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An outbreak of erythema infectiosum associated with human parvovirus infection.

Erythema infectiosum (EI) or fifth disease is a mild, acute exanthematous disease, occurring mainly among children, for which a causative virus has long been sought. In May 1983 an outbreak of exanthematous illness was reported in a primary school in North London. Children attending the school were investigated by questionnaire and 162 (43.9%) reported an illness with the features of EI. In each of 36 cases investigated virologically the illness was associated with parvovirus infection. Moreover, pre-existing antibody to parvovirus was correlated with protection from EI in 16 of 17 close family contacts of cases. We propose therefore that EI is the common manifestation of infection with the human parvovirus.

Adult↗

Isolation and species typing of Lyme borreliosis spirochaetes from UK patients with erythema migrans.

Skin biopsies taken from UK cases of erythema migrans rash were cultured for Borrelia burgdorferi sensu lato. Reverse line blotting was used to type the infecting genospecies in PCR-positive cultures and biopsies. B. garinii or B. afzelii was identified in 56% (5/9) of biopsies/cultures tested. All patients were tested by conventional serology. PCR confirmed infection in two patients where serological testing failed to detect antibody.

Bacterial Typing Techniques↗

Acute brucellosis presenting with erythema nodosum.

Brucellosis is a common world-wide zoonotic disease. Cutaneous manifestations are not specific and affect 1-14% of patients with brucellosis. We describe two cases of young males presenting with skin lesions of erythema nodosum on the anterior surface of the legs. Histopathology of skin biopsy revealed septal panniculitis, but the positive cultures of blood or bone marrow for Brucella melitensis established the diagnosis of brucellosis.

Adult↗

Early dissemination of Borrelia burgdorferi without generalized symptoms in patients with erythema migrans.

The diagnosis of erythema migrans (EM) is not always easy, and reports of culture- or PCR-confirmed diagnosis as well as reports of EM with simultaneous disseminated disease are few. Characteristics and incidence of EM in addition to frequency of early dissemination of B. burgdorferi were studied in the archipelago of South-Western Finland prospectively using questionnaires, skin biopsies and blood samples. Clinical EM was recognized in 82 patients (incidence 148/100,000 inhabitants/year). Of skin biopsy samples, 35.5% were positive by PCR (the majority B. garinii), and 21.5% by cultivation (all B. garinii). Of blood samples, 3.8% were positive by PCR, and 7.7% by cultivation. Of the patients, 30.9% were seropositive at the first visit, and 52.9% 3 weeks later. Of the patients with laboratory confirmed diagnosis, the EM lesion was ring-like in 31.8% and homogeneous in 65.9%. Dissemination of B. burgdorferi, based on culture or PCR positivity of blood samples, was detected in 11.0% of the patients. The frequency of generalized symptoms was nearly the same in patients with as in those without dissemination (22.2% vs 27.4%). Only 21.4% of the patients with culture-positive EM recalled a previous tick bite at the site of the EM lesion. We conclude that EM lesions are more often homogeneous than ring-like. B. burgdorferi may disseminate early without generalized symptoms.

Antibodies, Bacterial↗

Erythema multiforme due to contact with weeds: a recurrence after patch testing.

Erythema multiforme (EM) as a complication of patch testing (PT) is rare. A 52-year-old woman with a 13-year history of episodes of EM, after contact with weeds during home gardening, had had no recent history of herpes simplex, other infection, drug ingestion or vaccination. On examination, EM lesions were distributed on the exposed skin. 5 weeks after complete resolution, PT and photopatch testing (PPT) were done with fresh plants she brought in. She was PT with a standard series and the Hermal-Trolab plants, woods, tars, balsams and flavors series. Intradermal testing, with a 3 + reaction to mixed weed pollens, was done 3 weeks later. Specific IgE to weed pollens class 1 (CAP-Pharmacia) was detected. Eczematous PT reactions were obtained with fresh leaves: common chickweed (Stellaria media Caryophyllaceae), dandelion (Taraxacum officinale Compositae), field-milk thistle (Sonchus arvensis Compositae) and white clover (Trifolium repens Leguminosae). Photoaggravation was seen to common chickweed and dandelion. Positive PT was also seen with alantolactone. By the 4-day reading, a typical EM had commenced, coming up to quite the same extent as seen on admission. There was no photosensitivity (UV skin tester, K. Waldmann). In the essential oil obtained from common chickweed, thin layer chromatography (TLC) revealed the well-known contact allergens borneol, menthol, linalool, 1,8-cineole, and other terpenes such as epoxy-dehydro-caryophyllene, monoterpene alcohol-ester and caryophyllene. Up to now, no data on essential oil in Stellaria media (common chickweed) have been reported. It can be concluded that EM developed due to contact with weeds, and recurred after patch testing. Neither blistering nor eczematous lesions have been seen on her skin, making this case very unusual. As far as the world literature is concerned, this is only the 4th report of EM developing in association with patch testing.

Dermatitis, Occupational↗

Factor XIIIa+ dermal dendrocytes in erythema elevatum diutinum and ordinary cutaneous leukocytoclastic vasculitis lesions.

Factor XIIIa+ dermal dendrocytes belong to the dermal microvascular unit and are related to wound healing, angiogenic and fibrogenic processes. Erythema elevatum diutinum (EED) is a leukocytoclastic vasculitis followed by repair and fibrosis. In order to verify the involvement of fXIIIa+DD in the pathogenesis of EED and ordinary leukocytoclastic vasculitis (OLV) these cells were immune labeled with anti-factor XIIIa antibody and quantified in 15 biopsies of EED, 18 of OLV and compared with 11 fragments of normal skin (NS). The number of vessels was evaluated by endothelial cell staining with anti CD34 antibody. FXIIIa+DD appeared in both groups of vasculitis with hyperthophic dendrites, with no difference in their number at any level of the dermis. The number of fXIIIa+DD in the superficial dermis was higher in OLV than in NS (p<0.001). The number of dermal vessels in the EED group was higher at all dermis depths evaluated when compared with NS (p<0.05) and in the middle and deep dermis when compared with OLV (p<0.05). The results suggest the participation of fXIIIa+DD in the immunopathological mechanisms of both groups of vasculitis studied. However, there was no correlation between the number of fXIIIa+DD and angiogenesis and fibrogenesis in the EED lesions.

Adolescent↗

The relationship between constitutive pigmentation and sensitivity to ultraviolet radiation induced erythema is dose-dependent.

The relationship between skin colour and experimental exposure to ultraviolet radiation (UVR) B, with response measured as erythema was studied. Two reflectance methods were used to measure skin colour--tristimulus colorimetry using a Minolta instrument (summarized as the alpha characteristic angle) and the melanin index based on the Diastron reflectance instrument. As expected both measures are highly correlated (0.91). A dose-dependent relationship between skin colour measured as the alpha characteristic angle and UVR was established, with the gradient increasing from 0.99 at 119 mJ to 2.7 at 300 mJ, with the relevant standard errors being 0.39 and 0.47, respectively. Similarly, for the melanin index (where the scale goes in the opposite direction) the gradient differs between -0.49 for 119 mJ and -0.91 for 300 mJ, with the standard errors being 0.14 and 0.17 respectively. The proportion of variation explained is also greater at higher UVR challenge doses. Studies relating UVR sensitivity and pigmentation need to take account of the dose of UVR administered.

Dose-Response Relationship, Radiation↗

Erythema migrans: an unusual presentation.

A case of erythema migrans affecting the attached gingivae and the upper and lower labial mucosa is described. No lesions were found on the tongue although this is the site most commonly affected.

Adult↗

Erythema exsudativum multiforme induced by granulocyte colony-stimulating factor in an allogeneic peripheral blood stem cell donor.

We describe a healthy peripheral blood stem cell (PBSC) donor who developed a cutaneous reaction, erythema exsudativum multiforme, during the administration of granulocyte colony-stimulating factor (G-CSF) for mobilization. The cutaneous lesions were located on his hips, apart from the site of G-CSF injection. Treatment with topical corticosteroid was commenced, and the lesions resolved completely within a week. Adverse cutaneous reactions induced by G-CSF have been reported infrequently in healthy donors. Further documentation of cases and their full evaluation will be of great importance for both physicians and PBSC donor.

Adrenal Cortex Hormones↗

Calcipotriol for erythema annulare centrifugum.

: Erythema annulare centrifugum (EAC) is an uncommon inflammatory skin disease of unknown aetiology. No therapy is currently available. We describe a 73-year-old woman with a 3-year history of EAC that was resistant to topical and systemic glucocorticoids, antifungals, and psoralen plus ultraviolet A treatment. After 3 months of treatment with topical calcipotriol the lesions cleared completely and did not recur during a 6-month follow-up period. Vitamin D analogues may be of value in the therapy of EAC.

Aged↗

Etizolam-induced superficial erythema annulare centrifugum.

Erythema annulare centrifugum (EAC) is characterized by slowly enlarging annular erythematous lesions. Although the origin is not clear in most cases, EAC has been associated with infections, medications, and in rare cases, underlying malignancy. We describe a patient who developed annular erythematous lesions after etizolam administration. The eruptions were typical of the superficial form of EAC, both clinically and histopathologically. The lesions disappeared shortly after discontinuation of the medication. Patch testing with etizolam gave positive results. To our knowledge this is the first reported case of etizolam-induced superficial EAC.

Aged↗

Simultaneous occurrence of papulonecrotic tuberculide and erythema induratum and the identification of Mycobacterium tuberculosis DNA by polymerase chain reaction.

The simultaneous occurrence of two tuberculides in one patient is rare. We report the case of a 32-year-old man presenting with both papulonecrotic tuberculide and erythema induratum. Mycobacterial DNA was identified from both skin lesions by polymerase chain reaction using formalin-fixed and paraffin-embedded tissues, suggesting that tuberculides are related to tuberculosis. New skin lesions developed after the patient discontinued his medication on his own initiative, 2 months after triple antituberculous therapy had been started. It is important to continue therapy for a prolonged period.

Adult↗

Recurrent annular erythema in juvenile chronic myelogenous leukaemia.

Juvenile chronic myelogenous leukaemia (JCML) is a rare haematological malignancy of myelomonocytic lineage that affects patients less than 4 years of age and is known as an entity different from adult-type chronic myelogenous leukaemia. In JCML, skin manifestations are relatively common but most of them have been reported as a non-specific eruption, which histologically may show changes resembling neurofibromatosis or xanthogranuloma. We present a 2-year-old boy with JCML who developed a recurrent annular erythema in which leukaemic infiltrates were confirmed histologically, even though his bone marrow examination suggested that be remained in haematological remission.

Child, Preschool↗

Erythema elevatum diutinum and HIV infection: a report of five cases.

Erythema elevatum diutinum (EED) is emerging as a specific HIV-associated dermatosis, 11 cases having so far been reported in the medical literature and five patients with the disease having been seen by us during the last 4 years. As the disease is poorly known, it is easily confused with Kaposi's sarcoma or bacillary angiomatosis, but the histopathological features are diagnostic. EED is considered to be an immune complex-mediated vasculitis. A streptococcal infection seemed to be the trigger factor in four of our patients. Partial control of the cutaneous lesions was achieved by the use of antibiotics.

AIDS-Related Opportunistic Infections↗

Sun protection factor measurement of sunscreens is dependent on minimal erythema dose.

This study investigates the influence of skin colour and minimal erythema dose (MED) on the in vivo determination of sunscreen sun protection factors (SPFs). The MEDs of groups of 10-20 subjects were measured on the lower back with a 1000-W solar-simulated xenon arc lamp. Five sunscreens, with commercially measured SPFs ranging from 4 to 30 + were then tested on the different groups, and their SPFs were correlated with volunteers' MEDs. We found that the sunscreens had higher SPF values when tested on subjects with lower MEDs and paler skin. The SPF values obtained with our ultraviolet (UV) source were lower than the SPF values reported with commercially used solar simulators. We conclude that while SPF tests with artificial UV sources and pale-skinned volunteers can and should be used to rank the efficacy of various sunscreens in preventing sunburn, they should not be interpreted as measures of a sunscreen's absolute level of sun protection. Factors such as the differences in skin colour and MED between subjects used for SPF testing and the general population, the spectral differences between sunlight and artificial UV, as well as the tendency of the public to apply only small amounts of sunscreen and to re-apply it infrequently, mean that laboratory and sunlight SPFs may be markedly different.

Adult↗

Lupus erythematosus with antiphospholipid syndrome and erythema multiforme-like lesions.

The occurrence of erythema multiforme (EM) in patients with lupus erythematosus (LE) has been described previously as a coincidental association. In contrast, LE with EM-like lesions and a peculiar immunological pattern, including positive rheumatoid factor, antinuclear antibodies and a serum antibody against an extract of human tissues recently recognized as similar to Ro (SSA), constitutes an established entity named Rowell's syndrome. We describe a woman with LE and long-standing widespread vesiculobullous and necrotic haemorrhagic EM-like lesions in combination with Ro (SSA) and scl-70 antibodies and the typical laboratory findings of the antiphospholipid syndrome (APS), namely lupus anticoagulant, anticardiolipin antibodies and prolonged activated partial thromboplastin time. This case could conceivably be consistent with a diagnosis of Rowell's syndrome, if the latter is regarded as a clinicopathological spectrum. However, the coexistence of LE, persistent EM-like disease and incomplete APS may also fulfil the diagnostic criteria for the 'multiple autoimmune syndromes'. We speculate that the laboratory markers of APS play a pivotal part in such an unusual clinical presentation.

Adult↗

A case of erythema elevatum diutinum associated with B-cell lymphoma: a rare distribution involving palms, soles and nails.

We report a case of erythema elevatum diutinum (EED) in association with malignant B-cell lymphoma. A 62-year-old man developed EED with an unusual distribution involving the palms, soles and nails. Treatment with dapsone was effective for his skin and nails until he developed generalized lymphadenopathy which turned out to be malignant lymphoma. Many haematological diseases, e.g. IgA paraproteinaemia and myeloma, have been reported in association with EED, but not malignant lymphoma. Even though it may just be a coincidence, we would like to add malignant lymphoma as one of the diseases associated with EED because the activity of EED and malignant lymphoma fluctuated in parallel.

Anti-Infective Agents↗

Sequential erythema nodosum leprosum and reversal reaction with similar lesional cytokine mRNA patterns in a borderline leprosy patient.

We compare the clinical and histological data with the immunological status of a borderline leprosy patient who experienced an erythema nodosum leprosum (ENL) reaction followed by a reversal reaction (RR) after 12 weeks of anti-inflammatory treatment (pentoxifylline, PTX, 1200 mg daily). Skin biopsies, serum and blood samples were collected sequentially during the reactional episodes. At the outset of RR, the patient's lymphocytes secreted interferon (IFN) -gamma and there was a positive lymphoproliferative test in response to Mycobacterium leprae, which had been absent during ENL. The lepromin reaction reversed from negative (0 mm) at diagnosis, to positive (3 mm) 3 months after the development of RR. Tumour necrosis factor (TNF) -alpha levels in the serum decreased after 1 week of treatment and increased slightly thereafter. The immunohistochemical data for ENL showed a diffuse dermal and hypodermal infiltrate composed of mononuclear cells and neutrophils, while RR was characterized by an epithelioid granulomatous infiltrate with a marked presence of gammadelta T cells. Reverse transcription-polymerase chain reaction showed a mixed cytokine profile characterized by the expression of TNF-alpha, IFN-gamma, interleukin (IL) -6, IL-10 and IL-12 mRNA in the skin, which persisted throughout the development of ENL and RR lesions. IL-4 mRNA, first detected after 7 days of PTX treatment, was still present during RR. The results suggest the emergence of an initial Th0-like cytokine profile in ENL, typical of a state of immunoactivation, before conditions optimal for the appearance of an antigen-specific cell-mediated immune response and gammadelta T-cell migration are created.

Adult↗