Hemorrhagic Dermatitis Research Articles

Bullous haemorrhagic dermatitis induced by heparins and other anticoagulants: 94 cases from French pharmacovigilance centres and a literature review

BackgroundBullous haemorrhagic dermatitis (BHD) is an uncommon and highly particular side effect of various forms of heparins. MethodsTo better characterise the disease, we collected all cases from French Pharmacovigilance centres recorded over a 20-year period (37 cases) and performed a Medline literature search up to June 2020 (57 cases). ResultsIn all, 94 patients were identified (male/female ratio: 2.2) of mean age 73.5±12.1 years (31–94). Patients were treated with enoxaparin (n=66), unfractionated heparin (n=11), fondaparinux (n=10), tinzaparin (n=4), bemiparin (n=1), reviparin (n=1), dalteparin (n=1), and 4 with other anticoagulants: warfarin (n=3) and rivaroxaban (n=1). All cases presented with 1 to more than 100 haemorrhagic vesicles and bullae, distant from the injection sites, located mainly on the lower (75%) or upper limbs (69%). The lesions were asymptomatic, except in 5 patients who had pruritic or painful lesions. The interval between treatment initiation and BHD ranged from 6 hours to 30 days (mean: 8.4±7 days). Biopsy (n=53) showed intraepidermal or subcorneal cavity with red cells (n=39) or junctional blisters (n=10), with eosinophilic infiltrate only rarely. Direct immuno-fluorescence was negative in 19/20 cases and indirect immunofluorescence was negative in 8/8. The outcome was favourable in all cases, including in 12 patients for whom heparin was maintained. A 93-year-old patient died of compressive haematomas unrelated to BHD. We found 5 cases similar to BHD due to other anticoagulants. DiscussionThis is the largest comprehensive series of this adverse effect due to heparins or, more rarely, to other anticoagulants. Dermatologists must be aware of BHD, since this benign side effect does not necessarily require interruption of treatment. It is rare, considering the large-scale prescription of heparins, and occurs mainly in male patients aged over 70. Although the presentation is highly typical, the physiopathology is difficult to understand, as coagulation parameters are usually normal. Aging, skin fragility or mechanical factors might play a role.

A case of canine cutaneous pythiosis in Thailand

Introduction Pythium insidiosum causes pythiosis in humans and animals in tropical and subtropical climates. The clinical manifestations in humans are mostly systemic, vascular or ocular forms, in contrast to animals, which are cutaneous, subcutaneous and gastrointestinal forms. The highest incidence of human cases is reported in Thailand, however, no canine pythiosis has been documented yet.Case presentation A female, mixed-breed, stray dog showed severe extensive ulcerative haemorrhagic dermatitis at the perineum involving the anus and tail. On cytology, there were sparse branching septate fungal hyphae. The tissue samples were subjected to polymerase chain reaction and gene sequencing for fungal identification.Conclusion The results of the internal transcribed spacer 1 and 2 (ITS1 and ITS2) gene had 99 % homology to Pythium insidiosum (accession no. FJ17396) and the COX2 gene (accession no. GQ451572). The phylogenetic tree of both genes was classified in clade ATH. This is the first fully documented diagnosis of canine cutaneous pythiosis in Thailand.

A case of diquat poisoning in pigs

Diquat is a bipyridyl compound which belongs to the group of herbicides. Its activity is based on the liberation of the superoxide anion radical and, subsequently, hydrogen peroxide, leading to tissue destruction by oxidative stress. Acute poisoning is associated with high mortality within several hours to a few days. The reported case of poisoning occurred on a commercial farm. The fattening pigs of the Landrace and Large White breeds were affected. The pigs were kept on a deep litter. Reglone (active ingredient diquat dibromide, 200 g/l) was used on the farm fields to desiccate the clover crop. The dry clover straw was harvested and stored for approximately a month and then used as a litter. In total, 50 pigs were affected. The onset of the poisoning was very fast. Within eight hours after the litter administration, 20 animals died. The only clinical sign seen was severe haemorrhagic dermatitis. The pathological examination revealed acute superficial haemorrhagic dermatitis on the belly, the snout and the ears of the affected pigs. Hyperaemia of the tonsils, pharynx and oesophagus was diagnosed, as well as a pronounced hyperaemia of the stomach fundus. In the distal part of the trachea, there was a dense, white foam. The lungs were congested, with focal emphysema. The liver was slightly hyperaemic. The histological examination revealed a massive haemostasis in liver and diffuse acute polymorphonuclear hepatitis. The other organs were without changes. The examination revealed acute poisoning caused by the large body surface areas contacting with a toxic substance. The pigs that survived were immediately removed to a non-contaminated area. The changes on their skin were not so extensive compared to the dead ones. Within 5–7 days after the exposure to diquat, the skin lesions healed.

Lesions caused by virulent Aeromonas hydrophila in farmed catfish ( Ictalurus punctatus and I. punctatus × I. furcatus) in Mississippi.

In 2009, a virulent strain of Aeromonas hydrophila caused severe disease and high mortalities (motile aeromonad septicemia variant [MASv]) in farmed channel catfish ( Ictalurus punctatus) and hybrid catfish ( I. punctatus × I. furcatus) in eastern Mississippi and Alabama. As is common in MAS, there is severe hemorrhagic dermatitis with ulceration, as well as abdominal hyperemia, petechiation, and mild ascites. Additional findings in MASv cases include panophthalmitis and orbital cellulitis, leading to ocular rupture, and brains are often hyperemic with mild random acute hemorrhage. In MASv infections, there is consistently also marked hemorrhage and edema in the submucosa and muscularis of the stomach, with lymphangitis and a few bacteria, plus splenomegaly with infarcts. Microscopically, spleens have necrosis of ellipsoids with macrophage infiltration and small numbers of bacteria; however, large infarcts are filled with bacteria. Other organs, such as liver, kidneys, and intestine, which are typically associated with MAS caused by various aeromonad species, are less affected. The findings in the stomach have not been reported in MAS in farmed catfish, to our knowledge, and the splenic changes are highly characteristic of MAS compared to infection with other gram-negative bacteria, including Edwardsiella ictaluri and other aeromonad species and strains.

An Outbreak of Fatal Herpesvirus Infection in Domestic Rabbits in Alaska

A herpesvirus infection affecting mini Rex and crossbred meat rabbits was identified in a rabbitry in Alaska. Illness affected over half of the 55 rabbits on the premises, and 16 rabbits died or were euthanatized because of illness. Disease affected all ages from adults to nursing young and occurred over an approximately 2-month period. Clinical signs included conjunctivitis and periocular swelling, ulcerative dermatitis, progressive weakness, anorexia, respiratory distress, and abortion. Hemorrhagic dermatitis and panniculitis were associated with epidermal microvesicular degeneration, dermal and subcutaneous vascular necrosis, and thrombosis. Eosinophilic intranuclear inclusions consistent with herpesvirus were found within the epidermis and superficial follicular epithelium and within mesenchymal cells within the dermis and subcutis. Syncytial cells containing viral inclusions occurred within the epidermal and superficial follicular epithelium. Other findings were hemorrhagic necrosis of the myocardium with rare intranuclear inclusions within stromal cells, multifocal pulmonary hemorrhage, hemorrhage with sinus erythrophagocytosis in lymph nodes, and massive necrosis and fibrin deposition within red pulp of the spleen. A virus isolated from the skin produced syncytia, intranuclear inclusions, and cell lysis typical of herpesvirus in rabbit kidney cells in vitro. The viral isolate was characterized ultrastructurally as an enveloped virus with icosahedral nucleocapsids 100 nm diameter, consistent with a herpesvirus.

Porcine dermatitis and nephropathy syndrome. clinical and pathological features of cases in the United Kingdom (1993-1998).

This paper documents the salient clinical and pathological features of porcine dermatitis and nephropathy syndrome (PDNS) in 96 pigs submitted from 55 units in the UK from 1993 to 1998. This series of cases pre-dated the emergence of post-weaning multisystemic wasting syndrome (PMWS) in the UK. The morbidity during outbreaks was 1% or less. Affected pigs ranged from 14 to 70 kg in weight and most died after a short clinical illness. Fifty-five pigs had multifocal or coalescing erythematous skin lesions, some progressing to dermal necrosis. Biochemistry showed raised serum urea, creatinine and gamma globulin levels accompanied by proteinuria. All cases showed bilateral renal enlargement with petechiae throughout the cortices. Microscopically these renal lesions ranged in chronology from acute necrotizing glomerulitis and vasculitis with multiple hyaline casts in renal tubules to chronic glomerular sclerosis with interstitial inflammation and fibrosis. Haemorrhagic dermatitis when present was associated with necrotizing vasculitis in the dermal vessels. Vasculitis was sometimes detected in other tissues including subcutis, lymph nodes, spleen, liver, joint synovial membrane, gastric and intestinal submucosa or serosa and meninges but its frequency and distribution varied considerably in individual pigs. Immunostaining showed deposits of IgG and IgM in damaged glomeruli, renal casts and skin lesions. The aetiology and pathogenesis of the condition remain unknown but the histopathological and immunological findings suggest a systemic immune-complex disorder resulting in vasculitis with particular predilection for kidney and skin.

Multiple Bacteriosis, with Special Reference to Spoilage BacteriumShewanella putrefaciens, in Cage-Cultured Barramundi Perch in Malaysia

Abstract An incidence of multiple bacteriosis that caused heavy mortality in cage-cultured barramundi perch Lates calcarifer during May-July 1991 in the Pulau Ketam estuary in west coast of Malaysia was investigated. All fish showing hemorrhagic dermatitis were infected with Pseudomonas anguilliseptica and Vibrio alginolyticus, and the spoilage bacterium Shewanella putrefaciens was consistently isolated from all sampled fish. High-density culture under suboptimal nutritional and environmental conditions, together with feeding on spoiled coarse fish, was considered to have initiated the epizootic.

N‐3 fatty acid deficiency in man

A total of nine patients with n-3 fatty acid deficiency are described. They had been fed by gastric tube for 2.5-12 years, and had received 0.02-0.09% of calories as n-3 acids. The observed clinical symptoms of n-3 fatty acid deficiency were scaly and haemorrhagic dermatitis, haemorrhagic folliculitis of the scalp, growth retardation and impaired wound healing. All patients had extensive brain damage making it impossible to evaluate n-3 effects on cerebral functions. The patients were supplemented with cod liver and soya oil, alpha-linolenate followed by a purified fish oil, or with a mixture of linseed and cod liver oil. The results indicate that a dietary supply of 1.0-1.2% of alpha-linolenic acid is necessary to obtain a mid-normal lipid concentration of n-3 fatty acids, and suggest that the minimal dietary requirement is 0.2-0.3% of total calories. Long-chain n-3 fatty acids seem to be approximately twice as efficient as alpha-linolenic acid in maintaining normal n-3 fatty acid concentrations in plasma and red cell lipids.

Alpha-Linolenic acid and long-chain omega-3 fatty acid supplementation in three patients with omega-3 fatty acid deficiency: effect on lymphocyte function, plasma and red cell lipids, and prostanoid formation

alpha-Linolenic acid deficiency is described in three patients. Observed clinical symptoms were hemorrhagic dermatitis, hemorrhagic folliculitis, skin atrophy, and scaly dermatitis. Supplementation with ethyl alpha-linolenate followed by a purified fish oil (EPA-oil) began to normalize symptoms within 10 d. The mitogenic response in isolated lymphocytes was reduced whereas the number of T lymphocytes increased significantly. Serum thromboxanes, urinary excretion of 2,3-dinor-6-keto-prostaglandin F1 alpha (PGI2-M), and bleeding time were unaffected. The results indicate that omega-3 fatty acids are essential for normal accumulation of erythrocyte omega-6 acids. The dietary intake of long-chain omega-3 acids required to obtain midnormal concentrations of omega-3 acids in plasma and erythrocyte lipids was estimated to be 350-400 mg/d (0.4% of calories), whereas the corresponding mean intake of alpha-linolenic acid was 990 mg/d (1.0% of calories). It is suggested that essential fatty acid requirement should be stated as grams or milligrams per day, similarly to other essential nutrients.