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Sinha P, Sharma J, Tiwari S, Bhattacharjee S, Sinha A. A case of multidrug-resistant tuberculosis presenting as erythema elevatum diutinum: A rare association. Indian J Dermatol Venereol Leprol 2022; 88:548-550. [PMID: 35593283 DOI: 10.25259/ijdvl_1062_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/01/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Preema Sinha
- Department of Dermatology, Base Hospital, Lucknow, Uttar Pradesh, India
| | - Juhi Sharma
- Department of Dermatology, Base Hospital, Lucknow, Uttar Pradesh, India
| | - Saurabh Tiwari
- Department of Respiratory Medicine, Command Hospital, Lucknow, Uttar Pradesh, India
| | - Saikat Bhattacharjee
- Department of Radiodiagnosis and Imaging, Command Hospital, Lucknow, Uttar Pradesh, India
| | - Anamika Sinha
- Department of Pathology, Command Hospital, Lucknow, Uttar Pradesh, India
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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] [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] [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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Di Giacomo TB, Marinho RT, Nico MMS. Erythema elevatum diutinum presenting with a giant annular pattern. Int J Dermatol 2009; 48:290-2. [DOI: 10.1111/j.1365-4632.2009.03972.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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TASANEN K, RAUDASOJA R, KALLIOINEN M, RANKI A. Erythema elevatum diutinum in association with coetiac disease. Br J Dermatol 2008. [DOI: 10.1046/j.1365-2133.1997.d01-1250.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abenavoli L, Proietti I, Leggio L, Ferrulli A, Vonghia L, Capizzi R, Rotoli M, Amerio PL, Gasbarrini G, Addolorato G. Cutaneous manifestations in celiac disease. World J Gastroenterol 2006; 12:843-52. [PMID: 16521210 PMCID: PMC4066147 DOI: 10.3748/wjg.v12.i6.843] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Celiac disease (CD) is an autoimmune gluten-dependent enteropathy characterized by atrophy of intestinal villi that improves after gluten-free diet (GFD). CD is often associated with extra-intestinal manifestations; among them, several skin diseases are described in CD patients. The present review reports all CD-associated skin manifestations described in the literature and tries to analyze the possible mechanisms involved in this association. The opportunity to evaluate the possible presence of CD in patients affected by skin disorders is discussed.
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Affiliation(s)
- L Abenavoli
- Institute of Internal Medicine, Catholic University, L.go Gemelli 8, 00168 Rome, Italy
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Abstract
Erythema elevatum diutinum (EED) is a chronic cutaneous vasculitis occurring in association with a variety of conditions including autoimmunity, infectious disease, and hematological abnormalities. The role of associated medical problems is controversial, and the exact pathogenesis of EED is unknown. A series of six cases is reported. The typical clinical presentation was that of erythematous papules and plaques involving the extensor surfaces of the extremities. Histologically, a spectrum from leukocytoclastic vasculitis to vessel occlusion and dermal fibrosis was seen. The lesions of EED have many mimics clinically and histologically. Establishing the diagnosis of EED is important so appropriate screening for associated conditions can ensue. The vascular endothelium of EED stains positive for CD31, CD34, VEGF, and factor VIIIa and negative for factor XIIIa, TGFB, and LANA, a reaction pattern that does not distinguish it from similar appearing lesions. Thus, the chronic and recurrent nature of EED is the primary means of distinguishing it from entities that are clinically and histologically similar.
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Affiliation(s)
- Carter E Wahl
- University of California-San Diego, San Diego, California, USA
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Bordel MT, Bassas J, Morales AM, Tejerina JA, Aragoneses MH, Miranda A. Eritema elevatum diutinum. ACTAS DERMO-SIFILIOGRAFICAS 2003. [DOI: 10.1016/s0001-7310(03)76694-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Affiliation(s)
- L E Gibson
- Department of Dermatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Affiliation(s)
- C D Hensley
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Tasanen K, Raudasoja R, Kallioinen M, Ranki A. Erythema elevatum diutinum in association with coeliac disease. Br J Dermatol 1997. [PMID: 9155974 DOI: 10.1111/j.1365-2133.1997.tb02157.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Erythema elevatum diutinum (EED) has been described in association with several immunological or infectious diseases. We describe a female patient who presented with clinically and histologically typical EED in whom previously undiagnosed coeliac disease was found. Appearance of EED lesions was preceded by widespread joint pains. In extensive laboratory tests, the only abnormal findings were an elevated erythrocyte sedimentation rate (ESR) and decreased haemoglobin and folic acid levels. Later, IgA and IgG type antireticulin and antigliadin antibodies were detected. Serum total IgA was elevated but no paraproteinaemia was found. In lesional skin, granular deposits of IgA and C3 were seen at the dermo-epidermal junction. A duodenal biopsy revealed total villous atrophy. Dapsone treatment was partly effective but complete healing of the EED lesions was achieved only after the introduction of a strict gluten-free diet. The patient has now remained symptom-free on the diet for 1.5 years.
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Affiliation(s)
- K Tasanen
- Department of Dermatology, Oulu University Hospital, Finland
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Affiliation(s)
- P N Arora
- Senior Advisor (Dermatology and Venerology), Command Hospital (SC); Pune - 411 040
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Affiliation(s)
- V Farella
- Department of Dermatology, University of Florence, Italy
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LeBoit PE, Cockerell CJ. Nodular lesions of erythema elevatum diutinum in patients infected with the human immunodeficiency virus. J Am Acad Dermatol 1993; 28:919-22. [PMID: 8496454 DOI: 10.1016/0190-9622(93)70130-l] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Erythema elevatum diutinum (EED) is a rare, chronic form of cutaneous vasculitis that can result in fibrosis. Four patients infected with the human immunodeficiency virus (HIV) had unusual nodular lesions of EED. OBJECTIVE Our purpose was to document the occurrence of these lesions in HIV-infected patients and to characterize the histopathologic and immunophenotypic features of nodular EED. METHODS Clinicopathologic studies were supplemented by special stains of biopsy specimens. RESULTS EED may be a complication of HIV infection. Nodules of EED are composed of small aggregates of Mac-387+ spindled cells. Within the aggregates can be seen neutrophils, nuclear dust, and fibrin. The marked fibrosis of the lesions may account for the lack of response to dapsone. CONCLUSION EED should be considered in the differential diagnosis of juxta-articular nodules in HIV-infected patients; its diagnosis can be confirmed by biopsy.
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Affiliation(s)
- P E LeBoit
- Department of Pathology, School of Medicine, University of California, San Francisco 94143-0506
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Bernard P, Bedane C, Delrous JL, Catanzano G, Bonnetblanc JM. Erythema elevatum diutinum in a patient with relapsing polychondritis. J Am Acad Dermatol 1992; 26:312-5. [PMID: 1569248 DOI: 10.1016/0190-9622(92)70043-f] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A 69-year-old man with a history of relapsing polychondritis developed a widespread cutaneous eruption that was clinically and histologically typical of erythema elevatum diutinum. This eruption was accompanied by a recurrence of arthralgias. The significance of this association between relapsing polychondritis and erythema elevatum diutinum, which has not been previously reported, is discussed.
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Affiliation(s)
- P Bernard
- Department of Dermatology, CHRU Dupuytren, Limoges, France
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Buahene K, Hudson M, Mowat A, Smart L, Ormerod AD. Erythema elevatum diutinum--an unusual association with ulcerative colitis. Clin Exp Dermatol 1991; 16:204-6. [PMID: 1934575 DOI: 10.1111/j.1365-2230.1991.tb00348.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We report the association of erythema elevatum diutinum (EED) with ulcerative colitis (UC). The patient, whose history included rheumatoid disease, diabetes mellitus (type I) and hypothyroidism developed EED during a severe acute exacerbation of UC which resolved following colectomy. To our knowledge this is the first report of such an association. Also of interest was the observation of Köebner phenomenon occurring at the sites where blood vessels were damaged.
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Affiliation(s)
- K Buahene
- Department of Dermatology, Aberdeen Royal Infirmary, UK
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Erythematous and Erythematosquamous Skin Diseases. Dermatology 1991. [DOI: 10.1007/978-3-662-00181-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Collier PM, Neill SM, Branfoot AC, Staughton RC. Erythema elevatum diutinum--a solitary lesion in a patient with rheumatoid arthritis. Clin Exp Dermatol 1990; 15:394-5. [PMID: 2225548 DOI: 10.1111/j.1365-2230.1990.tb02126.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Erythema elevatum diutinum is a rare disease of unknown aetiology. It is usually symmetrical with multiple lesions. An association with rheumatoid has previously been reported. We report a case of atypical erythema elevatum diutinum affecting the right elbow of a female patient with seropositive rheumatoid arthritis.
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Affiliation(s)
- P M Collier
- Department of Dermatology, Westminster Hospital, London, UK
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Wolff HH, Maciejewski W, Scherer R. [Erythema elevatum diutinum. I. Electron microscopy of a case with extracellular cholesterosis (author's transl)]. Arch Dermatol Res 1978; 261:7-16. [PMID: 637575 DOI: 10.1007/bf00455370] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
1. A typical case of Erythema elevatum diutinum (E.e.d.) with extracellular cholesterosis is described clinically and histologically in a 48-year-old woman. The disease had a course of 15 years. 2. Electron microscopy confirmed the histological and immunfluorescent findings of leucocytoclastic vasculitis. In older lesions, histiocytes/macrophages predominate. Intra- and extracellular lipid depositions showed a variety of ultrastructural characteristics which differed from electron microscopical findings described in other disorders associated with lipid deposition. 3. The findings are in accordance with the hypothesis that the primary event in E.e.d. is a special type of chronic leukocytoclastic vasculitis. Subsequently, the damage of the vessel walls and focal necrosis may lead to secondary lipid deposition.
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Wolff HH, Scherer R, Maciejewski W, Braun-Falco O. [Erythema elevatum diutinum. II. Immunoelectronmicroscopical study of leukocytoclastic vasculitis within the intracutaneous test reaction induced by streptococcal antigen (author's transl)]. Arch Dermatol Res 1978; 261:17-26. [PMID: 345975 DOI: 10.1007/bf00455371] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A leukocytoclastic vasculitis was induced by intracutaneous injection of streptococcal antigen in a patient with erythema elevatum diutinum (E.e.d.). The immunoelectronmicroscopical demonstration of C3 was performed by use of the peroxidase-antiperoxidase multistep technique 24 h after the injection of the antigen. Deposits of C3 were found between endothelial cells, on the outer surface of endothelial cells, pericytes, and smooth muscle cells, as well as within the multilayered basal lamina of small vessels. Intact and disintegrating neutrophils accumulate within the vessel walls and in their surroundings. Necrosis and fibrin deposition are present in advanced stages. The findings demonstrate the sequence of events in leukocytoclastic vasculitis at the ultrastructural level. They also support the hypothesis that in E.e.d. an Arthus type reaction induced by bacterial antigens may be of pathogenetic significance.
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Abstract
Paraproteinaemia (IgGkappa) was observed in a 68 year-old patient with erythema elevatum diutinum. The association of this skin disease with paraproteinaemia as already reported by other authors may indicate a pathogenetic relationship.
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Morrison JG, Hull PR, Fourie E. Erythema elevatum diutinum, cryoglobulinaemia, and fixed urticaria on cooling. Br J Dermatol 1977; 97:99-104. [PMID: 889706 DOI: 10.1111/j.1365-2133.1977.tb15435.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A mixed cryoglobulin (IgG/IgM) was detected in a patient with erythema elevatum diutinum. Cold exposure activated the complement system and provoked a fixed urticarial reaction with the histology of a leukocytoclastic vasculitis.
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Cream JJ, Levene GM, Calnan CD. Erythema elevatum diutinum: an unusual reaction to streptococcal antigen and response to dapsone. Br J Dermatol 1971; 84:393-9. [PMID: 5089943 DOI: 10.1111/j.1365-2133.1971.tb02522.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Hines HL. Erythema elevatum diutinum. DERMATOLOGIA INTERNATIONALIS 1968; 7:70-4. [PMID: 5741772 DOI: 10.1111/j.1365-4362.1968.tb05635.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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HEITE HJ, SCHARWENKA HX. Erythema elevatum diutinum, Granuloma anulare, Necrobiosis lipoidica und Granulomatosis disciformis Gottron-Miescher. Arch Dermatol Res 1959; 208:260-90. [PMID: 13628073 DOI: 10.1007/bf00482816] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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HERZBERG JJ. [Extracellular cholesterinosis of Kerl-Urbach, a variant of erythema elevatum diutinum]. Arch Dermatol Res 1958; 205:477-96. [PMID: 13534379 DOI: 10.1007/bf00482767] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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WARTZKI IM. Erythema elevatum diutinum. Australas J Dermatol 1955; 3:87-90. [PMID: 13283932 DOI: 10.1111/j.1440-0960.1955.tb01503.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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