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Papulonecrotic tuberculide and erythema induratum as presenting manifestations of tuberculosis.

We describe a patient with two tuberculides, erythema induratum and papulonecrotic tuberculide. At presentation these were the only manifestations of tuberculosis and they responded dramatically to antituberculous therapy. With the rise in incidence of tuberculosis in Western countries these and other presentations of tuberculosis will be seen with increasing frequency and may provide the only clue to the underlying diagnosis.

Adult↗

A study by means of a new assay of the relationship between an outbreak of erythema infectiosum and non-immune hydrops fetalis caused by human parvovirus B19.

An enzyme-linked immunosorbent assay (ELISA), used to detect IgG and IgM antibody specific for human parvovirus B19, was established by use of human parvovirus B19 capsid protein VP-1 expressed in Escherichia coli. Paired samples of serum derived from 44 mothers and single samples derived from 24 babies having unexplained non-immune hydrops fetalis (NIHF), were tested by means of the assay. Five cases (11%) of NIHF were suspected of having been induced by intrauterine human parvovirus B19 infection because the samples of maternal serum were positive for parvovirus B19 IgM antibody. Four of the five cases arose during an outbreak of erythema infectiosum. According to our study and previous reports over 90% of NIHF caused by parvovirus B19 intrauterine infection have become clinically overt in the second trimester of pregnancy during a period ranging from 15 to 27 weeks of gestation.

Blotting, Western↗

Isolation of spirochetes from the skin of patients with erythema chronicum migrans in Austria.

Spirochetal organisms were isolated from biopsies (skin punches) of the erythematous anular skin lesion of three patients with erythema chronicum migrans. The organisms were cultivated in modified Kelly's medium and - after an incubation period of 2 weeks - discovered by dark field microscopy (X 200). Compared with the Lyme disease agent Borrelia burgdorferi the organisms did not differ in shape, motility and reaction with polyclonal antiserum. Differences to B. burgdorferi were found in (i) very slow growth of the isolated organisms in modified Kelly's medium and in (ii) non reactivity with monoclonal antibodies against the outer membrane protein of B. burgdorferi. It is concluded that the Austrian isolates are closely related to but not identical with the Lyme disease agent.

Adult↗

Erythema chronicum migrans Afzelius in Sweden. A study on 231 patients.

In order to describe the clinical manifestations of erythema chronicum migrans Afzelius (ECMA) in Sweden and to compare them with those in Lyme disease in the United States, 231 patients with ECMA were investigated. Although there are many similarities between the two disorders the findings also point to differences. The skin lesions were of longer duration (median 5-6 weeks) than those in Lyme disease but less often multiple (8%). General symptoms were found in about half of the patients with a short disease duration (less than or equal to 3 weeks), but were usually mild. Laboratory abnormalities were noted in only a minority of the cases. At the time of diagnosis none of the patients had spirochete-induced arthritis, but in three of them cardiac involvement was suspected. Among 16 untreated patients meningitis later developed in two patients and arthritis in one. Diagnostic procedures such as serologic testing and cultivation of spirochetes are discussed.

Adolescent↗

Microbiological findings in erythema (chronicum) migrans and related disorders.

In order to evaluate the virtual advantage of proving borrelial infection in dermatoses clinically diagnosed as erythema (chronicum) migrans (ECM), acrodermatitis chronica atrophicans (ACA) or lymphadenosis cutis benigna (LCB) by means of histological, cultural or serological trials, skin and serum samples obtained from altogether 99 patients suffering from these dermatoses were examined. Serum and--to some extent--skin specimens gained from healthy individuals (n = 36), patients with not tick bite associated disorders of skin, internal organs and nervous system (n = 121) were used as controls. In addition, serum specimens from patients enduring circumscribed scleroderma (morphea), n = 31, and sera of Bavarian forest workers (n = 211) were proven for the presence of borrelial antibodies. Using an indirect immunofluorescence assay with borrelial strains, propagated in inbred mice, as antigens, elevated IgM- and/or IgG antibody titers were found in 51 (84%) out of 61 ECM-, in 17 (100%) ACA- and in 2 (33%) out of 6 LCB-sera. Antibody titers decreased significantly after adequate antibiotic therapy. The groups in comparison yielded spirochetal serum antibodies as follows: Healthy individuals and patients with various diseases 7 out of 157 (4.5%), morphea patients 7 out of 31 (23%) and forest workers 71 out of 211 (34%). Borrelia burgdorferi was cultivated from 6 out of 32 skin and from 1 blood specimen obtained from ECM patients and from 1 out of 5 ACA skin specimens. Borreliae could also be detected in the blood of 3 out of 11 thymusaplastic nude mice after intraperitoneal implantation of ECM-tissue. More frequently than borreliae spindle-shaped bacteria resembling fusobacterium sp. were detected not only by in vitro cultivation of ECM and ACA skin samples, but also in the blood of thymusaplastic mice after implantation of ECM-tissue. By Warthin-Starry silver strain borrelia-like structures were detected in 9 out of 28 ECM, in 3 out of 12 ACA and in 1 out of 5 LCB skin specimens. Therefore in our experience serological examinations turned out to be the most productive diagnostic tool.

Adolescent↗

Treatment and course of erythema chronicum migrans.

72 patients with Erythema chronicum migrans were treated with phenoxymethyl penicillin, 1,5 mill. IU p.o. three times a day for 14 days. Two children got the same therapy, but in a dosage of 400,000 IU three times a day for 10 days. In three of 15 skin samples, taken from the periphery of ECM lesions, spirochetal organisms were isolated. Of the 72 patients 16 had raised IgG (greater than or equal to 128) and 9 had raised IgM (greater than or equal to 64) titers to Borrelia burgdorferi. Under treatment with phenoxymethyl penicillin (penicillin V) all ECM lesions resolved within 6 to 10 days. After an observation period of 9 to 14 months no major or minor late manifestations of Lyme disease have developed in any of the 72 patients.

Adolescent↗

Facial erythema as a result of benzophenone allergy.

Benzophenones are common causes of photoallergy and are increasingly used in products other than traditional sunscreens. Patients may be unaware of any sunscreen exposure when using a product such as shampoo containing benzophenone. Benzophenones also may produce photoallergic contact urticaria, in addition to delayed contact and photocontact dermatitis, which may complicate the clinical presentation. Allergy to benzophenone should be considered in the diagnosis of patients with patchy erythema of the face and neck that is not typically eczematous and that may otherwise be attributed to a rosacea diathesis, lupus erythematosis, or simple flushing. Patch and photopatch testing are indicated to evaluate these patients for allergy to benzophenone.

Adult↗

Erythema multiforme.

Erythema multiforme (EM) is an episodic, variable, self-limited, and often recurrent inflammatory disorder of the skin and mucous membranes. In this article a definition of EM is proposed, its known clinical and histopathologic spectrum is reviewed, an approach to diagnosis and treatment is suggested, and documented evidence regarding its etiology and pathogenesis is presented. EM would appear to be a hypersensitivity reaction to a variety of precipitating agents. It has been directly linked to Mycoplasma pneumoniae and herpes simplex virus infections and possibly is triggered by a number of other infectious agents and by certain drugs. Accumulating observations of diverse immunologic phenomena suggest an underlying immune mechanism of as yet unclear type. Future investigation should be directed toward defining diagnostic criteria, evaluating reported etiologic associations, and clarifying the immunologic basis of this complex and enigmatic disorder.

Diagnosis, Differential↗

Eruptive nevocytic nevi following erythema multiforme.

A patient with erythema multiforme developed many nevocytic nevi, including a large cluster of such lesions at the sites of healed blisters. The development of eruptive nevocytic nevi in this pattern suggests that cutaneous injury plays a role in their pathogenesis.

Blister↗

Erythema dyschromicum perstans.

Erythema dyschromicum perstans (EDP) was first described in 1957, and electron microscopic studies were reported in 1969. Herein, we describe five cases and compare light and electron microscopic findings, direct and indirect immunofluorescence, and dopa-positive melanocyte counts between normal and affected skin. The results indicate that EDP is a clinically characteristic disorder with a lichenoid reaction in its active phase. This lichenoid reaction leads to a pronounced incontinence of pigment and to decreased numbers of melanocytes and of tyrosinase activity in the involved epidermis. These findings support the suggestion that EDP and lichen planus pigmentosus are possible the same entity. Direct inmunofluorescence and fine structural studies show similar findings to lichen plunus. Patients have low-titer antibodies to extranuclear basal cell components.

Adolescent↗

Failure of systemically administered corticosteroids to suppress UVB-induced delayed erythema.

The effects of systemic corticosteroids on ultraviolet-induced delayed erythema were observed in a double-blind controlled study. The backs of human volunteers were irradiated with ultraviolet B (UVB) sources, and subsequent response was observed while ingesting prednisone (80 mg by mouth for 3 days) of placebo. Prednisone given 24 hours before, immediately after, 24 hours or 48 hours after exposure did not increase the redness, edema, or tenderness of the exposed sites.

Clinical Trials as Topic↗

Erythema marginatum in rheumatic fever: early diagnosis by skin biopsy.

Skin biopsy of a 10-year-old boy with a 3-week history of recurrent rash and fever demonstrated histologic changes suggesting a diagnosis of erythema marginatum associated with rheumatic fever. Subsequently, the patient developed classic cardiac and arthritic manifestations. Skin biopsy is recommended for the early diagnosis of rheumatic fever.

Biopsy↗

Erythema multiforme: a critical review of characteristics, diagnostic criteria, and causes.

Erythema multiforme (EM), in its modern definition, is an acute, self-limited syndrome with distinctive skin lesions with or without mucosal lesions. Use of the terminology "EM minor" and "EM major" is a reasonable approach to separating the classical mild cutaneous syndrome, as described by Hebra (EM minor), from the usually more severe syndrome, with marked mucosal damage, as described by Stevens and Johnson (EM major). Until objective markers for EM are available, we propose preliminary diagnostic criteria for EM, based primarily on clinical features. Although hundreds of factors have been reported to cause EM, only a limited number are reasonably well documented as possible precipitating agents. Recurrent herpes simplex is an important etiologic factor in EM minor, while mycoplasmal infections and drugs may be associated with EM major. Progress in the understanding of EM will require careful attention to definition and diagnostic criteria and identification of distinct clinical and etiologic subsets within the spectrum of EM.

Erythema Multiforme↗

Erythema gyratum repens unassociated with internal malignancy.

A case report of erythema gyratum repens occurring in a 68-year-old man is presented. Evaluation and follow-up for development of malignancy over a 39-month period failed to reveal evidence of malignancy. The patient died of an unrelated cause. Autopsy did not demonstrate any evidence of malignancy.

Aged↗

Isolation and characterization of the Lyme disease spirochete from the skin of patients with erythema chronicum migrans.

The Lyme disease spirochete, which had previously been isolated with difficulty from human skin lesions of erythema chronicum migrans of Lyme disease, was grown from six of fourteen skin biopsies cultured in a newly modified Kelly's medium. In two instances the Lyme disease spirochetes that were grown were also seen in histopathologic sections. Organisms grew in clumps in liquid culture medium. All six isolates reacted with a monoclonal antibody to a 31,000-dalton outer membrane protein. Only three of six reacted to a monoclonal antibody to a 34,000-dalton outer membrane protein, suggesting that different subtypes of this organism may infect man. Penicillin, erythromycin, and minocycline were bactericidal agents to all six spirochetes. These in vitro findings may be helpful in determining specific antibiotic treatment of Lyme disease, which was previously based primarily on clinical observations.

Adult↗

Annular erythema of infancy.

An urticarial annular erythema began in our patient at 6 weeks of age and resolved completely by 14 months of age. Individual lesions lasted 2 to several days and tended to erupt in cycles, with each cycle lasting 5 to 6 weeks. The lesions were totally asymptomatic and left no residual scaling or hyperpigmentation. Histologically, a dense perivascular infiltrate of lymphocytes, histiocytes, eosinophils, and a few plasma cells was evident. The clinical appearance, course, and histologic characteristics resemble closely the case reported by Peterson and Jarratt in 1981.

Biopsy↗

Erythema chronicum migrans of Lyme disease: diagnosis by monoclonal antibodies.

We demonstrated spirochetes from a skin lesion of the erythema chronicum migrans in a patient with Lyme disease by the murine monoclonal antibody (H9724). Frozen skin biopsy specimens reacted with murine monoclonal antibodies (H5332, H9724, and H4825) and were examined by indirect immunofluorescence assay. The spirochetes stained with monoclonal antibody H9724 and fluorescein isothiocyanate-conjugated second antibody (goat antimouse IgG). The antibody H9724 is specific for the periplasmic flagellae (axial filaments) of several Borrelia species, including Ixodes dammini spirochete (Borrelia burgdorferi). No immunofluorescence staining was demonstrated with either monoclonal antibody H5332, specific for an outer membrane protein of North American strains of B. burgdorferi, or the antibody H4825, specific for an outer membrane protein of B. hermsii.

Adult↗

Successful treatment of glucagonoma-related necrolytic migratory erythema with dacarbazine.

A 63-year-old man with a glucagonoma syndrome is described. The diagnosis was confirmed by necrolytic migratory erythema, which is the most distinctive feature of the clinical syndrome. There was no chance of operative resection of the tumor because of liver metastases at the time of diagnosis. The patient was treated with dacarbazine. During this treatment the skin lesions disappeared completely.

Adenoma, Islet Cell↗