter-observer reproducibility of this PI index were 15%, 18% and 21% respectively of the mean of the observed difference at the malleolar level. The chromameter also provided an erythema index, which appears to be less relevant and more variable than the PI, but which might add potentially useful information regarding the characterization of skin inflammation related to the venous disease.

CONCLUSION

This study shows that chromametry can be used in clinical research studies to quantify skin changes associated with CVD. Whether it can also be useful for early detection and follow-up of patients with venous trophic changes remains to be investigated.

Statin use and calcific uremic arteriolopathy: a matched case-control study

BACKGROUND

Calcific uremic arteriolopathy (CUA), also known as calciphylaxis, is characterized by vascular calcification, thrombosis and intense inflammation. Prior research has shown that statins have anticalcification, antithrombotic and antiinflammatory properties; however, the association between statin use and CUA has not been investigated.

METHODS

This matched case-control study included 62 adult maintenance hemodialysis (HD) patients with biopsy-confirmed CUA diagnosed between the years 2002 and 2011 (cases). All cases were hospitalized at the time of diagnosis. Controls (n = 124) were hospitalized maintenance HD patients without CUA (matched to cases by gender and timing of hospitalization). Univariate and multivariable logistic regression models were applied to compute odds ratio (OR) and 95% confidence intervals (CI) for CUA in statin users, and also to examine previously described associations.

RESULTS

The mean age of cases was 58 years. Most were females (68%), and of white race (64%). Statin use was more common in controls than in cases (39 vs. 19%, p < 0.01). Statin use was associated with lower odds of CUA in unadjusted (OR 0.38, 95% CI 0.18-0.79) and adjusted (OR 0.20, 95% CI 0.05-0.88) analyses. Hypercalcemia (OR 2.25, 95% CI 1.14-4.43), hypoalbuminemia (OR 5.73, 95% CI 2.79-11.77), calcitriol use (OR 5.69, 95% CI 1.02-31.77) and warfarin use (OR 4.30, 95% CI 1.57-11.74) were positively associated with CUA in adjusted analyses whereas paricalcitol and doxercalciferol were not (OR 1.33, 95% CI 0.54-3.27).

CONCLUSION

Statin use may be negatively associated with odds of CUA. Further large prospective studies with attention to potential confounders are needed to confirm these findings.

Progressive late-onset of cutaneous angiomatosis as possible sign of cerebral cavernous malformations

BACKGROUND

Cerebral cavernous malformations (CCM) comprise enlarged capillary cavities in the central nervous system, with possible retinal or cutaneous vascular malformations. This condition is associated with CCM1, CCM2, and CCM3 gene mutations.

OBJECTIVE

Cutaneous clinical, histological and cerebral MRI findings, including CCM1, CCM2, and CCM3 gene sequencing, of two unrelated, neurological symptom-free patients who consulted for late-onset of deep multiple cutaneous angiomatoid lesions, are described.

RESULTS

The diagnosis of multiple cutaneous angiomatosis was confirmed and related to CCM as detected by MRI in both cases. Analysis of our patients showed normal nucleotide sequences of the genes proposed.

CONCLUSIONS

A progressive late-onset of multiple, deep cutaneous venous malformations may indicate the need to investigate a potential coexistence of CCM by MRI. Early diagnosis and prompt treatment is required in these patients. The absence of CCM1, CCM2, and CCM3 mutations might indicate that different genes could be involved in the pathogenesis of these late-onset patients. Careful questioning about family history of CCM is important; our first patient's daughter had a history of cerebral cavernoma.

An approach to vasculitis and vasculopathy

My approach to vasculitis and vasculopathy includes: (1) Determine the level of care the patient needs. If I am not sure, I will order a basic laboratory evaluation while I decide on the more specific laboratory tests to order and of course do a skin biopsy. (2) Determine if the eruption represents vasculitis or vasculopathy. The presence of livedo reticularis or retiform purpura points toward vasculopathy, but keep in mind the overlap, especially with the ANCA-associated vasculitides. (3) If vasculitis, rule out the secondary causes (ie, infection, drug reactions, malignancy, connective-tissue disorders) first. (4) Determine the size of the vessel involvement and the organ systems involved, which will narrow down the differential diagnosis. Although no one approach works for everyone, I find this method to be simple and keeps you organized when tackling the workup of vasculitis and vasculopathy.

[Skin vessel lesions in aluminum potroom workers]

The features of development of the skin vessels lesions in 550 aluminum production workers have been investigated. The high prevalence of these disorders have been revealed in anode-operators and cell-operators, 49, 3 and 26.0% of workers, respectively. The regularity and staging of the development of this abnormity have been established, etiology, pathogenesis and clinical significance of those remain unknown.

[Vascular changes in severe carpal tunnel syndrome: a differential diagnosis of vasculitis]

Carpal tunnel syndrome may present with skin lesions. This may lead to a differential diagnosis with vasculitis. Sympathetic nervous system perivascular involvement and recurrent injuries secondary to sensory loss are probably part of the mechanism of injury. In this case, we also comment on the pathogenic role of persistent median artery associated with a bifid median nerve.

Livedo racemosa, secondary to drug-induced systemic lupus erythematosus

We present a 40-year-old man with erythematous-to-violaceous, broken, reticulated patches on the upper chest, back, and extremities, which is consistent with livedo racemosa. The cutaneous findings appeared after an increase in dilantin dose and subsequently improved after a reduction in dilantin dose. Furthermore, antinuclear antibodies and antihistone antibodies were detected. We therefore believe that the livedo racemosa is a cutaneous manifestation of a drug-induced systemic lupus erythematosus. We review the distinctive features of livedo racemosa as well as its associations with several disorders. Although there are no effective treatments for livedo racemosa, patients often are placed on low-dose aspirin and counseled to avoid smoking in an effort to protect against their increased risk of stroke and arterial thrombosis.

Cutaneous vasculitis: a review of aetiology and clinical manifestations in 85 patients in Malaysia

Cutaneous vasculitis presents with a variety of clinical morphologies and causes significant morbidity. A total of 85 patients with cutaneous vasculitis at Hospital Kuala Lumpur were retrospectively reviewed. Palpable purpura was seen in 49.4% and frequently involved the lower limbs (50.6%). Identifiable causes include drugs (28.2%), infections (20.0%) and connective tissue disorders (16.5%). Non steroidal antiinflammatory were the commonest group of drugs responsible for 25% of cases while B-haemolytic streptococci was the leading infectious cause (64.7%).

Lower extremity ulcers in connective tissue disease

Lower extremity ulcers are a late complication of connective tissue diseases and occur more commonly in patients with these diseases than in the general population. Although these lesions have historically been attributed to vasculitis, it is now recognized that inflammatory vessel injury accounts for fewer than 20% of ulcers in connective tissue disease. The pathogenesis of these lesions is complex, and often several processes act synergistically to initiate and perpetuate tissue injury. We review the evidence for antiphospholipid antibodies and prothrombotic states contributing to a vasculopathy in patients with connective tissue disease, precipitating ulceration and impairing healing.

Physiologic anemic macules

Anemic-appearing macules of the extremities that fluctuate with temperature and position have been referred to as Bier spots. After review of the literature and innumerable clinical presentations, we propose that the best description and better nomenclature is physiologic anemic macules. We present the case of a 27-year-old woman with physiologic anemic macules and review the history of this condition.

Clinical approach to cutaneous vasculitis

Vasculitis is an inflammatory process affecting the vessel wall and leading to its compromise or destruction and subsequent hemorrhagic and ischemic events. Vasculitis can be classified as a primary phenomenon (e.g. idiopathic cutaneous leukocytoclastic angiitis or Wegener granulomatosis) or as a secondary disorder (connective tissue disease [CTD], infection, or adverse drug eruption-associated vasculitis). Cutaneous vasculitis may present as a significant component of many systemic vasculitic syndromes such as rheumatoid vasculitis or anti-neutrophil cytoplasmic antibody (ANCA)-associated primary vasculitic syndromes (Wegener granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis). Cutaneous vasculitis manifests most frequently as palpable purpura or infiltrated erythema indicating dermal superficial, small-vessel vasculitis, and less commonly as nodular erythema, livedo racemosa, deep ulcers, or digital gangrene implicating deep dermal or subcutaneous, muscular-vessel vasculitis. A biopsy extending to the subcutis taken from the most tender, reddish or purpuric lesional skin is the key to obtaining a significant diagnostic result and serial sections are often required for identifying the main vasculitic lesion. Coexistence of pan-dermal small-vessel vasculitis and subcutaneous muscular-vessel vasculitis usually indicates CTD, ANCA-associated vasculitis, Behçet disease, or malignancy-associated vasculitis. A concomitant biopsy for direct immunofluoresence evaluation contributes to accurate diagnosis by distinguishing IgA-associated vasculitis (Henoch-Schönlein purpura) from IgG-/IgM-associated vasculitis, which has prognostic significance. Treatment for cutaneous vasculitis should include avoidance of triggers (excessive standing, infection, drugs) and exclusion of vasculitis-like syndromes (pseudovasculitis) such as thrombotic disorders (e.g. anti-phospholipid antibody syndrome). In most instances, cutaneous vasculitis represents a self-limited condition and will be relieved by leg elevation, avoidance of standing, and therapy with NSAIDs. For mild recurrent or persistent disease, colchicine and dapsone are first-choice agents. Severe cutaneous disease requires treatment with systemic corticosteroids or more potent immunosuppression (azathioprine, methotrexate, cyclophosphamide). A combination of corticosteroids and cyclophosphamide is required therapy for systemic vasculitis, which is associated with a high risk of permanent organ damage or death. In cases of refractory vasculitis, plasmapheresis and intravenous immunoglobulin are viable considerations. The new biologic therapies that act via cytokine blockade or lymphocyte depletion, such as the tumor necrosis factor-alpha inhibitor infliximab and the anti-B-cell antibody rituximab, respectively, are showing benefit in certain settings such as CTD and ANCA-associated vasculitis.

Cutaneous allergic vasculitis due to Solenopsis geminata (Hymenoptera: Formicidae) envenomation in Indonesia

Severe cutaneous allergic vasculitis in a 60 year-old Caucasian male following the bite of the tropical fire ant, Solenopsis geminata (F.) is reported. Over the course of 8 weeks, the pathology progressed from an extensive red papular urticaria to vasculitis with peri-vascular inflammation and ulceration of the skin on the feet, ankles and lower limbs. Many of the affected areas of the skin eventually became covered with black eschar associated with further tissue breakdown and ulcer formation. After debridement, compression dressings, antimicrobial ointment and corticosteroids, complete healing eventually took place with only residual scarring. An awareness of the severe dermatologic reactions caused by a bite of S. geminata, albeit rare, is clinically important. Recognizing the characteristic skin lesions caused by the bite of S. geminata, treated with prompt administration of appropriate chemotherapy will speed recuperation of the patient and reduce possible secondary complications.

[Vascular emergencies in dermatology]

Life-threatening vascular complications of the skin are rare and usually reflect underlying systemic diseases. Lesions are sudden in onset, become necrotic and may be severe or life-threatening. Effective management requires an understanding of the underlying medical condition, such as arterial thrombosis, temporal arteritis, calciphylaxis and purpura fulminans. In contrast, the acute painful symptoms of erythromelalgia often lead to an urgent dermatologic consultation but pose no acute risk.

Clusters of disease manifestations in patients with antiphospholipid syndrome demonstrated by factor analysis

The antiphospholipid syndrome (APS) is now recognized as a multi-system disease, the clinical expression of which may include various target-organs involvements. Despite the reported heterogeneity in clinical presentation of APS, the interrelations between various manifestations of the disease has not yet been studied. We evaluated the principle associations between a variety of clinical manifestations in APS patients, applying factor analysis. Two-hundred and forty-six APS patients were studied. The following disease manifestations were used for the factor analysis: recurrent fetal loss, intrauterine growth restriction (IUGR), venous and arterial thrombosis, cardiac valves thickening/dysfunction, valvular vegetations, stroke, epilepsy, migraine, arthritis, livedo reticularis, thrombocytopenia, leukopenia and autoimmune hemolytic anemia (AIHA). The results were further analysed in relation to sex and to primary APS versus APS associated with SLE. Five factors were derived, which accounted for 59.7% of the variance of the matrix. Factor 1 (which explained 18.5% of variance of the original matrix) represented the association between cardiac valves abnormalities, livedo reticularis and AIHA. Factor 2 (13.8% of variance) represented association between arthritis, thrombocytopenia and leukopenia. Factor 3 (10.3% of variance) represented an association between recurrent fetal loss and IUGR. Factor 4 (9.3% of variance) represented inverse correlation between arterial and venous thrombosis. Factor 5 (7.8% of variance) represented an association between epilepsy and migraine. Application of factor analysis revealed specific clusters of cardiac, cutaneous, hematological and neurological manifestations. Our result also point to a possible divergence of arterial and venous thrombotic tendency. Awareness of these patterns might give us a better understanding of the disease.

Granulomatous arteritis in cutaneous lesions of Churg?Strauss syndrome

BACKGROUND

Although granulomatous arteritis is usually found in extracutaneous Churg-Strauss syndrome (CSS) lesions, the vasculitis in CSS cutaneous lesions typically shows small vessel vasculitis (leukocytoclastic vasculitis) without demonstrating the feature of granulomatous arteritis confirming the proper classification of CSS in the category of granulomatous vasculitis.

METHODS

Four deep excisional biopsies were obtained from three untreated CSS patients who presented with livedo reticularis and subcutaneous nodules. Tissue blocks were recut and submitted for hematoxylin and eosin and elastic tissue staining to evaluate the histological features of the affected vessels. Immunostaining for histiocytes, lymphocytes, and neutrophils were performed on serial sections to confirm the cellular infiltration.

RESULTS

In all specimens, subcutaneous granulomatous arteritis was observed. The unique histological feature distinct from other vasculitic disorders is characterized by marked infiltration of histiocytes and multinucleated giant cells in and around the disrupted subcutaneous arterial walls mixed with an eosinophilic infiltrate. In two specimens, granulomatous arteritis was found in the subsequent serial sections, not in the initial sections. The initial section may show extravascular granulomatous inflammation without evidence of vasculitis.

CONCLUSIONS

Granulomatous arteritis as identified in the extracutaneous lesions can also be found in subcutaneous CSS lesions presenting with livedo reticularis and/or subcutaneous nodules.

An Unusual Case of Livedoid and Necrotic Lesions in a Drug Addict

Skin biopsies were performed in a patient with livedoid and necrotic lesions of the forearm. Periodic acid-Schiff-stained and birefringent Maltese cross-patterned foreign bodies were observed in capillary vessels. It was consistent with the diagnosis of intra-arterial injections of a substance containing corn starch. This finding confirmed the clinical diagnosis of intra-arterial injection of solubilized tablets of buprenorphine. This case constitutes a rare clinical presentation of foreign bodies injections in a drug addict.

Cytomegalovirus-associated cutaneous vasculopathy and scleroderma sans inclusion body change

Viruses have long been held to be of pathogenetic importance in the evolution of autoimmune connective tissue disease. We describe 7 adults who developed cutaneous connective tissue disease stigmata in temporal association with recent cytomegalovirus (CMV) infection but without the classic cytopathic changes of CMV infection. We examined 7 adults with clinical presentations encompassing cutaneous vasculitis in 4 and scleroderma in 3. In all 7 patients, there was either IgM seropositivity for CMV and/or CMV DNA isolation from peripheral blood. Although no CMV inclusions were seen, in situ hybridization studies revealed very focal CMV RNA transcript expression with localization mainly to the endothelium. The patients with vasculitis treated with ganciclovir had improvement or resolution of symptoms, whereas only 1 patient with scleroderma received antiviral therapy, without benefit. Another scleroderma patient responded to infliximab therapy. Abortive/partial CMV reactivation can be associated with a syndrome complex mimicking and/or triggering a primary immune-based cutaneous microvascular injury syndrome. Antiviral therapy appears to be of therapeutic value in those cases associated with active necrotizing vasculitic changes. The role of tumor necrosis factor alpha blockers in scleroderma cases temporally associated with CMV infection requires further evaluation.