Erythematous Induration Research Articles

A case of cutaneous variant of intravascular large B-cell lymphoma in which dermoscopy revealed telangiectasias associated with erythematous induration.

Intravascular large B-cell lymphoma (IVLBCL) is a rare type of extranodal, diffuse, large B-cell lymphoma characterized by the selective growth of lymphoma cells within the lumen of small blood vessels, with no lymphadenopathy or masses. Herein, we report a cutaneous variant of IVLBCL that is rare in Asia. A healthy 73-year-old Japanese woman presented to our hospital with painful erythematous indurations and telangiectasia of the lower extremities, which was confirmed on dermoscopy. Physical examination revealed no systemic involvement, and laboratory parameters were within normal ranges. No abnormal fluorodeoxyglucose (FDG) uptake was detected on 18FDG positron emission tomography/computed tomography. Histopathological examination revealed proliferation and dilatation of blood vessels in the subcutis layer, occluded by CD20-positive atypical lymphoid cells. Thus, the patient was diagnosed with a cutaneous variant of IVLBCL without systemic symptoms. In conclusion, it is important to confirm telangiectasia using dermoscopy and perform skin biopsies in patients presenting with sudden-onset erythematous induration.

Pyoderma gangrenosum ‒ cutaneous and extracutaneous manifestations

Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis with extracutaneous manifestations and associated systemic disorders, including inflammatory bowel diseases, arthritis and haematological malignancies. The pathogenesis of PG is still not fully understood. The cutaneous lesions are often polymorphic and include papules, nodules, sterile pustules with erythematous induration, which quickly evolve into necrotic painful ulcerations. PG can also affect lungs, spleen, liver, pancreas, kidneys, bones and eyes. The treatment of PG is long and challenging and involves the use of sytemic corticoteroids, immunosupressive drugs and biological therapies with concomitant pain management and wound care.

Eschar or Ecthyma or Both?

We report a case of scrub typhus with coexistent Pseudomonas aeruginosa skin infection in the same patient. A 6-year-old Chinese boy presented with 5 days of fever, 2 days of right thigh swelling, and an insect bite mark over the swelling. A full blood count had been performed prior to hospital consultation, and showed neutropenia and thrombocytopenia. Initial clinical examination revealed a tender erythematous induration with a central punctum on his right thigh, which progressed to form a rolled-up papule with black central necrosis. The clinical suspicion was of an eschar, although ecthyma gangrenosum could not be ruled out. He had recently returned from a recreational trip in the United States 3 weeks earlier, and had travelled to Wisconsin and Las Vegas. He was treated initially for right thigh cellulitis with parenteral ampicillin and cloxacillin, but after infectious disease consultation, he was commenced on intravenous ciprofloxacin. A wound culture grew P. aeruginosa, while rickettsial serology was positive for Orientia tsutsugamushi. He responded clinically to ciprofloxacin and was discharged well, and an outpatient review showed significant improvement of his cutaneous lesion.

Extravasation of a percutaneous femoral hepatic infusion device.

Extravasation of a percutaneous femoral hepatic infusion device.

Image Diagnosis: Foot Pain and Fever

A 59-year-old man with a history of poorly controlled type II diabetes and hypertension presented to the Emergency Department complaining of 5 hours of severe right foot pain and drainage from the plantar surface. He denied trauma or inciting injury. The patient was unable to walk because of the pain. On physical examination, his temperature was 100.2 F; his heart rate was 105 beats/minute; and he had marked tender erythematous induration with a fluid-filled bulla over the dorsum of his foot. There was foul-smelling exudate draining from the first web space. Palpable crepitus was appreciated. Anterior-posterior (Figure 1) and lateral (Figure 2) films of the foot demonstrate subcutaneous air originating in the dorsum of his foot tracking both to the plantar surface and the posterior ankle region. The patient was treated with broad-spectrum intravenous antibiotics (vancomycin, gentamicin, and metronidazole) and taken to the operating room where an open transmetatarsal amputation took place because of necrotizing fasciitis. Tissue ischemia and “bubbly tissues in the subcutaneous layer” were noted. Tissue cultures grew Enterobacter cloacae, Streptococcus agalactiae, and Staphylococcus aureus. This patient recovered without further complications and was discharged on hospital day 7. Figure 1 Anterior-posterior view of the right foot. Figure 2 Lateral view of the right foot. Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and fascia (as evidenced by air on this patient's plain films). Typical sites for this infection are the lower extremities, abdomen, and perineum.1 The incidence of such infections in the US is estimated at 500 to 1500 cases per year, with a case-fatality rate of 24% and is more commonly associated with injection drug use, diabetes mellitus, immunosuppression, and obesity.2,3

Persistierende Schwellung nach Spülung eines Abszesses mit Octenisept®

We report the case of a long-lasting cutaneous side effect after inappropriate use of Octenisept® solution (containing octenidine and phenoxyethanol). Following lavage of an abscess in the inguinal region, a painful erythematous induration mimicking cellulitis persisted for several months. Manual lymphatic drainage considerably improved the symptoms. Octenisept® shows considerable tissue toxicity in vivo including - but not restricted to - blood vessel damage. Deterioration of endothelial cells followed by oedema and continued tissue damage can be seen histologically. Despite the fact that there is a circular letter issued by the manufacturer as well as a boxed warning on the bottles, the awareness to avoid this misuse of Octenisept® is still lacking.

Kasabach-Merritt Syndrome Arising from Tufted Angioma Successfully Treated with Systemic Corticosteroid

We report a case of Kasabach-Merritt syndrome arising from a tufted angioma successfully treated with systemic corticosteroid. A 2-month-old male infant presented with a palm-sized, erythematous induration on his left pubis. The lesion was diagnosed as tufted angioma histopathologically. After 1 month, the lesion suddenly expanded to the abdomen and scrotum. Initial laboratory tests were consistent with consumptive coagulopathy. He was diagnosed with Kasabach-Merritt syndrome and treated with intravenous dexamethasone at 0.32 mg/kg/day (equivalent to prednisolone 2.0 mg/kg/day). Two days after initiating the treatment, his platelet counts recovered and the lesion ceased to expand. Steroid therapy was converted to oral prednisolone and the dosage was subsequently tapered, and the lesion gradually involuted with no signs of recurrence for a year.

The skin pathergy test: innately useful?

Pathergy is the term used to describe hyper-reactivity of the skin that occurs in response to minimal trauma. A positive skin pathergy test (SPT), characterised by erythematous induration at the site of the needle stick with a small pustule containing sterile pus at its centre, is among the criteria required for a diagnosis of Behçet's disease (BD) and in certain population has been shown to be highly specific for this condition. Problems with standardising the induction manoeuvre for the SPT as well as the method of assessment of the response have limited the usefulness of the SPT in the clinical setting. Extensive investigation into histopathological and immunological aspects of pathergy has led to a number of hypotheses relating to the aetiology of the skin pathergy reaction and the disease itself, but the cause is considered to be unknown. Pathergy lesions, the development of new skin lesions or the aggravation of existing ones following trivial trauma, are also reported in pyoderma gangrenosum and has been noted in other neutrophilic dermatoses such as Sweet's syndrome. The response of such patient groups to the systematic application of the SPT has not been described. We propose that a new way of considering the pathergy reaction is to see it as an aberration of the skin's innate reactivity from a homeostatic reactive mode closely coupled to tissue healing to an abnormal destructive/inflammatory mode. Our understanding of BD and other similar conditions would profit by more detailed mechanistic knowledge of skin homeostasis to minimal trauma in both health and disease through a more structured and systematic use of the SPT.

Calcinose cutanée et sous-cutanée après injection d’héparine calcique : à propos de deux cas

Subcutis calcinosis, characterized by abnormal calcium deposition in the skin, is a rare side effect of calcium containing heparins. Two patients with renal failure presented skin lesions after receiving a calcium-containing heparin treatment. The first patient exhibited erythematous nodules on the abdomen and the second a large erythematous induration of the abdomen and nodules on the thighs. Both had normal blood analysis. The diagnosis of subcutis calcinosis was confirmed by the histological exam showing calcium deposit in the dermis and hypodermis. Outcome was unfavourable in one of the patients who developed a superinfection and skin necrosis lesion requiring surgery at 2 months. Subcutis calcinosis is a rare and probably underdiagnosed disease. To our knowledge, only 10 cases have been reported. The pathogenesis is not well-known, tissue damage and calcium disorders are considered as risk factors. The differential diagnoses that can be suspected include calciphylaxis, such as calcifying panniculitis and other local side effects of heparins. Outcome is usually favourable without treatment. We describe two cases of iatrogenic subcutis calcinosis after injections of calcium-containing heparins, including the second case of poor outcome. Clinicians should be aware of this adverse effect since other heparins such as fondaparinux or low-weight molecular heparins are contraindicated in patients with renal failure, leading to a large prescription of calcium-containing heparins in this population.

Carcinoma erysipelatoides from squamous cell carcinoma of unknown origin

Carcinoma erysipelatoides, also known as inflammatory metastatic carcinoma, is a rare form of cutaneous metastasis from a malignancy. The characteristic histopathological finding is metastatic tumour cells inside the dermal lymphatic ducts. It is frequently observed in patients with breast carcinoma as well as adenocarcinoma of pancreas, rectum, lung, ovary and parotid gland. We present a 66-year-old man diagnosed to have metastatic squamous cell carcinoma by aspiration cytology from an enlarged neck lymph node and a core biopsy of a left axillary mass. He subsequently received radiotherapy; however, due to intolerance to erythema and swelling on local irradiated skin, radiotherapy was deferred. Skin lesions on upper chest and neck area, consisting of erythematous induration with telangiectasia and tenderness, progressed slowly and were treated as cellulitis. The erythema remained stationary with antibiotic treatment. Skin biopsy shows poorly differentiated squamous carcinoma cells within dermis and dilated dermal vessels.

Are cysteinyl leukotrienes involved in allergic responses in human skin?

Cysteinyl leukotrienes have been suggested to be involved in producing the symptoms of both the early and late phases of the allergic response in the lung and other tissues. To use scanning laser Doppler imaging, microdialysis and immunocytochemistry to explore the mediator and cellular mechanisms of the dermal allergic response. Thirteen atopic volunteers received intradermal injections into the forearm of grass pollen or D. pteronyssinus extract. Changes in dermal blood flow up to 8 h were monitored by scanning laser Doppler imaging. The release of histamine, PGD2 and LTC4/D4/E4 was assessed by dermal microdialysis. Skin biopsies were taken at 6 h to determine numbers of mast cells, eosinophils, basophils, Langerhans' cells, and monocytes/macrophages, and the expression of COX-1, COX-2, 5-LO and FLAP. Allergen provocation produced an immediate weal and flare response followed by an erythematous induration peaking at 6 h. During the first hour, c. 84 pmoles of histamine and c. 0.3 pmoles of PGD2 were recovered by microdialysis (both P < 0.001) but LTC4/D4/E4 was undetectable. No histamine, PGD2 or LTC4/D4/E4 was detectable at later times. Immunocytochemical examination of biopsies taken at 8 h showed increased numbers of eosinophils and basophils and in COX-2, 5-LO and FLAP, but not COX-1. Expression of 5-LO and FLAP was associated primarily with eosinophils. These findings suggest that inflammatory cells recruited to the site of allergen injection are not activated to release detectable amounts of cysteinyl leukotrienes. Hence, it is unlikely that the late-phase erythematous induration is mediated by this autocoid.