Nodular erythema elevatum diutinum in an HIV-1 infected woman: response to dapsone and antiretroviral therapy

Erythema elevatum diutinum: a case report and review of literature

Erythema elevatum diutinum (EED) is a rare cutaneous leukocytoclastic vasculitis thought to be related to increased levels of circulating antibodies. It has been shown to be associated with HIV infection, tuberculosis, as well as various autoimmune diseases. A retrospective review of all cases of EED indexed in PubMed between 1990 and 2014 was performed. Inclusion criteria for articles was availability of full text in English and a biopsy-confirmed diagnosis of EED. All other articles were excluded. Cases were stratified by age and anatomic location of the lesions. Treatment response was coded as "complete," "partial," and "none." A total of 133 cases of EED with 381 lesions detailed in case reports and case series were included. Twenty-one cases were associated with HIV. Of 47 patients with reported paraproteinemias, IgA paraproteinemia was found in 57.45%, IgG paraproteinemia in 29.8%, IgM paraproteinemia in 10.6%, and IgD paraproteinemia in 2.1% of cases. Of 40 (30.1%) patients with reported comorbid autoimmune disease, rheumatoid arthritis was associated with 10 cases. Cancer was found to be associated with 9.77% of cases. Seventy-five patients were treated with dapsone, with 36 (48%) achieving complete treatment response, 24 (32%) achieving partial response, and seven (9.3%) achieving no response. Keeping the clinical associations of EED in mind, especially malignancy, is critical in management of the disease. More structured studies need to take place in order to fully define the mechanisms and strength of these associations.

Erythema elevatum diutinum as a first clinical manifestation for diagnosing HIV infection: case history

CONTEXT

Erythema elevatum diutinum is a chronic and rare dermatosis that is considered to be a variant of leukocytoclastic vasculitis. It is probably mediated by immune complexes. It is generally associated with autoimmune, neoplastic and infectious processes. Recently, it has been added to the group of specific dermatoses that are associated with HIV.

CASE REPORT

We report on the case of a patient who had erythema elevatum diutinum as the first clinical evidence for diagnosing HIV infection. Dapsone was used in the treatment of this patient, and partial regression of the lesions was achieved within 15 days, even before anti-retroviral therapy was prescribed.

CONCLUSION

When there is a diagnosis of erythema elevatum diutinum, HIV infection should be investigated, especially in atypical and exacerbated clinical manifestations.

Erythema Elevatum Diutinum in the Setting of Connective Tissue Disease and Chronic Bacterial Infection

Erythema elevatum diutinum (EED) is a rare and chronic cutaneous leukocytoclastic vasculitis. It is predominantly seen on the extensor surfaces of the extremities. Although a specific cause is largely unknown, EED has been noted to occur in association with a wide variety of diseases. A 28-year-old man with systemic lupus erythematosus (SLE) and a 53-year-old woman with an overlap syndrome of rheumatoid arthritis and polymyositis are presented. Both patients developed EED in the setting of chronic recurrent bacterial infections. Patients with a connective tissue disease are at increased risk for such infections secondary to immunosuppression, either from the disease itself or secondary to immunosuppressive therapy. EED has been independently reported to occur in the setting of connective tissue disease as well as in the setting of chronic infection. Our patients had both of these underlying conditions, which are known to predispose patients to immune complex-mediated vasculitides, in this case EED. One patient's EED responded to treatment of the SLE and the other improved, as has been previously reported with dapsone.

Kawasaki-like syndromes and other vasculitic syndromes in HIV-infected patients

Excluding drug-related hypersensitivity reactions, vasculitic syndromes are not common in HIV-positive patients. Review of the existing literature suggests that HIV positive patients may be predisposed to polyarteritis nodosa, microscopic polyarteritis, Kawasaki-like syndromes, acute occlusion syndromes, primary angiitis of the central nervous system and erythema elevatum diutinum. With the exception of erythema elevatum diutinum, these vasculitic syndromes have significant morbidities and mortality if they are not treated. It is therefore important to make these diagnoses and to initiate appropriate therapy in a timely fashion. Because fevers, malaise, weakness, rashes, headaches and neurologic symptoms are common in HIV-positive patients, it is probable that some cases of vasculitis go undiagnosed. In this report, we review vasculitic syndromes seen in HIV-positive patients. We also re-examine a previously published case of a young HIV-positive male who died of an acute myocardial infarction without atherosclerotic disease. Immunohistopathology of the affected arteries suggests that he died of a Kawasaki-like syndrome.

Dapsone and sulfones in dermatology: overview and update

In their 60-year history, dapsone and the sulfones have been used as both antibacterial and anti-inflammatory agents. Dapsone has been used successfully to treat a range of dermatologic disorders, most successfully those characterized by abnormal neutrophil and eosinophil accumulation. This article reviews and updates the chemistry, pharmacokinetics, clinical application, mechanism of action, adverse effects, and drug interactions of dapsone and the sulfones in dermatology.

Erythema elevatum diutinum and HIV infection: a report of five cases

Erythema elevatum diutinum (EED) is emerging as a specific HIV-associated dermatosis, 11 cases having so far been reported in the medical literature and five patients with the disease having been seen by us during the last 4 years. As the disease is poorly known, it is easily confused with Kaposi's sarcoma or bacillary angiomatosis, but the histopathological features are diagnostic. EED is considered to be an immune complex-mediated vasculitis. A streptococcal infection seemed to be the trigger factor in four of our patients. Partial control of the cutaneous lesions was achieved by the use of antibiotics.