Erythema elevatum diutinum with primary Sjögren syndrome associated with IgA antineutrophil cytoplasmic antibody

Sjögren syndrome overlapping with ANCA-associated vasculitis: Four additional cases and systematic literature review

OBJECTIVES

Sjögren's syndrome (SS) and ANCA-associated vasculitis (AAV) have distinct clinical presentation and evolution, with paucity of reports on overlap syndrome. We aimed to better characterize this entity.

METHODS

We report four additional cases from the Montpellier university hospital. We also performed a systematic literature review, according to PRISMA guidelines, in Medline, Embase, Web of science, Cochrane Library, and grey literature. Demographic, clinical, and paraclinical data on SS and AAV were analysed.

RESULTS

A total of 3133 articles was identified in databases, with 2695 articles screened for eligibility. After exclusion, we had 30 articles on 40 patients to analyse, in addition to 4 patients from our local recruitment (44 patients overall). Patients were female in 81.8%, with median age at AAV onset of 63.5 years. All patients but one presented with SS before, or concomitantly to the diagnosis of AAV, with a median delay of 12 months between both diagnoses. AAV predominantly had renal involvement (35/44 patients, 79.5%), anti-MPO antibodies being the most frequent (35 patients), even in patients presenting with granulomatosis with polyangiitis. We observed significantly more Raynaud phenomenon and associated auto-immune diseases in the group of non-granulomatous AAV (10 patients versus 1, p = 0.015 and 8 patients versus 0, p = 0.013, respectively).

CONCLUSIONS

This is the largest descriptive study on the association between SS and AAV, providing information on this challenging diagnosis and interplay between these two diseases. Particular attention should be paid in the first months after diagnosis, given the specific complications and outcomes of each disease.

Associated Pyoderma Gangrenosum, Erythema Elevatum Diutinum, and Chronic Recurrent Annular Dermatosis: The Neutrophilic Disease Spectrum

Neutrophilic dermatoses (ND) refer to a group of skin diseases characterized histologically by a cutaneous infiltrate of mature polymorphonuclear cells without an identifiable cause. Previously described as autonomous, these clinically distinct entities are included in the spectrum of neutrophilic disease due to the existence of overlapping forms, as described in our observation. Erythema elevatum diutinum (EED) is a rare dermatosis characterized by reddish-violaceous to browning papulonodular and plaques and belongs to the spectrum of cutaneous leukocytoclastic vasculitis. Chronic recurrent annular neutrophilic dermatosis (CRAND) is an exceptional neutrophilic dermatosis characterized by chronic annular lesions and the absence of generalized signs or hematological abnormalities. Histological features are similar to those seen in Sweet’s syndrome.

A 55-year-old woman with a history of pyoderma gangrenosum (PG) presented successively with two rare forms of ND, namely, EED and CRAND. There were no clinical or paraclinical arguments for any underlying systemic disease. Treatment with azathioprine 100 mg/day and topical steroids led to a total regression of lesions after a nine-month follow-up.

Our observation is important because it reports two rare entities, CRAND and EED. Their occurrence in a single patient with a history of PG illustrates the concept of “neutrophilic disease” reported in the 1990s.

Atypical Presentation of Erythema Elevatum Diutinum in a Patient With Hashimoto's Disease

Erythema elevatum diutinum (EED) is a cutaneous vasculitis that is characterized by histopathologic findings of neutrophilic infiltration, vessel fibrosis, and leukocytoclasia. It most often presents as papules, plaques, and nodules on the extensor surfaces of the extremities. Herein, we present a case of a 44-year-old woman with Hashimoto's disease with an atypical presentation of EED on the palmar surface of the thumb, in addition to the classic appearance on the elbow. Diseases associated with EED, including autoimmune conditions, are discussed.

Erythema elevatum diutinum: a case report and review of literature

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.

Granuloma Faciale and Erythema Elevatum Diutinum in Relation to Immunoglobulin G4-Related Disease: An Appraisal of 32 Cases

OBJECTIVES

To elucidate whether granuloma faciale (GF) and erythema elevatum diutinum (EED), two inflammatory skin dermatoses, meet the consensus histopathologic diagnostic criteria for immunoglobulin G4-related disease (IgG4-RD).

METHODS

With institutional review board approval, we assessed the clinical, microscopic, and immunophenotypic features of skin specimens of patients with GF and EED. We compared these findings with previously published consensus diagnostic criteria for IgG4-RD.

RESULTS

Thirty-two patients (GF, n = 25; EED, n = 7) met study inclusion criteria. Histopathologic findings of small-vessel vasculitis, dermal fibrosis, and plasma cell infiltrates were uniformly present, and eosinophilic inflammation was frequent. No specimen met diagnostic criteria for IgG4-RD.

CONCLUSIONS

Our results indicate that despite some histopathologic similarities between GF/EED and IgG4-RD, the cases did not meet the consensus immunohistochemical diagnostic criteria for IgG4-RD.

ANCA-associated vasculitis in patients with primary Sjögren's syndrome: detailed analysis of 7 new cases and systematic literature review

OBJECTIVES

To describe the clinical presentation, management and prognosis of patients diagnosed with both primary Sjögren's syndrome (pSS) and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

METHODS

French nation-wide survey completed by a systematic literature review.

RESULTS

This work identified 7 new cases of coexisting pSS and AAV: 2 microscopic polyangiitis (MPA), 2 granulomatosis with polyangiitis (GPA), 2 anti-myeloperoxidase (MPO)-ANCA renal-limited AAV, and 1 eosinophilic granulomatosis with polyangiitis (EGPA). The systematic literature search identified 15 previously published cases. Among the 22 patients, 19 were females. Mean age at diagnosis of AAV was 63.9±9.8years. All individuals with available information experienced at least one extra-glandular manifestation attributable to pSS. p-ANCA with anti-MPO specificity were found in 76.2% (16/21), c-ANCA with anti-PR3 specificity in 14.3% (3/21) and isolated c-ANCA in 13.6% (3/22). Vasculitis involved kidneys (n=13), lungs (n=8), skin (n=6), peripheral nerves (n=5), central nervous system (n=2), small bowel (n=1), muscle (n=1), ear chondritis (n=1) and sinuses (n=1). The mean AAV follow-up was 73.5 (±120.0) months. While on treatment, disease remission occurred in 77.3% of cases, and one death was reported in the first 6months after diagnosis.

CONCLUSION

This work shows that AAV may occur in patients with pSS. These are most commonly p-ANCA associated vasculitis with anti-MPO specificity. AAV may reveal an underlying pSS or arise during its evolution, but did not precede pSS in any of these cases. AAV occurrence appears to be correlated with extra-glandular manifestations of pSS.

Erythema elevatum diutinum coexisting with ankylosing spondylitis

A 43-year-old woman presented to our hospital with the complaint of a reddish-purple rash on the extensor sides of her forearms. She had been diagnosed with ankylosing spondylitis 7 years ago. On physical examination, reddish-purple nodules were detected on the pretibial areas of both legs and extensor sides of both hands and forearms. Neutrophil, eosinophil, lymphocyte, and mixed-type leukocyte infiltration and erythrocyte extravasation were observed in skin biopsy. Erythema elevatum diutinum (EED) was diagnosed. For treatment, sulphasalazine, colchicine, and diclofenac were started. After 3 months of treatment, the lesions were healed. To the best of our knowledge, this is the first report of EED coexisting with ankylosing spondylitis.

Dermatologic manifestations of Sjögren syndrome

BACKGROUND

Sjögren syndrome (SS) is a chronic autoimmune inflammatory disease that involves primarily the exocrine glands, resulting in their functional impairment. SS typically presents as dry eyes (xerophthalmia) and dry mouth (xerostomia). This process can manifest either as the independent phenomenon of primary SS or as secondary SS when found in the context of another autoimmune process, most commonly rheumatoid arthritis or systemic lupus erythematosus. Nearly half of the patients with SS develop cutaneous manifestations, which may include dry skin (xeroderma), palpable and nonpalpable purpura, and/or urticaria-like lesions. These cutaneous manifestations have been underemphasized because they are often overshadowed by the more prominent sicca symptoms. However, certain skin findings are of paramount clinical and prognostic importance as they confer an increased risk for the development of life-threatening conditions, including multisystem vasculitis and non-Hodgkin lymphoma.OBJECTIVE AND CONCLUSIONS:In this review, the cutaneous manifestations of primary SS are discussed, with an emphasis on those findings that portend an increased risk of mortality.

[Erythema elevatum diutinum associated with pyoderma gangrenosum in an HIV-positive patient]

BACKGROUND

Erythema elevatum diutinum (EED) is a very rare form of chronic dermatosis clinically characterised by reddish-violet papular nodules extending to the surfaces of the limbs and extremities. Histologically, there are classically two phases of progression initially involving associated neutrophilic dermatosis and leucocytoclastic vasculitis, which is later followed by fibrosis of characteristic appearance. We report the association of EED and pyoderma gangrenosum in a patient infected with HIV.

PATIENTS AND METHODS

A 53-year-old male seen since 1989 for HIV infection had been presenting firm bilateral and symmetrical nodules on the feet for 6 months. Histological analysis of one of these nodules resulted in diagnosis of chronic erythema elevatum diutinum and treatment with dapsone was initiated. Three months later, despite regression of the EED lesions under dapsone, two large pustules appeared on the outer aspect of the right leg; they were confluent and progressed towards a superficial ulcer with rounded edges with a clinical appearance evocative of pyoderma gangrenosum (PG). Histopathological analysis demonstrated a massive dermal infiltrate beneath the ulcer comprising neutrophils with evidence of leucocytoclasia, all of which militated in favour of the diagnosis of pyoderma gangrenosum.

DISCUSSION

We report for the first time the association of two forms of neutrophilic dermatosis, EED and PG, in an HIV-positive patient. This case report and certain data in the literature suggest that the various forms of neutrophilic dermatosis tend to result in a range of lesions rather than in clearly distinct entities.