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Feng H, Li S, Jie Y. Leucocytoclastic Vasculitis Presenting as Bilateral Ulcerative Keratitis: A Case Report. Clin Med Insights Case Rep 2023; 16:11795476231204358. [PMID: 37808226 PMCID: PMC10559690 DOI: 10.1177/11795476231204358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/08/2023] [Indexed: 10/10/2023]
Abstract
Introduction Small artery disease caused by neutrophils and immune-mediated is known as leucocytoclastic vasculitis (LCV). Clinically, it manifests as palpable, asymptomatic purpuric papules on the limbs. Ocular manifestation is rare. Here, we describe a case of peripheral ulcerative keratitis (PUK) associated with LCV. Case presentation A 59-year-old man was referred to the hospital with blurred vision due to corneal perforation in his left eye. He complained of itchy nodules on his hands and lower legs for 15 years and the skin biopsy of the back of his hand revealed LCV 6 years ago, which suggested erythema elevatum diutinum. The patient was under treatment with anti-inflammatory and immunosuppressive drugs and physical features of LCV seen in him included erythema on his hands and legs. After receiving conjunctival flap covering surgery, the corneal perforation was resolved. Conjunctival flaps covered cornea that limited his vision to hand motion. Six months later, he was referred to our clinic again because of pain, redness, photophobia, and tearing in the right eye, presenting with PUK. Necrotic tissue was removed during surgery, which also included a conjunctival flap covering procedure. Following surgery, the symptoms were reduced, and the postoperative eye condition remained stable. Conclusion To our knowledge, it is the first case of PUK secondary to LCV which was diagnosed 6 years ago. This case demonstrates that PUK associated with LCV can be successfully treated by surgical interventions.
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Affiliation(s)
| | | | - Ying Jie
- Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing Tongren Eye Center, Beijing Institute of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Akhavanrezayat A, Hien DL, Pham BH, Nguyen HV, Tuong Ngoc TT, Al-Moujahed A, Uludag G, Karkhur S, Doan HL, Nguyen QD. Impending central retinal vein occlusion in patient with idiopathic cutaneous leukocytoclastic vasculitis. Am J Ophthalmol Case Rep 2020; 20:100934. [PMID: 33015410 PMCID: PMC7522751 DOI: 10.1016/j.ajoc.2020.100934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/16/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022] Open
Abstract
Purpose To report a case of impending central retinal vein occlusion (CRVO) associated with idiopathic cutaneous leukocytoclastic vasculitis (LCV) that demonstrated significant resolution following treatment with intravenous (IV) methylprednisolone. Observations A 27-year-old man presented to a tertiary Uveitis Clinic with a five-day history of blurry vision in the right eye (OD). He had a history of a purpuric rash and arthralgias five years ago and a biopsy-confirmed diagnosis of LCV controlled with colchicine two years ago in India. Recently, he presented with a recurrent rash and severe abdominal pain. After being evaluated by rheumatology and gastroenterology, he was placed on Helicobacter pylori treatment and high dose oral prednisone, which improved his skin and gastrointestinal symptoms. At the first ophthalmic exam, his systemic findings included lower extremity purpura. His best-corrected visual acuity (BCVA) was 20/20 in both eyes (OU). Slit-lamp examination revealed no cells or flare in OU. Dilated fundus exam showed mild enlarged, tortuous veins, optic nerve hemorrhage, and intraretinal hemorrhages temporal to the macula in OD. Spectral-domain optical coherence tomography (SD-OCT) demonstrated multiple hyper-reflective, plaque-like lesions involving the inner nuclear layer, consistent with paracentral acute middle maculopathy (PAMM). The patient was diagnosed with impending central retinal vein occlusion (CRVO) in OD. Laboratory evaluations were unremarkable. Aspirin was initially started for the patient but was later held due to the worsening of retinal hemorrhage and retinal vein tortuosity at the one-week follow-up. The patient then received three doses of intravenous methylprednisolone, followed by systemic oral prednisone and mycophenolate mofetil. One month later, retinal hemorrhages, venous stasis, and skin manifestations resolved. Conclusion and importance Ocular involvement in LCV is rare and may present with different manifestations. The index case is the first report of impending CRVO in a patient with idiopathic LCV and without any other known risk factors for CRVO. Our report not only describes the unique course of LCV-related ocular involvement, but also introduces and underscores a potentially effective therapeutic plan.
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Affiliation(s)
| | - Doan Luong Hien
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA.,Pham Ngoc Thach University of Medicine, Saigon, Viet Nam
| | - Brandon H Pham
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Huy Vu Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Than Trong Tuong Ngoc
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA.,Pham Ngoc Thach University of Medicine, Saigon, Viet Nam
| | | | - Gunay Uludag
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Samendra Karkhur
- Department of Ophthalmology, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Huy Luong Doan
- Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
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Doktor V, Hadi A, Hadi A, Phelps R, Goodheart H. Erythema elevatum diutinum: a case report and review of literature. Int J Dermatol 2018; 58:408-415. [PMID: 30074624 DOI: 10.1111/ijd.14169] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/04/2018] [Accepted: 07/07/2018] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Vladyslava Doktor
- Dermatology Department, St. John's Episcopal Hospital, Far Rockaway, NY, USA
| | - Ahmed Hadi
- The Kimberly and Eric J. Waldman Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ali Hadi
- The Kimberly and Eric J. Waldman Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert Phelps
- The Kimberly and Eric J. Waldman Department of Dermatology and Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Herbert Goodheart
- The Kimberly and Eric J. Waldman Department of Dermatology and Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Momen S, Jorizzo J, Al-Niaimi F. Erythema elevatum diutinum: a review of presentation and treatment. J Eur Acad Dermatol Venereol 2014; 28:1594-602. [DOI: 10.1111/jdv.12566] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 04/29/2014] [Indexed: 01/19/2023]
Affiliation(s)
- S.E. Momen
- St John's Institute of Dermatology; London UK
| | - J. Jorizzo
- Wake Forest Baptist Health; Winstom Salem North Carolina USA
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Rocha G, Mednick ZD. Progressive Cicatrizing Endotheliitis Associated with Leucocytoclastic Vasculitis and Crohn Disease. Ocul Immunol Inflamm 2013; 21:241-3. [DOI: 10.3109/09273948.2012.761241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Lekhanont K, Patarakittam T, Mantachote K, Waiyawatjamai P, Vongthongsri A. Progressive Keratolysis with Pseudopterygium Associated with Erythema Elevatum Diutinum. Ophthalmology 2011; 118:927-33. [DOI: 10.1016/j.ophtha.2010.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 08/11/2010] [Accepted: 09/14/2010] [Indexed: 11/30/2022] Open
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Abstract
Leucocytoclastic vasculitis is an immune-mediated, neutrophil-induced small vessel disease. Clinically, it presents with cutaneous palpable painless purpuric papules on the extremities. Ocular manifestation reported in the literature is rare and includes peripheral ulcerative keratitis, panuveitis and multifocal retinitis all preceded by cutaneous lesions. Herein a fatal case of leucocytoclastic vasculitis initially presenting with bilateral marginal keratitis without any cutaneous lesions is reported.
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Abstract
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.
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Affiliation(s)
- Carol M Woody
- Section of Dermatology, Department of Internal Medicine, The Medical College of Georgia, 1004 Chafee Avenue, Augusta, GA 30912, USA
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Mitamura Y, Fujiwara O, Miyanishi K, Sato H, Saga K, Ohtsuka K. Nodular scleritis and panuveitis with erythema elevatum diutinum. Am J Ophthalmol 2004; 137:368-70. [PMID: 14962440 DOI: 10.1016/s0002-9394(03)00907-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2003] [Indexed: 11/30/2022]
Abstract
PURPOSE To report a case of nodular scleritis and panuveitis associated with erythema elevatum diutinum, a rare immunocomplex-mediated skin disease. DESIGN Observational case report. METHODS A 22-year-old woman who was diagnosed with erythema elevatum diutinum developed nodular scleritis and panuveitis of the right eye. She had experienced peripheral ulcerative keratitis with corneal perforation. RESULTS All other known causes of nodular scleritis and panuveitis were investigated and ruled out. CONCLUSIONS Erythema elevatum diutinum should be considered as an underlying systemic disease associated with nodular scleritis and panuveitis as well as peripheral keratitis.
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Affiliation(s)
- Yoshinori Mitamura
- Department of Ophthalmology, School of Medicine, Sapporo Medical University, Sapporo, Japan.
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Kaufmann J, Schulze E, Voigt U, Strobel J, Hein G, Stein G. Orbital inflammatory pseudotumor due to hypersensitivity vasculitis and mononeuritis multiplex in a patient with atypical, cANCA-positive Wegener's granulomatosis. Rheumatol Int 2003; 23:138-42. [PMID: 12700924 DOI: 10.1007/s00296-002-0236-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2002] [Accepted: 07/25/2002] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We report on a 60-year-old woman with a retro-orbital pseudotumor and polyneuropathy. The retro-orbital inflammation was histologically diagnosed as hypersensitivity vasculitis (HV). As cytoplasmatic antineutrophilic cytoplasmatic antibody (cANCA) and anti-proteinase-3 antibody were detected, the differential diagnosis also included atypical Wegener's granulomatosis. Hypersensitivity vasculitis is defined as small-vessel vasculitis mediated by the deposition of immune complexes (Arthus reaction) after exposure to various agents such as drugs, toxins, and infections. Since an inflammatory retro-orbital pseudotumor due to HV has not previously been reported, the following case is presented. METHODS AND MAIN OUTCOME MEASURES Magnetic resonance imaging (MRI) revealed retro-orbital infiltrate without granuloma. Histology from an orbital biopsy confirmed HV. Electromyography was used for the diagnosis of polyneuropathy. Serum investigation indicated erythrocyte sedimentation rate (ESR) >100 mm/h, C-reactive protein (CRP) 223 mg/l, antinuclear antibodies 1:80, and cANCA 100 U/ml. RESULTS The bilateral orbital pseudotumor, polyneuropathy, and serum levels of inflammation reactants (ESR and CRP) improved from therapy with corticosteroids (1 g of methylprednisolone initially) and azathioprine (150 mg/day). CONCLUSIONS Because of cANCA and anti-proteinase-3 antibody positivity, this case can be viewed more as an atypical Wegener's granulomatosis than a systemic HV. The causal variety of inflammatory orbital pseudotumor, including HV and different therapeutic consequences, requires histological differentiation from usual orbital pseudotumors.
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Affiliation(s)
- Jörg Kaufmann
- Division of Rheumatology and Osteology, Department of Internal Medicine IV, Friedrich Schiller University, Erlanger Allee 101, 07740, Jena, Germany.
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Abstract
PURPOSE To describe a case of peripheral keratitis associated with erythema elevatum diutinum (EED), an unusual immune-complex-mediated cutaneous vasculitis. DESIGN Observational case report. METHODS A 25-year-old man who was diagnosed 15 months previously with erythema elevatum diutinum presented with an inflammatory peripheral keratitis of the left eye. RESULTS Serologic investigations for systemic disorders associated with vasculitic peripheral ulcerative keratitis were unremarkable. As the sclerokeratitis was thought to represent an ocular extension of the patient's cutaneous vasculitis, dapsone therapy was initiated and resulted in a rapid response of both the cutaneous and the ocular inflammation. CONCLUSIONS Erythema elevatum diutinum should be included in the differential diagnosis of vasculitic peripheral keratitis.
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Affiliation(s)
- Anthony J Aldave
- Department of Ophthalmology, University of California, San Francisco/Francis I Proctor Foundation, San Francisco, California, USA.
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