Tocilizumab-Induced Erythema Annulare Centrifugum

We report the case of a 42-year-old woman with rheumatoid arthritis undergoing treatment with subcutaneous tocilizumab for the past 6 months. Three days after the administration, an asymptomatic inflammatory annular plaque of 4 cm with discrete whitish scales at the inner border margin developed at the injection site in the left iliac fossa. A smaller plaque in the left groin appeared soon after. The mycological exam was negative. Histology showed a lymphoplasmacytic superficial and deep perivascular, and periadnexal, dermal infiltrate, without epidermal changes. Lesions spontaneously regressed in 4 months. The diagnosis was clinically and histologically consistent with erythema annulare centrifugum, following the exclusion of other differential diagnoses. Erythema annulare centrifugum represents a delayed-type hypersensitivity reaction generally considered idiopathic or otherwise related to numerous triggers, including drugs such as biologics. We describe the first reported case of tocilizumab-induced erythema annulare centrifugum. This case should alert dermatologists to this relatively rare and complex entity and should raise awareness to cutaneous biologic drug reactions.

Annually Recurring Erythema Annulare Centrifugum: A New Case Series with Review of the Literature

Annually recurring erythema annulare centrifugum (AR-EAC) is a rare variant, characterized by typical annular plaques recurring in the same period of the year. We describe 5 new cases and present a review of the literature. Patients were 3 females and 2 males with an age range of 25–55 years. Multiple annular plaques were located at the thighs in 4 patients and the neck in one patient. In 1 patient, a single lesion was present. Plaques were recurring in summer in 3 cases; in 1 case, in spring; and another patient, in winter since 3–4 years. Lesions were self-healing in few days or weeks. Histologically, the epidermis presented mild acanthosis with patchy spongiosis, slight parakeratosis, and mild exocytosis. There was a perivascular lympho-histiocytic infiltrate of variable intensity in the superficial dermis, with occasional eosinophils. In 1 case, the inflammatory infiltrate reached the deep dermis. Mucin deposition was absent. Phenotyping studies in 1 case revealed a predominance of T cells, with a small B-cell component. Moreover, a moderate number of CD123⁺ plasmacytoid dendritic cells and CD1a⁺ dendritic cells were noted. Fourteen cases of AR-EAC have been published previously. Collectively, patients' age ranged from 16 to 83 years, with a mean age of 47 years and a disease duration of 1–30 years. Lesions affected more frequently extremities and recurred most commonly in summer. Patients were all in good general health. Topical corticosteroids were the mainstay of treatment. AR-EAC is a benign disorder, the nature of which remains enigmatic.

Recurrent Erythema Annulare Centrifugum due to Influenza Type A

Erythema annulare centrifugum (EAC) is a rare erythema characterized by erythematous and urticarial papules or annular plaques that enlarges centrifugally. The lesions usually involve the thighs and the legs. Several disorders are occasionally associated with EAC, infections, including mycoses, bacteria, or viruses and drugs have also been regarded as possible causes of this eruption. We present a 42-year-old dark-skinned woman affected by recurrent EAC that appeared secondary to influenza type A (H1N1). Histopathology showed a superficial form of EAC. In our case, a previous cytomegalovirus and Epstein-Barr virus (EBV) infection were identified and no underlying other diseases were found. Clarithromycin with calcipotriol betamethasone treatment was temporarily efficacious. In the last 3 years, the lesions started to appear every 2 weeks and tended to regress with local treatment after a variable period. We believe that the latent cytomegalovirus and the reactivity induced by EBV combined with influenza can determine, in our case, a cell mediate cutaneous immune response, which leads to the peculiar inflammatory disease known as EAC.

[Multiple erythema annulare centrifugum associated with knee monoarthritis revealing Capnocytophagacanimorsus infection]

INTRODUCTION

Capnocytophagacanimorsus (C. canimorsus), a commensal Gram-negative bacillus found in the oral cavity of dogs and cats, is pathogenic for humans, with the most common clinical manifestations being septicemia, meningitis and endocarditis. Herein we report a case of CC bacteremia manifesting as multiple plaques of erythema annulare centrifugum associated with monoarthritis of the knee.

PATIENTS AND METHODS

A 66-year-old man consulted for a skin rash and monoarthritis of the right knee with fever following an insect bite on his right hallux. Cutaneous examination revealed numerous erythematous annular plaques on the trunk and limbs with centrifugal extension. Analysis of synovial fluid from the right knee showed an inflammatory liquid with a sterile bacteriological culture and PCR was negative for Borrelia. C. canimorsus bacteria were isolated from blood cultures. 16S RNA PCR performed on the synovial fluid was positive for the same organism. The patient's history revealed that his hallux wound had been licked by his dog.

DISCUSSION

C. canimorsus most frequently affects immunosuppressed subjects. Cutaneous signs are seen in half of all cases, most frequently presenting as cellulitis, pathological livedo or thrombotic purpura. We report herein a case of CC bacteremia in an immunocompetent patient manifesting as multiple plaques of erythema annulare centrifugum, an unusual sign, and monoarthritis of one knee.

A 78-Year-Old Female with a Diffuse Pruritic Rash and Palmoplantar Desquamation

Mycosis fungoides, the most common cutaneous T-cell lymphoma, is known to exhibit varied clinical presentations and mimic many other dermatoses. This morphological heterogeneity can often lead to initial misdiagnoses resulting in significant delays from symptom onset to diagnosis. We report a case of mycosis fungoides imitating clinical and histopathological features of erythema annulare centrifugum.

Erythromycin as a Safe and Effective Treatment Option for Erythema Annulare Centrifugum

Background:

Erythema annulare centrifugum (EAC) is an inflammatory dermatosis with unknown etiology. It is usually self-limited, but chronic disease may be difficult to treat. We observed incidentally the therapeutic effect of erythromycin for EAC among patients taking erythromycin for other diseases.

Aim:

To evaluate the treatment response of erythromycin for EAC.

Materials and Methods:

During the study period, from July 2007 to February 2011, all patients with EAC were assigned to erythromycin stearate tablet 1000 mg per day for two weeks. EAC was diagnosed by a constellation of clinical and pathological findings. The efficacy (before and after the treatment) was assessed clinically by one dermatologist and photographically by two blinded dermatologists. Secondary outcomes included adverse drug effects and recurrence.

Results:

Eight patients were enrolled in this study. Most patients had chronic relapsing disease with poor response to previous treatment. All the patients showed rapid response with profound reduction in the size of lesion and erythema two weeks after initiation of erythromycin treatment. The response was so obvious and complete that a coincidental response was less likely. Three patients had recurrence of disease and they tended to have more extensive lesions. Readministration of erythromycin was effective. All patients tolerated the treatment well.

Conclusion:

Our study documented erythromycin as a safe and cost-effective treatment for EAC.

Erythema Annulare Centrifugum: A Rare Skin Finding of Autoimmune Hepatitis

Erythema annulare centrifugum is characterized by dermal perivascular lymphocytic infiltrates. It is often associated with infections, autoimmune or neoplastic diseases but in most cases the cause is unexplained. A case of erythema annulare centrifugum related to autoimmune hepatitis in a 24-year-old woman is described in this case report. Clinical response of the autoimmune hepatitis to a combination therapy with corticosteroids and azothiopurine was achieved. Although partially regressed for the first 12 months of theraphy, the skin lesions did not disappear completely. However, after 18 months of continious treatment there was no skin lesion.

Figurate Erythema Resembling Erythema Annulare Centrifugum in a Ferret with Adrenocortical Adenocarcinoma-associated Alopecia

Resumen- Describimos un caso de alopecia simétrica bilateral en un hurón hembra esterilizada de 3 años. El cuadro resultó estar asociado con un adenocarcinoma adrenocortical y con concentraciones séricas elevadas de estradiol. Además el animal presentaba eritema figurado en la zona dorsolateral, lumbosacra y en la cola con caracteristicas clinicas e histopatológicas parecidas al eritema annulare centrifugum de la especie humana. El eritema figurado se trató con éxito con un producto comercial que contiene el ácido graso omega-3/omega-6. [Scott D. W., Gould, J. W., Cayatte, S. M., Lawrence, H. J., Miller, W. H., Jr. Figurate erythema resembling erythema annulare centrifugum in a ferret with adrenocortical adenocar-cinoma-associated alopecia (Eritema figurado parecido a eritema anulare centrifugum en un hurón con alopecia asociada a un adenocarcinoma adrenocortical). Abstract- Bilaterally symmetric alopecia and vulvar enlargement is reported in a 3-year-old, spayed female ferret. The condition was ultimately shown to be associated with an adrenocortical adenocarcinoma and elevated serum estradiol concentrations. In addition, the ferret had a figurate erythema over the dorsolateral lumbosacral region and tail that was clinically and histopathologically similar to erythema annulare centrifugum in humans. The figurate erythema was successfully treated with a commercial omega-3/omega-6 fatty acid-containing product.