[Polyarthritis and papular eruption revealing leprosy]

Leprosy is generally revealed by cutaneous lesions often associated to nerve impairment. Rarely, it may be revealed by polyarthritis. The diagnosis, often delayed in the cutaneous-nevritic form because of the low prevalence of the disease in metropolitan France, is very difficult in case of rheumatic presentation. We report the case of a 28 year-old woman from Mali, who was diagnosed with lepromatous borderline leprosy with reversal reaction occurring in the postpartum as she presented with polyarthritis and skin lesions.

Survenue d’un psoriasis au cours d’un traitement par infliximab pour fasciite de Shulman

BACKGROUND

Anti-TNFalpha drugs are used in certain rheumatologic and gastrointestinal inflammatory diseases and are also effective in cutaneous psoriasis. Several case reports have recently been published concerning induction of paradoxical psoriasis during the course of anti-TNF therapy. We report a new case involving infliximab used to treat Shulman fasciitis.

CASE REPORT

A 39-year-old woman was treated with infliximab for corticoid-dependent Shulman fasciitis. No personal or familial cutaneous psoriasis was noted in her history. Two months after the third infusion, she developed psoriasis vulgaris and pustular palmoplantar psoriasis which improved under topical corticosteroids. Her psoriatic lesions worsened one month after the first maintenance infusion. Since the Shulman fasciitis was not under control, infliximab was withdrawn and replaced with azathioprine. Six months later, her psoriasis was in remission and the Shulman fasciitis was under control.

DISCUSSION

TNFalpha plays an important role in the physiopathology of psoriasis through its action on inflammatory infiltrate, angiogenesis and keratinocyte proliferation. Several studies have reported the efficiency of TNFalpha inhibitors in moderate to severe cutaneous psoriasis. However, fourteen cases of induction or worsening of psoriasis have been reported with these drugs, suggesting a class effect. We report a new case of cutaneous psoriasis induced by infliximab in a patient presenting corticoid-dependent Shulman fasciitis, and we discuss the possible immunological mechanisms responsible for this paradoxical side effect. Other cutaneous lesions have been reported during treatment with TNFalpha inhibitors. The benefits of this treatment on the underlying inflammatory disease must be balanced against the potential cutaneous side effects when deciding whether to continue with anti-TNFalpha treatment.

[Pancreatic panniculitis revealing a pancreaticportal fistula and portal thrombosis]

BACKGROUND

Pancreatic panniculitis is a rare condition that usually occurs in association with acute or chronic pancreatitis or pancreatic carcinoma. We report a case of pancreatic panniculitis revealing a pancreaticportal fistula and portal thrombosis.

CASE REPORT

A 79-year-old man was admitted for nodular panniculitis of the lower extremities without any digestive symptoms. Laboratory tests revealed very high plasma levels of amylase and lipase. A skin biopsy showed lobular panniculitis with ghost cells characteristic of pancreatic panniculitis. Rare pancreatic calcifications and portal thrombosis were seen on an abdominal CT scan and on endoscopic ultrasound examination of the pancreas. A pancreaticportal fistula was detected by endoscopic retrograde pancreatography. Finally, an endoscopic pancreatic prothesis was inserted in Wirsung's canal after failure of medical treatment (parenteral nutrition and octreotide). Skin lesions resolved and plasma pancreatic enzymes normalized.

DISCUSSION

This case report is interesting because of the lack of gastrointestinal symptoms associated with pancreatic panniculitis and the discovery of a chronic pancreatitis of uncertain etiology. This case highlights the need to screen for pancreaticportal fistula and portal thrombosis, which are often associated with pancreatic panniculitis.

[Extensive cutaneous candidiasis revealing cutaneous T-cell lymphoma: 2 cases]

BACKGROUND

During the course of immunodeficiency diseases, severe candidiasis can occur with extensive cutaneous and mucous membrane lesions. However, blood dyscrasias are very rarely revealed by diffuse candidiasis. We report two case of cutaneous T-cell lymphoma revealed by extensive and atypical cutaneous candidiasis.

PATIENTS AND METHODS

Case No. 1:A 72-year-old woman presented a pruritic rash of circinate, serpiginous patches on glabrous skin and skinfolds with multiple intertrigo and rapidly worsening palmoplantar keratoderma. All mycological skin specimens tested positive for Candida albicans. Histological examination of a biopsy sample from a serpiginous patch revealed the presence of fungal elements while palmoplantar keratoderma biopsy showed an epidermotropic lymphocytic infiltrate in the superficial dermis evocative of mycosis fungoides. Blood tests showed a white cell count of 28 600/mm3 with 14% circulating Sezary cells and a T-cell clone. The T-cell lymphoma was treated with methotrexate, but the disease worsened a few months later, progressing to CD30- large T-cell pleomorphic lymphoma. The patient died of severe sepsis. Case No 2:A 60-year-old man presented a macular rash over the face, trunk and skinfolds as well as erythematous scaly annular plaques of the glabrous skin with lymphadenopathy. Cultures of skin scrapings were all positive for Candida albicans. Blood tests showed a white cell count of 15 000/mm3 with 30% circulating Sezary cells. A trunk patch biopsy revealed the histological appearance of mycosis fungoides. There was a T-cell clone in the peripheral blood and skin.

DISCUSSION

In both cases, the patients presented with widespread annular and erythematous scaly lesions of the glabrous skin and skinfolds with evidence of Candida albicans on fungal tests of all skin scrapings. The discovery of circulating Sezary cells on a systematic smear for hyperleukocytosis led us to suspect underlying cutaneous T-cell lymphoma, which was confirmed by biopsy of the skin lesions accompanying the mycoses. Widespread cutaneous candidiasis can occur in patients with cell-mediated immunodepression. Cutaneous T-cell lymphoma can enhance such candidiasis through interference with skin integrity and impairment of cell-mediated immunity, with large amounts of IL10 and TGF-B, increased secretion of soluble interleukin-2 receptors (CD25) and impaired CD8 suppressor cell function.

Syndrome de vol vasculaire

BACKGROUND

Ischemic steal syndrome is a complication of arteriovenous access creation for hemodialysis, and is little known among dermatologists despite the fact is fairly common and has a cutaneous presentation. Herein we report the case of a man presenting with serious ischemic injuries to the fingers associated with steal syndrome.

OBSERVATION

A 49-year-old diabetic man presented with painful acrosyndrome of the left hand, with a necrotic ulcer on the third finger appearing 5 months after the creation of an arteriovenous access. Clinical examination showed marked pain relief after manual compression of the fistula. Arteriography showed an overfunctional fistula, causing decreased distal perfusion pressure, and this was consistent with the diagnosis of steal syndrome. Banding of the anastomosis was performed but was insufficient to spare the finger from amputation.

DISCUSSION

The aim of our case-report is to increase awareness among dermatologists of this fairly frequent complication of arteriovenous accesses. We discuss the physiopathology, risk factors, clinical features and therapeutic management of this condition. Since diagnosis of steal syndrome is fairly straightforward, early detection is essential. Only adequate surgical management can avoid gangrenous manifestations leading to more or less widespread amputation.

Leg ulcers and the Urgocell Non-Adhesive wound dressing

The objectives of this clinical trial were to evaluate the efficacy and tolerance of the Urgocell Non-Adhesive (NA) dressing in the local management of venous or mixed leg ulcers. The study was a non-comparative, prospective, multicentre (15 centres) phase III, clinical trial. The studied population was composed of non-immunodepressed adults presenting a venous or mixed leg ulcer, uninfected, non-cancerous, present for less than 18 months. Patients were followed up for 6 weeks with a weekly visit, including a clinical examination, area tracings and photographs. Evaluation by nursing staff and patients was performed at each dressing changed. Forty-three patients were included, presenting a leg ulcer with a mean surface area of 10.7 cm2. The surface area was reduced by a mean of 38% after 6 weeks of treatment. Four local adverse events were deemed to be related to the tested treatment and acceptability was noted very good for patients and nursing staff. The Urgocell NA dressing, combined with compression therapy, promoted the healing of the chronic wounds under study. The good tolerance and acceptability of the tested dressing were greatly appreciated.

Regression of cutis calcinosis with diltiazem in adult dermatomyositis

Calcinosis cutis is common in several connective tissue diseases such as dermatomyositis, scleroderma or lupus erythematous. In dermatomyositis, it is more likely to concern children than adults but it is not exceptional in adults. Several treatments have been used empirically with inconsistent success. We report a case of adult cutis calcinosis associated with dermatomyositis which responded dramatically to treatment with diltiazem.