Histopathology of cutaneous changes in non-drug-induced coma

Cutaneous eccrine inflammation and necrosis: review of inflammatory disorders affecting the eccrine apparatus including new associations

Despite being frequently overlooked during the examination of histopathological sections, eccrine sweat glands can offer clues for diagnosing various skin conditions. They provide important functions and can lead to several diseases when inflamed or injured. This review article provides information regarding eccrine physiology as well as well-established and novel entities that occur in association with eccrine gland pathology.

Coma blisters in children: case report and review of the literature

Coma-induced blisters is a rare condition associated with prolonged impairment of conscious level, which is relatively well-known in adults following overdose with barbiturates. However, it has been very rarely described in children. A case of coma-bullae occurring in an 11-year-old child with meningoencephalitis is herein reported. The bullous lesions occurred on the limbs and trunks, and evolved into necrotic ulcers in a few days. No correlation with any drug overdosage was found. A skin biopsy revealed epidermal and eccrine sweat gland necrosis with abundant neutrophils, and thrombosis of the vessels in the lower dermis. A comprehensive review of the literature showed that only 5 cases of coma-bullae in children have been published so far. Coma blistering resolves spontaneously within days or weeks. Diagnosis of coma-bullae may require careful clinical-pathologic correlation to exclude other blistering diseases in children.

Immunohistochemical investigation of the coma blister and its pathogenesis

The erythematous patches and vesicles that are observed in coma patients, usually from an overdose of medication, are known as coma blisters. However, it is unknown whether the degenerated sweat gland is a necrosis or apoptosis. We immunohistochemically examined such skin lesions to investigate the characteristics and pathogenesis of the coma blister. Skin lesions were obtained from a forensic autopsy case, a woman in her thirties, of caffeine intoxication. Those lesions were observed in the left femoral, the lower left thigh, and the right knee. Histologically, the skin lesions showed that the keratinocytes had necrosed and the epidermis was thin in some areas. Eccrine sweat gland degeneration was observed. Obvious inflammatory cell infiltrations were not detected. Immunohistochemically, we stained each skin lesion against CD3, CD8, CD45RO, cytokeratin, 70 kD heat shock protein, ubiquitin, 150 kD oxygen regulated protein, and caspase-cleaved keratin 18 neo-epitope M30. They were also stained with an in situ apoptosis detection kit. Degenerated sweat glands featured CD45RO and M30 immunoreactivity. Immunohistochemical staining for CD45RO, CK-L, and M30 might be useful to observe sweat gland degeneration in the coma blister. Therefore, the apoptosis might be related to coma blisters and sweat gland degenerations.

Coma Blisters

Coma blisters are lesions that occur in the setting of a variety of neurological diseases. Although most commonly associated with barbiturate overdose, they can be seen in the setting of coma due to other etiologies. Blisters develop 48–72 h after the onset of unconsciousness. We report the case of a 29-year-old man who presented to the emergency department with confusion and progressive loss of consciousness. He had high serum glucose, abnormal hepatic and kidney function tests and a normal toxicological screening. 24 h after admission he was comatose and was started on antibiotics for presumed bacterial meningoencephalitis. Two days after the onset of coma, multiple tense hemorrhagic blisters appeared on the patient's extremities. Skin biopsy revealed an intraepidermal blister with variable degrees of epidermal necrosis. Five days later the patient was fully recovered with no neurological sequelae. No topical treatment was necessary, with complete resolution of the skin lesions two weeks later.

Coma blisters in 2 children on anticonvulsant medication

Blister formation and eccrine sweat gland necrosis have been recognized to occur in states of impaired consciousness and were first reported following barbiturate intoxication. Their etiology is complex and cannot simply be explained by pressure effects. Now that barbiturates are less frequently used, clinicians are likely to be less aware of the phenomenon of coma blister formation; however, newer drugs have also been associated with the occurrence of coma blisters. We describe 2 new associations of coma blisters and anticonvulsants in children. In the first child, blisters recurred on multiple occasions along with obtundation and edema. Our aims are to alert clinicians to the occurrence of coma blisters in children sedated on anticonvulsant medications and to report the new finding of recurrent coma blisters.

Drug-induced sweat gland necrosis in a non-comatose patient: a case presentation

BACKGROUND

Coma-induced bullae and sweat gland necrosis is a rare clinicopathological entity often associated with drug-induced coma.

SUBJECT

We report a case with clinical and histopathologic findings characteristic of blisters and sweat gland necrosis occurring in a non-comatose patient.

CONCLUSIONS

Skin blisters with underlying sweat gland necrosis is an entity previously reported to occur in comatose patients, our findings open new questions about the role of the drugs in the pathogenesis of those conditions.

Cutaneous eruptions in coma patients with nontraumatic rhabdomyolysis

BACKGROUND

Rhabdomyolysis has been described most commonly after muscle injury but may also result from coma due to alcohol intake or drug abuse. Its clinical findings usually occur as muscular pain and swelling, but these symptoms are also seen in as many as 60% of patients with nontraumatic rhabdomyolysis. The diagnosis of slight nontraumatic rhabdomyolysis is often difficult to establish clinically. Few previous studies have reported cutaneous symptoms in nontraumatic rhabdomyolysis.

OBJECTIVE

We attempted to elucidate a relationship between nontraumatic rhabdomyolysis and cutaneous eruption.

METHODS

We studied 7 patients who were diagnosed as having massive to slight nontraumatic rhabdomyolysis with a cutaneous eruption in pressure areas at the first visit to our hospital between March 28, 1988, and June 27, 1998.

RESULTS

They revealed wine-red-colored urine and elevated serum myogenic enzyme. Two patients complained of muscle pain. In all patients, cutaneous eruptions including well-demarcated erythema, bullae and deep ulcers were observed in areas of pressure. The pathological findings of 5 cutaneous eruptions revealed necrosis of sweat ducts and glands in the dermis.

CONCLUSIONS

The pathogenesis of nontraumatic rhabdomyolysis and the cutaneous eruptions in coma patients has not been elucidated, but these conditions are due to similar factors; pressure and hypoxia are considered to be important causative factors for both. Cutaneous eruptions in the coma patient may be an important clinical symptom of nontraumatic rhabdomyolysis.

Early immunological defects in comatose patients after acute brain injury

Object. The aim of this prospective study was to evaluate the phagocytic, humoral, and cellular arms of the immune system in comatose patients shortly after severe brain injury and to compare the findings with those reported earlier in patients in a persistent vegetative state. The study was conducted in intensive care units and immunology laboratories of university-affiliated hospitals in central Israel.

Methods. The study group consisted of 14 men aged 16 to 65 years who were comatose as a result of acute brain injury due to mechanical trauma. All were studied within 72 hours of injury. Brain damage was severe in all cases (Glasgow Coma Scale score < 8). Healthy age- and sex-matched volunteers served as simultaneous controls.

Infections arose in nine (75%) of the 12 patients in whom data were available; the cumulative mortality rate was 38% (five of 13 patients in whom outcome data were available). Every patient exhibited one or more defects in at least one arm of the immune system. Significant deficiencies were noted in neutrophil superoxide release, immunoglobulin (Ig)G, IgG1, IgM, C1q, C2, properdin, alternate C pathway, T cells, T helper cells, T suppressor cells, and natural killer cells. In an earlier series of patients examined by the authors months after the primary insult, these impairments were absent in most of the patients in the vegetative state.

Conclusions. Significant deficiencies of the immune system, particularly the cellular arm, are precipitated by severe brain injury within 72 hours of the event. These impairments probably play a role in the high rate of complicating infections and multiple organ failure. Together with earlier findings, the results of this study indicate that if brain-injured patients survive these hazards, their immune system will eventually recover.

Coma-induced bullae and sweat gland necrosis following clobazam

Coma-induced bullae and sweat gland necrosis is a rare clinicopathological entity described in association with a variety of aetiopathological conditions all of which have resulted in an impairment of conscious level. We report the first case observed in association with clobazam, used as adjunctive therapy for resistant epilepsy in a 4-year old. The potential underlying mechanisms and previously reported associations are discussed.