Neutrophilic vascular reactions

Dermatologic diseases are classified most commonly by morphology, by pathogenesis, or by etiology. Nontraditional classifications may be useful in terms of providing a reassessment of traditional views about disease interrelationships. This review of dermatoses characterized by neutrophilic infiltrates and dermal vessel changes reveals evidence suggesting that these dermatoses result from immune complex-mediated, neutrophil-induced dermal vessel damage. Therapeutic approaches to these heretofore unlinked dermatoses are remarkably similar.

Acute febrile neutrophilic dermatosis (Sweet's syndrome) and myeloproliferative disorders

Acute febrile neutrophilic dermatosis (ND) consists of the abrupt onset of red, tender, cutaneous plaques on the face, extremities, and upper trunk, accompanied by fever, malaise, and neutrophilic leukocytosis. Histologically, there are distinctive, dense, dermal infiltrates of neutrophils. Response to systemic steroids is dramatic. This report describes four patients with leukemia or preleukemia and ND (LND), reviews reports of 12 similar patients, and compares LND with ND in otherwise healthy individuals (idiopathic ND, IND). Although lesions of LND more frequently had vesiculobullous appearances or location on mucous membranes, this study showed no consistent difference between LND and IND with regard to cutaneous signs, symptoms, histologic findings, and response to therapy. The first episode of LND either preceded or followed documentation of the myeloproliferative disorder, and the most common associated hematologic conditions were acute myeloid or myelomonocytic leukemia. Moderate to severe anemia was present in nine of ten patients whose first episode of LND preceded the discovery of the hematologic condition by eight months or less. The presence of anemia is the most obvious and readily detectable difference between LND and IND. The possibility of an underlying myeloproliferative disorder should be considered in all patients with ND, and LND should not be confused with infectious complications in patients known to have myeloproliferative disorders.

Histopathologic and immunopathologic study of pyoderma gangrenosum

Sixty-three patients with pyoderma gangrenosum were seen and studied at the Mayo Clinic from 1971 to 1980. Biopsies from the erythematous border or necrotic edge of the pyoderma gangrenosum lesions usually demonstrated a characteristic pathogenic morphologic evolution. The early lesions revealed mild to moderate perivascular lymphocytic infiltrate associated with endothelial swelling. The fully developed lesions demonstrated necrosis in addition to a dense lymphocytic infiltration surrounding as well as involving the blood vessels. Extravasation of erythrocytes and thrombosis sometimes were seen. Ulceration, infarction, and abscess formation were found in the later stages of evolution. Direct immunofluorescence results were positive in the blood vessels of 36 of 65 (55%) specimens. IgM, C3, and fibrin were found in the papillary and reticular dermal vessels. IgG and IgA were only occasionally present. Pyoderma gangrenosum appears to be a reactive process that is manifested as a vasculitis. Biopsy material from the advancing active erythematous border has early characteristic dermatopathologic findings of lymphocytic vasculitis. Cutaneous vascular immune deposits suggest an immune pathogenesis of either an immune complex disease or lymphocytotoxic reaction.

Superficial granulomatous pyoderma: a localized vegetative form of pyoderma gangrenosum

Twenty-five patients had superficial ulcerative and vegetative pyoderma with granulomatous histologic findings. Healing occurred without systemic corticosteroid therapy in all but three patients. All patients had clinical pyoderma gangrenosum. In five patients the lesion occurred after surgery of the skin. Histopathologic study of 40 biopsy specimens showed focal neutrophilic abscesses of the papillary dermis, often with peripheral palisading histiocytes and foreign-body giant cells. Pseudoepitheliomatous, vegetative hyperplasia and sinus tract formation were observed frequently. All patient had massive areas of plasmacytosis, and 13 had eosinophils. Granulation tissue, hemorrhage, and fibrosis were additional features in some areas. Foreign material in the lesions was considered unimportant, except in one patient with a starch granuloma. Therapy with local corticosteroids, minocycline, tetracycline, or sulfa drugs resulted in healing in 15 patients. We believe that we have identified a localized, limited form of chronic superficial pyoderma gangrenosum with verrucous and ulcerative lesions and a granulomatous histologic appearance that represents a unique pattern of this disease in some patients.

Pyoderma gangrenosum in inflammatory bowel disease

Since 1954, 34 patients have attended St. Mark's Hospital with pyoderma gangrenosum in association either with ulcerative colitis (22 patients) or Crohn's disease (12 patients). Lesions were multiple in 71 per cent and over half were situated below the knees. Ulcerative colitis was active in 11 patients (50 per cent) and Crohn's disease was active in nine (75 per cent) when pyoderma gangrenosum was diagnosed. Associated illnesses--most commonly a seronegative arthritis affecting large joints--were present in 55 per cent and 92 per cent of cases respectively. A diffuse pustular rash appeared in six patients, synchronously with pyoderma in five. In a further seven patients (two with ulcerative colitis, five with Crohn's disease) the onset or course of pyoderma might have been linked to the presence of non-dermatological suppuration. Pyoderma resolved without intestinal resection in two-thirds of patients. When present at the time of surgical resection (15 procedures in 13 patients), pyoderma healed promptly in six cases, only with additional therapy in four cases and very slowly or not at all in five cases. Pyoderma gangrenosum occurs in both ulcerative colitis and Crohn's disease. Healing after intestinal resection is unpredictable both with respect to timing and extent of resection.

An outbreak of pyodermas among neonates caused by ultrasound gel contaminated with methicillin-susceptible Staphylococcus aureus

OBJECTIVE

To investigate an outbreak of methicillin-susceptible Staphylococcus aureus (MSSA) infections in a neonatal clinic.

DESIGN

Prospective chart review, environmental sampling, and genotyping by two independent methods: pulsed-field gel electrophoresis (PFGE) and randomly amplified polymorphic DNA polymerase chain reaction (RAPD-PCR). A case-control study was performed with 31 controls from the same clinic.

SETTING

A German 1,350-bed tertiary-care teaching university hospital.

RESULTS

There was a significant increase in the incidence of pyodermas with MSSA; 10 neonates in good physical condition with no infection immediately after birth developed pyodermas. A shared spatula and ultrasound gel were the only identified infection sources. The gel contained MSSA and was used for hip joint sonographies in all neonates. PFGE and RAPD-PCR patterns from 6 neonates and from the gel were indistinguishable and thus genetically related clones. The case-control study revealed no significant risk factor with the exception of cesarean section (P=.006). The attack rate by days of hip-joint sonography between April 15 and April 27, 1994, was 11.8% to 40%.

CONCLUSIONS

Inappropriate hygienic measures in connection with lubricants during routine ultrasound scanning may lead to nosocomial S. aureus infections of the skin. To our knowledge this source of S. aureus infections has not previously been described.

Pyoderma faciale: a clinical study of twenty-nine patients

Pyoderma faciale is a distinctive entity. Twenty-nine patients with this process were seen in the Mayo Clinic from 1969 to 1980. Twenty-seven patients had follow-up that ranged from 1 month to 11 years, and twenty-two had follow-up of 3 years or more. Clinical features that characterize the patients were (1) female predominance, (2) onset later than teenage acne vulgaris, generally at 19 to 40 years of age, (3) rapid onset and progression, (4) facial involvement with sparing of the back and chest, (5) cysts, swelling, and purulent drainage with a lack of comedones, and (6) paucity of systemic complaints. Patients were treated with multiple forms of therapy simultaneously, often including Vleminckx packs, oral antibiotics, incision and drainage, ultraviolet B, and intralesional steroids. Of twenty-five patients available for follow-up at 1 year, twenty-three had achieved remission, though fifteen patients required ongoing treatment to maintain optimal control. Twenty-three patients had scarring as a sequela. Patients with pyoderma faciale represent a subset of patients with acne in whom the outlook is favorable with appropriate therapy.

[Causes of pilonidal sinus and pyoderma fistulans sinifica]

Pilonidal sinus is of the same origin as the Pyodermia fistulans sinifica . Both diseases are retention dermatopathies . These sinuses are not of congenital origin. Our observations have made an acquired origin seem more likely. Deep skin folds in the rima ani, the stiffness of the body hairs, the rolling movement of naturally separated hairs push the hair through the skin like a pin. If a hair is rubbed, it moves in the direction of its root with the peripherally directed hair scales. Excision of the sinus area and transplantation of an epithelial flap is the best therapy.

Pyoderma gangrenosum in myelodysplasia and acute leukaemia

Pyoderma gangrenosum is a rare occurrence in patients with haematological malignancy. This characteristic but nonspecific inflammatory process with skin destruction occurred in 4 patients with myelodysplasia, in one with acute leukaemic transformation of myelofibrosis, and in de novo acute myeloblastic leukaemia in another. Clinically, the cutaneous lesion in these patients differed from that associated with inflammatory bowel disease, arthritis, or the idiopathic type of pyoderma gangrenosum by having the vesiculo-bullous borders. Histopathological differences were also evident since more superficial layers of the skin were involved in the ulceration than typically encountered in patients with non-malignant systemic disease. Despite the less penetrating nature of this variant, treatment of the pyoderma gangrenosum is unsatisfactory and in the absence of effective therapy for the underlying disease, healing occurred only in the patient with acute leukaemia who achieved complete remission in response to chemotherapy.

Pyodermatitis-pyostomatitis vegetans

A 43-year-old woman developed annular and pustular cutaneous lesions preceded by tiny yellow pustules coating the surface of the oral mucosa. The clinical, histological and immunopathological evidence clearly showed that the patient had pyodermatitis-pyostomatitis vegetans. It is suggested that this disease is a distinct entity which should be differentiated from pemphigus vegetans.

Pyoderma gangrenosum in pediatric acquired immunodeficiency syndrome

We describe two children with human immunodeficiency virus infection in whom pyoderma gangrenosum developed. Although pyoderma gangrenosum most commonly occurs in children with inflammatory bowel disease, it has also been described in patients with a variety of immunodeficiencies. In such patients a vigorous search to exclude a treatable infection should be made before the lesions are treated as pyoderma gangrenosum.

Cyclosporine therapy for pyoderma gangrenosum associated with sclerosing cholangitis and ulcerative colitis

Malignant pyoderma of the right ear developed in a 58-year-old woman, and it spread insidiously over the entire right side of the face. Pyoderma gangrenosum was diagnosed on the basis of clinical and histologic findings and the patient's history of ulcerative colitis and sclerosing cholangitis. After successive therapeutic failures with a score of conventional approaches over an 18-month period, oral cyclosporine, 10 mg/kg/day, was started. Significant healing of the skin was noted within 1 month. There was an associated remission of the patient's cholangitis and inflammatory bowel disease. The dosage of cyclosporine was progressively tapered and then discontinued after 7 months, when healing was complete. No relapse occurred in the subsequent 14 months, and there was an associated remission of the patient's cholangitis and inflammatory bowel disease. Cyclosporine merits serious attention for treatment of both pyoderma gangrenosum and sclerosing cholangitis.

Cutaneous cryptococcosis simulating pyoderma gangrenosum

A 33-year-old white man with a history of chronic ulcerative colitis presented with multiple cutaneous ulcers and an indurated cellulitic area on his right thigh. Clinically, the ulcers were considered to represent pyoderma gangrenosum. However, tissue biopsy revealed copious yeast forms that were identified as Cryptococcus neoformans. The indurated area on the right thigh later ulcerated, and tissue culture of this area also revealed Cryptococcus. This case illustrates that when pyoderma gangrenosum is diagnosed, the possibility of deep fungal infection should be considered and excluded by appropriate studies.

Superficial granulomatous pyoderma: clinicopathologic spectrum

Superficial granulomatous pyoderma is a form of pyoderma gangrenosum characterized by superficial ulceration and a chronic course. Histopathologic examination shows a granulomatous response. We report two new cases of superficial granulomatous pyoderma in detail and briefly review the clinical data of five previous cases included in a recent series. These lesions typically begin as single furunculoid papules that most commonly occur on the trunk and that may arise at sites of surgical treatment or other pathergic stimuli. The lesions progress to superficial ulcers with a relatively clean base and vegetative borders. Tetracycline, minocycline, sulfapyridine, dapsone, and intralesionally administered corticosteroids have been effective anti-inflammatory agents, producing healing and allowing avoidance of the use of systemic corticosteroids in the management of most patients with superficial granulomatous pyoderma.

Papular urticaria: a histopathologic study of 30 patients

Papular urticaria is the result of hypersensitivity (id-reaction) to bites from certain insects such as mosquitoes gnats, fleas, mites, and bedbugs. Papular urticaria is common in childhood and is characterized by symmetrically distributed pruritic papules and papulovesicles. Scratching causes erosions and ulcerations. Pyoderma is common. Lesions occur in crops. The histopathologic features of papular urticaria are inadequately documented. In a prospective study we recorded the histopathologic features of 30 patients (female, 18; male, 12) with papular urticaria. Their ages ranged from 6-343 months (median = 21 months, mean = 37.73 months). Features that presented in more than 50% of cases included mild acanthosis, mild spongiosis, exocytosis of lymphocytes, mild subepidermal edema, extravasation of erythrocytes, a superficial and deep mixed inflammatory cell infiltrate of moderate density, and interstitial eosinophils. We recognized lymphocytic (n = 4), eosinophilic (n = 9), neutrophilic (n = 7), and mixed (n = 9) subtypes. Immunohistochemistry was performed on formalin-fixed, paraffin-embedded sections from 10 cases and revealed abundant T-lymphocytes (CD45RO, CD3) and macrophages (CD68) in all cases. B-lymphocytes (CD20) and dendritic antigen-presenting cells (S100) were absent. Direct immunofluorescence staining was conducted on cryostat-prepared sections from 26 specimens. Deposition of IgA, IgG, IgM, C3, and fibrin could not be demonstrated. The histopathologic differential diagnosis of papular urticaria includes other spongiotic dermatitides, pityriasis lichenoides et varioliformis acuta, the pruritic papular eruption of human immunodeficiency virus disease, and papulonecrotic tuberculid. Papular urticaria with marked spongiosis and a dense inflammatory cell infiltrate cannot be reliably distinguished from arthropod bites on clinical and histopathologic grounds. The present study provides morphologic and immunohistochemical evidence that a type I hypersensitivity reaction plays a central role in the pathogenesis of papular urticaria. The putative antigen remains undetermined.

Atypical bullous pyoderma gangrenosum associated with myeloid malignancies

Atypical bullous pyoderma gangrenosum was diagnosed during the course of a myeloid malignancy in three patients. One patient had chronic myeloid leukaemia, one acute myeloid leukaemia, and the third, refractory anaemia with excess of blasts. This atypical form of pyoderma gangrenosum has been specifically associated with myeloid malignancies. The atypical appearance of the skin lesions and the clinical context in which they arose caused the true diagnosis to be delayed in all cases. Treatment with steroids was associated with rapid healing of the skin lesion. The histopathological changes in the skin biopsy specimens from these cases were non-specific, and although the histology was considered to be atypical of pyoderma gangrenosum in one case, the unusual features could be attributed to the patient's neutropenia. (Skin biopsy was performed to exclude other specific pathology). Atypical bullous pyoderma gangrenosum is an uncommon association of the myeloid malignancies. It may remain unrecognised and should be considered more often.

Direct immunofluorescence in pyoderma gangrenosum

Direct immunofluorescence was done in fifty-one cases of pyoderma gangrenosum. Biopsy specimens were taken from the peripheral erythematous zone of the lesion. In thirty-one cases (61%), there was positive immunofluorescence, with perivascular deposition of immune reactants being the most frequent pattern (twenty-seven cases). These findings support a vasculitic pathogenesis of pyoderma gangrenosum.

Leishmaniosis and generalized demodicosis in three dogs: a clinicopathological and immunohistochemical study

This paper describes the clinicopathological and immunohistochemical aspects of the skin lesions in three dogs with leishmaniosis and generalized demodicosis. Diffuse alopecia, crusts, folliculitis and furunculosis, as commonly seen in generalized demodicosis, were prominent in all the dogs. MicroIscopically, there was a diffuse and perifollicular superficial and deep granulomatous dermatitis and, in two dogs, both Copyright Demodex canis mites and Leishmania spp. amastigotes were observed in the same lesions. Numerous Mac387(+)macrophages were observed in the inflammatory infiltrates, but macrophages loaded with amastigotes were Mac387(-). In all cases, immunoreactive CD3 lymphocytes were sparse, both in the granulomatous and perifollicular infiltrates. There were numerous IgG+, IgG4(+)-secreting plasma cells in areas of folliculitis and furunculosis and fewer IgG2(+), IgG3(+), IgA+and IgM+-secreting plasma cells in the inflammatory infiltrate. In all cases, MHC Class II was expressed by the majority of dermal macrophages and dendritic cells, as well as by lymphocytes and fibroblasts. The paucity of CD3(+)lymphocytes, usually abundant in D. canis lesions, points to leishmania-induced cell-mediated immunosuppression as a predisposing factor for generalized demodicosis.

Intralesional steroid therapy of pyoderma gangrenosum

Treatment of pyoderma gangrenosum complicating ulcerative colitis has in the past been frustrating and usually unsuccessful, frequently resulting in colectomy. Intralesional steroid therapy has been used off and on in a few patients, but the treatment is not widely known to gastroenterologists. We report two patients successfully treated for early pyoderma gangrenosum by intralesional injection of triamcinolone acetonide (Kenalog, 40 mg injection) together with conventional doses of systemic steroids. A single series of injections was sufficient to bring about healing of the lesions in both patients. The treatment permitted early discharge of patients from the hospital, and the skin lesions were completely healed within 2 months. The lesions have not recurred in follow-up examinations of 11/2 and 21/2 years, respectively. We hope that other physicians will find this approach equally effective.