Sweet's syndrome with pulmonary involvement: Case report and literature review

Paediatric Sweet's syndrome with pulmonary involvement triggered by severe inflammatory bowel disease and emergent total abdominal colectomy with literature review

Sweet's syndrome (SS) is a neutrophilic dermatosis characterised by the acute onset of erythematous papules or plaques and a constellation of symptoms including fever, leucocytosis, and histopathology demonstrating nodular, pustular, or diffuse infiltrate of neutrophils with marked papillary oedema. SS can be a manifestation of inflammatory bowel disease and often coincides with periods of disease flares. Only a few cases of SS associated with ulcerative colitis are reported in the literature, and no cases have involved pulmonary manifestations in the paediatric population. We present a case of a 14-year-old girl presenting with new onset ulcerative colitis requiring emergent colectomy with subsequent development of pulmonary SS. Treatment consisted of intravenous and oral corticosteroids and dapsone. SS should be considered in the differential diagnosis of prolonged fever with cutaneous involvement and systemic symptoms. Special consideration should be given to paediatric patients with extracutaneous manifestations, particularly pulmonary involvement.

Pulmonary pathology in vasculitis

Pulmonary involvement is frequent in vasculitis, particularly in ANCA-associated small vessel vasculitis. Laboratory and radiological data alone are often sufficient to confirm the clinical hypothesis, but sometimes the pathologist plays a crucial role in the differential diagnosis and the patient's management. In this review, the pathologic features of pulmonary vasculitis and the pathologist's role in this field are illustrated.

Unique challenges to diagnosing sweet syndrome following induction chemotherapy for relapsed Acute Myeloid Leukemia (AML): A case and brief-review

Background

Sweet Syndrome (SS) is a rare inflammatory skin condition characterized by the sudden appearance of tender, erythematous or violaceous papules, plaques, and nodules typically found on the face, neck, shoulder, upper extremities, and trunk. Often, SS is difficult to diagnose because of its various non-specific manifestations, including fever, arthralgia, myalgia and ocular involvement. In most cases described in literature, cutaneous and pulmonary symptoms of SS present in a concomitant manner. Several reported cases of pulmonary SS have shown that if left untreated, acute respiratory distress syndrome can ensue and progress to fatal respiratory failure.

Case report

A 58-year-old female with acute myeloid leukemia (AML) secondary to chronic lymphocytic leukemia (CLL) presented with new nodular lesions, dyspnea, and fevers. Chest X-ray revealed pulmonary infiltrates. The patient developed new facial lesions and worsening hypoxic respiratory failure. Further infectious workup was negative. She was found to have SS with pulmonary involvement and initiated on high-dose intravenous (IV) steroids with marked clinical improvement.

Conclusions

Major and minor criteria for the diagnosis of lung-associated SS should be carefully evaluated, especially when a biopsy is unavailable. The following case report describes the clinical course and outcomes from treatment for this patient.

Neutrophilic Dermatoses and Their Implication in Pathophysiology of Asthma and Other Respiratory Comorbidities: A Narrative Review

Neutrophilic dermatoses (ND) are a polymorphous group of noncontagious dermatological disorders that share the common histological feature of a sterile cutaneous infiltration of mature neutrophils. Clinical manifestations can vary from nodules, pustules, and bulla to erosions and ulcerations. The etiopathogenesis of neutrophilic dermatoses has continuously evolved. Accumulating genetic, clinical, and histological evidence point to NDs being classified in the spectrum of autoinflammatory conditions. However, unlike the monogenic autoinflammatory syndromes where a clear multiple change in the inflammasome structure/function is demonstrated, NDs display several proinflammatory abnormalities, mainly driven by IL-1, IL-17, and tumor necrosis factor-alpha (TNF-a). Additionally, because of the frequent association with extracutaneous manifestations where neutrophils seem to play a crucial role, it was plausible also to consider NDs as a cutaneous presentation of a systemic neutrophilic condition. Neutrophilic dermatoses are more frequently recognized in association with respiratory disorders than by chance alone. The combination of the two, particularly in the context of their overlapping immune responses mediated primarily by neutrophils, raises the likelihood of a common neutrophilic systemic disease or an aberrant innate immunity disorder. Associated respiratory conditions can serve as a trigger or may develop or be exacerbated secondary to the uncontrolled skin disorder. Physicians should be aware of the possible pulmonary comorbidities and apply this knowledge in the three steps of patients' management, work-up, diagnosis, and treatment. In this review, we attempt to unravel the pathophysiological mechanisms of this association and also present some evidence for the role of targeted therapy in the treatment of both conditions.

Insights Into the Pathogenesis of Sweet's Syndrome

Sweet's syndrome, also known as Acute Febrile Neutrophilic Dermatosis, is a rare inflammatory condition. It is considered to be the prototype disease of neutrophilic dermatoses, and presents with acute onset dermal neutrophilic lesions, leukocytosis, and pyrexia. Several variants have been described both clinically and histopathologically. Classifications include classic Sweet's syndrome, malignancy associated, and drug induced. The cellular and molecular mechanisms involved in Sweet's syndrome have been difficult to elucidate due to the large variety of conditions leading to a common clinical presentation. The exact pathogenesis of Sweet's syndrome is unclear; however, new discoveries have shed light on the role of inflammatory signaling, disease induction, and relationship with malignancy. These findings include an improved understanding of inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic contributions. Continued investigations into effective treatments and targeted therapy will benefit patients and improve our molecular understanding of inflammatory diseases, including Sweet's syndrome.

An Unlikely Rapid Transformation of Myelodysplastic Syndrome to Acute Leukemia: A Case Report

INTRODUCTION

Myelodysplastic syndrome is characterized by stem-cell-derived clonal myelopoiesis with an alteration in proliferation and differentiation. This condition carries a potential for transformation to acute leukemia, primarily in cases that are accompanied by high-risk features at diagnosis.

CASE PRESENTATION

A 68-year-old man with recently diagnosed myelodysplastic syndrome and Sweet syndrome (acute febrile neutrophilic dermatosis) presented to our Emergency Department with shortness of breath. During his hospital course, he developed signs and symptoms, predominantly consisting of respiratory difficulties, that were not typically characteristic of transformation to acute leukemia. Several days into his hospitalization, it was determined that the patient's underlying hematologic process seemed to have rapidly evolved into an acute myeloid leukemia, which accounted for the progression of symptoms. This patient ultimately opted for comfort measures only and died shortly thereafter.

DISCUSSION

Two important factors stood out as representing an atypical presentation. First, this patient lacked any of the high-risk features of myelodysplastic syndrome that typically portend transformation. In addition, his progression to acute leukemia in 28 days from the time of diagnosis was far more rapid than the 274-day median previously described in the literature. We theorize that the presence of Sweet syndrome may have served as a predisposing factor to transformation. This finding may offer benefit to physicians to potentially better predict this outcome and pursue more aggressive treatment measures earlier in the course of the disease in such a setting.

Not so sweet; severe Sweet's syndrome presenting as SIRS and pleural effusion

Acute febrile neutrophilic dermatosis (Sweet's syndrome) is a rare inflammatory condition which presents as abrupt onset of painful erythematous plaques or nodules, often associated with fever and leucocytosis. Many extracutaneous manifestations are described in literature, but pulmonary manifestations and systemic inflammatory response syndrome (SIRS) are rare. Here we report a case of a 35-year-old male who presented with SIRS and pleural effusion. The presence of vesiculobullous and pustular skin lesions raised the suspicion of Sweet's syndrome and it was confirmed by skin biopsy. Initiation of systemic glucocorticoids lead to complete resolution of symptoms.