A case of mevalonate kinase deficiency, neonatal Sweet syndrome, and inflammatory bowel disease

Mevalonate kinase deficiency is a group of rare metabolic autoinflammatory disorders that present with recurrent fevers, abdominal pain, arthralgias, adenopathy, and a variety of cutaneous manifestations. The skin findings may mimic cellulitis, erythema elevatum diutinum, IgA vasculitis, and Sweet syndrome, and there is often a morbilliform or urticarial rash and aphthous stomatitis. Mevalonate kinase deficiency is one of the identified monogenic variants that can cause very early onset inflammatory bowel disease (IBD). We present a rare case of a patient with mevalonate kinase deficiency, neonatal Sweet syndrome, and infantile-onset IBD, who has been successfully treated with canakinumab therapy.

Lesional Infiltration of Eosinophils, Basophils, and M2 Macrophages Expressing Eotaxin-1 and Eotaxin-3 in Granuloma Faciale, but not in Erythema Elevatum Diutinum

Abstract is missing (Short communication)

SARS-CoV-2-Induced Vasculitic Skin Lesions Are Associated with Massive Spike Protein Depositions in Autophagosomes

In patients infected with severe acute respiratory syndrome coronavirus 2, vasculopathic changes of the skin are associated with a severe prognosis. However, the pathogenesis of this vasculopathy is not conclusively clarified. In this study, 25 prospectively collected skin samples from patients with COVID-19-related skin lesions were examined for vasculopathic changes and, in case of vasculitis, were further analyzed with electron microscopy and immunohistochemistry. Vasculopathy was observed in 76% of all COVID-19-related inflammatory skin lesions. Visual endothelial changes without manifest leukocytoclastic vasculitis were found in 60% of the COVID-19-related skin lesions, whereas leukocytoclastic vasculitis was diagnosed in 16%. In the cases of vasculitis, there were extensive spike protein depositions in microvascular endothelial cells that colocalized with the autophagosome proteins LC3B and LC3C. The autophagy protein complex LC3-associated endocytosis in microvascular endothelial cells seems to be an important pathogenic factor for severe acute respiratory syndrome coronavirus 2-related vasculitis in the skin. On ultrastructural morphology, the vasculitic process was dominated by intracellular vesicle formation and endothelial cell disruption. Direct presence of severe acute respiratory syndrome coronavirus 2 particles in the skin was not observed. Therefore, our results suggest that instead of direct viral infection, dermal vasculitic lesions in COVID-19 are caused by severe acute respiratory syndrome coronavirus 2 spike protein deposition followed by endothelial damage with activation of autophagy.

[Immunoglobulin A vasculitis]

The immune-mediated small vessel vasculitis is known as Schoenlein-Henoch purpura predominantly from pediatrics and in these cases occurs more frequently after infections of the upper airways. In adults, immunoglobulin A (IgA) vasculitis often proceeds more severely und recurrently with the classical tetrad of skin manifestations in the sense of leukocytoclastic vasculitis, joint affection, gastrointestinal involvement and IgA nephritis, in contrast to the mostly mild and self-limiting course in children. The background of this systemic vasculitis with formation of IgA immune complexes is considered to be an altered glycosylation of IgA, as this causes the exposure of binding sites for autoantibodies so that an immune complex reaction can be elicited. This ultimately leads to perivascular deposition of IgA and a further activation of neutrophils. Groundbreaking in the diagnostics is the histological detection of leukocytoclastic vasculitis and in cases of renal manifestations a kidney biopsy with characteristic deposits of immune complexes, which cannot be clearly differentiated from IgA nephropathy. The treatment is aimed at the respective manifestation and is mostly based on consensus recommendations due to the lack of randomized studies. In addition to immunosuppressive medication, in the presence of a chronic kidney disease general nephroprotection is becoming increasingly more important also by inhibition of sodium-glucose transporter 2 (SGLT2). The type and extent of kidney involvement and also rare cardiac manifestations are the main determinants of the prognosis. Continuous medical accompaniment of those affected is necessary due to the possible progression of the disease and the risk of recurrence.

Neutrophilic Dermatosis of the Hands: A Case Report

Neutrophilic dermatosis of the hands (NDDH) is a localized variant of Sweet's syndrome which has been recently introduced. Strutton et al.in 1996 and then in Galaria et al. in 2000 reported cases with violaceous papulonodules on the dorsal surfaces of the hands with histopathological findings of a neutrophilic dermatosis in association with leukocytoclasia, but clinically and histologically without true vasculitis findings. Eventually, they proposed the term NDDH for these lesions (1,2). A 46-year-old man was referred to our outpatient dermatology clinic with a painful ulcerative lesion on the dorsal side of the left hand that had been present for one year. Initially, the lesion had appeared as a small purulent papule, which gradually extended to a large ulcer. The patient underwent frequent referrals to several physicians and had taken a variety of topical and systemic antibiotics, meglumine antimoniate (Glucantime), and amphotericin with the clinical diagnosis of cutaneous bacterial or fungal infections, or leishmaniasis. All of these therapeutic regimes were ineffective in eradicating the lesion. Given the history, he denied any trauma to the site of lesion; he also did not report any similar lesions in his family. The physical examination revealed an extensive tender ulcer of 4×7 cm2 in size, with a shallow violaceous border superimposed on an edematous region on the dorsal side of the left hand. Atrophic scars resulting from old similar lesions were visible on the dorsal aspects of the 3rd and 4th proximal and middle metacarpal joints (Figure 1). The examination of the other parts of the body was unremarkable. Laboratory tests showed an impaired white blood cell count and their differentiation, including leukocytosis (white blood cell count of 16.12/mm3) with neutrophilia (neutrophil percent at 65.9%). Additionally, altered liver function tests were remarkable for high serum levels of AST (SGOT) (105 IU/L) and ALT(SGPT) (355 IU/L), while the total bilirubin and alkaline phosphatase were within normal limits. Hemoglobin levels (13.90 g/dL) and platelet count (272/mm3) were within normal range. The other laboratory tests, including serological tests for fasting blood sugar, hemoglobin A1c, creatinine, BUN, and an immunoassay for ruling out vasculitis lesions (anti-MPO (P-ANCA) and anti-PR3 (C-ANCA)) revealed no remarkable results. An erythrocyte sedimentation rate of 16 mm/h was reported. A biopsy was performed. Histologic features demonstrated a dense, diffuse dermal infiltrate comprised almost entirely of neutrophils. The epidermis was slightly acanthotic and showed small foci of spongiosis, but the inflammatory infiltrate remained largely in the dermis. Sheets of neutrophils were present, admixed with karyorrhectic debris. The infiltrate did not appear to be peri-vascular, and most vessels that could be observed clearly appeared to be undamaged. However, some vessels appeared to show some neutrophils infiltrating vessel walls (Figures 2a, b). Based upon histopathologic examination, the diagnosis of neutrophilic dermatosis of the hands (NDDH) was suggested. The work-up findings for ruling out neoplastic diseases were unremarkable. Clinically, patients with NDDH show various morphologic patterns of the lesions on the dorsal aspect of the hands, including violaceous edematous plaques or ulcers with undermined borders, hemorrhagic bullae, necrotic pyoderma-like lesions with pseudovesiculation, and atypical pyoderma gangrenosum-like lesions (1). This disease is more common in women (70%) than in men (3). NDDH has been reported in association with malignancies (such as leukemia and lymphoma), myelodysplasia, inflammatory bowel diseases, seropositive arthritis, sarcoidosis, HCV infection, and medications (such as lenalidomide, thalidomide, vaccinations, fertilizer, etc.) (1). Among them, neoplastic diseases are the most common association, which has been reported in 27% of the cases. It may thus represent a paraneoplastic phenomenon (3). Histopathological study is mandatory for achieving a definite diagnosis of NDDH. Its pathological findings include subepidermal edema, a dense and diffuse dermal infiltration of neutrophils along with leukocytoclastic debris, and extravasated erythrocytes, which are not associated with true vasculitis (1,3). However, the presence or absence of some vasculitic features as a histopathological finding depends on the time of biopsy with regard to the evolutionary phases of the lesion (3). In our case, the diffuse nature of the infiltrate was somewhat indicative against the diagnosis of leukocytoclastic vasculitis. Additionally, the possibility of infection was excluded empirically (due to the ineffectiveness of previous therapies without doing cultures or PCR), and indirectly through biopsy. Cohen (4) and Cohen and Kurzrok (5) explained the presence of vasculitis in Sweet's syndrome and NDDH as an epiphenomenon in which the damaged vessel is as an "innocent bystander" in the background of an inflammatory dermatosis. Eventually, they concluded that the presence or absence of vasculitis has a secondary importance in the diagnosis of NDDH. The following entities should be considered in the differential diagnoses of NDDH: cutaneous infections, vesiculobullous pyoderma gangrenosum (atypical), bullous erythema multiforme, pustular drug reactions, rheumatoid neutrophilic dermatosis, bowel-associated dermatosis-arthritis syndrome, and erythema elevatum diutinum (1-3). In our case, based on the pathological examination, the differential diagnosis included neutrophilic dermatosis such as Sweet's syndrome or neutrophilic dermatosis of the dorsal hands. It is essential to exclude an infectious etiology that might include a bacterial infection, or less likely a fungal or atypical mycobacterial infection, given the lack of any granulomatous component. However, some atypical mycobacterial infections can demonstrate a brisk neutrophilic infiltrate and relatively sparse granulomatous responses (6). For the same reason (lack of significant histiocytes), we thought that palisaded neutrophilic and granulomatous dermatosis associated with connective tissue disease was less likely. The relationship between this disease entity and a superficial variant of pyoderma gangrenosum remains unclear. The treatment of NDDH includes systemic corticosteroids, dapsone, methotrexate, potassium iodide, colchicine, and minocycline (2). NDDH is often misdiagnosed as an infectious condition, which can result in inappropriate antibiotic therapy, surgical debridement, and even amputation (7). Therefore, early diagnosis and initiation of appropriate treatment should be mainstay of its treatment.

Infections or Vaccines Associated with Finkelstein-Seidlmayer Vasculitis: Systematic Review

Finkelstein-Seidlmayer vasculitis, also referred to as acute hemorrhagic edema of young children, is a rare small-vessel leukocytoclastic vasculitis. This condition is skin-limited, mainly affects infants up to 2 years of age and spontaneously remits. It has been suggested that an infection or a vaccine precede (by ≤ 14 days) this vasculitis. To better understand the interplay between infections or vaccines and Finkelstein-Seidlmayer vasculitis, we utilized the data contained in the Acute Hemorrhagic Edema BIbliographic Database AHEBID. The database, initiated in 2019, is being regularly updated, encompasses the entire original literature on Finkelstein-Seidlmayer vasculitis published after the original description and is attainable on request. The possible existence of an infectious or a vaccine precursor was addressed in 447 cases. Most cases were preceded by an infection (N = 384; 86%), by a vaccination (N = 20; 4.4%), or both an infection and a vaccination (N = 17; 3.8%). No precursor was reported in the remaining cases (N = 26; 5.8%). Two distinct infections preceded the onset of the vasculitis in 11 of the 381 cases with infection-associated Finkelstein-Seidlmayer vasculitis. The following infectious precursors were reported: upper respiratory tract infection (N = 292); acute gastroenteritis (N = 40); a benign febrile infection (N = 36); lower respiratory tract infection (N = 22); further infections (N = 8). The temporal relationship between the infectious precursor and the onset of the skin eruption was detailed in 336 cases: 54 cases developed before resolution and 282 after resolution of the infection. In conclusion, most cases of Finkelstein-Seidlmayer vasculitis are preceded by an infection. In a minority of cases, this skin vasculitis develops before resolution of the infection. In most cases, however, this vasculitis develops after resolution of the infection. More rarely, this vasculitis is preceded by a vaccination.

SEVERE LEUKOCYTOCLASTIC VASCULITIS AFTER COVID-19 VACCINATION - CAUSE OR COINCIDENCE? CASE REPORT AND LITERATURE REVIEW

Vaccination has been the most powerful tool to fight the COVID-19 pandemic while the specific treatment options in clinical practice have been under review for approval and authorization by regulatory bodies. After registration of different vaccines, it is important to ensure a post-marketing surveillance to identify potential risks not observed in controlled trials. Authors report on the case of an 80-year-old male patient who developed severe leukocytoclastic vasculitis of skin and oral mucous membrane after receiving the second dose of COVID-19 mRNA vaccine. He was treated successfully with prednisolone. We also provide a literature review on other reported cases of COVID-19 vaccine induced vasculitis. This type of an adverse reaction seems to be rare. Fortunately, most cases were temporary and well controlled by corticosteroids. The majority of vaccine-associated vasculitis cases have been observed in association with BONT162b2 mRNA vaccine although other vaccines also may cause the event. The knowledge of this possible adverse event is important for early diagnosis and intervention.

Double whammy: anticoagulant-related nephropathy with leukocytoclastic vasculitis due to warfarin

Anticoagulation-related nephropathy (ARN) is a rare form of acute kidney injury where the use of anticoagulation causes hemorrhage in various compartments of nephron including glomerulus, renal tubules, and interstitial compartment. Also, warfarin-induced vasculitis is an extremely rare condition characterized by the appearance of purpuric lesions on the skin which on biopsy are suggestive of leukocytoclastic vasculitis (LV). We hereby report a case presenting with coexistent warfarin-induced nephropathy and cutaneous vasculitis. A 64-year-old male, on warfarin for 10 years, presented with complaints of palpable purpuric rashes over lower limbs, hematuria, and decrease urine output. INR was in the supratherapeutic range (INR-6.3). Skin biopsy of the lesion was suggestive of LV and kidney biopsy showed RBCs in Bowman's capsule, RBCs and RBC casts in tubules suggestive of ARN. All vasculitic markers were negative. Thus, a diagnosis of warfarin-induced nephropathy and cutaneous vasculitis was made. Warfarin was discontinued and oral steroids were started. Gradually, his skin lesions improved, and he became dialysis independent. He was then discharged on apixaban. On follow-up after 3 months, his skin lesions had disappeared with partial recovery of kidney function (cr-5.49).

Acute Hemorrhagic Edema of Infancy With Associated Hemorrhagic Lacrimation

ABSTRACT

Acute hemorrhagic edema of infancy is a rare leukocytoclastic vasculitis that affects infants and children aged 4 to 24 months. We report a case of a 5-month-old girl with purpuric lesions with associated hemorrhagic lacrimation and epistaxis.

Neutrophil Extracellular Traps are Present in Immune-complex-mediated Cutaneous Small Vessel Vasculitis and Correlate with the Production of Reactive Oxygen Species and the Severity of Vessel Damage

Formation of neutrophil extracellular traps has been implicated in autoimmunity. However, the presence and clinical relevance of neutrophil extracellular traps in immune-complex-mediated cutaneous small and medium vessel vasculitides has not been investigated. This study retrospectively analysed 72 patients with histology-proven hypersensitivity vasculitis (n = 21), IgA vasculitis (n = 22), urticarial vasculitis (n = 22), erythema elevatum diutinum (n = 3) and polyarteritis nodosa (n = 4). Neutrophil extracellular traps were detected in hypersensitivity vasculitis, IgA vasculitis, urticarial vasculitis and erythema elevatum diutinum, but not in polyarteritis nodosa lesions. Neutrophil extracellular traps were found around inflamed vessels, and their formation was highest early after the onset of vasculitis and decreased progressively thereafter. Neutrophil extracellular traps were strongly correlated with the histological severity of vasculitis and the production of reactive oxygen species. Both hypersensitivity vasculitis and IgA vasculitis showed significantly more neutrophil extracellular traps than did urticarial vasculitis, independent of the histological severity and duration of vasculitis. These results provide evidence on the implication of neutrophil extracellular traps in the early phases of immune-complex-mediated small vessel vasculitis.

Secondary vasculitis - omitted manifestation of many diseases

Secondary vasculitides usually accompany various common and rare conditions, Their clinical picture is very diverse, they can be loclaized or genaralized. Most frequently, we find parainfectious, drug-related and paraneoplastic vasculitides, less commonly in connective tissue diseases, after radiotherapy or transplantation. Vasculitides may be associated to infection of any origin. Drug-related vasculitides are mainly confined to the skin with picture of leukocytoclastic angiitis but visceral organs may be involved too. Paraneoplastic vasculitides usually accompany solid tumours and lymphoproliferative processes. When related to connective tissue diseases we can observe vasculitis in rheumatoid arthritis, systemic lupus erythematosus, Sjoegren syndrome, systemic sclerosis and other conditions. The diagnosis of vasculitis is usually based on pathological findings from biopsy. Management lies in treatment of underlying disease and if it is ineffective combined immunosuppression should be introduced.

ANCA Associated Vasculitis Secondary to Levamisole-Adultered Cocaine with Associated Membranous Nephropathy: A Case Series

BACKGROUND

Cocaine is a risk factor for acute kidney injury and chronic kidney disease with progression to end-stage renal disease. Levamisole is an adulterant that is added to cocaine to enhance its euphoric effects. Levamisole-adulterated cocaine (LAC) is associated with the distinct clinical syndromes of agranulocytosis, leukocytoclastic vasculitis, cocaine-induced midline destructive lesions (CIMDL), and ANCA-associated vasculitis (AAV) with pauci-immune necrotizing glomerulonephritis.

METHODS

We reviewed all cases of AAV secondary to LAC at our institution.

RESULTS

We report 3 cases of AAV secondary to LAC and associated membranous nephropathy (MN). The first and second cases are concurrent AAV secondary to LAC and associated MN while the third case involves the development of MN after AAV secondary to LAC.

CONCLUSIONS

Clinicians should be aware of this novel association of LAC with MN.

IgG4-Related Sialoadenitis with a Skin Lesion and Multiple Mononeuropathies Suggesting Coexistent Cryoglobulinemic Vasculitis

A 68-year-old man was admitted because of weakness of the left leg, dysesthesiae of the extremities and bilateral lower extremity purpura. A neurological examination showed mononeuritis multiplex with laboratory evidence of hypocomplementemia, cryoglobulinemia and leukocytoclastic vasculitis in the biopsy of a skin specimen. The patient also exhibited bilateral submandibular gland swelling, elevated serum IgG4 levels and infiltration of a large number of IgG4-positive plasma cells in the submandibular glands. These findings were consistent with both cryoglobulinemic vasculitis and IgG4-related disease. The administration of oral prednisolone (1 mg/kg/day) resolved the neurological manifestations and the swelling of the submandibular glands and cryoglobulinemia.

Hypersensitivity syndromes

The hypersensitivity syndromes are a group of diseases in which the cutaneous vasculature is altered through immunologic or nonimmunologic mechanisms. These reactions range in severity from mild to life-threatening and can be triggered by drugs, infectious agents, foods, or environmental allergens. Although their causes may vary, the morphologic appearance of these entities may be similar making a clinical diagnosis a challenge.

Acute and chronic urticaria. Challenges and considerations for primary care physicians

Urticaria and angioedema are common dermatologic problems seen by primary care physicians. A carefully taken history, physical examination, specific tests, and skin biopsy often provide useful diagnostic information. In patients with chronic urticaria, urticarial vasculitis and diseases that mimic urticaria need to be ruled out. A variety of treatment options are available for patients with urticaria and urticarial vasculitis. Pharmacologic therapy is useful when the specific cause is undetermined. When a trigger has been identified, the patient must avoid exposure to it. Patient education is an important component of management and should include instructions on crisis management, particularly for patients who have angioedema or a tendency for anaphylaxis.

Low molecular weight C1q-precipitins in hypocomplementemic vasculitis-urticaria syndrome: partial purification and characterization as immunoglobulin

A lupus-like syndrome involving chronic urticaria with cutaneous vasculitis, systemic symptoms, hypocomplementemia with preferential depletion of C1q, and low m.w. (7S) C1q-precipitins has recently been defined. The C1q-precipitin activity (C1q-p) seems to represent a diagnostic marker of the disease, but its chemical nature is not yet clear. We have partially purified and characterized C1q-p from the serum of two patients with this syndrome and compared its activity with the C1q-precipitating activity of aggregated human gamma-globulin (AHGG) anti-C1q antibodies, and several polynucleotides including DNA and polyinosinic acid. C1q-p was found to partition with IgG during precipitation by ammonium sulfate and low ionic strength buffer as well as during column chromatography on DEAE-cellulose and G-200 Sephadex. Like AHGG, but in complete contrast to the polynucleotides, the C1q-precipitating activity of C1q-p was sensitive to pepsin, trypsin, and acidic conditions, but unaffected by DNAse or RNAse; the C1q-precipitating activity of anti-C1q antibody was not diminished by any of these procedures. Thus, C1q-p consists of gamma-migrating protein of low m.w., and its C1q-precipitating activity is indistinguishable from that of AHGG. These results are consistent with the concept that C1q-p is comprised, at least in part, of IgG that binds C1q via the Fc portion of the molecule.