Eosinophilic fasciitis, morphea and vitiligo in a single patient. Ann Dermatol Venereol. 2014;141:598-602. [PMID: 25288063 DOI: 10.1016/j.annder.2014.06.019]

A Severe Case of Overlap of Morphea and Eosinophilic Fasciitis after Burn Injuries

Background

Generalized morphea is a rare fibrosing skin illness that progresses from erythematous, violet-colored skin patches to sclerotic plaques. Another uncommon immune-mediated connective tissue disease called eosinophilic fasciitis (EF) evolves to cause sclerosis and woody skin induration. The coexistence of the two is extremely rare and has a poorer prognosis. Our case report is one of the first to report burn injuries as a trigger factor for EF and generalized morphea overlap. Case Presentation. A 36-year-old man presented with acute onset of rapidly progressing skin thickening, tender edema, and skin contractures involving all extremities, shortly after enduring burn injuries from a gasoline explosion. Workup was remarkable for peripheral eosinophilia, hypergammaglobulinemia, and elevated C-reactive protein. Skin biopsy demonstrated sclerodermoid changes and sclerotic thickening of subcutaneous fibrous septa associated with stromal mucin, dermal perivascular, diffuse lymphoplasmacytic infiltrate with eosinophils, decreased CD34 expression, and increased factor XIIIa. He was subsequently diagnosed with an overlap of generalized morphea and eosinophilic fasciitis. The patient had only limited improvement with steroids, methotrexate, mycophenolate mofetil, and intralesional triamcinolone acetonide injections.

Conclusion

Generalized morphea with concomitant EF indicates some degree of therapeutic resistance and poor prognosis with a low quality of life. Burn injuries can be a trigger factor for this overlap syndrome. Prompt identification of at-risk individuals and initiating aggressive management are necessary.

Hypereosinophilia, mastectomy, and nephrotic syndrome in a male patient: A case report

BACKGROUND

Hypereosinophilia (HE) is a heterogeneous disease of unknown etiology in which tissue and organ injury is inflicted by excess numbers of circulating or infiltrating eosinophils. Herein, we describe a patient with rare organ damage due to HE and review the pertinent literature.

CASE SUMMARY

A 43 year-old Chinese man with a 13-year history of eosinophilia and shortness of breath for 7 d presented to our hospital. During the course of his illness, the patient variably presented with gastrointestinal symptoms, eczema, vitiligo, mastitis, joint symptoms, nephrotic syndrome, and interstitial pneumonia. The chronic mastitis proved burdensome, necessitating bilateral mastectomy. HE was diagnosed by repeat bone marrow biopsy, and a kidney biopsy showed focal segmental glomerulosclerosis. Intermittent steroidal therapy is typically initiated to relieve such symptoms, although relapse and organ involvement often ensue once treatment is withdrawn. We administered methylprednisolone sodium succinate (40 mg/d) intravenously for 3 d, followed by oral tablets at the same dose. Subsequent computed tomography (CT) of the chest CT showed relative improvement of the interstitial pneumonia. The patient is currently on a continuous regimen of oral steroid, and his condition is stable.

CONCLUSION

HE is heterogeneous condition. This is the first reported case of bilateral mastectomy in a male patient with longstanding HE.

Quality of Life, Burden of Disease, Co-morbidities, and Systemic Effects in Vitiligo Patients

Vitiligo is a complex, systemic disease associated with many autoimmune and autoinflammatory conditions. Additionally, the cutaneous changes of vitiligo have significant effects on quality of life and self-esteem. Further efforts are needed to increase our understanding of vitiligo comorbidities as well as to increase awareness of the psychological effects of vitiligo.

[Eosinophilic fasciitis (Shulman's disease): Diagnostic and therapeutic review]

Eosinophilic fasciitis (EF) is a rare connective tissue disease characterized by symmetrical and painful swelling with a progressive induration and thickening of the skin and soft tissues. The diagnosis of EF is often based on the association of characteristic skin or subcutaneous abnormalities and a thickened fascia with an inflammatory infiltration, mostly composed of lymphocytes and eosinophils. A peripheral eosinophilia is frequently present (60-90%) but is not mandatory for the EF diagnosis. At the onset, the morphological diagnosis might be helped by a muscle magnetic resonance imaging, which typically may evidence an increased signal intensity within the fascia and marked fascia enhancement after gadolinium administration at the acute phase of the disease. Differential diagnoses include eosinophilia-myalgia syndrome after L-tryprophane ingestion, hypereosinophilic syndromes (HES), systemic sclerosis, eosinophilic granulomatosis with polyangeitis, and peripheral T cell lymphomas with cutaneous involvement. There is no consensual therapeutic strategy. However, oral corticosteroids, with or without methylprednisolone pluses, remain the mainstay treatment with a significant improvement for the majority of patients. It might be associated to an immunosuppressive drug, mainly methotrexate, in patients with morphea-like lesions or an unsatisfactory response to corticosteroids alone.