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Abstract
Inflammatory dermatoses encompass a variety of histologic patterns that affect different portions of the skin. In spongiotic, psoriasiform, lichenoid, pityriasiform, and blistering disorders, there are predominately epidermal and junctional activities with variable superficial dermal inflammation. Hypersensitivity reactions can show either epidermal or mostly dermal changes depending on whether the exposure of the exogenous allergen occurs through an external or internal route, respectively. Exceptions include erythema multiforme and Stevens-Johnson syndrome/toxic epidermal necrolysis, where the etiology is often due to infection or ingested medications, but the histologic features are almost exclusively confined to the epidermis and dermoepidermal junction. Autoimmune disorders are unique in that lesions typically incorporate a mixture of epidermal and dermal inflammatory patterns with periadnexal inflammation, while the vast majority of vasculitis/vasculopathy and alopecia have changes limited to only the vessels and hair follicles, respectively. It is critical to recognize that a relatively limited number of histologic patterns are seen in a large array of clinical entities. Therefore, clinicopathologic correlation and careful examination of histologic details are of the utmost importance when evaluating skin biopsies for inflammatory disorders.
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Affiliation(s)
- Andy C Hsi
- 1 Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Ilana S Rosman
- 1 Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri.,2 Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri
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Xing C, Shen H, Xu J, Liu Z, Zhu J, Xu A. A Fatal Case of Febrile Ulceronecrotic Mucha-Habermann Disease which Presenting as Toxic Epidermal Necrolysis. Indian J Dermatol 2017; 62:675. [PMID: 29263553 PMCID: PMC5724328 DOI: 10.4103/ijd.ijd_631_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Febrile ulceronecrotic Mucha-Habermann disease (FUMHD), a severe form of pityriasis lichenoides et varioliformis acuta, is an inflammatory dermatosis of unknown etiology manifested by ulcerative and necrotic lesions accompanied by systemic manifestations. The mortality rate of FUMHD is about 15%. It is reported here a case of FUMHD presenting as toxic epidermal necrolysis that resulted in multiple organ failure and death.
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Affiliation(s)
- Chenjing Xing
- Department of Dermatology, Hangzhou Institute of Dermatology and Venereology, The Third People's Hospital of Hangzhou, Hangzhou, China
| | - Hong Shen
- Department of Dermatology, Hangzhou Institute of Dermatology and Venereology, The Third People's Hospital of Hangzhou, Hangzhou, China
| | - Junzhu Xu
- Department of Dermatology, Hangzhou Institute of Dermatology and Venereology, The Third People's Hospital of Hangzhou, Hangzhou, China
| | - Zehu Liu
- Department of Dermatology, Hangzhou Institute of Dermatology and Venereology, The Third People's Hospital of Hangzhou, Hangzhou, China
| | - Jun Zhu
- Department of Dermatology, Hangzhou Institute of Dermatology and Venereology, The Third People's Hospital of Hangzhou, Hangzhou, China
| | - Aie Xu
- Department of Dermatology, Hangzhou Institute of Dermatology and Venereology, The Third People's Hospital of Hangzhou, Hangzhou, China
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Nofal A, Assaf M, Alakad R, Amer H, Nofal E, Yosef A. Febrile ulceronecrotic Mucha-Habermann disease: proposed diagnostic criteria and therapeutic evaluation. Int J Dermatol 2015; 55:729-38. [DOI: 10.1111/ijd.13195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/13/2015] [Accepted: 08/24/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Ahmad Nofal
- Department of Dermatology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Magda Assaf
- Department of Pathology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Rania Alakad
- Department of Dermatology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Hala Amer
- Al-Haud Al-Marsoud Dermatology Hospital; Cairo Egypt
| | - Eman Nofal
- Department of Dermatology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Ayman Yosef
- Department of Dermatology; Faculty of Medicine; Zagazig University; Zagazig Egypt
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Shah DJ, Dhir R, Shah H, Chawla N. Steroid unresponsive case of ulcerative mucha-habermann disease (febrile ulcernecrotic mucha-habermann disease) treated with methotrexate. Indian J Dermatol 2014; 59:631. [PMID: 25484416 PMCID: PMC4248524 DOI: 10.4103/0019-5154.143572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 20 year old male presented with fever associated with eruption of papules, plaques and vesiculobullous lesions on the chest, back, extremities, palms, soles, and genital mucosa of 20 days duration. Histopathological examination revealed epidermal clefts, edema and vacuolar degeneration of keratinocytes, basal cell degeneration, and dermal perivascular lymphocytic infiltrate. On the basis of clinical features and histology, a diagnosis of febrile ulceronecrotic Mucha-Habermann disease (FUMHD) was made. Treatment with doxycycline (100 mg BD for 4 weeks) and oral prednisolone 60 mg/day tapered to 25 mg in 4 weeks led to initial response that was followed by a relapse on tapering steroid. Addition of methotrexate (7.5 mg increased to 15 mg in 2 weeks) led to a dramatic response.
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Affiliation(s)
- Deepam J Shah
- Department of Dermatology, INHS Asvini, Colaba, Mumbai, Maharashtra, India
| | - Rajeev Dhir
- Department of Dermatology, INHS Asvini, Colaba, Mumbai, Maharashtra, India ; Department of Venerology, INHS Asvini, Colaba, Mumbai, Maharashtra, India ; Department of Lerprosy, INHS Asvini, Colaba, Mumbai, Maharashtra, India
| | - Harsh Shah
- Department of Dermatology, INHS Asvini, Colaba, Mumbai, Maharashtra, India
| | - Naveen Chawla
- Department of Pathology, INHS Asvini, Colaba, Mumbai, Maharashtra, India
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Lejuste FX, Michaux C, Lehners C, Calteux N. Febrile ulceronecrotic Mucha-Habermann disease. BMJ Case Rep 2013; 2013:bcr2013009739. [PMID: 24127370 PMCID: PMC3822268 DOI: 10.1136/bcr-2013-009739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The Mucha-Habermann disease is an inflammatory disease of the skin and is a variant of pityriasis lichenoides et varioliformis acuta. We describe the case of a 64-years-old woman who was admitted for erysipelas of the face. Despite treatment, evolution was marked by the appearance of a necrotising ulcerative area in the centre of the erysipelas associated with local oedema and headache. A skin biopsy revealed a pityriasis lichenoides et varioliformis acuta. Corticosteroids led to a rapid stabilisation of lesions, and after 6 months the patient shows only a small area of frontal hypopigmentation. The aetiology remains uncertain. There is no established standard treatment. We would like to draw attention of the medical and surgical specialists to this rare disease. The diagnosis should be considered in a necrotic lesion associated with rapid expansion of systemic and peripheral cutaneous signs. Diagnosis must be considered to avoid unnecessary debridement and extensive scars.
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Affiliation(s)
- F-X Lejuste
- Service de Chirurgie Plastique Reconstructrice et Esthétique, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
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Parfenova MA, Belousova IE, Samtsov AV. Ulceronecrotic Mucha Habermann’s disease: case study. VESTNIK DERMATOLOGII I VENEROLOGII 2013. [DOI: 10.25208/vdv619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The rare dermatosis febrile ulceronecrotic Mucha Gabermann’s disease is described. Etiology, pathogenesis, clinical and pathomorphological criteria of diagnosis, treatment of the disease are discussed. Based on the literature review describes the historical and current data classification of the disease and patient management tactics.
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Febrile Ulceronecrotic Mucha-Habermann Disease (Pityriasis Lichenoides et Varioliformis Acuta Fulminans) Associated With Parvovirus Infection. Am J Dermatopathol 2013; 35:503-6. [DOI: 10.1097/dad.0b013e3182770626] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rosman IS, Liang LC, Patil S, Bayliss SJ, White AJ. Febrile ulceronecrotic Mucha-Habermann disease with central nervous system vasculitis. Pediatr Dermatol 2013; 30:90-3. [PMID: 22276640 DOI: 10.1111/j.1525-1470.2011.01669.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Febrile ulceronecrotic Mucha-Habermann disease (FUMHD) is a severe variant of pityriasis lichenoides et varioliformis acuta (PLEVA). We report a case of FUMHD in an 11-year-old boy who subsequently developed neurologic symptoms and was found to have necrotizing vasculitis on brain biopsy. Over 5 years of follow-up, he had one biopsy-proven recurrence of his skin lesions and continued rehabilitation and treatment for residual neurologic complications. This case provides histological evidence of central nervous system vasculitis associated with FUMHD. Our patient's disease was eventually controlled with cyclophosphamide.
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Affiliation(s)
- Ilana S Rosman
- Division of Dermatology, Department of Internal Medicine, School of Medicine Washington University, and St. Louis Children's Hospital, St. Louis, Missouri 63110, USA
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Pityriasis lichenoides chronica associated with herpes simplex virus type 2. Case Rep Dermatol Med 2012; 2012:737428. [PMID: 23243523 PMCID: PMC3518091 DOI: 10.1155/2012/737428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 10/23/2012] [Indexed: 11/18/2022] Open
Abstract
Introduction. Pityriasis lichenoides is a rare, acquired spectrum of skin conditions of an unknown etiology. Case Report. A 28-year-old man presented with recurrent outbreaks of herpes simplex virus associated with the onset of red-to-brown maculopapules located predominantly in trunk in each recurrence. Positive serologies to herpes simplex virus type 2 were detected. Histopathological examination of one of the lesions was consistent with a diagnosis of pityriasis lichenoides chronica. Discussion. Pityriasis lichenoides is a rare cutaneous entity of an unknown cause which includes different clinical presentations. A number of infectious agents have been implicated based on the clustering of multiple outbreaks and elevated serum titers to specific pathogens (human immunodeficiency virus, cytomegalovirus, Epstein-Barr virus, Toxoplasma gondii, and herpes simplex virus). In our patient, resolution of cutaneous lesions coincided with the administration of antiviral drugs and clinical improvement in each genital herpes recurrence. In conclusion, we report a case in which cutaneous lesions of pityriasis lichenoides chronica and a herpes simplex virus-type 2-mediated disease have evolved concomitantly.
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Kaufman WS, McNamara EK, Curtis AR, Kosari P, Jorizzo JL, Krowchuk DP. Febrile ulceronecrotic Mucha-Habermann disease (pityriasis lichenoides et varioliformis acuta fulminans) presenting as Stevens-Johnson syndrome. Pediatr Dermatol 2012; 29:135-40. [PMID: 22084981 DOI: 10.1111/j.1525-1470.2011.01608.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present two pediatric patients with pityriasis lichenoides et varioliformis acuta fulminans whose admitting diagnosis was Stevens Johnson Syndrome. The patients were successfully treated with methotrexate and prednisone. These cases highlight the importance of early recognition and treatment of this disease to prevent further morbidity and a potentially fatal prognosis.
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Affiliation(s)
- William S Kaufman
- Department of Dermatology, Wake Forest Baptist Health, Winston-Salem, NC 27104, USA
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Meziane L, Caudron A, Dhaille F, Jourdan M, Dadban A, Lok C, Chaby G. Febrile Ulceronecrotic Mucha-Habermann Disease: Treatment with Infliximab and Intravenous Immunoglobulins and Review of the Literature. Dermatology 2012; 225:344-8. [PMID: 23391565 DOI: 10.1159/000346245] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 11/26/2012] [Indexed: 11/19/2022] Open
Affiliation(s)
- L Meziane
- Department of Dermatology, Amiens University Medical Centre, South Hospital, and University Picardie Jules Verne, Amiens, France.
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Perrin BS, Yan AC, Treat JR. Febrile ulceronecrotic Mucha-Habermann disease in a 34-month-old boy: a case report and review of the literature. Pediatr Dermatol 2012; 29:53-8. [PMID: 21906156 DOI: 10.1111/j.1525-1470.2011.01531.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a case of febrile ulceronecrotic Mucha-Habermann disease (FUMHD) in a 34-month-old boy. Our patient had a history of biopsy-proven pityriasis lichenoides et varioliformis acuta (PLEVA) since age 2. At 34 months, his skin lesions rapidly progressed to ulceration and necrosis in the setting of high fever. Skin biopsy revealed an intense lichenoid infiltrate with parakeratosis at the edges of areas of epidermal necrosis consistent with FUMHD, which is the severe variant of PLEVA. Despite initial treatment with prednisolone, his disease progressed to involve more than 50% of his body surface area. In addition to corticosteroids, he was treated with intravenous immunoglobulin, dapsone, and acyclovir, without complete resolution of disease. Methotrexate successfully cleared his skin disease and systemic symptoms. This patient highlights the exceptional response of FUMHD to methotrexate. Based on our review of the literature, this also represents the youngest reported case of FUMHD.
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Affiliation(s)
- Bridget S Perrin
- School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Zhang LX, Liang Y, Liu Y, Ma L. Febrile ulceronecrotic Mucha-Habermann's disease with pulmonary involvement. Pediatr Dermatol 2010; 27:290-3. [PMID: 20609148 DOI: 10.1111/j.1525-1470.2010.01141.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report a case of febrile ulceronecrotic Mucha-Habermann disease (FUMHD) in a 12-year-old boy. After 1 week of typical cutaneous appearance of pityriasis lichenoides et varioliformis acuta (PLEVA), he was given a percutaneous injection of measles virus vaccine, and then extensive polymorphous, papular, and ulcerohemorrhagic skin lesions developed along with intermittent high temperature, hepatic dysfunction, and hypoalbuminemia. Thoracic CT scan showed parenchymal nodular infiltration at the tip of vascular structures. Skin biopsy showed a combination of the classic features of PLEVA and an allergic vasculitis. We treated him with prednisolone and methotrexate (MTX) successfully. The evolution in our patient suggests that FUMHD may have been triggered by virus vaccination. We also emphasize that FUMHD in children may be successfully treated with a combination of systemic MTX and high-dose corticosteroids.
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Affiliation(s)
- Li-xin Zhang
- Department of Dermatology, Beijing Children's Hospital, Capital Medical University, Beijing, China
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Affiliation(s)
- Anubhav Thukral
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Uttar Pradesh, India.
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Di Giunta G, da Silva AMG, Sotto MN. Inducible nitric oxide synthase in pityriasis lichenoides lesions. J Cutan Pathol 2009; 36:325-30. [PMID: 19220629 DOI: 10.1111/j.1600-0560.2008.01028.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pityriasis lichenoides (PL) is an inflammatory skin disease of unknown etiology. Nitric oxide (NO) has emerged as an important mediator of many physiological functions. The importance of NO-mediated signaling in skin diseases has been reported by several studies. METHODS A review of clinical records and histopathological slides of 34 patients diagnosed with PL was performed. Three different groups of skin biopsies including PL chronica (24 patients), PL et varioliformis acuta (10 patients) and 15 normal skin samples were subjected to the immunohistochemistry technique for inducible nitric oxide synthase (iNOS) detection. RESULTS Normal skin group exhibited a few number of iNOS-positive cells in the dermis and rare positive cells in the upper epidermis, unlike abundant epidermal and dermal iNOS expression observed in both PL groups. CONCLUSION According to our results, we hypothesize that NO produced by iNOS could participate in PL pathogenesis. Abnormal and persistent responses to unknown antigens, probably a pathogen, associated with NO immunoregulatory functions could contribute to the relapsing course observed in PL. NO anti-apoptotic effect on T-cell lymphocytes could play a role on maintenance of reactive T cells, leading to a T-cell lymphoid dyscrasia.
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Affiliation(s)
- Gabriella Di Giunta
- Department of Pathology, Santa Catarina Federal University, Florianópolis, Brazil.
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Febrile ulceronecrotic Mucha–Habermann disease associated with herpes simplex virus type 2. J Am Acad Dermatol 2009; 60:149-52. [PMID: 19103367 DOI: 10.1016/j.jaad.2008.07.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 07/13/2008] [Accepted: 07/21/2008] [Indexed: 11/22/2022]
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Aydogan K, Saricaoglu H, Turan H. Narrowband UVB (311 nm, TL01) phototherapy for pityriasis lichenoides. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2008; 24:128-33. [PMID: 18477131 DOI: 10.1111/j.1600-0781.2008.00350.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND/PURPOSE Narrowband (NB) UVB (NB-UVB) phototherapy has recently demonstrated high levels of efficacy and tolerability in a variety of skin diseases. The purpose of the present study was to assess the efficacy of NB-UVB phototherapy in the management of pityriasis lichenoides (PL). METHODS The therapeutic response in 31 PL patients (23 pityriasis lichenoides et varioliformis acuta; PLEVA, eight pityriasis lichenoides chronica; PLC) treated with NB-UVB phototherapy between 2000 and 2007 was assessed. RESULTS NB-UVB treatment led to a complete response (CR) in 15 out of 23 PLEVA patients (65.2%) with a mean cumulative dose of 23 J/cm(2) after a mean number of 43.4 exposures and a partial response (PR) in eight patients (34.8%) with a cumulative dose of 15.6 J/cm(2) after a mean number of 32.3 exposures. NB-UVB treatment led to CR in seven out of eight PLC patients (87.5%) with a mean cumulative dose of 18.4 J/cm(2) after a mean number of 45.8 exposures and PR in one patient (12.5%) with a cumulative dose of 9.1 J/cm(2) after a mean number of 19 exposures. Relapses occurred in four PL patients within a mean time period of 6 months. CONCLUSION NB-UVB therapy is an effective, safe and practical alternative treatment modality for the management of PLEVA and PLC.
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Affiliation(s)
- Kenan Aydogan
- Department of Dermatology, Faculty of Medicine, Uludag University, Bursa, Turkey.
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Abstract
Interface dermatitis can be classified based upon the cell type that dominates the infiltrate (ie, neutrophilic, lymphocytic, or lymphohistiocytic) or by the intensity of the interface inflammation. Regarding lymphocytic interface dermatitis, there are 2 broad categories: cell-poor interface dermatitis, when only a sparse infiltrate of inflammatory cells is present along the dermoepidermal junction, or cell rich, which typically occurs as a heavy bandlike infiltrate that obscures the basal layers of the epidermis. In the case of lymphocytic interface dermatitis, the latter is often termed a lichenoid interface dermatitis. This review focuses upon the mononuclear cell-predominant forms of interface dermatitis.
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Affiliation(s)
- A Neil Crowson
- Department of Dermatology, University of Oklahoma and Regional Medical Laboratories, St John Medical Center, 1923 S Utica Ave, Tulsa, OK 74104, USA.
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Xu CF, Zhu LX, Xu XM, Chen WC, Wu DP. Endoscopic diagnosis of gastrointestinal graft-versus-host disease. World J Gastroenterol 2008; 14:2262-7. [PMID: 18407606 PMCID: PMC2703857 DOI: 10.3748/wjg.14.2262] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the diagnostic value of endoscopy in patients with gastrointestinal graft-versus-host disease (GI GVHD).
METHODS: We identified 8 patients with GI GVHD following allogeneic hematopoietic stem cell trans-plantation (HSCT). GVHD was defined histologically as the presence of gland apoptosis, not explained by other inflammatory or infectious etiologies.
RESULTS: The symptoms of GI GVHD included anorexia, nausea, vomiting, watery diarrhea, abdominal pain, GI bleeding, etc. Upper endoscopic appearance varied from subtle mucosal edema, hyperemia, erythema to obvious erosion. Colonoscopic examination showed diffuse edema, hyperemia, patchy erosion, scattered ulcer, sloughing and active bleeding. Histological changes in GI GVHD included apoptosis of crypt epithelial cells, dropout of crypts, and lymphocytic infiltration in epithelium and lamina propria. The involvement of stomach and rectocolon varied from diffuse to focal.
CONCLUSION: Endoscopy may play a significant role in early diagnosis of GI GVHD patients following allogeneic HSCT, and histologic examination of gastrointestinal biopsies is needed to confirm the final diagnosis.
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Abstract
Parapsoriasis is a peculiar reaction pattern of the skin that appears to have a spectrum with small plaque parapsoriasis at one end and large plaque at the other. The spectrum between is bridged by pityriasis lichenoides, pityriasis lichenoides chronica, pityriasis lichenoides et varioliformis acuta, and lymphomatoid papulosis. The highlights of the clinical pattern of these diseases has been succinctly elucidated here to facilitate their recognition in day-to-day dermatologic practice. Their possible etiopathogenesis has been brought to focus in the light of changing concepts reported in the literature. Further, possible future implications demand a meticulous follow-up because, in a few cases, true neoplasms may ultimately develop. Treatment modalities are briefly discussed.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Centre, Sehgal Nursing Home, Panchwati, Azadpur, New Delhi, India.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to educate the reader about two cutaneous lymphoproliferative diseases in childhood: pityriasis lichenoides and cutaneous T-cell lymphoma. Pityriasis lichenoides has traditionally been divided into acute and chronic subtypes. The two forms of the disease, however, are best thought of as two ends of a benign lymphoproliferative spectrum. Cutaneous T-cell lymphoma is a rare but underrecognized cutaneous malignancy in children. Early stage disease and hypopigmented presentation are characteristic of pediatric cutaneous T-cell lymphoma. The optimal investigation and treatment plans are still controversial. RECENT FINDINGS This article will summarize recent articles on pityriasis lichenoides and pediatric cutaneous T-cell lymphoma, including recent findings from an international registry of pediatric cutaneous T-cell lymphoma. SUMMARY After reading this review, the reader should be able to recognize the clinical presentation of pityriasis lichenoides, to understand the overlap between its acute and chronic forms, and to recognize its relationship with cutaneous T-cell lymphoma. In addition, the reader will appreciate the challenges in diagnosing and treating pediatric cutaneous T-cell lymphoma.
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Affiliation(s)
- Joseph Lam
- Rady Children's Hospital, University of California, San Diego, San Diego, California, USA
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Abstract
Pityriasis lichenoides (PL) is an uncommon, acquired spectrum of skin conditions that poses various challenges to patients as well as clinicians. It is a difficult and debatable disorder to diagnose, categorize, and treat. Besides these inherent obstacles, PL merits awareness because of its potential to progress to cutaneous lymphoma or an ulceronecrotic presentation, both of which carry a significant risk of mortality. The scope of PL presentations is delineated along a continuum of multiple variants including pityriasis lichenoides et varioliformis acuta (PLEVA), pityriasis lichenoides chronica (PLC), and febrile ulceronecrotic Mucha-Habermann disease (FUMHD). Classification of these presentations as separate subsets is debatable in view of their overlapping clinical, histopathologic, and etiologic features. PLEVA generally presents as an acute-to-subacute skin eruption of multiple, small, red papules that develops into polymorphic lesions and vacillates with periods of varying remissions as well as possible sequelae of hyper/hypopigmentation and varicella-like scars. PLC has a more gradual manifestation of very small red-to-brown flat maculopapules with mica-like scale; it also follows a relapsing course but with long periods of remission. FUMHD is an acute and severe generalized eruption of purpuric and ulceronecrotic plaques with associated systemic involvement and a mortality rate of up to 25%; hence, it should be approached as a dermatologic emergency.Histopathological evaluation of PL usually reveals dermal, wedge-shaped, lymphocytic infiltrate, epidermal spongiosis, parakeratosis, and variable necrosis of keratinocytes. PLC demonstrates more subtle histology whereas, at the other end of the spectrum, febrile ulceronecrotic FUMHD exhibits the most exaggerated histological features. The pathogenic mechanism behind PL is unclear although infectious or drug-related hypersensitivity reactions versus premycotic lymphoproliferative disorder are the mainstay theories. The foremost therapies for PLEVA and PLC are phototherapy, systemic antibacterials, and topical corticosteroids. Aggressive treatment with immunosuppressant and/or immunomodulating agents as well as intensive supportive care are recommended for FUMHD. We first describe a representative case of a 14-year-old boy with PLC who was successfully treated with narrow-band UVB. We then review the pathophysiology, classification, and treatment of PL.
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Affiliation(s)
- Amor Khachemoune
- Department of Dermatology, New York University School of Medicine, New York, NY 10016, USA.
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Bowers S, Warshaw EM. Pityriasis lichenoides and its subtypes. J Am Acad Dermatol 2006; 55:557-72; quiz 573-6. [PMID: 17010734 DOI: 10.1016/j.jaad.2005.07.058] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Revised: 07/05/2005] [Accepted: 07/23/2005] [Indexed: 11/18/2022]
Abstract
Pityriasis lichenoides represents a unique group of inflammatory skin disorders that include pityriasis lichenoides et varioliformis acuta (PLEVA), febrile ulceronecrotic Mucha-Habermann disease (a subtype of PLEVA), and pityriasis lichenoides chronica. The history, epidemiology, clinical features, pathophysiology, and treatment of this group of conditions are reviewed in this manuscript.
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Pavlotsky F, Baum S, Barzilai A, Shpiro D, Trau H. UVB therapy of pityriasis lichenoides - our experience with 29 patients. J Eur Acad Dermatol Venereol 2006; 20:542-7. [PMID: 16684281 DOI: 10.1111/j.1468-3083.2006.01531.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pityriasis lichenoides comprises a clinical and pathological spectrum of disorders. So far no highly effective treatment has been reported. Previous small studies have suggested that ultraviolet B (UVB) is a good alternative. METHODS This is a retrospective analysis of 29 pityriasis lichenoides patients treated in our institution with broad- or narrow-band UVB during the period 1996-2002. Twenty-one of these patients had one or more previous unsuccessful treatments. RESULTS Complete response was achieved in 93.1% in both treatment groups, with 73% of them still relapse free after a mean follow-up of 58 and 38 months in broad- and narrow-band UVB treatment groups, respectively. Mild side-effects were observed in about one-third of the patients. CONCLUSION We believe both forms of UVB are a good option for pityriasis lichenoides and should be considered as the first line in generalized cases interested in treatment.
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Affiliation(s)
- F Pavlotsky
- Phototherapy Unit, Department of Dermatology, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel-Aviv University, Israel.
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Malnar T, Milavec-Puretic V, Rados J, Zarkovic K, Dobric I. Febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta with fatal outcome. J Eur Acad Dermatol Venereol 2006; 20:303-7. [PMID: 16503892 DOI: 10.1111/j.1468-3083.2006.01389.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Ulceronecrotic Mucha-Habermann disease is a severe, febrile form of pityriasis lichenoides et varioliformis acuta. The condition may sometimes have a fatal outcome, especially in elderly patients. In this paper, we are reporting on a 60-year-old male patient who suffered from the eruption of erythematous, haemorrhagic, ulceronecrotic papules accompanied by high temperature. Erosions and ulceronecrotic papules covered over 80% of his body. Three weeks after his admittance to our hospital, clinical signs resembling ileus together with the leucocytosis occurred. The patient was transferred to the department of internal medicine and later to the surgery department. The fulminant course of the disease could not be stopped, and the patient died of severe intestinal and colon gangrene caused by the massive thrombosis of superior mesenteric artery. Up to date, only 23 cases of this severe form of the disease have been reported, and even with the early recognition, fulminant course may lead to death.
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Affiliation(s)
- T Malnar
- Dermatovenereology Unit, Cakovec General Hospital, Cakovec, Croatia (Hrvatska).
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Tsianakas A, Hoeger PH. Transition of pityriasis lichenoides et varioliformis acuta to febrile ulceronecrotic Mucha-Habermann disease is associated with elevated serum tumour necrosis factor-alpha. Br J Dermatol 2005; 152:794-9. [PMID: 15840118 DOI: 10.1111/j.1365-2133.2005.06485.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Febrile ulceronecrotic Mucha-Habermann disease (FUMHD) represents a fulminant and potentially lethal variant of pityriasis lichenoides. Only 24 cases have been described so far. We report a 9-year-old boy who initially presented with classical pityriasis lichenoides et varioliformis acuta (PLEVA) following a mild enteritis. Three weeks later, his skin lesions started to ulcerate progressively, involving > 90% of his body surface, accompanied by high fever, normal C-reactive protein, but highly elevated serum levels of tumour necrosis factor (TNF)-alpha. Methotrexate 10 mg m(-2) weekly was required to halt disease progression, while oral steroids (initial dose 2.8 mg kg(-1) daily) alone proved insufficient. Sequential histology revealed progressively dense perivascular and intramural lymphocytic inflammation as well as keratinocyte necrosis. Our case demonstrates the clinical and histological continuum between 'classical' PLEVA and FUMHD and points to the potentially pathogenic significance of TNF-alpha. We hypothesize that in future cases, treatment with TNF-alpha antagonists might represent a reasonable alternative to high-dose immunosuppressive therapy.
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Affiliation(s)
- A Tsianakas
- Division of Paediatric Dermatology, Department of Dermatology, University of Hamburg, Martinistr. 52, D-20246 Hamburg, Germany
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Yeh SP, Chiu CF, Lee CC, Peng CT, Kuan CY, Chow KC. Evidence of parvovirus B19 infection in patients of pre-eclampsia and eclampsia with dyserythropoietic anaemia. Br J Haematol 2004; 126:428-33. [PMID: 15257717 DOI: 10.1111/j.1365-2141.2004.05043.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Parvovirus B19 (PVB19) infection can induce transient anaemia in patients with increased erythropoiesis. However, the dynamic change within the bone marrow after PVB19 infection is not well understood. Increased erythropoiesis is a physiological phenomenon in puerperital women. Nevertheless, anaemia as a result of PVB19 infection in puerperital women has never been reported. We report one patient with eclampsia and two patients with pre-eclampsia who had transient, severe anaemia during the puerperital period because of PVB19 infection. Viral genomes were detected in the peripheral blood during the anaemic period by polymerase chain reaction and became undetectable after the anaemia was resolved. Viral genomes and protein could also be detected in bone marrow by in situ hybridization and immunohistochemical staining, respectively. Serial aspiration cytology of bone marrow showed severe dysplastic change involving erythroid precursors with a few apoptotic cells at the initial onset of anaemia, markedly increased apoptotic cells that was confirmed by the increased expression of activated caspase 3, around the nadir of anaemia, and a normal marrow picture without features of apoptosis after recovery from anaemia. Our data indicates that PVB19 infection can induce transient, severe dyserythropoietic anaemia in puerperital women with pre-eclampsia/eclampsia and the pathogenetic mechanism may probably involve the induction of apoptosis following PVB19 infection.
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Affiliation(s)
- Su-Peng Yeh
- Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
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