1
|
Ashrafzadeh S, Fedeles F. What the rheumatologist needs to know about skin biopsy. Best Pract Res Clin Rheumatol 2023; 37:101838. [PMID: 37268560 DOI: 10.1016/j.berh.2023.101838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 06/04/2023]
Abstract
The skin biopsy plays an important and powerful role in helping diagnose rheumatic diseases that present with cutaneous findings. As the skin is a very accessible organ, and the skin biopsy can be performed quickly as an in-office procedure, the skin biopsy is utilized frequently in patients with rheumatic diseases. However, the more challenging aspects of performing the biopsy, such as identifying the type of biopsy to perform, the site (s) to biopsy, the type of media to use, and the interpretation of histopathologic data are nuanced and require considerable thought. In this review, we discuss the common skin findings in rheumatic diseases and the general indications for skin biopsies in these diseases. We then summarize how to perform various skin biopsy techniques and how to select the biopsy technique. Finally, we discuss important rheumatic disease-specific considerations for skin biopsy, including where to biopsy and how to interpret the pathologic reports.
Collapse
Affiliation(s)
- Sepideh Ashrafzadeh
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Flavia Fedeles
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
2
|
Logothetis CN, Konstantinov NK, Reyes MD, Emil NS, Tzamaloukas AH. Development of Lupus Erythematosus Tumidus During the Course of Systemic Sclerosis. Cureus 2021; 13:e18064. [PMID: 34671535 PMCID: PMC8520756 DOI: 10.7759/cureus.18064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 11/24/2022] Open
Abstract
A man with systemic sclerosis (SS), manifested by characteristic skin lesions, gastro-esophageal reflux disease, and pulmonary fibrosis producing progressive respiratory failure, and a positive antinuclear antibody consistent with reactivity to fibrillarin, developed skin lesions with the clinical and histological characteristics of lupus erythematosus tumidus (LET) 10 years after the diagnosis of SS. His respiratory failure progressed and he expired from sepsis after tracheal intubation and mechanical ventilation two years after developing LET. The association of SS and LET, not described until now, raises questions about its pathogenesis and its prognostic significance.
Collapse
Affiliation(s)
| | | | - Michael D Reyes
- Pathology, Raymond G. Murphy Veterans Affairs (VA) Hospital, Albuquerque, USA
| | - N Suzanne Emil
- Internal Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | | |
Collapse
|
3
|
Park JK. Detrimental Effects of Endovascular Intervention in Active Rheumatoid Vasculitis. Vasc Specialist Int 2018; 34:39-43. [PMID: 29984217 PMCID: PMC6027803 DOI: 10.5758/vsi.2018.34.2.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/05/2018] [Accepted: 04/19/2018] [Indexed: 12/02/2022] Open
Abstract
Balloon angioplasty can cause shear stress and tear of the vascular endothelium during mechanical dilatation, leading to increased inflammation and coagulation reactions of the vascular endothelium. Herein, a worst case of active rheumatoid vasculitis is described, where due to progressing ischemic necrosis of the leg, endovascular intervention was unavoidably performed in the presence of active rheumatoid vasculitis. After percutaneous balloon angioplasty, the patient developed recurrent thrombotic occlusion of the leg arteries, and finally, limb amputation resulted in despite vigorous treatment including medication, immunosuppression, catheter-directed thrombolysis, and post-thrombolysis anticoagulation. This case report indicates that endovascular intervention may be detrimental to the active rheumatoid vasculitis. Until the development of treatment guideline to prevent or control inflammatory reaction, endovascular intervention for the active rheumatoid vasculitis may not be appropriate as a first line therapy even though there is progressing ischemic necrosis.
Collapse
Affiliation(s)
- Jong Kwon Park
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| |
Collapse
|
4
|
Caimi G, Carlisi M, Urso C, Lo Presti R, Hopps E. Clinical disorders responsible for plasma hyperviscosity and skin complications. Eur J Intern Med 2017; 42:24-28. [PMID: 28390781 DOI: 10.1016/j.ejim.2017.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 03/30/2017] [Accepted: 04/03/2017] [Indexed: 12/17/2022]
Abstract
In this brief review, we have examined some clinical disorders which are associated to an altered hemorheological profile and at times accompanied by skin ulcers. This skin condition may be, in fact, observed in patients with primary plasma hyperviscosity such as multiple myeloma, Waldenstrom macroglobulinemia, cryoglobulinemia, cryofibrinogenemia, dysfibrinogenemia and connective tissue diseases. It must be underlined that the altered hemorheological pattern is not the only responsible for this skin complication but, as it worsens the microcirculatory flow, it contributes to determine the occurrence of the skin ulcers.
Collapse
Affiliation(s)
- Gregorio Caimi
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy.
| | - Melania Carlisi
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| | - Caterina Urso
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| | - Rosalia Lo Presti
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| | - Eugenia Hopps
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| |
Collapse
|
5
|
Abstract
Almost all granulomatous skin disorders can cause red lesions on the face. Such disorders may include many bacterial, fungal, or parasitic infections, noninfectious inflammatory disorders, foreign body reactions, and even neoplasms. Clinically, they usually present with papules, plaques, nodules, and/or abscesses, which may ulcerate. It may be helpful in their differential diagnosis to define certain clinical patterns, such as multiple and discrete papules, necrotic or umbilicated papules or nodules, annular plaques, vegetative plaques or tumors, verrucous plaques or tumors, abscesses and/or sinuses, and lymphocutaneous pattern. Some disorders, such as sarcoidosis, can cause a wide variety of lesions. We accept that cutaneous leishmaniasis is also among such great imitators.
Collapse
|
6
|
Cuesta-Mateos C, Colom-Fernández B, Portero-Sainz I, Tejedor R, García-García C, Concha-Garzón MJ, De las Heras-Alonso ME, Martínez MA, Juarez C, Muñoz-Calleja C. Autoantibodies against TIF-1-γ and CADM-140 in Spanish patients with clinically amyopathic dermatomyositis (CADM): clinical significance and diagnostic utility. J Eur Acad Dermatol Venereol 2014; 29:482-9. [PMID: 25065441 DOI: 10.1111/jdv.12591] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 05/13/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Patients with clinically amyopathic dermatomyositis (CADM) appear to be at risk for developing cancer and interstitial lung diseases, but population data to confirm this hypothesis are limited. Moreover, CADM presents cutaneous and histological findings that may overlap with subacute cutaneous lupus erythematosus (SCLE). OBJECTIVES To determine the association between myositis-specific autoantibodies, myositis-associated autoantibodies and CADM in Spanish patients. In addition, to study the usefulness of these autoantibodies in the differential diagnosis between CADM and SCLE. METHODS Serum samples were tested for myositis-specific autoantibodies and myositis-associated autoantibodies through immunoprecipitation and other standardized methods. RESULTS Anti-CADM-p140 and anti-p155 antibodies were the only myositis-specific autoantibodies found and were associated with interstitial lung diseases and cancer respectively. No myositis-associated autoantibodies were found in CADM. Moreover, clinical subsets and proportions seemed to differ from Asian cohorts, where anti-CADM-p140 is considered a CADM hallmark antibody and a risk factor for the development of interstitial lung disease. Interestingly, anti-SSA was highly associated with SCLE, whereas no myositis-specific autoantibodies were found in this entity. LIMITATIONS OF THE STUDY Association between CADM and myositis-specific autoantibodies and differences between CADM and SCLE were tested on a relatively small cohort of patients. CONCLUSION There is an association between cancer-associated myositis and interstitial lung diseases and their hallmark autoantibodies in our cohort. In addition, the combined determination of myositis-specific autoantibodies and SSA autoantibodies may help to accurately discriminate SCLE from CADM.
Collapse
Affiliation(s)
- C Cuesta-Mateos
- Departamento de Inmunología, Instituto de Investigación Sanitaria Hospital Universitario de la Princesa, Madrid, Spain; IMMED S.L., Immunological and Medicinal Products, Madrid, Spain
| | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Dabiri G, Falanga V. Connective tissue ulcers. J Tissue Viability 2013; 22:92-102. [PMID: 23756459 DOI: 10.1016/j.jtv.2013.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 04/30/2013] [Indexed: 01/10/2023]
Abstract
Connective tissue disorders (CTD), which are often also termed collagen vascular diseases, include a number of related inflammatory conditions. Some of these diseases include rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis (scleroderma), localized scleroderma (morphea variants localized to the skin), Sjogren's syndrome, dermatomyositis, polymyositis, and mixed connective tissue disease. In addition to the systemic manifestations of these diseases, there are a number of cutaneous features that make these conditions recognizable on physical exam. Lower extremity ulcers and digital ulcers are an infrequent but disabling complication of long-standing connective tissue disease. The exact frequency with which these ulcers occur is not known, and the cause of the ulcerations is often multifactorial. Moreover, a challenging component of CTD ulcerations is that there are still no established guidelines for their diagnosis and treatment. The morbidity associated with these ulcerations and their underlying conditions is very substantial. Indeed, these less common but intractable ulcers represent a major medical and economic problem for patients, physicians and nurses, and even well organized multidisciplinary wound healing centers.
Collapse
Affiliation(s)
- Ganary Dabiri
- Department of Dermatology and Skin Cancer, Roger Williams Medical Center, 50 Maude Street, Providence, RI 02908, USA
| | | |
Collapse
|
8
|
Kronbichler A, Mayer G. Renal involvement in autoimmune connective tissue diseases. BMC Med 2013; 11:95. [PMID: 23557013 PMCID: PMC3616816 DOI: 10.1186/1741-7015-11-95] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 02/11/2013] [Indexed: 01/04/2023] Open
Abstract
Connective tissue diseases (CTDs) are a heterogeneous group of disorders that share certain clinical presentations and a disturbed immunoregulation, leading to autoantibody production. Subclinical or overt renal manifestations are frequently observed and complicate the clinical course of CTDs. Alterations of kidney function in Sjögren syndrome, systemic scleroderma (SSc), auto-immune myopathies (dermatomyositis and polymyositis), systemic lupus erythematosus (SLE), antiphospholipid syndrome nephropathy (APSN) as well as rheumatoid arthritis (RA) are frequently present and physicians should be aware of that.In SLE, renal prognosis significantly improved based on specific classification and treatment strategies adjusted to kidney biopsy findings. Patients with scleroderma renal crisis (SRC), which is usually characterized by severe hypertension, progressive decline of renal function and thrombotic microangiopathy, show a significant benefit of early angiotensin-converting-enzyme (ACE) inhibitor use in particular and strict blood pressure control in general. Treatment of the underlying autoimmune disorder or discontinuation of specific therapeutic agents improves kidney function in most patients with Sjögren syndrome, auto-immune myopathies, APSN and RA.In this review we focus on impairment of renal function in relation to underlying disease or adverse drug effects and implications on treatment decisions.
Collapse
Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Anichstraße 35, Innsbruck, 6020, Austria
| | | |
Collapse
|
9
|
Lee ES. Skin and Rheumatic Disease. JOURNAL OF RHEUMATIC DISEASES 2013. [DOI: 10.4078/jrd.2013.20.4.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Eun-So Lee
- Department of Dermatology, Ajou University School of Medicine, Suwon, Korea
| |
Collapse
|
10
|
Obermoser G, Sontheimer RD, Zelger B. Overview of common, rare and atypical manifestations of cutaneous lupus erythematosus and histopathological correlates. Lupus 2010; 19:1050-70. [PMID: 20693199 DOI: 10.1177/0961203310370048] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The skin is the second most frequently affected organ system in lupus erythematosus. Although only very rarely life threatening--an example is lupus erythematosus-associated toxic epidermal necrolysis--skin disease contributes disproportionally to disease burden in terms of personal and psychosocial wellbeing, vocational disability, and hence in medical and social costs. Since several manifestations are closely associated with the presence and activity of systemic lupus erythematosus, prompt and accurate diagnosis of cutaneous lupus erythematosus is essential. This review aims to cover common, rare, and atypical manifestations of lupus erythematosus-associated skin disease with a detailed discussion of histopathological correlates. Cutaneous lupus erythematosus covers a wide morphological spectrum well beyond acute, subacute and chronic cutaneous lupus erythematosus, which are commonly classified as lupus-specific skin disease. Other uncommon or less well-known manifestations include lupus erythematosus tumidus, lupus profundus, chilblain lupus, mucosal lupus erythematosus, and bullous lupus erythematosus. Vascular manifestations include leukocytoclastic and urticarial vasculitis, livedoid vasculopathy and livedo reticularis/ racemosa. Finally, we discuss rare presentations such as lupus erythematosus-related erythema exsudativum multiforme (Rowell syndrome), Kikuchi-Fujimoto disease, extravascular necrotizing palisaded granulomatous dermatitis (Winkelmann granuloma), and neutrophilic urticarial dermatosis.
Collapse
Affiliation(s)
- G Obermoser
- Baylor Institute for Immunology Research, Dallas, TX, USA.
| | | | | |
Collapse
|