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Algarin YA, Pariser R. Painful, Tender, Localized, Idiopathic Livedo Reticularis. Cureus 2024; 16:e52311. [PMID: 38357060 PMCID: PMC10866324 DOI: 10.7759/cureus.52311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 02/16/2024] Open
Abstract
Livedo reticularis (LR) is a unique cutaneous condition characterized by a reddish-blue to purple, net-like cyanosis of the skin, often associated with disturbances in cutaneous blood flow. This case report discusses a 30-year-old woman with a history of Hashimoto thyroiditis, vitamin D deficiency, migraines, and goiter who presents with painful, localized LR on her right flank. Despite her extensive medical history, there were no significant findings in her laboratory and imaging studies, including a normal epidermis in skin biopsies. The LR in this case is distinguished by its persistence and the presence of pain, a symptom not commonly associated with LR. Various treatments, including 5% lidocaine ointment, oral analgesics, and gabapentin, were considered, but her symptoms remained stable over 13 months. This case exemplifies the complexity of LR, particularly when presenting with atypical symptoms like pain. It highlights the need for further research into the pathophysiology and treatment of LR, especially in cases deviating from the typical symptomatology, and suggests the potential value of a multi-disciplinary approach to management.
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Affiliation(s)
| | - Robert Pariser
- Dermatology, Eastern Virginia Medical School, Norfolk, USA
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2
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Ahsen A, Korsun P, Albahra F, Nair R, Tariq Z. Capnocytophaga canimorsus Infection in a 38-Year-Old Male after a Dog Bite. Case Rep Infect Dis 2023; 2023:9917898. [PMID: 37876860 PMCID: PMC10593545 DOI: 10.1155/2023/9917898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 09/06/2023] [Accepted: 09/23/2023] [Indexed: 10/26/2023] Open
Abstract
Here, we present a unique case of a 38-year-old male with a history of alcohol use disorder and multiple sexual partners, who presented with fulminant sepsis with shock, multiorgan failure, and livedo racemosa after a dog bite the week prior. The patient was intubated on arrival and was started on vasopressors and antibiotics. Eventually, the patient's clinical status improved, and he was transferred out of the intensive care unit. Blood cultures tested positive for oxidase-positive Gram-negative rods two days after collection, and species identification showed Capnocytophaga canimorsus.
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Affiliation(s)
- Ahmad Ahsen
- Department of Internal Medicine, Medical City Fort Worth, Fort Worth, TX, USA
| | - Philip Korsun
- Department of Internal Medicine, Medical City Fort Worth, Fort Worth, TX, USA
| | - Fadi Albahra
- Department of Internal Medicine, Medical City Fort Worth, Fort Worth, TX, USA
| | - Ranjit Nair
- Department of Critical Care, Medical City Fort Worth, Fort Worth, TX, USA
| | - Zain Tariq
- Department of Infectious Disease, Medical City Fort Worth, Fort Worth, TX, USA
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3
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Barsan Kaya T, Kaya Erdoğan H, Güneş D, Aydemir Ö. Livedo racemosa associated with central venous catheter use in a newborn. Pediatr Dermatol 2023; 40:148-150. [PMID: 35859318 DOI: 10.1111/pde.15098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/10/2022] [Indexed: 01/25/2023]
Abstract
Livedo racemosa (LRac) refers to violaceous, red, or blue netlike mottling of the skin in an irregular pattern caused by circulatory abnormalities. Central venous catheters (CVC) are widely used in neonates who require intensive care to offer steady intravenous access. CVCs are covered with a hydrophilic polymer gel that reduces friction between the sheath and the vessel wall, thereby minimizing vascular spasm, irritation, and aneurysm formation. However, the introduction of foreign material into the vein carries a risk of embolization. Recently, LRac was reported as a cutaneous manifestation of hydrophilic polymer gel embolization (HPE) in adults. We present a case of LRac in a newborn that developed following CVC insertion and resolved spontaneously after the catheter was removed.
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Affiliation(s)
- Tuğba Barsan Kaya
- Department of Neonatology, Eskişehir Osmangazi University, Faculty of Medicine, Eskişehir, Turkey
| | - Hilal Kaya Erdoğan
- Department of Dermatology, Eskişehir Osmangazi University, Faculty of Medicine, Eskişehir, Turkey
| | - Damla Güneş
- Department of Neonatology, Eskişehir Osmangazi University, Faculty of Medicine, Eskişehir, Turkey
| | - Özge Aydemir
- Department of Neonatology, Eskişehir Osmangazi University, Faculty of Medicine, Eskişehir, Turkey
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Farabi B, Toquica Gahona C, Atak MF, Gunduz H, Ismail Mendi B, Goldust M. Livedo racemosa presenting as first manifestation in a patient with multiple myeloma complicated with cryoglobulinemic vasculitis. J Cosmet Dermatol 2022; 21:6464-6465. [PMID: 35593539 DOI: 10.1111/jocd.15103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/17/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Banu Farabi
- Department of Internal Medicine, Saint Peter's University Hospital, New Brunswick, New Jersey, USA
| | - Christian Toquica Gahona
- Department of Internal Medicine, Saint Peter's University Hospital, New Brunswick, New Jersey, USA
| | | | - Hasret Gunduz
- Department of Dermatology, Ankara University, Ankara, Turkey
| | | | - Mohamad Goldust
- Department of Dermatology, University Medical Center, Mainz, Germany
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5
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Extended amantadine-induced livedo reticularis. Rev Neurol (Paris) 2021; 177:1301-1303. [PMID: 34229870 DOI: 10.1016/j.neurol.2021.02.395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/16/2021] [Accepted: 02/23/2021] [Indexed: 11/22/2022]
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6
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Starmans NLP, Zoetemeyer S, van Dijk MR, Kappelle LJ, Frijns CJM. The diagnostic value of skin biopsies in Sneddon syndrome. PLoS One 2021; 16:e0253365. [PMID: 34181656 PMCID: PMC8238230 DOI: 10.1371/journal.pone.0253365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Sneddon syndrome (SS) is defined by widespread livedo reticularis (LR) and stroke. There is no single diagnostic test for SS and diagnosis can be solely based on clinical features. This cross-sectional case-control study aimed to determine the diagnostic value of skin biopsies in SS patients. MATERIALS AND METHODS We studied skin biopsies from patients with a clinical diagnosis of SS or isolated LR. We also studied controls with vitiligo or normal skin. Biopsies were considered standardized if 3 biopsies were taken from the white centre of the livedo and reached until the dermis-subcutis border. Biopsies were scored for features of an occlusive microangiopathy without knowledge of the clinical features. Sensitivity and specificity of the biopsy findings were calculated with the clinical criteria as the reference standard. RESULTS We included 34 SS patients, 14 isolated LR patients and 41 control patients. Biopsies of 17 patients with SS (50%), 4 with isolated LR (31%) and 10 control patients (24%) showed at least one artery in the deep dermis with a thickened vessel wall combined with recanalization or neovascularization (sensitivity 50% and specificity 69% with LR as reference). Standardized biopsies increased the sensitivity to 70%. In a post hoc analysis the combination of an occlusive microangiopathy and the presence of a livedo pattern in the superficial dermis increased the specificity to 92%. CONCLUSIONS Standardized skin biopsies can support the clinical diagnosis of SS. An occlusive microangiopathy as the only positive criterion for the diagnosis of SS had insufficient specificity for a definite diagnosis.
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Affiliation(s)
- N. L. P. Starmans
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - S. Zoetemeyer
- Department of Pathology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - M. R. van Dijk
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - L. J. Kappelle
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - C. J. M. Frijns
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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7
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Katunina EA. [Amantadine in the treatment of Parkinson's disease. New opportunities in the context of COVID-19]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:101-106. [PMID: 34037362 DOI: 10.17116/jnevro2021121041101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article presents data from recent studies on the mechanisms of action and clinical efficacy of amantadines, and also describes a possible protective effect against COVID-19.
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Affiliation(s)
- E A Katunina
- Pirogov Russian National Research Medical University, Moscow, Russia.,Federal Center for Brain and Neurotechnology, Moscow, Russia
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Abstract
Raynaud's phenomenon, which is characterized by episodic digital pallor, cyanosis and rubor upon exposure to cold environment or to stress, is relatively common, although the prevalence depends on the climate. Still, it is under-diagnosed, under-treated, and often confused with other conditions. Primary Raynaud's phenomenon (i.e., Raynaud disease) must be distinguished from secondary Raynaud's phenomenon (i.e., Raynaud syndrome) as long-term morbidity and outcomes differ vastly between the two conditions. Additionally, the practitioner must differentiate between Raynaud's phenomenon and related vascular disorders, such as acrocyanosis, pernio, and livedo reticularis. In this article, we review differences between the conditions and suggest an approach to diagnosis and treatment strategy for these disorders.
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Affiliation(s)
- Eunjung Choi
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Stanislav Henkin
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Niemann N, Billnitzer A, Jankovic J. Parkinson's disease and skin. Parkinsonism Relat Disord 2020; 82:61-76. [PMID: 33248395 DOI: 10.1016/j.parkreldis.2020.11.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/18/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022]
Abstract
Parkinson's disease is associated with a variety of dermatologic disorders and the study of skin may provide insights into pathophysiological mechanisms underlying this common neurodegenerative disorder. Skin disorders in patients with Parkinson's disease can be divided into two major groups: 1) non-iatrogenic disorders, including melanoma, seborrheic dermatitis, sweating disorders, bullous pemphigoid, and rosacea, and 2) iatrogenic disorders related either to systemic side effects of antiparkinsonian medications or to the delivery system of antiparkinsonian therapy, including primarily carbidopa/levodopa, rotigotine and other dopamine agonists, amantadine, catechol-O-methyl transferase inhibitors, subcutaneous apomorphine, levodopa/carbidopa intestinal gel, and deep brain stimulation. Recent advances in our understanding of the role of α-synuclein in peripheral tissues, including the skin, and research based on induced pluripotent stem cells derived from skin fibroblasts have made skin an important target for the study of Parkinson's disease pathogenesis, drug discovery, novel stem cell therapies, and diagnostics.
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Affiliation(s)
- Nicki Niemann
- Muhammad Ali Parkinson Center, Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA.
| | - Andrew Billnitzer
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
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Hartig F, Reider N, Sojer M, Hammer A, Ploner T, Muth CM, Tilg H, Köhler A. Livedo Racemosa - The Pathophysiology of Decompression-Associated Cutis Marmorata and Right/Left Shunt. Front Physiol 2020; 11:994. [PMID: 33013436 PMCID: PMC7497564 DOI: 10.3389/fphys.2020.00994] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/22/2020] [Indexed: 11/13/2022] Open
Abstract
Decompression sickness and arterial gas embolism, collectively known as decompression illness (DCI), are serious medical conditions that can result from compressed gas diving. DCI can present with a wide range of physiologic and neurologic symptoms. In diving medicine, skin manifestations are usually described in general as cutis marmorata (CM). Mainly in the Anglo-American literature the terms cutis marmorata, livedo reticularis (LR), and livedo racemosa (LRC) are used interchangeably but actually describe pathophysiologically different phenomena. CM is a synonym for LR, which is a physiological and benign, livid circular discoloration with a net-like, symmetric, reversible, and uniform pattern. The decompression-associated skin discolorations, however, correspond to the pathological, irregular, broken netlike pattern of LRC. Unlike in diving medicine, in clinical medicine/dermatology the pathology of livedo racemosa is well described as a thrombotic/embolic occlusion of arteries. This concept of arterial occlusion suggests that the decompression-associated livedo racemosa may be also caused by arterial gas embolism. Recent studies have shown a high correlation of cardiac right/left (R/L) shunts with arterial gas embolism and skin bends in divers with unexplained DCI. To further investigate this hypothesis, a retrospective analysis was undertaken in a population of Austrian, Swiss, and German divers. The R/L shunt screening results of 18 divers who suffered from an unexplained decompression illness (DCI) and presented with livedo racemosa were retrospectively analyzed. All of the divers were diagnosed with a R/L shunt, 83% with a cardiac shunt [patent foramen ovale (PFO)/atrium septum defect (ASD)], and 17% with a non-cardiac shunt. We therefore not only confirm this hypothesis but when using appropriate echocardiographic techniques even found a 100% match between skin lesions and R/L shunt. In conclusion, in diving medicine the term cutis marmorata/livedo reticularis is used incorrectly for describing the actual pathology of livedo racemosa. Moreover, this pathology could be a good explanation for the high correlation of livedo racemosa with cardiac and non-cardiac right/left shunts in divers without omission of decompression procedures.
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Affiliation(s)
- Frank Hartig
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | - Norbert Reider
- Department of Dermatology, University Clinic Innsbruck, Innsbruck, Austria
| | - Martin Sojer
- Department of Neurology, University Clinic Innsbruck, Innsbruck, Austria
| | - Alexander Hammer
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | - Thomas Ploner
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | | | - Herbert Tilg
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | - Andrea Köhler
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
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Abstract
PURPOSE OF THE REVIEW To review the available evidence on the management of a variety of non-criteria manifestations in antiphospholipid syndrome (APS), including valvular disease, alveolar hemorrhage, thrombocytopenia, hemolytic anemia, APS nephropathy, skin ulcers, livedo reticularis, cognitive dysfunction, and epilepsy. RECENT FINDINGS Current treatment relies on low-level evidence and mainly on expert consensus due to the rarity and the heterogeneity of non-criteria APS manifestations and the diversity in management approaches. Conventional anticoagulation and/or antiplatelet APS treatment do not adequately control most of non-criteria manifestations. Increasing knowledge about the contribution of inflammatory in addition to, or independently of, thrombotic mechanisms in non-criteria APS manifestations provides insight into the potential effect of novel therapies targeting B-cells, mammalian target of rapamycin, neutrophil, and complement or interferon pathways. Existing evidence is limited by lack of high-quality studies. Better understanding of the pathophysiology and clinical phenotypes of APS and well-designed prospective studies of homogenous populations are needed to provide evidence-based recommendations for the management of non-criteria APS manifestations.
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12
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Mitri F, Enk A, Bersano A, Kraemer M. Livedo racemosa in neurological diseases: an update on the differential diagnoses. Eur J Neurol 2020; 27:1832-1843. [DOI: 10.1111/ene.14390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 11/29/2022]
Affiliation(s)
- F. Mitri
- Department of Dermatology University Hospital Heidelberg Heidelberg Germany
| | - A. Enk
- Department of Dermatology University Hospital Heidelberg Heidelberg Germany
| | - A. Bersano
- Cerebrovascular Unit Fondazione IRCCS Istituto Neurologico ‘Carlo Besta’ Milan Italy
| | - M. Kraemer
- Department of Neurology Alfried Krupp von Bohlen und Halbach Hospital Essen Germany
- Department of Neurology Heinrich Heine University Hospital Düsseldorf Germany
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13
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Kong SS, Azarfar A, Bhanusali N. Sneddon syndrome: under diagnosed disease, complex clinical manifestations and challenging diagnosis. A case-based review. Rheumatol Int 2020; 41:987-991. [PMID: 32533291 DOI: 10.1007/s00296-020-04625-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/09/2020] [Indexed: 11/26/2022]
Abstract
Herein, we report a case-based review of the Sneddon Syndrome (SS), a rare chronic condition which affects small to medium blood vessels. It is known by its skin presentation, livedo racemosa (LRC), and the relapsing cerebrovascular events. However, neither LRC nor cerebrovascular events are exclusive to SS. A 36-year-old female with history of mitral valve prolapse, hypothyroidism, Raynaud phenomenon, hypertension, migraines, and four episodes of transient ischemic attacks (TIA), presented to our clinic with new skin findings, suggestive of LRC. Based on her previous history, current presentation and skin biopsy results, she was diagnosed with SS secondary to antiphospholipid syndrome. The present report illustrates the difficulty in recognizing SS and how the heterogeneity of the disease may be contributing to the difficulty making a distinct diagnosis.
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Affiliation(s)
- Steve S Kong
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - Azin Azarfar
- University of Central Florida HCA Healthcare GME, 6850 Lake Nona Blvd, Orlando, FL, 32827, USA.
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, FL, USA.
| | - Neha Bhanusali
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
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14
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Bersano A, Kraemer M, Burlina A, Mancuso M, Finsterer J, Sacco S, Salvarani C, Caputi L, Chabriat H, Oberstein SL, Federico A, Lasserve ET, Hunt D, Dichgans M, Arnold M, Debette S, Markus HS. Heritable and non-heritable uncommon causes of stroke. J Neurol 2020; 268:2780-2807. [PMID: 32318851 DOI: 10.1007/s00415-020-09836-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/15/2022]
Abstract
Despite intensive investigations, about 30% of stroke cases remains of undetermined origin. After exclusion of common causes of stroke, there is a number of rare heritable and non-heritable conditions, which often remain misdiagnosed, that should be additionally considered in the diagnosis of cryptogenic stroke. The identification of these diseases requires a complex work up including detailed clinical evaluation for the detection of systemic symptoms and signs, an adequate neuroimaging assessment and a careful family history collection. The task becomes more complicated by phenotype heterogeneity since stroke could be the primary or unique manifestation of a syndrome or represent just a manifestation (sometimes minor) of a multisystem disorder. The aim of this review paper is to provide clinicians with an update on clinical and neuroradiological features and a set of practical suggestions for the diagnostic work up and management of these uncommon causes of stroke. The identification of these stroke causes is important to avoid inappropriate and expensive diagnostic tests, to establish appropriate management measures, including presymptomatic testing, genetic counseling, and, if available, therapy. Therefore, physicians should become familiar with these diseases to provide future risk assessment and family counseling.
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Affiliation(s)
- A Bersano
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - M Kraemer
- Department of Neurology Alfried, Krupp-Hospital, Essen, Germany.,Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - A Burlina
- Neurological Unit, St. Bassano Hospital, Bassano del Grappa, Italy
| | - M Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - J Finsterer
- Krankenanstalt Rudolfstiftung, Messerli Institute, Vienna, Austria
| | - S Sacco
- Department of Neurology, Avezzano Hospital, University of L'Aquila, L'Aquila, Italy
| | - C Salvarani
- University of Modena and Reggio Emilia, and Azienda USL-IRCCS, Reggio Emilia, Italy
| | - L Caputi
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - H Chabriat
- Department of Neurology and CERVCO, DHU Neurovasc, INSERM U1141, University of Paris, Paris, France
| | - S Lesnik Oberstein
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - A Federico
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - E Tournier Lasserve
- Department of Genetics, Lariboisière Hospital and INSERM U1141, Paris-Diderot University, Paris, France
| | - D Hunt
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, EH4 2XU, UK
| | - M Dichgans
- Institute for Stroke and Dementia Research, Klinikum Der Universität München, Munich, Germany
| | - M Arnold
- Inserm Centre Bordeaux Population Health (U1219), University of Bordeaux, Bordeaux, France
| | - S Debette
- Department of Neurology, INSELSPITAL, University Hospital Bern, Bern, Switzerland
| | - H S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Pincelli MS, Echavarria AMJ, Criado PR, Marques GF, Morita TCAB, Valente NYS, de Carvalho JF. Livedo Racemosa: Clinical, Laboratory, and Histopathological Findings in 33 Patients. INT J LOW EXTR WOUND 2020; 20:22-28. [DOI: 10.1177/1534734619896938] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Livedo racemosa is a cutaneous finding characterized by a persistent, erythematous, or violaceous discoloration of the skin, in a broken, branched, discontinuous, and irregular pattern. A retrospective review of 33 cases with clinical diagnosis of livedo racemosa over the past 6 years was evaluated in the dermatology department of a tertiary care hospital. We found predominance in Caucasian women (78.8%); age ranged from 8 to 81 years, with a mean age of 36 years. Livedo racemosa was described as generalized in 12 patients (36.4%), although the main localization was on lower limbs (42%). After laboratory testing and histopathological examinations, 12 patients (36.4%) were classified with idiopathic livedo racemosa; secondary diseases were diagnosis in 21 patients (63.6%), including Sneddon’s syndrome, cutaneous polyarteritis nodosa, systemic lupus erythematosus, and others. Medical history of thrombotic events was described in 8 (24.2%) patients, and also 8 (24.2%) patients had abnormal results for 2 or more thrombophilia laboratory tests. Skin biopsy showed no histological abnormalities in 11 cases (33.3%), thrombosis of dermal blood vessels in 10 (30.3%), intimal/subintimal thickening in 7 (21.2%), and vasculitis in 5 (15.2%). In conclusion, livedo racemosa is a clinical feature that might be correlated to vascular disorders, such as thrombotic and/or hypercoagulable states, autoimmune diseases, and neoplastic diseases, or it can be secondary to specific medications. It is essential to establish a correct approach in cases of livedo racemosa, which includes anamnesis, physical examination, laboratory test, histological examination, and complementary examination according to clinical findings, in order to diagnosis underlying causes.
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Grangeon L, Guey S, Schwitalla JC, Bergametti F, Arnould M, Corpechot M, Hadjadj J, Riant F, Aloui C, Drunat S, Vidaud D, Tournier-Lasserve E, Kraemer M. Clinical and Molecular Features of 5 European Multigenerational Families With Moyamoya Angiopathy. Stroke 2020; 50:789-796. [PMID: 30908154 DOI: 10.1161/strokeaha.118.023972] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose Moyamoya angiopathy (MMA) is a rare cerebral vasculopathy outside of Asia. In Japanese patients, a vast majority of patients carry the founder p.R4810K variant in the RNF213 gene, and familial cases are around 10%. In European patients, data about familial occurrence are limited. The aim of this study was to characterize the clinical and molecular features of several European families with a parent-to-child transmission of MMA. Methods Out of 126 MMA probands referred, we identified 113 sporadic probands and 13 familial probands. Segregation analysis showed a vertical parent-to-child pattern of inheritance in the families of 5 of these probands. All 5 families were of German or Dutch ancestry. We investigated the clinical features of affected members and used whole-exome sequencing to screen RNF213 and 13 genes involved in Mendelian MMA and to identify genes recurrently mutated in these families. Results Twelve affected MMA patients were identified, including 9 females and 3 males. Age at clinical onset ranged from 11 to 65 years. In 3 of 5 families, associated livedo racemosa was found. We did not detect any deleterious variants in the 13 known MMA genes. RNF213 rare missense variants predicted to be pathogenic were detected in all affected members of 2 of these families, as well as 2 candidate variants of the PALD1 gene. Conclusions Nonsyndromic MMA was identified in 5 European families, including 2 to 3 clinically affected cases segregating with a parent-to-child pattern of inheritance in each family. Molecular screening detected rare deleterious variants within RNF213 and PALD1 in all affected members of 2 of these 5 families, as well as in some clinically unaffected members. Altogether these data raise the difficult and, to date unanswered, question of the medical indication of presymptomatic screening.
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Affiliation(s)
- Lou Grangeon
- From the Sorbonne Paris Cité, Inserm UMR-S1161, Génétique et physiopathologie des maladies cérébro-vasculaires, Université Paris Diderot, France (L.G., S.G., F.B., M.A., C.A. E.T.-L.)
| | - Stéphanie Guey
- From the Sorbonne Paris Cité, Inserm UMR-S1161, Génétique et physiopathologie des maladies cérébro-vasculaires, Université Paris Diderot, France (L.G., S.G., F.B., M.A., C.A. E.T.-L.)
| | | | - Françoise Bergametti
- From the Sorbonne Paris Cité, Inserm UMR-S1161, Génétique et physiopathologie des maladies cérébro-vasculaires, Université Paris Diderot, France (L.G., S.G., F.B., M.A., C.A. E.T.-L.)
| | - Minh Arnould
- From the Sorbonne Paris Cité, Inserm UMR-S1161, Génétique et physiopathologie des maladies cérébro-vasculaires, Université Paris Diderot, France (L.G., S.G., F.B., M.A., C.A. E.T.-L.)
| | - Michaelle Corpechot
- AP-HP, Service de génétique moléculaire neurovasculaire, Centre de Référence des Maladies Vasculaires Rares du Cerveau et de l'œil, Groupe Hospitalier Saint-Louis Lariboisière, Paris, France (M.C., J.H., F.R., E.T.-L.)
| | - Jessica Hadjadj
- AP-HP, Service de génétique moléculaire neurovasculaire, Centre de Référence des Maladies Vasculaires Rares du Cerveau et de l'œil, Groupe Hospitalier Saint-Louis Lariboisière, Paris, France (M.C., J.H., F.R., E.T.-L.)
| | - Florence Riant
- AP-HP, Service de génétique moléculaire neurovasculaire, Centre de Référence des Maladies Vasculaires Rares du Cerveau et de l'œil, Groupe Hospitalier Saint-Louis Lariboisière, Paris, France (M.C., J.H., F.R., E.T.-L.)
| | - Chaker Aloui
- From the Sorbonne Paris Cité, Inserm UMR-S1161, Génétique et physiopathologie des maladies cérébro-vasculaires, Université Paris Diderot, France (L.G., S.G., F.B., M.A., C.A. E.T.-L.)
| | - Severine Drunat
- AP-HP, Service de génétique, Groupe Hospitalier Robert Debré, Paris, France (S.D.)
| | - Dominique Vidaud
- AP-HP, Service de génétique, Groupe hospitalier Cochin, Paris, France (D.V.)
| | - Elisabeth Tournier-Lasserve
- From the Sorbonne Paris Cité, Inserm UMR-S1161, Génétique et physiopathologie des maladies cérébro-vasculaires, Université Paris Diderot, France (L.G., S.G., F.B., M.A., C.A. E.T.-L.).,AP-HP, Service de génétique moléculaire neurovasculaire, Centre de Référence des Maladies Vasculaires Rares du Cerveau et de l'œil, Groupe Hospitalier Saint-Louis Lariboisière, Paris, France (M.C., J.H., F.R., E.T.-L.)
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital Essen, Germany (J.C.S., M.K.).,Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany (M.K.)
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17
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Clinical presentation of Moyamoya angiopathy in Europeans: experiences from Germany with 200 patients. J Neurol 2019; 266:1421-1428. [DOI: 10.1007/s00415-019-09277-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
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18
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Goyal P, Dayal S, Sahu P. Generalized Livedo Reticularis: A Rare Variety. Indian J Dermatol 2019; 64:59-61. [PMID: 30745637 PMCID: PMC6340240 DOI: 10.4103/ijd.ijd_246_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Livedo reticularis can present with progressive ischemia and diffuse cutaneous involvement with or without any evidence of systemic diseases. Livedo reticularis (LR) is a livedoid discoloration of the skin in a reticular pattern. We report the case of a 30-year-old male who presented with an asymptomatic, red-colored, net-like rash all over the body for 4 years. Laboratory investigations were performed to rule out any systemic involvement. Biopsy showed perivascular mononuclear cell infiltrate and occasional arteriole showed thickening of the wall with obliteration of the lumen and extensive collagenization in dermis, suggesting a diagnosis of LR. The patient was advised oral pentoxifylline 400 mg thrice daily with oral nifedipine 10 mg twice daily, and mild improvement was seen after 6 weeks of therapy.
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Affiliation(s)
- Pallavi Goyal
- Department of Dermatology, Venereology and Leprosy, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Surabhi Dayal
- Department of Dermatology, Venereology and Leprosy, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Priyadarshini Sahu
- Department of Dermatology, Venereology and Leprosy, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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Abstract
In the contemporary era of medical diagnosis via sophisticated radiographic imaging and/or comprehensive serological testing, a focused physical examination remains paramount in recognizing the cutaneous manifestations of chronic vascular disease. Recognition of the unique cutaneous signs of lymphatic and venous hypertension assists in the diagnosis as well as the staging and classification of both lymphedema and chronic venous insufficiency. Awareness of explicit dermatologic vasomotor manifestations aids not only in the identification of acrocyanosis, Raynaud phenomenon, pernio, and erythromelalgia but also mitigates confusion related to their clinical overlap. Although the clinical signs of peripheral artery disease are not necessarily specific or sensitive, a knowledge of suggestive dermatologic findings is helpful in recognition of severe limb ischemia. A brief review of the epidemiology, etiology, pathogenesis, and therapy of cutaneous related chronic vascular disease follows including an emphasis on characteristic clinical features supported by illustrative photographs.
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Affiliation(s)
- Steven M Dean
- Division of Cardiovascular Medicine, Ohio State University Wexner Medical Center, Columbus, OH.
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Johnston J, Noakes R, Davidson K. Atypical presentation of livedo racemosa in a factor V Leiden heterozygous positive patient with Pseudomonas aeruginosa urosepsis. Australas J Dermatol 2016; 58:e144-e147. [PMID: 27858977 DOI: 10.1111/ajd.12554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 07/26/2016] [Indexed: 12/01/2022]
Abstract
Impairment of the protein C pathway, detectable by reduced plasma levels of activated protein C (APC), are risk factors for venous thrombosis. Activated protein C maintains clotting homeostasis by regulation of pro-coagulant factors Va and VIIIa. Both infection and the factor V Leiden mutation reduce the formation of APC from protein C in the blood. With low levels of APC, excess factors Va and VIIIa exist, increasing the risk of thrombus formation. Livedo racemosa is characterised by a striking, violaceous branch-like pattering of the skin. It is similar to livedo reticularis, but with a different morphology and histopathology. In this case report we present the first case of livedo racemosa, in an 89-year-old factor V Leiden-positive patient with a Pseudomonas aeruginosa urinary tract infection. The cutaneous biopsies demonstrated vasculopathy with intraluminal thrombi in subcutaneous vessels with no evidence of inflammatory vasculitis.
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Affiliation(s)
- Jesse Johnston
- Veracity Clinical Research, Brisbane, Queensland, Australia.,Queensland Institute of Dermatology, Brisbane, Queensland, Australia
| | - Rowland Noakes
- Queensland Institute of Dermatology, Brisbane, Queensland, Australia
| | - Kurt Davidson
- Veracity Clinical Research, Brisbane, Queensland, Australia
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22
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Grzybowski A, Sak J, Żołnierz J. Ian Bruce Sneddon (1915–1987). J Neurol 2016; 263:1261-2. [PMID: 26725088 PMCID: PMC4893366 DOI: 10.1007/s00415-015-7997-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 12/09/2015] [Accepted: 12/10/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Andrzej Grzybowski
- Department of Ophthalmology, Poznań City Hospital, ul. Szwajcarska 3, 61-285, Poznan, Poland.
- University of Warmia and Mazury, Olsztyn, Poland.
| | - Jarosław Sak
- Department of Ethics and Human Philosophy, Medical University of Lublin, ul. Staszica 4/6,102 (Collegium Maximum), 20-059, Lublin, Poland
| | - Joanna Żołnierz
- Department of Ethics and Human Philosophy, Medical University of Lublin, ul. Staszica 4/6,102 (Collegium Maximum), 20-059, Lublin, Poland
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23
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Ünlü O, Zuily S, Erkan D. The clinical significance of antiphospholipid antibodies in systemic lupus erythematosus. Eur J Rheumatol 2016; 3:75-84. [PMID: 27708976 PMCID: PMC5042235 DOI: 10.5152/eurjrheum.2015.0085] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 12/20/2015] [Indexed: 12/22/2022] Open
Abstract
Antiphospholipid syndrome (APS) is the association of thrombosis and/or pregnancy morbidity with antiphospholipid antibodies (aPL). Thirty to forty percent of systemic lupus erythematosus (SLE) patients are tested positive for aPL, which may have an impact on the SLE presentation, management, and prognosis. Compared with SLE patients without aPL, those with aPL have a higher prevalence of thrombosis, pregnancy morbidity, valve disease, pulmonary hypertension, livedo reticularis, thrombocytopenia, hemolytic anemia, acute/chronic renal vascular lesions, and moderate/severe cognitive impairment; worse quality of life; and higher risk of organ damage. The use of low-dose aspirin (LDA) is controversial for primary thrombosis and pregnancy morbidity prevention because of the lack of strong prospective controlled data. Similarly, the use of anticoagulation is controversial for patients with an aPL-related nephropathy. Until further studies are available, physicians should discuss the risk/benefits of LDA or anticoagulation as well as the available literature with patients.
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Affiliation(s)
- Ozan Ünlü
- Division of Rheumatology, Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Stephane Zuily
- Division of Vascular Medicine, Centre Hospitalier Universitaire de Nancy, Regional Competence Centre For RareVascular and Systemic Autoimmune Diseases, Nancy, France
| | - Doruk Erkan
- Division of Rheumatology, Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
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Bersano A, Morbin M, Ciceri E, Bedini G, Berlit P, Herold M, Saccucci S, Fugnanesi V, Nordmeyer H, Faragò G, Savoiardo M, Taroni F, Carriero M, Boncoraglio Giorgio B, Perucca L, Caputi L, Parati Eugenio A, Kraemer M. The diagnostic challenge of Divry van Bogaert and Sneddon Syndrome: Report of three cases and literature review. J Neurol Sci 2016; 364:77-83. [DOI: 10.1016/j.jns.2016.03.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 02/27/2016] [Accepted: 03/04/2016] [Indexed: 10/22/2022]
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Quaresma MV, Gomes ACD, Serruya A, Vendramini DL, Braga L, Buçard AM. Amantadine-induced livedo reticularis--Case report. An Bras Dermatol 2016; 90:745-7. [PMID: 26560223 PMCID: PMC4631243 DOI: 10.1590/abd1806-4841.20153394] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 02/18/2014] [Indexed: 12/05/2022] Open
Abstract
Livedo reticularis is a spastic-anatomical condition of the small vessels which
translates morphologically by a reticular pattern, interspersing cyanosis, pallor and
erythema. The same can be congenital or acquired. Among the acquired, we highlight
the physiological livedo reticularis and the idiopathic livedo by vasospasm; the
latter configures the most common cause. The drug-induced type is less common. The
drugs amantadine and norepinephrine are often implicated. Cyanosis is usually
reversible if the causative factor is removed, however, with chronicity, the vessels
may become permanently dilated and telangiectatic. We report a case of a patient
diagnosed with Parkinson’s disease with chronic livedo reticularis associated with
the use of amantadine and improvement after discontinuation of the drug.
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Affiliation(s)
| | | | - Aline Serruya
- Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Lara Braga
- Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Alice Mota Buçard
- Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Abstract
Livedo reticularis (LR) is a cutaneous physical sign characterized by transient or persistent, blotchy, reddish-blue to purple, net-like cyanotic pattern. LR is a benign disorder affecting mainly middle-aged females, whereas livedo racemosa (LRC) is pathologic, commonly associated with antiphospholipid antibody syndrome. This article aims to review the causes of LR and LRC along with the evaluation and management.
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Affiliation(s)
| | - Snehal Lunge
- Department of Dermatology, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
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Criado PR, Alavi A, Valente NYS, Sotto MN. Amantadine-Induced Livedo Racemosa. INT J LOW EXTR WOUND 2015; 15:78-81. [DOI: 10.1177/1534734615603566] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although livedo reticularis is a known adverse effect of amantadine, only limited studies have addressed this association. Livedo racemosa in contrast to livedo reticularis is characterized by a striking violaceous netlike pattern of the skin similar to livedo reticularis with a different histopathology and morphology (irregular, broken circular segments). In this case report, we present 2 cases of livedo racemosa and edema of lower extremities following amantadine treatment. The cutaneous biopsies in both cases showed intraluminal thrombi in subcutaneous blood vessels without evidence of vasculitis, which is consistent with livedo racemosa.
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Sotiriou A, Sventzouri S, Nepka M, Magira EE. Acute generalized livedo racemosa caused by Capnocytophaga canimorsus identified by MALDI-TOF MS. Int J Infect Dis 2015; 33:196-8. [PMID: 25677725 DOI: 10.1016/j.ijid.2015.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 02/03/2015] [Accepted: 02/04/2015] [Indexed: 10/24/2022] Open
Abstract
Independent of the size of the dog and the type of injury, serious infections may follow a dog bite and these may result in the abrupt onset of multiorgan failure. Early recognition of the warning signs with regard to the underlying severity of the infection is of the utmost importance. Reticulate skin eruptions constitute a precursory phenomenon.
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Affiliation(s)
- Adamantia Sotiriou
- Department of First Critical Care, Evangelismos Hospital, School of Medicine, National University of Athens, 50 Marathonos, Vrilisia Athens 15235, Greece
| | - Stefania Sventzouri
- Department of 3(rd) Internal Medicine, Evangelismos Hospital, Athens, Greece
| | - Martha Nepka
- Department of Microbiology, Evangelismos Hospital, Athens, Greece
| | - Eleni E Magira
- Department of First Critical Care, Evangelismos Hospital, School of Medicine, National University of Athens, 50 Marathonos, Vrilisia Athens 15235, Greece.
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Fierini F, Barilaro A, Giambene B, Carlucci G, Grandi V, Maio V, Pantoni L. Moyamoya in a patient with Sneddon's syndrome. Clin Neurol Neurosurg 2015; 129:34-6. [DOI: 10.1016/j.clineuro.2014.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 11/23/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
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Sundriyal D, Kumar N, Kumar G, Walia M. Livedo reticularis heralding hypercalcaemia of malignancy. BMJ Case Rep 2014; 2014:bcr2013201371. [PMID: 24832704 PMCID: PMC4024535 DOI: 10.1136/bcr-2013-201371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2014] [Indexed: 11/04/2022] Open
Abstract
The term livedo reticularis is used to describe net-like purple rash usually on the lower limbs. It is an important clinical sign with diverse aetiologies. Hypercalcaemia is an uncommon but important clinical entity, sometimes associated with livedo reticularis. Generally, hypercalcaemia of renal failure and secondary hyperparathyroidism has been reported with this condition. We report a case of livedo reticularis heralding onset of hypercalcaemia of malignancy.
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Affiliation(s)
- Deepak Sundriyal
- Department of Medical Oncology, Dharamshila Hospital, New Delhi, India
| | - Naveen Kumar
- Department of Internal Medicine, PGIMER & Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Gaurav Kumar
- Department of Medicine, V.M.M.C. and Safdarjung Hospital, New Delhi, India
| | - Meenu Walia
- Department of Medical Oncology, Dharamshila Hospital, New Delhi, India
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31
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Berlit P, Kraemer M. Cerebral vasculitis in adults: what are the steps in order to establish the diagnosis? Red flags and pitfalls. Clin Exp Immunol 2014; 175:419-24. [PMID: 24117125 DOI: 10.1111/cei.12221] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2013] [Indexed: 12/29/2022] Open
Abstract
Cerebral vasculitis is a rare cause of juvenile stroke. It may occur as primary angiitis of the central nervous system (PACNS) or as CNS manifestation in the setting of systemic vasculitis. Clinical hints for vasculitis are headache, stroke, seizures, encephalopathy and signs of a systemic inflammatory disorder. Diagnostic work-up includes anamnesis, whole body examination, laboratory and cerebral spinal fluid (CSF) studies, magnetic resonance imaging (MRI), angiography and brain biopsy. Due to the rarity of the disease, exclusion of more frequent differential diagnoses is a key element of diagnostic work -up. This review summarizes the steps that lead to the diagnosis of cerebral vasculitis and describes the red flags and pitfalls. Despite considering the dilemma of angiography-negative vasculitis and false-negative brain biopsy in some cases, it is important to protect patients from 'blind' immunosuppressive therapy in unrecognized non-inflammatory differential diagnosis.
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Affiliation(s)
- P Berlit
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
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Engeholm M, Leo-Kottler B, Rempp H, Lindig T, Lerche H, Kleffner I, Henes M, Dihné M. Encephalopathic Susac's Syndrome associated with livedo racemosa in a young woman before the completion of family planning. BMC Neurol 2013; 13:185. [PMID: 24274741 PMCID: PMC4222806 DOI: 10.1186/1471-2377-13-185] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 11/20/2013] [Indexed: 01/11/2023] Open
Abstract
Background Susac’s Syndrome (SS) consists of the triad of encephalopathy, branch retinal artery occlusions (BRAO) and hearing loss (HL). Histopathologically, SS is characterised by a microangiopathy, and some observations suggest that an immune-mediated damage of endothelial cells might play a role. These findings also implicate a similarity between SS and other autoimmune diseases, most notably juvenile dermatomyositis (JDM). However, SS and JDM are commonly thought to affect distinct and non-overlapping sets of organs, and it is currently not clear how these specificities arise. Moreover, in the absence of clinical trials, some authors suggest that therapeutic approaches in SS should rely on the model of other autoimmune diseases such as JDM. Case presentation Here, we report a case of SS in a 32-year-old pregnant woman. She initially was admitted to the hospital with subacute severe encephalopathy and multifocal neurologic signs. As cranial magnetic resonance imaging (MRI) revealed multifocal white matter lesions including the corpus callosum, erroneously a diagnosis of multiple sclerosis (MS) was made, and intravenous methylprednisolone (IVMP) therapy was initiated. A few days later, an exanthema appeared on the trunk and extremities, which was diagnosed as livedo racemosa (LR). Several weeks later, the patient was readmitted to the clinic with an obscuration of her left visual hemifield and a bilateral HL. Ophthalmologic examination revealed extensive ischemic damage to both retinae. Now the correct diagnosis of SS was established, based on the above triad of clinical symptoms in conjunction with typical MRI and fundoscopic findings. When SS was diagnosed, the standard therapy with intravenous cyclophosphamide (IVCTX) was not instituted because of a significant risk of permanent infertility. Instead, sustained control of disease activity could be achieved with a therapeutic regime combining prednisolone, intravenous immunoglobulins (IVIG), mycophenylate mofetil (MM), and methotrexate (MTX). Conclusions An association with LR has only been described in very few cases of SS before and further underlines the pathogenetic relationship between SS and other autoimmune diseases such as JDM. In young women with SS and the desire for a child the combination of MM and MTX may represent a reasonable alternative to IVCTX.
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Affiliation(s)
- Maik Engeholm
- Department of Neurology and Hertie Institute for Clinical Brain Research, Hoppe-Seyler-Str, 3, 72076 Tübingen, Germany.
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Sangle SR, Tanikawa A, Schreiber K, Zakalka M, D'Cruz DP. The prevalence of abnormal pulse wave velocity, pulse contour analysis and ankle-brachial index in patients with livedo reticularis: a controlled study. Rheumatology (Oxford) 2013; 52:1992-8. [PMID: 23893524 DOI: 10.1093/rheumatology/ket227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the prevalence of abnormal pulse wave velocity (PWV), pulse contour analysis (PCA) and abnormal ankle-brachial pressure index (ABPI) in patients with livedo reticularis (livedo) and without livedo. METHODS We recruited 74 patients, of whom 41 had livedo: 16 APS, 9 APS with SLE and 16 with livedo (negative for aPL or lupus). The other group of 33 patients without livedo consisted of 10 APS, 8 APS with SLE and 15 with SLE only. Livedo was diagnosed and confirmed by a dermatologist. PWV was assessed in fasting patients by the Micro Medical PulseTrace analyser using a 4 MHz continuous-wave directional Doppler probe and digital PCA was analysed by Micro Medical PulseTrace by the same operator. Chi-square with Yates's correction was used for comparing results. RESULTS The median age of the livedo patients was 46 (29-71) years and of the non-livedo patients was 45 (25-68) years. Abnormal values of PWV in 10/41 (24.40%), ABPI in 4/41 (9.8%) and PCA in 10/41 (24.40%) patients were observed in the livedo group and in the non-livedo group abnormal values of PWV in 1/33 (P ≤ 0.025), ABPI in 0/33 (P = NS) and PCA in 5/33 (P = NS) were observed. CONCLUSION Patients with livedo reticularis are more likely to have abnormal PWV, indicating arterial stiffness.
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Affiliation(s)
- Shirish R Sangle
- Lupus Research Unit, Rayne Institute, St Thomas' Hospital, London SE1 7EH, UK. david.d'
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Lekich C, Parsi K. Heterotopic ossification of small saphenous vein and panniculitis ossificans of chronic venous insufficiency presenting with livedo racemosa. Phlebology 2013; 29:401-6. [PMID: 23846577 DOI: 10.1177/0268355513495829] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Livedo racemosa is a reticulate eruption that presents with branched and partially blanchable incomplete rings. Livedo racemosa is distinct from livedo reticularis, a similar condition that presents with a diffuse and symmetrical blanchable eruption. In contrast to livedo reticularis which may be physiological, livedo racemosa is always associated with an underlying pathology. To our knowledge, this is the first report of panniculitis ossificans and heterotopic ossification of small saphenous vein (SSV) presenting with livedo racemosa. METHODS We present a 70-year-old male referred for investigation and management of progressive pigmentation and 'lipodermatosclerosis' of lower limbs. There was no history of deep venous thrombosis but an earlier ultrasound had detected a non-occlusive thrombus in the left SSV. Examination and investigations revealed the skin eruption to be livedo racemosa and the associated subcutaneous induration and nodularity to be due to panniculitis ossificans. Biopsy of the SSV demonstrated segmental heterotopic ossification. Duplex ultrasound demonstrated bilateral superficial and deep venous incompetence but no evidence of an acute or chronic venous thrombosis. The patient was diagnosed with heterotopic ossification secondary to venous insufficiency and managed conservatively. CONCLUSION Livedo racemosa may be an early sign of panniculitis ossificans and its presence should trigger further diagnostic investigations.
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Affiliation(s)
| | - Kurosh Parsi
- Department of Dermatology, St. Vincent's Hospital, Sydney, Australia University of New South Wales, Sydney, Australia
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35
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Silva SBGD, Miot HA. Case for diagnosis. An Bras Dermatol 2012; 87:319-21. [PMID: 22570045 DOI: 10.1590/s0365-05962012000200025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 02/04/2011] [Indexed: 11/22/2022] Open
Abstract
We report the case of a 58-year-old white female with Parkinson's disease. She evolved to an extensive livedo reticularis in the limbs and abdomen after commencing treatment with amantadine. We discuss the diagnostic approach to livedo reticularis and its differential diagnoses, emphasizing that the drug etiology must be considered when investigating livedo reticularis.
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Abstract
Systemic polyarteritis nodosa (PAN) is a vasculitis characterized and defined by necrotizing inflammatory changes in medium and/or small arteries. Children and adults with vasculitis differ in the relative frequency of some clinical manifestations and concomitant diseases. The European League against Rheumatism (EULAR)/Pediatric Rheumatology European Society (PRES) working group has proposed a classification of childhood vasculitis. With support from EULAR, the Pediatric Rheumatology International Trials Organization (PRINTO), and PRES, a formal statistical validation process, which included large-scale, web-based data collection, was undertaken. I now propose a set of criteria for systemic juvenile PAN that combines a modified mix of the EULAR/PRES criteria and the EULAR/PRINTO/PRES criteria. Cutaneous juvenile PAN is characterized by the presence of cutaneous features with no systemic involvement. The common cutaneous manifestations include cutaneous nodules and livedo racemosa. Our research group previously established an algorithm for the differential diagnosis of primary cutaneous vasculitis. We have recently developed a new version of that algorithm to diagnose vasculitis with cutaneous manifestations from a dermatologic point of view. Treatment of systemic juvenile PAN is based on a combination of corticosteroids and immunosuppressant agents. The clinical course of cutaneous juvenile PAN is generally benign.
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Affiliation(s)
- Tamihiro Kawakami
- Department of Dermatology, St. Marianna University School of Medicine, Kawasaki, Japan.
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El Benaye J, Hsaini Y, Zoobo T, Ghfir M, Bourazza A, Sedrati O. [Sneddon's syndrome]. Presse Med 2012; 42:138-44. [PMID: 22652061 DOI: 10.1016/j.lpm.2012.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 03/04/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022] Open
Abstract
Sneddon's syndrome is still raising some nosological and etiopathogenic questions. The occurrence of ischemic stroke in young adults especially in the presence of livedo racemosa should suggest the diagnosis and encourage to perform a skin biopsy, which could strengthen the diagnosis. Management begins with prevention of vascular risk factors and treatments based primarily on anti-thrombotic. Large series of studies over several years could provide clarification of the etiopathogenesis of this syndrome and pave the way for the development of diagnostic criteria and new effective therapies in order to prevent progression to irreversible cognitive impairment.
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Affiliation(s)
- Jalal El Benaye
- Hôpital militaire d'instruction Med V, service de dermatologie, Rabat, Maroc
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Shen S, Williams RA, Kelly RI. Neuropathy in a patient with lymphocytic thrombophilic arteritis. Australas J Dermatol 2012; 54:e28-32. [DOI: 10.1111/j.1440-0960.2011.00827.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
OPINION STATEMENT Livedo reticularis is a violaceous mottling of the skin with a "fishnet" reticular appearance. Primary and secondary etiologies exist, including a pathologic variant termed livedo racemosa. No evidence-based medicine exists to guide therapy for this disorder, but most patients with primary and secondary livedo reticularis are asymptomatic and do not require treatment. In the rare instance that a patient with primary livedo reticularis experiences mild symptoms such as episodic numbness and tingling, avoidance of cold and vasoconstricting substances should be encouraged. Lastly, judicious dosing of a vasodilator such as a calcium channel blocker can be prescribed. Patients with secondary livedo reticularis or livedo racemosa may benefit from these same therapeutic suggestions; however, treating the proximate cause of livedo with a systemic association is encouraged and is most likely to yield cutaneous improvement. Although antiplatelet and/or anticoagulant therapy is often required when treating a patient with the antiphospholipid antibody syndrome or Sneddon's syndrome, the attendant livedo racemosa typically remains unchanged or progresses despite this treatment.
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Affiliation(s)
- Steven M Dean
- Division of Cardiovascular Medicine, 200 Davis Heart Lung Institute, The Ohio State University College of Medicine, 473W. 12th Avenue, Columbus, OH, 43210, USA,
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Turc G, Monnet D, Dupin N, Beuvon F, Guiraud V, Amor MB, Touzé E. Skin involvement in Susac's syndrome. J Neurol Sci 2011; 305:152-5. [DOI: 10.1016/j.jns.2011.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 01/26/2011] [Accepted: 03/01/2011] [Indexed: 10/18/2022]
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Facial livedo racemosa as a warning sign of cholesterol embolism from atherosclerotic plaques of the carotid artery. J Am Acad Dermatol 2011; 64:1203-5. [PMID: 21571195 DOI: 10.1016/j.jaad.2009.08.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 08/24/2009] [Accepted: 08/24/2009] [Indexed: 11/23/2022]
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Cervera R, Tektonidou MG, Espinosa G, Cabral AR, González EB, Erkan D, Vadya S, Adrogué HE, Solomon M, Zandman-Goddard G, Shoenfeld Y. Task Force on Catastrophic Antiphospholipid Syndrome (APS) and Non-criteria APS Manifestations (II): thrombocytopenia and skin manifestations. Lupus 2011; 20:174-81. [DOI: 10.1177/0961203310395052] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The objectives of the ‘Task Force on Catastrophic Antiphospholipid Syndrome (APS) and Non-criteria APS Manifestations’ were to assess the clinical utility of the international consensus statement on classification criteria and treatment guidelines for the catastrophic APS, to identify and grade the studies that analyze the relationship between the antiphospholipid antibodies and the non-criteria APS manifestations, and to present the current evidence regarding the accuracy of these non-criteria APS manifestations for the detection of patients with APS. This article summarizes the studies analyzed on thrombocytopenia and skin manifestations, and presents the recommendations elaborated by the Task Force after this analysis.
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Affiliation(s)
- R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
| | - MG Tektonidou
- First Department of Internal Medicine, Medical School, National University of Athens, Athens, Greece
| | - G Espinosa
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
| | - AR Cabral
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - EB González
- Division of Rheumatology, Department of Medicine, The University of Texas Medical Branch (UTMB), Galveston, Texas, USA
| | - D Erkan
- The Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
| | - S Vadya
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, USA
| | - HE Adrogué
- The Methodist Hospital Transplant Center, Fannin, Houston, Texas, USA
| | - M Solomon
- Department of Dermatology, Chaim Sheba Medical Center, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Zandman-Goddard
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine C, Wolfson Medical Center, Tel Hashomer, Israel
| | - Y Shoenfeld
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Zublodovitz Center for Autoimmune Diseases and Department of Medicine B, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Chou RC, Mihm MC, Stone JH. A 44-year-old woman with right ankle pain. Arthritis Care Res (Hoboken) 2010; 62:1665-72. [PMID: 20506413 DOI: 10.1002/acr.20242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 04/20/2010] [Indexed: 12/09/2022]
Affiliation(s)
- Richard C Chou
- Massachusetts General Hospital, Harvard Medical School, Boston, 02114, USA
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Kraemer M, Berlit P. Primary central nervous system vasculitis and moyamoya disease: similarities and differences. J Neurol 2009; 257:816-9. [PMID: 20037765 DOI: 10.1007/s00415-009-5425-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 11/21/2009] [Accepted: 12/09/2009] [Indexed: 11/30/2022]
Affiliation(s)
- Markus Kraemer
- Department of Neurology, Alfried Krupp von Bohlen und Halbach Hospital, Alfried-Krupp-Strasse 21, 45117 Essen, Germany.
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Caldas CAM, de Carvalho JF. Primary antiphospholipid syndrome with and without Sneddon's syndrome. Rheumatol Int 2009; 31:197-200. [PMID: 20012621 DOI: 10.1007/s00296-009-1310-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 11/29/2009] [Indexed: 02/06/2023]
Abstract
The main objective of this study was to compare clinical and laboratory data obtained from patients with primary antiphospholipid syndrome (PAPS) with and without Sneddon's syndrome (SS). A transverse study with 54 (85.2% female) PAPS patients (Sapporo criteria) was performed. Demographic, drug use, and antiphospholipid antibodies data were evaluated, as well as clinical and laboratory findings of SS. Patients were subdivided into one of two groups: PAPS with SS and PAPS without SS. Both groups were similar with respect to age (p = 0.05), gender (p = 0.34), race (p = 0.31), weight (p = 0.93), height (p = 0.27), and body mass index (p = 0.75); however, the SS group exhibited higher disease duration (96.0 ± 54.9 vs. 55.2 ± 52.0 months, p = 0.01). By definition, all PAPS with SS patients suffer from stroke, an arterial event; the frequency of stroke events (28.5 vs. 7.5%, p = 0.04), as well as of limb ischemia (100 vs. 30.0%, p < 0.0001) was higher in this group than in the PAPS without SS group. On the other hand, patients in the PAPS without SS group had more venous events, such as deep venous thrombosis, than those in the PAPS with SS group (80.0 vs. 50.0%, p = 0.03). In conclusion, an understanding of the relationship between APS and SS is important in order to identify a subgroup for which more rigorous accompaniment and therapy may be necessary.
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Affiliation(s)
- Cezar Augusto Muniz Caldas
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo e Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Avenida Dr. Arnaldo 455, 3º andar, sala 3190, 01246-903, São Paulo, SP, Brazil
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Rebollo Álvarez-Amandi M, Ricart Colomé C. A propósito de un signo cutáneo de vasculopatía sistémica. Med Clin (Barc) 2009; 132:785-6. [DOI: 10.1016/j.medcli.2009.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 02/17/2009] [Indexed: 11/28/2022]
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Martínez-Valle F, Ordi-Ros J, Selva-O'Callaghan A, Balada E, Solans-Laque R, Vilardell-Tarres M. Livedo racemosa as a marker of increased risk of recurrent thrombosis in patients with negative anti-phospholipid antibodies. Med Clin (Barc) 2009; 132:767-71. [PMID: 19403146 DOI: 10.1016/j.medcli.2008.09.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 09/30/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Livedo reticularis racemosa and cerebrovascular lesions characterize Sneddon's syndrome. We report 23 patients with livedo racemosa and describe the association with thrombotic events. Our objective was to determine whether livedo racemosa may be an independent clinical marker for the development of thrombotic events in patients who test negative for anti-phospholipid antibodies. METHODS Twenty-three patients with widespread livedo racemosa were studied. None of the patients were positive for anti-phospholipid antibodies. The clinical protocol included a register of thrombotic events, fetal death or miscarriages, hypertension, and valvular heart disease. Cerebral MRI and echocardiography were systematically performed in all patients. RESULTS Nineteen patients (82.60%) had thrombotic events. Fifteen (65.21%) had arterial thrombosis and eleven (47.82%) presented venous occlusions. Seven patients (30.43%) had both arterial and venous thrombosis. Fetal losses were recorded in seven cases (30.43%), with a total number of 33; five patients had 3 or more fetal losses. Eleven out of 23 patients (47.82%) had valvular heart disease. Arterial hypertension was detected in 16 (69.56%) patients. Four patients did not have thrombotic events but had other clinical manifestations. After anti-coagulation therapy was withdrawn, a new thrombotic event was observed in 9 out of the 14 treated patients (64.28%). CONCLUSIONS Livedo racemosa seems to be a good clinical marker for the detection of hypercoagulable states even in the absence of anti-phospholipid antibodies or other known biologic markers of thrombosis. Long-term anti-coagulation is probably warranted in patients with livedo racemosa and a previous thrombotic event.
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Affiliation(s)
- Ferran Martínez-Valle
- Research Unit in Systemic Autoimmune diseases, Vall d'Hebron Research Institute, Hospital Vall d'Hebron, Barcelona, Spain.
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Kawakami T, Yamazaki M, Mizoguchi M, Soma Y. Differences in anti-phosphatidylserine-prothrombin complex antibodies and cutaneous vasculitis between regular livedo reticularis and livedo racemosa. Rheumatology (Oxford) 2008; 48:508-12. [DOI: 10.1093/rheumatology/kep036] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kraemer M, Berlit P. Cerebral haemorrhage as the presenting form of Sneddon's syndrome. Clin Neurol Neurosurg 2008; 110:533. [DOI: 10.1016/j.clineuro.2008.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Revised: 02/10/2008] [Accepted: 02/11/2008] [Indexed: 11/29/2022]
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