Eosinophilic cellulitis as a result of onchocerciasis

Wells syndrome and its relationship to Churg-Strauss syndrome

BACKGROUND

  Wells syndrome has been described as an inflammatory disorder based on typical clinical appearance combined with the histopathological presence of eosinophilic infiltrates and flame figures in the absence of vasculitis. Churg-Strauss syndrome, on the other hand, is primarily a diffuse, necrotizing vasculitis but is also typically displaying eosinophils and flame figures. Despite several parallels, the present understanding of these two diseases excludes any pathogenetic relationship.

METHODS

  We describe the clinical course and histopathological appearance of three patients who had initially been diagnosed with Wells syndrome that developed into Churg-Strauss syndrome during the course of their disease.

RESULTS

  The clinical presentation of all three patients led to the diagnosis of Wells syndrome by independent specialists. Histopathology showed an eosinophilic infiltrate and flame figures next to features of leukocytoclastic vasculitis. Detailed examination revealed asthma bronchiale and additional symptoms indicating Churg-Strauss syndrome. The initial diagnosis of Wells syndrome had to be revised to Churg-Strauss syndrome.

CONCLUSION

  We conclude that Wells syndrome could be the starting point of a pathogenetic process that might reach its maximum in Churg-Strauss syndrome. As a clinical consequence, patients with Wells syndrome should be evaluated and followed for Churg-Strauss syndrome.

Febrile "migrating" eosinophilic cellulitis with hepatosplenomegaly: adult toxocariasis - a case report

Background

Eosinophilic cellulitis (Wells' syndrome) is a polyetiologic clinical entity with still obscure pathogenesis. Clinically overt toxocariasis is uncommon in adults, yet helminthozoonoses, including toxocariasis have been occasionally implicated in the pathogenesis of eosinophilic cellulitis.

Case representation

A 55-year-old female patient presented with a skin biopsy verified recurring febrile eosinophilic cellulitis, blood eosinophilia (42%), slight anaemia (Hct 35%), hepatosplenomegaly and positive specific anti-Toxocara canis antibodies. Toxocariasis-associated eosinophilic cellulitis was diagnosed. Already two weeks after treatment with thiabendazole the skin lesions resolved, T. canis antibody titre normalized eight months after treatment and no recurrences of eosinophilic cellulitis have been observed (for meanwhile three years).

Conclusion

The clinical characteristics (relapsing skin lesions, fever, hepatosplenomegaly), the laboratory features (blood eosinophilia, modest anemia, positive T. canis serology) and the clinical course after treatment, all support a causal relationship between Toxocara infection and the disease of this patient. We propose that in this context eosinophilic cellulitis must be interpreted as the leading symptom of a "skin-predominant" form of overt adult toxocariasis out of a spectrum of toxocariasis-associated febrile, "migrating-relapsing", organotropic eosinophilic inflammatory syndromes.

Dermatologic Manifestations of the Hypereosinophilic Syndromes

Skin is a commonly affected organ in hypereosinophilic syndromes (HES). Cutaneous lesions may be an important presenting sign, may be extremely debilitating, and often reflect disease activity in HES. Recognition of dermatologic manifestations is important in approaching diagnosis and treatment of HES. This article reviews cutaneous involvement in HES and other eosinophil-associated skin diseases.

Insect-bite-like Wells' syndrome in association with mantle-zone lymphoma

Wells' syndrome is a multifaceted dermatosis with a wide morphological spectrum, ranging from characteristic cellulitis-like erythema and wheals to an unusual presentation of vesicles and bullae. We describe a patient in whom Wells' syndrome presented as an insect-bite-like eruption and was associated with underlying mantle-cell lymphoma. We recommend meticulous investigation of patients diagnosed with Wells' syndrome manifesting as an insect-bite-like eruption.

Comparison of clinical history and dermatologic findings in 29 dogs with severe eosinophilic dermatitis: a retrospective analysis

The medical records and histopathological sections of 29 dogs diagnosed with a unique eosinophilic dermatitis resembling Wells' syndrome were reviewed in an attempt to elucidate the pathogenesis of this syndrome. The medical records were reviewed for information on dermatological lesion appearance, systemic signs in other organ systems, clinical analyte abnormalities, and drug therapy. Histological sections of dogs with moderate to severe eosinophilic dermatitis without folliculitis and furunculosis were reviewed and evaluated for the presence of collagen flame figures. Three categories of patients were found. Category 1 consisted of 17 dogs treated for vomiting and/or diarrhoea (often haematochezia or haematemesis) prior (mean: 4.6 days) to the onset of skin lesions. Fourteen category 1 dogs had erythematous lesions (macules, papules or plaques) that were most pronounced on the abdomen. Sixteen of the 17 dogs received multiple classes of drugs, and 59% were hypoalbuminemic. Category 2 consisted of five dogs that had skin lesions and gastrointestinal signs at presentation and four of these dogs were hypoalbuminemic. Category 3 included seven dogs without enteric illness. A positive drug score was found in six category 1 dogs and one each from categories 2 and 3. Eighteen cases had eosinophilic dermatitis without flame figures, seven cases had early flame figures and four had well-developed flame figures. These changes did not correlate with the categories of clinical presentation. More than 50% of the dogs developed eosinophilic dermatitis following treatment for severe gastrointestinal disease. The authors propose that this represents a unique syndrome that may have causal drug association.

Bullous "cellulitis" with eosinophilia: case report and review of Wells' syndrome in childhood

A 1-year-old girl presented with acute onset of edematous erythematous plaques associated with bullae on her extremities and accompanied by peripheral eosinophilia. She was afebrile, and the skin lesions were pruritic but not tender. The patient was treated with intravenously administered antibiotics for presumed cellulitis, without improvement. However, the lesions responded rapidly to systemic steroid therapy. On the basis of lesional morphologic features, peripheral eosinophilia, and cutaneous histopathologic features, a diagnosis of Wells' syndrome was made. Wells' syndrome is extremely rare in childhood, with 27 pediatric cases reported in the literature. Because it is seen so infrequently, there are no specific guidelines for evaluation and management of Wells' syndrome among children. The diagnosis should be considered for children with presumed cellulitis and eosinophilia who fail to respond to antibiotics. Evaluation should include a directed history, physical examination, complete blood count, and stool testing for ova and parasites, to identify potential triggers. Treatment is with systemic steroid therapy unless disease is limited, in which case medium/high-potency topical steroids may be indicated. If systemic features are prominent or disease is chronic (lasting >6 months), then a referral to hematology/oncology should be considered.

Wells' syndrome: a clinical and histopathologic review of seven cases

Wells' syndrome, or eosinophilic cellulitis, is characterized clinically by an acute dermatitis resembling cellulitis, which evolves into violaceous plaques that resolve spontaneously without scarring. The histopathologic features are dynamic, starting with dermal edema and infiltration of eosinophils, the development of "flame figures," and finishing with the appearance of phagocytic histiocytes. We present the clinical and histopathologic features of seven cases of eosinophilic cellulitis.

Nodular presentation of eosinophilic cellulitis (Wells' syndrome)

Eosinophilic cellulitis is a rare condition of unknown aetiology. The classical presentation is of a tender or mildly pruritic cellulitis-like eruption, that has typical histology characterized by tissue eosinophilia, oedema and "flame" figures. Other reported clinical presentations include papular and nodular eruptions. It may be recurrent, and preceded at a variable time by a pruritic papular eruption. We describe a patient with the rare nodular variant of eosinophilic cellulitis affecting the palms of the hands, which occurred 2 years after a nonspecific pruritic papular eruption, without an obvious precipitant and in the absence of the more typical cellulitis-like plaques.

Wells' syndrome associated with recurrent giardiasis

Wells' syndrome (WS) is a rare, recurrent, inflammatory dermatosis of uncertain pathogenesis, although a hypersensitivity response to different stimuli has been postulated. Several cases in association with parasitic infections have been described. We present a patient with WS associated with recurrent giardiasis. The course of the dermatosis was strictly related to the course of the parasitic infection. Both diseases disappeared with antiparasitic treatment. To our knowledge, this association is here reported for the first time.

Wells' syndrome in childhood: case report and review of the literature

We report a severe case of Wells' syndrome, or eosinophilic cellulitis, after a bee sting in a 4-year-old girl. The patient had a widespread, painful, blistering eruption that was subsequently complicated by Pseudomonas aeruginosa superinfection and septicemia, hypoalbuminemia, anemia, and neutropenia. The skin lesions responded to systemic steroid therapy. There was residual scarring alopecia of the scalp. There have been 17 previous reports of childhood Wells' syndrome. We believe that this disorder is a distinct entity that should be considered in the differential diagnosis of blistering diseases in children.

Cutaneous onchocerciasis

Onchocerciasis was diagnosed when a skin biopsy specimen immersed in saline revealed microfiliariae. The patient was a 22-year-old student from Cameroon, West Africa, complaining of small, recurrent, pruritic papules on his thighs. Chemotherapy with ivermectin, an established antiparasitic agent with newly recognized anti-onchocercal potential, was well tolerated, and microfilariae were not detected in post-therapy skin biopsy specimens. The diagnosis of onchocerciasis should be entertained in individuals returning or emigrating from endemic areas.