Discoid lupus erythematosus and lupus profundus in childhood: a report of two cases

Panniculitis in Children

Panniculitides form a heterogenous group of inflammatory diseases that involve the subcutaneous adipose tissue. These disorders are rare in children and have many aetiologies. As in adults, the panniculitis can be the primary process in a systemic disorder or a secondary process that results from infection, trauma or exposure to medication. Some types of panniculitis are seen more commonly or exclusively in children, and several new entities have been described in recent years. Most types of panniculitis have the same clinical presentation (regardless of the aetiology), with tender, erythematous subcutaneous nodules. Although the patient's age and the lesion site provide information, a histopathological assessment is sometimes required for a definitive diagnosis and classification of the disorder. In children, most panniculitides are lobular. At present, autoimmune inflammatory diseases and primary immunodeficiencies have been better characterised; panniculitis can be the presenting symptom in some of these settings. Unexplained panniculitis in a young child should prompt a detailed screen for monogenic immune disorders because the latter usually manifest themselves early in life. Here, we review forms of panniculitis that occur primarily in children, with a focus on newly described entities.

Panniculitis in childhood-onset systemic lupus erythematosus: a multicentric cohort study

OBJECTIVE

To evaluate prevalence, clinical manifestations, laboratory abnormalities, treatment and outcome in a multicenter cohort of childhood-onset systemic lupus erythematosus (cSLE) patients with and without panniculitis.

METHODS

Panniculitis was diagnosed due to painful subcutaneous nodules and/or plaques in deep dermis/subcutaneous tissues and lobular/mixed panniculitis with lymphocytic lobular inflammatory infiltrate in skin biopsy. Statistical analysis was performed using Bonferroni correction(p < 0.004).

RESULTS

Panniculitis was observed in 6/847(0.7%) cSLE. Painful subcutaneous erythematosus and indurated nodules were observed in 6/6 panniculitis patients and painful subcutaneous plaques in 4/6. Generalized distribution was evidenced in 3/6 and localized in upper limbs in 2/6 and face in 1/6. Cutaneous hyperpigmentation and/or cutaneous atrophy occurred in 5/6. Histopathology features showed lobular panniculitis without vasculitis in 5/6(one of them had concomitant obliterative vasculopathy due to antiphospholipid syndrome) and panniculitis with vasculitis in 1/6. Comparison between cSLE with panniculitis and 60 cSLE without panniculitis with same disease duration [2.75(0-11.4) vs. 2.83(0-11.8) years,p = 0.297], showed higher frequencies of constitutional involvement (67% vs. 10%,p = 0.003) and leukopenia (67% vs. 7%,p = 0.002). Cutaneous atrophy and hyperpigmentation occurred in 83% of patients.

CONCLUSIONS

Panniculitis is a rare skin manifestation of cSLE occurring in the first three years of disease with considerable sequelae. The majority of patients have concomitant mild lupus manifestations.

Lupus profundus limited to a site of trauma: Case report and review of the literature

Lupus erythematosus profundus (LEP) is a rare form of chronic cutaneous lupus erythematosus. We report on a case of a 56-year-old Caucasian woman who presented with a single, persistent, painful rash on the left hip and lateral aspect of the left upper thigh, which had been present for 2.5 years. The patient had a history of previous injury to this area before the rash started. Clinical findings showed an inflamed, hyperpigmented, and indurated plaque with a linear skin invagination and no associated systemic symptoms. A skin biopsy test result confirmed the diagnosis of LEP and the clinical and laboratory examinations ruled out systemic lupus erythematosus. After 2 months of treatment with methotrexate 20 mg weekly and 1 month of prednisolone 7.5 mg daily, the skin rash improved considerably. We also present a brief review of the epidemiology, etiology, clinical features, histopathology, laboratory findings, differential diagnosis, and treatment of LEP.

Lupus erythematosus panniculitis in children: report of three cases and review of previously reported cases

Lupus erythematosus panniculitis (LEP) is a rare finding in children, with only 12 fully reported prior cases in the English literature. We describe three cases of LEP in children younger than 18 and compare them to previous cases reported in the literature. We examine laboratory tests performed, biopsy results, age at onset and diagnosis, presence or absence of systemic symptoms, and outcomes after treatment. It is unknown what the risk is of these patients developing future systemic lupus erythematosus. We also discuss the relevance of subcutaneous panniculitis-like T-cell lymphoma, because the clinical and pathologic pictures are similar in presentation.

Intravenous immunoglobulin in lupus panniculitis

Systemic lupus erythematosus (SLE) is a disease of unknown cause that may involve one or many organ or systems. Skin involvement is a major feature in this disease, and a wide variety of skin conditions may be present. Lupus erythematosus panniculitis (LEP) constitutes a rare form of cutaneous lupus characterized by recurrent nodular or plaque lesions that can vary from a benign and mild course to a more disfiguring disease. Initial therapy includes corticosteroids, antimalarials, and azathioprine and, in refractory cases, two antimalarials in association, mycophenolate mofetil, or other immunomodulators. Intravenous immuglobulin (IVIG) is used in many autoimmune disorders, like in SLE, although clinical trials have not yet taken place. In this report, we review skin manifestations of SLE and their treatment, IVIG, and finally a case of LEP successfully treated with IVIG when other therapy modalities failed.

Lupus eritematoso discóide na infância

OBJETIVO: Realizar revisão da literatura sobre o lupus eritematoso discóide (LED) na infância. FONTES DE DADOS: Livros-texto e artigos de revistas indexadas pelo Medline e SciELO nos últimos dez anos, usando as seguintes palavras-chave: "discoid lupus erythematosus", "chronic cutaneous lupus erythematosus", "lupus erythematosus in childhood", "lupus erythematosus in children", "discoid lupus erythematosus in childhood", "discoid lupus erythematosus in children". SÍNTESEDOS DADOS: A idade de início da doença ocorre predominantemente entre cinco e dez anos e a história familiar de lupus eritematoso está presente em 11 a 35% dos casos. A relação gênero feminino/masculino varia de 1/1 a 2,4/1. Por sua vez, 24 a 27% dos pacientes com LED desenvolvem lupus eritematoso sistêmico (LES). Lesões discóides localizadas (que acometem cabeça e pescoço) são observadas em 56 a 75% dos pacientes. A face é o local mais acometido. O LED localizado e o generalizado apresentam evolução semelhante. Os achados histológicos são típicos, mostrando dermatite de interface. IgM e IgG são os depósitos mais freqüentes na zona da membrana basal da epiderme. Os tratamentos geralmente utilizados são: fotoproteção, corticosteróides tópicos e antimaláricos. Imunossupressores, talidomida, dapsona e retinóides podem ser usados nos casos refratários. CONCLUSÕES: O LED da infância parece ter pequeno predomínio no gênero feminino, alta prevalência de história familiar de lupus eritematoso e elevada proporção que evolui para a forma sistêmica da doença, comparada ao LED do adulto. O LED localizado e o generalizado apresentam prognósticos semelhante. Os achados histológicos não foram diferentes daqueles descritos no LED do adulto.

The dynamism of cutaneous lupus erythematosus: mild discoid lupus erythematosus evolving into SLE with SCLE and treatment-resistant lupus panniculitis

We present a 47-year-old Caucasian female who initially presented with mild discoid lupus erythematosus that evolved into systemic lupus erythematosus with subacute cutaneous LE and treatment-recalcitrant lupus panniculitis. Conventional therapy with antimalarials, systemic steroids, azathioprine, cyclophosphamide, methotrexate, and pulse doses of methylprednisolone did not control the course of the disease. Cyclosporin-A treatment led to clinical improvement and maintained remission.

Kollagenosen im Kindesalter

Connective tissue diseases are a heterogeneous group of chronic multisystem inflammatory disorders including systemic lupus erythematosus (SLE), progressive systemic sclerosis (PSS), dermato- (DM) and polymyositis (PM), mixed connective tissue disease (MCTD), and Sjögren's syndrome (SS). Patients can present with similar clinical features, particularly during the first onset of symptoms, which frequently makes the diagnosis of a specific disease difficult. The incidence of connective tissue diseases is much lower in children than adults; however, the clinical picture is more variable. Clinical signs, such as fatigue, fever, or weight loss, may precede any systemic organ involvement and in children, mucocutaneous manifestations develop most frequently during the varying disease course. This review summarizes recent information on epidemiology, clinical manifestations, diagnostic procedures, and treatment strategies of the different connective tissue diseases, concentrating on specific problems in childhood.

A case of lupus erythematosus profundus with unusual manifestations

We describe a 16-year old female with lupus erythematosus panniculitis with unusual manifestations. She had noted to have developed erythematous nodules and plaques in the right axilla and inguinal region at the age of one year. These lesions resolved gradually with scar formation. However, new lesions were noted at the same locations in the following years. Some of her lesions at the scalp and the left axillary regions developing within the last two years slowly enlarged showing an annular configuration and subsequently resulted in hair loss. The erythematous border of her lesion in the left axilla consisted of two parallel red lines. Histopathological and direct immunofluorescent findings were consistent with lupus erythematosus panniculitis. Similar clinical findings in the same locations were also observed in the mother.

Lupus erythematosus: uncommon presentations

Lupus erythematosus is the great imitator of other diseases. There is a broad range of cutaneous symptoms induced by lupus or by its various treatments. This article provides a short overview of uncommon presentations of cutaneous symptoms in the lupus spectrum.

Panniculite lupique

Lupus panniculitis is characterized by a T-cell lymphocyte infiltration of the fat, with fibrosing and cicatricial progression. The lesions are predominantly found on the head and the upper part of the body; they are more frequent in young women. Diagnosis is based on the integration of the clinical and histological data, which renders a deep cutaneous biopsy indispensable. Histopathology is the key to the differential diagnosis, which essentially includes subcutaneous T-cell lymphoma. The lupus panniculitis lesions can be isolated or, more often, integrated within a known lupus disease, usually of good prognosis. Treatment relies above all on synthetic anti-malarials, occasionally associated with local or general corticosteroids.