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PubMed2000

A case of intravascular large B-cell lymphoma mimicking erythema nodosum: the importance of multiple skin biopsies.

BACKGROUND: Intravascular lymphoma is a rare disease characterized by the proliferation of neoplastic monuclear cells within the lumens of small blood vessels. The neoplastic cells are usually of B-cell origin, and rarely of T-cell or histiocytic origin. Although this clinicopathological entity of lymphoma has not been listed in general pathological classifications such as REAL classification or the Working Formulation, it is recently in the WHO classification scheme, which is essentially an updated REAL scheme, and the EORTC classification scheme. METHODS: In this report, a 62-year-old woman with intravascular large B-cell lymphoma was observed by clinical, histopathological, immunohistochemical and molecular methods. RESULTS: A 62-year-old woman presented with large erythematous macules on the bilateral thighs and lower legs. The lesions were accompanied with hard, tender, intradermal or subcutaneous nodules mimicking erythema nodosum. Histopathological examination in the first biopsy revealed non-specific panniculitis compatible with erythema nodosum. The second biopsy revealed emboli of atypical lymphocytes within many of the dilated and proliferated vessels in the deep dermis and subcutaneous tissue. These cells were positive for L-26 and kappa light chain, and negative for lambda light chain, factor VIII-related antigen, CD30, CD34, CD68 and UCHL-1. These findings confirmed the diagnosis of intravascular large B-cell lymphoma. A laboratory examination showed a high level of LDH and abnormal cells in the bone marrow. An MRI of the brain and computed tomographic (CT) scans of the chest and abdomen revealed no evidence of malignancy. Before the treatment, the size of the nodules decreased spontaneously by about 50% in one month and significantly in two months. Although combination chemotherapy, which consisted of CHOP, brought her partial remission, she experienced neurological symptoms 6 months after the initial treatment and died of brain metastasis 9 months after the treatment. CONCLUSIONS: This is a unique case for two following reasons: 1) the first biopsy revealed non-specific findings compatible with erythema nodosum; and 2) before the treatment, the nodules regressed spontaneously. Dermatologists should take multiple skin biopsies for EN lesions with the non-specific histopathological findings not to refute the existence of this disease.

Biopsy↗
PubMed2003

Time course of ultraviolet B-induced erythema in people with red hair harbouring homozygous melanocortin 1 receptor mutations.

It has previously been reported that the time course of erythema may be delayed in those with sun-sensitive skin types and those with skin cancer. One molecular explanation for this putative phenotype would be that it is caused by mutations of the melanocortin 1 receptor (MC1R). In the present study of 20 persons, 10 of whom were MC1R homozygous, we measured erythema over a 21-day period in response to a range of ultraviolet B doses using methods that improved on previous studies. We could detect no consistent differences in ultraviolet radiation-induced erythema between the groups studied. The pharmacological mechanisms underpinning such prolonged inflammatory responses merit further investigation.

Case-Control Studies↗
PubMed1989

Recurrent erythema multiforme: a possible role of foodstuffs.

Seven patients are described, who presented with a history of recurrent episodes of erythema multiforme and who were subsequently found to be sensitive, by patch testing, to benzoic acid. Advice on avoidance of benzoic acid resulted in resolution of attacks in four patients, but three patients who were not able to adhere to an exclusion diet continued to have symptoms. These findings implicate benzoic acid, a food preservative, as an aetiological factor in erythema multiforme. It is proposed that patch testing to food substances should be carried out on patients who present with recurrent erythema multiforme, since avoidance of potential allergens may lead to resolution of symptoms.

Adolescent↗
PubMed2004

Ultraviolet-radiation-induced erythema and suppression of contact hypersensitivity responses in patients with polymorphic light eruption.

Ultraviolet-radiation suppresses cell-mediated immunity in healthy humans. It has been postulated that, in the short term, this immunosuppression prevents autoimmune responses to ultraviolet-radiation damaged skin. Patients with polymorphic light eruption (PLE) demonstrate abnormal responses to ultraviolet-radiation suggestive of an immune response to an ultraviolet-radiation-induced antigen. We investigated whether PLE patients (n=22) were resistant to ultraviolet-radiation-induced immunosuppression compared to skin-type, aged-matched controls (n=23). Groups of patients and controls (six subjects per group) received a single dose of solar-simulated ultraviolet-radiation of either 0, 0.6, 1 or 2 minimal erythema doses (MED). Erythema was quantified using a reflectance meter and all volunteers were sensitised on the irradiated site with dinitrochlorobenzene. Contact hypersensitivity responses (CHS) to dinitrochlorobenzene were quantified after challenge using ultrasound. Ultraviolet-radiation-induced erythema was comparable in patients and controls. CHS was comparable in unirradiated patients and controls. UVR-induced a dose-dependent suppression of CHS in all volunteers but patients were more resistant to immunosuppression after 1MED. Exposure to 1MED suppressed CHS by 78% in controls but induced less suppression in patients (44%, p < 0.01). Our data suggest that PLE patients have a flaw in their immunoregulatory response to ultraviolet-radiation it is only apparent over a narrow dose range around 1 MED.

Adult↗
PubMed2000

Calcipotriol ointment and cream or their vehicles applied immediately before irradiation inhibit ultraviolet B-induced erythema.

Results of ultraviolet (UV) B phototherapy can be improved by the application of calcipotriol, but studies are needed to decide how the two treatments should be combined. We studied the effect of UVB after application of calcipotriol ointment (50 microg g-1) and calcipotriol cream (50 microg g-1) and determined the optimal time of application of calcipotriol when combined with UVB phototherapy (280-350 nm), in a single-blinded randomized vehicle-controlled study of 37 healthy adult volunteers. Calcipotriol ointment or cream was applied randomly on five areas on the back at different time intervals from UVB irradiation. One area was left untreated as the control. Application times were the evening before, the morning before, 2 h before, immediately before, and immediately after irradiation. UVB irradiation was administered by TL20W/12 fluorescent tube lamps at increasing doses (20, 25, 32, 40, 50 and 64 mJ cm-2) to six subunits of each test area. Clinical assessment was performed 24 h after UVB irradiation by a blinded investigator. Calcipotriol ointment and cream were applied in 19 and 18 subjects, respectively, and erythema was measured for each application time quantified. We found that erythemal reactions were significantly smaller when calcipotriol ointment or cream was applied immediately before irradiation compared with all other application times. To explain these findings, a vehicle control study was performed. No difference in erythema was seen between calcipotriol medication and the vehicle controls. Spectrophotometric analysis of the calcipotriol cream and ointment showed no UV absorbance in the UVB range. No signs of photosensitization were noted. In conclusion, the vehicles of the calcipotriol ointment and cream inhibit the induction of erythema by UVB irradiation if applied immediately before phototherapy. Consequently, calcipotriol ointment and cream should not be applied directly before UVB irradiation; however, they may be applied at any time up to 2 h prior to or immediately after UVB irradiation. Possible explanations for this sunscreen activity are discussed.

Adolescent↗
PubMed2002

Reliance on erythema scores may mask severe atopic dermatitis in black children compared with their white counterparts.

BACKGROUND: The prevalence of atopic dermatitis (AD) has been shown to be higher in London-born black Caribbean children than in their white counterparts, but little is known about the severity of the disease. OBJECTIVES: To carry out a longitudinal survey to investigate potential risk factors for AD severity in children. We report our findings in relation to differences in disease severity between white and black children and the effect of inclusion and exclusion of erythema scores on this comparison. METHODS: The recruited children were identified by their general practitioners (GPs) as having presented with AD, and the U.K. diagnostic criteria for AD were used to verify the diagnosis. Interview and clinical examination of children took place up to four times, 6 months apart. Each time, the same observer assessed AD severity using the SCORAD (SCORe Atopic Dermatitis) index. Potential risk factors and confounders were evaluated with a five-page questionnaire. Non-parametric tests were used for statistical analysis and the study participant remained the unit of the analysis. RESULTS: In total, 137 children (82 urban and 55 rural) were recruited, and each seen up to four times. This gave 380 observations (69% of an expected 548). The urban population contained 42 (51%) white children, 26 (32%) black children and 14 (17%) from other races. The rural population was entirely white. The 14 children from other races were completely excluded from the statistical analysis. The black children were all born in the U.K. On crude analysis, children with black skin showed a non-significantly lower risk of severe disease when compared with white children (odds ratio, OR 0.84; 95% confidence interval, CI 0.4-1.76; P = 0.65), while a highly significantly increased risk was found after adjusting for erythema score (OR 5.93; 95% CI 1.94-18.12; P = 0.002). The difference remained significant even after controlling for other potential confounders. CONCLUSIONS: Black children with AD are about six times more at risk of having severe AD than their white counterparts. GPs and dermatologists should note that erythema can be a misleading indicator of severity in black children. Difficulties of assessment due to skin pigmentation might mean that severe cases are not being detected and appropriately treated.

Black or African American↗
PubMed2001

Muco-cutaneous retinoid-effects and facial erythema related to the novel triazole antifungal agent voriconazole.

Voriconazole is a new azole antifungal drug with activity against a wide range of systemic fungal pathogens, including Aspergillus spp. Five patients with chronic invasive aspergillosis were treated for 12-58 weeks with voriconazole, 200 mg twice daily and developed facial erythema and cheilitis. One who received 58 weeks of therapy also developed discoid lupus erythematosus-like lesions on both sides of her neck. Both erythema and cheilitis resolved after discontinuation of voriconazole. Serum retinoids were elevated in the three patients in whom they were measured. Voriconazole has the potential for retinoid-like side-effects and facial erythema.

Adult↗
PubMed2002

Chronic moderate heat dermatitis (erythema ab igne) in five dogs, three cats and one silvered langur.

Erythema ab igne, an old and rare disease in the human literature, is an erythematous, often pigmented, reticular, macular dermatosis that occurs at the site of repeated exposure to moderate heat. We identified lesions consistent with erythema ab igne in five dogs, three cats and one silvered langur (Trachypithecus cristatus[Raffles, 1821]). In dogs and cats, the cutaneous lesion distribution typically reflected chronic exposure to moderate heat during lateral or sternal recumbency. The silvered langur developed cutaneous lesions on the dorsal neck from exposure to a heat lamp. Principal clinical lesions consisted of irregular areas of alopecia (7/9) and erythema (7/9), sometimes with hyperpigmentation (3/9). Principal histological features consisted of karyomegaly (9/9) and keratinocyte atypia (4/9), scattered apoptotic or vacuolated basal cells and/or apoptotic keratinocytes (6/9), mild mixed mononuclear interstitial or interface dermatitis (9/9) with adnexal atrophy (8/9), and a variable number of wavy eosinophilic elastic fibres (9/9). The presence of these cutaneous lesions in an animal indicates that the environment should be evaluated for exposure to chronic moderate heat, and the heat source should be eliminated or modified to prevent further exposure and progression of lesions.

Animal Husbandry↗
PubMed2001

Persistent erythema multiforme: a report of three cases.

Three cases of persistent erythema multiforme, two of unknown aetiology and one precipitated by influenza are reported. Lesions were widespread, mostly atypical in appearance and regressed in response to immunosuppressants (systemic steroids and/or azathioprine) or, in one case, to dapsone. One patient developed erythroderma responding eventually to etretinate. Histology in all patients was consistent with the mixed, epidermodermal pattern of erythema multiforme. There were no significant laboratory abnormalities nor marked symptomatology apart from itching. The persistent form appears to belong to the spectrum of erythema multiforme being heterogeneous with respect to inducing stimuli, including viral antigens, neoplastic or inflammatory disease or unknown causes. Whenever it is possible, treatment should be adjusted depending on the causative agent.

Adult↗
PubMed2001

Linear IgA dermatosis presenting with erythema annulare centrifugum lesions: report of three cases in adults.

Linear IgA dermatosis presented with erythema annulare centrifugum lesions in three elderly women. Search for underlying malignancy revealed low-grade B-cell lymphoma in one case. In addition to subepidermal blistering, histology showed a typical mixed infiltrate of granulocytes and eosinophils and, occasionally, papillar microabsesses in one case. In the two other subjects, characteristic subepidermal lining with granulocytes was observed. Immunofluorescence studies confirmed the diagnosis, while autoantibodies characteristic for dermatitis herpetiformis were absent. To our knowledge this is the second report of adult linear IgA dermatosis in association with erythema annulare centrifugum lesions. Our observations concord with several other reports of figurate erythema associated with autoimmune blistering disease and other immune disorders. Common antibody-related immunological mechanisms indicate that the two distinct clinical pictures are probably stages of the same pathogenic entity.

Adrenal Cortex Hormones↗
PubMed2003

Erythema induratum of Bazin and Poncet's disease -- successful treatment with antitubercular drugs.

Erythema induratum of Bazin (EIB) is considered a tuberculide reaction and consists of recurrent painful nodules predominantly on the calves. Clinically it has common features with diseases like nodular vasculitis, perniosis, polyarteritis nodosa and erythema nodosum. Poncet's disease is a reactive arthritis that may accompany tuberculosis. We report a case of a young woman in which the simultaneous occurrence of erythema induratum of Bazin and Poncet's disease led to a clinical picture very similar to Löfgren's syndrome. The final diagnosis was obtained by polymerase chain reaction detection of mycobacterial DNA in a skin biopsy. A systemic therapy with tuberculostatic drugs led to the disappearance of symptoms. The presented case shows the usefulness of polymerase chain reaction diagnostics in EIB patients without other clinical signs of tuberculosis and a confusing combination of symptoms, and further confirms the presence of mycobacterial DNA in EIB lesions.

Adult↗
PubMed2003

Pustular acral erythema in a patient with acute graft-versus-host disease.

Acral erythema is a well-known side-effect of chemotherapy treatment but it is not common in patients undergoing bone marrow transplant. We report a post-transplant patient with clinical and histological acute graft-versus-host disease (GVHD) who concurrently developed acral erythema presenting as painful, well-defined and self-limiting palmar erythema with pustules. A skin biopsy from the palm showed abnormal keratinocyte maturation and eccrine squamous syringometaplasia. This case illustrates the difficulties in establishing the differential diagnosis of cutaneous eruptions in patients undergoing bone marrow transplant.

Adrenal Cortex Hormones↗
PubMedDate not supplied

Acute generalized varicella zoster in the setting of preexisting generalized erythema.

We report a 5-year-old girl who initially had generalized erythema from scarlet fever. Four days later she developed sheets of monomorphous vesicles in the areas of erythema. A Tzanck smear of a vesicle base showed multinucleated giant cells, and viral culture grew varicella zoster virus, confirming a clinical diagnosis of varicella. This case illustrates that, with a background of preexisting erythema, varicella may present in an atypical manner.

Acute Disease↗
PubMedDate not supplied

Atypical erythema toxicum neonatorum of delayed onset in a term infant.

We describe a 10-day-old term infant who presented to the emergency room with an acute pustular eruption. Laboratory tests and clinical outcome confirmed the diagnosis of erythema toxicum neonatorum. A full septic workup was performed and all cultures were negative. Wright-stained smear of pustular contents showed a predominance of neutrophils with 10% eosinophils. The white blood cell count was 19,000/mm3 with 10% eosinophils. The eruption resolved spontaneously at 15 days of age leaving no sequelae. This is the first fully documented case of erythema toxicum in a term infant occurring as late as 10 days of age. When erythema toxicum presents in an atypical fashion, diagnostic tests are important to exclude other causes of pustular dermatoses of the neonate.

Eosinophils↗
PubMed2000

Allergic contact dermatitis to tea tree oil with erythema multiforme-like id reaction.

The commercial production of tea tree oil, extracted from Melaleuca alternifolia Cheel, has considerably increased over the past 15 years in response to a strong demand for natural remedies and aromatic substances. The number of case reports that describe allergic contact dermatitis (ACD) to this essential oil is also on the rise. We report an additional case of ACD to tea tree oil that presented with an extensive erythema multiforme-like reaction. A skin biopsy was performed from a targetlike lesion distant from the site of the initial dermatitis. The patient was treated with systemic and topical corticosteroids. Five months later, he was patch tested to the North American standard series, to his own tea tree oil, to a fresh batch of tea tree oil, and to some related allergens. The skin biopsy showed a spongiotic dermatitis without histological features of erythema multiforme. Patch testing elicited a 3+ reaction to old, oxidized tea tree oil, a 2+ reaction to fresh tea tree oil, a 2+ reaction to colophony, a 1+ reaction to abitol, and a 1+ reaction to balsam of Peru. We believe this is the first report of erythema multiforme-like reaction secondary to ACD from tea tree oil. Other interesting features are the stronger reaction to oxidized than to fresh tea tree oil, and concomitant reactivity to colophony, abitol, and balsam of Peru.

Allergens↗
PubMed2000

Sarcoid and erythema nodosum arthropathies.

Sarcoidosis is a systemic granulomatous disease of unknown origin, characterized in affected organs by an accumulation of activated T lymphocytes and macrophages. Musculoskeletal manifestations of sarcoidosis include acute and chronic arthritis and muscular and osseous sarcoidosis. In certain populations, acute sarcoidosis often presents with constitutional symptoms, polyarthritis and erythema nodosum (Löfgren's syndrome). Erythema nodosum, often with joint symptoms, also occurs in association with several other conditions including infections, medications and other underlying diseases. The diagnosis of sarcoidosis should be based on a tissue biopsy, but a patient with typical Löfgren's syndrome may not require biopsy proof. Among the long list of biochemical markers that have been suggested as aids for diagnosis and monitoring of sarcoidosis, calcium in serum and urine and angiotensin-converting enzyme in serum are well-established clinical tools. Serum angiotensin-converting enzyme can be used for monitoring disease activity in the individual patient, but because of lack of sensitivity and specificity its diagnostic value is rather low. Non-steroidal anti-inflammatory agents usually effectively alleviate acute sarcoid arthritis and joint symptoms associated with erythema nodosum. In severe acute arthritis and in chronic arthritis, corticosteroids may be required to control the symptoms. In patients requiring persistent corticosteroid therapy, antimalarial agents and methotrexate constitute therapeutic alternatives.

Arthritis↗
PubMed1998

[Optic neuropathy after erythema infectiosum].

BACKGROUND: Optic neuropathies can not always easily be classified as neuritis or ischemic disease. CASE REPORT: A 39 year old woman suffered from unilateral optic neuropathy 9 days after the acute onset of a general disease with erythema and joint swellings. The optic disc swelling and visual fields resembled an anterior ischemic optic neuropathy, however, a marked improvement was achieved by steroid treatment. The general disease proved to be erythema infectiosum. CONCLUSIONS: Erythema infectiosum as a frequent children's disease causes very rarely central nervous involvement, optic neuropathy has not been reported yet. In cases of atypical optic neuropathies search for an underlying systemic disease is of value.

Adult↗
PubMedDate not supplied

Long-term serological follow-up of patients treated for chronic cutaneous borreliosis or culture-positive erythema migrans.

The kinetics of antibodies to Borrelia burgdorferi following successful treatment of early and late cutaneous borreliosis were analysed in consecutive serum samples by an enzyme-linked immunosorbent assay (ELISA) technique. Twenty-three patients with culture positive erythema migrans were followed for 23+/-14 months: 41% stayed seronegative, 35% showed an isolated immunoglobulin M (IgM) response, 8% an isolated IgG response and 16% a combined IgM and IgG responses. In general, antibody levels peaked within the first 3 months of symptom onset, whereafter a gradual decline was observed within 1 year. Twenty-two patients with chronic cutaneous borreliosis were followed for 23+/-11 months and all patients stayed IgG positive. Nearly three-quarters showed a clear decline in IgG levels over the years, while the rest did not. After 9+/-1 years 88% of 16 patients examined were still IgG positive. In conclusion, treatment of erythema migrans should be initiated on clinical appearance as a substantial number of patients stayed seronegative. Treatment success may in part be monitored serologically for both seropositive erythema migrans and chronic cutaneous borreliosis as most patients show declining titres after successful treatment. However, continuously high titres do not necessarily indicate treatment failure.

Acrodermatitis↗