Lupus erythematosus associated with erythema multiforme: report of two cases and review of the literature

Neuropsychiatric manifestations in an adolescent male with Rowell syndrome

A 15-year-old boy presented with fever, skin, and oral lesions for 4 weeks. The cutaneous lesions were suggestive of subacute cutaneous lupus erythematosus and erythema multiforme. His clinical, histopathological, and immunological features were indicative of Rowell syndrome and he satisfied the diagnostic criteria of Rowell syndrome proposed by Zeitouni et al. He subsequently developed neurological manifestations and was diagnosed to have neuropsychiatric systemic lupus erythematosus. We report this case for the unusual occurrence of a rare entity like Rowell syndrome in an adolescent male with co-existence of neuropsychiatric systemic lupus erythematosus.

Rowell's syndrome: a rare but distinct entity in rheumatology

Rowell's syndrome is a rare disorder characterised by an association of lupus erythematosus with erythema multiforme (EM)-like skin lesions. EM as the initial clinical presentation of systemic lupus erythematosus is also atypical and even rarer. We report the case of an 18-year-old girl admitted to our hospital with fever and polyarthralgia along with multiple discrete ill-defined target lesions with crust formation over forehead, cheek, external ears, scalp, upper chest and back (predominantly over sun-exposed areas) with ulceration over hard palate. Investigations revealed pancytopaenia, a positive rheumatoid factor, positive antinuclear antibody with a speckled pattern, anti-Smith antibody and strongly positive anti-Ro. Patient was diagnosed with Rowell's syndrome as per clinical and laboratory features. Majority of skin lesions including oral ulcerations subsided gradually after treatment with steroids and hydroxychloroquine.

Rowell syndrome with recurrence from photoexacerbation: A case report

Rowell syndrome is a controversial entity composed of erythema multiforme-like lesions coexisting with lupus erythematosus. We describe a case of a 61-year-old male with a history of systemic lupus erythematosus who presented with photoexacerbated flaccid bullae and erosive plaques after repetitive sun exposure. Based on his clinical history, biopsy, and laboratory findings, he fulfilled diagnostic criteria for Rowell syndrome as described by Zeitouni et al. With oral prednisone, hydroxychloroquine, mycophenolate mofetil, and local wound care with petrolatum, the patient’s number of lesions decreased, as well as his pain and tenderness. He subsequently did not develop any new erosions. This case highlights the diagnostic criteria of this hybrid clinicopathological syndrome and its nature of photosensitivity.

Current Perspectives on Erythema Multiforme

Recognition and timely adequate treatment of erythema multiforme remain a major challenge. In this review, current diagnostic guidelines, potential pitfalls, and modern/novel treatment options are summarized with the aim to help clinicians with diagnostic and therapeutic decision-making. The diagnosis of erythema multiforme, that has an acute, self-limiting course, is based on its typical clinical picture of targetoid erythematous lesions with predominant acral localization as well as histological findings. Clinically, erythema multiforme can be differentiated into isolated cutaneous and combined mucocutaneous forms. Atypical erythema multiforme manifestations include lichenoid or granulomatous lesions as well as lesional infiltrates of T cell lymphoma and histiocytes. Herpes simplex virus infection being the most common cause, other infectious agents like-especially in children-Mycoplasma pneumoniae, hepatitis C virus, Coxsackie virus, and Epstein Barr virus may also trigger erythema multiforme. The second most frequently identified cause of erythema multiforme is drugs. In different studies, e.g., allopurinol, phenobarbital, phenytoin, valproic acid, antibacterial sulfonamides, penicillins, erythromycin, nitrofurantoin, tetracyclines, chlormezanone, acetylsalicylic acid, statins, as well as different TNF-α inhibitors such as adalimumab, infliximab, and etanercept were reported as possible implicated drugs. Recently, cases of erythema multiforme associated with vaccination, immunotherapy for melanoma, and even with topical drugs like imiquimod have been described. In patients with recurrent herpes simplex virus-associated erythema multiforme, the topical prophylactic treatment with acyclovir does not seem to prevent further episodes of erythema multiforme. In case of resistance to one virostatic drug, the switch to an alternative drug, and in patients non-responsive to virostatic agents, the use of dapsone as well as new treatment options, e.g., JAK-inhibitors or apremilast, might be considered.

[A new case of Rowell's syndrome]

INTRODUCTION

This article introduces a new case of Rowell's syndrome, a controversial entity defined by the association of lupus erythematosus and erythema multiforme.

OBSERVATION

A 43-year-old woman was diagnosed with lupus erythematosus induced by esomeprazole. Because her eruption did not improve after withdrawal of the drug, hydroxychloroquine was administered. Two weeks later, the patient described new annular lesions on her chest and arms, both erosive and crusted, and some had a target-like appearance. The oral mucosa was also affected. Histology revealed sub-epidermal blistering with keratinocytic necrosis, strongly suggesting erythema multiforme. Screening for other causes of erythema multiforme proved negative. A positive outcome was achieved with corticosteroids and hydroxychloroquine. One year later, the patient was in complete remission for both lupus erythematosus and erythema multiforme.

DISCUSSION

The association of lupus erythematosus and erythema multiforme first described in 1963 is known as Rowell's syndrome. While diagnostic criteria have been established in the literature, the reality of this entity is still contested. The annular lesions of subacute lupus erythematosus may be confused with the lesions of erythema multiforme. As suggested in the above section, other authors consider Rowell's syndrome to be a singular entity. Indeed, our patient developed lesions distinct from those initially suggesting subacute lupus erythematosus, in particular: the target-like aspect of the elementary lesions, mucosal involvement, a distinct histological aspect, and dissociated outcomes. Ultimately, the definition of Rowell's syndrome remains highly debated.

Rowell's syndrome in an Indian male and review of the literature

Lupus erythematosus (LE) with erythema multiforme-like lesions with its characteristic serological picture had been described in 1963. We report a 33-year-old married male who presented with skin lesions of various morphology on different body parts since four months. The skin lesions ranged from lupus-specific tumid LE to Rowell's syndrome and discoid LE. Histopathology of skin biopsy from all representative sites showed different forms of lupus erythematosus. Antinuclear and anti-double-stranded DNA was positive; however, serology for anti-SSA and anti-SSB was negative. There were no symptoms specific for organ involvement. It is unusual to document various morphological types in a single patient of lupus erythematosus. We document this case as all forms of cutaneous LE including Rowell's syndrome were evident in a single male patient.

Rowell's Syndrome to ds-DNA Negative Lupus Nephritis: A Yet Unreported Progression

Rowell's syndrome is now identified as a subtype of subacute lupus erythematosus (LE) with erythema multiforme-like skin lesions, positive serum rheumatoid factor, anti-Ro La positivity and speckled pattern of antinuclear antibodies. Here we describe a case of Rowell's syndrome in an 18-year-old female who was found to be ds-DNA negative, who later progressed to develop stage V lupus nephritis (LN) over a course of 4 months. Although extremely rare, most cases of LN are drug induced. Of only seven cases of non-drug induced LN with negative dsDNA, none had cutaneous involvement. Ours was a unique case of progression of Rowells syndrome to ds-DNA negative LN.

Rowell syndrome

Rowell syndrome is a rare disease consisting of erythema multiforme-like lesions associated with lupus erythematosus. The syndrome occurs mostly in middle-aged women. The authors describe the syndrome in a 15-year-old boy who responded well to systemic steroids and hydroxychloroquine.

Photodistributed erythema multiforme

Although the existence of photodistributed erythema multiforme has been recognized for years, few cases have been described to date. It is an uncommon, and probably underdiagnosed, skin disorder that can affect individuals of both sexes and all ages. It has been associated with drugs, reactivation of herpes simplex virus infection, and polymorphous light eruption. A diagnosis is made on the basis of history, physical examination, histology, and phototesting. The condition runs a benign, self-limiting course but patients may experience outbreaks for several years if the causative agent is not eliminated. It is treated symptomatically and patients are advised to avoid triggers and excessive sun exposure.

The last word on the so-called 'Rowell's syndrome'?

To date, 71 patients having the so-called 'Rowell's syndrome' (RS) have been reported in the literature. However, most of them did not show all the clinical and serological features first described by Rowell and co-workers in 1963. Moreover, since then, subacute cutaneous lupus erythematosus (SCLE) has been identified and the diagnostic criteria as well as the clinical features of erythema multiforme (EM) defined. Accordingly several authors have questioned the existence of RS over the past years. In the present paper, the main clinical, histopathological and immunopathological features of both SCLE and EM are described and all of the cases of RS reported in the literature are also reviewed in depth. A real association between discoid LE and EM was present only in a minority of cases and could be considered a mere coincidence. As for other associations, e.g. those between CLE and lichen planus or psoriasis, the coexistence of CLE and EM does not justify the framing of a separate syndrome as suggested by Rowell et al.

Rowell syndrome--case report with discussion of significance of diagnostic accuracy

Rowell syndrome is a very controversial condition and though defining diagnosing criteria exist, many previously published cases lack one or more of these criteria. It represents the combination of cutaneous lupus erythematosus and erythema multiforme in one single individual. In order to discuss relevance of diagnostic and defining criteria the authors use a case seen in our outpatient service that was primarily diagnosed as Rowell syndrome. But due to lacking criteria, the authors rediagnosed this patient as an unusual variation of lupus erythematosus.

[Skin manifestations in lupus erythematosus: clinical aspects and therapy]

Lupus erythematosus (LE) is an inflammatory autoimmune disorder, which is characterized by clinically heterogeneous manifestations of different organs. In systemic LE (SLE) the skin, the musculoskeletal system, the kidneys, the cardiovascular and central nervous systems can be involved. The skin lesions can be divided into LE-specific and LE-non-specific manifestations, the former represent the subtypes of cutaneous LE (CLE). The diagnosis is confirmed by clinical, histopathological, immunoserological and genetic features. The treatment is similar for the different subtypes of CLE; however, the therapeutic regimen should be individually defined in each patient. Antimalarials are still the first-line systemic therapy and in addition to sunscreens, glucocorticosteroids and calcineurin inhibitors have an important impact as topical agents in this disease.

Drug-induced subacute cutaneous lupus erythematosus: evidence for differences from its idiopathic counterpart

BACKGROUND

Drug-induced subacute cutaneous lupus erythematosus (DI-SCLE) is a lupus variant with predominant skin involvement temporally related to drug exposure and resolving after drug discontinuation. It usually presents with annular polycyclic or papulosquamous eruptions on sun-exposed skin and shows serum anti-Ro/SSA antibodies.

OBJECTIVES

To address the question whether DI-SCLE differs significantly from idiopathic SCLE by virtue of clinical features.

METHODS

Ninety patients with SCLE seen in our departments from 2001 to 2010 were reviewed. Eleven of them diagnosed as having DI-SCLE were evaluated for type of skin lesions, systemic involvement, clinical course, and histopathological, direct immunofluorescence and laboratory findings. The cutaneous features were compared with those of the 79 patients with idiopathic SCLE.

RESULTS

The cutaneous picture was widespread in 82% of patients with DI-SCLE and in 6% of those with idiopathic SCLE [odds ratio (OR) 66·6, 95% confidence interval (CI) 11·2-394·9; P = 0·0001]. Bullous and erythema multiforme (EM)-like lesions were present in 45% of patients with DI-SCLE and in 1% of those with idiopathic SCLE (OR 65·0, 95% CI 6·5-649·6; P = 0·0001). Vasculitic lesions were observed in 45% of patients with DI-SCLE and in 3% of those with idiopathic SCLE (OR 32·1, 95% CI 5·1-201·7; P = 0·0001). Malar rash occurred in 45% of patients with DI-SCLE and in 6% of those with idiopathic SCLE (OR 12·3, 95% CI 2·8-54·9; P = 0·001). Visceral manifestations were excluded in all patients with DI-SCLE. Anti-Ro/SSA antibodies were found in all but one patient with DI-SCLE and disappeared after resolution in 73% of cases.

CONCLUSIONS

DI-SCLE differs from idiopathic SCLE by virtue of distinctive cutaneous features, particularly the widespread presentation and the frequent occurrence of malar rash and bullous, EM-like and vasculitic manifestations.

Rowell's syndrome: presenting features of systemic lupus erythematosus

A subset of patients with lupus erythematosus develops erythema multiforme-like skin lesions with speckled pattern of antinuclear antibodies, positive rheumatoid factor, anti-Ro (SS-A), and anti-La antibodies (SS-B), which known as Rowell's syndrome. We report an adolescent boy presented with erythema multiforme-like skin lesions and pericardial effusion; he fulfilled criteria of both Rowell's syndrome and systemic lupus erythematosus (SLE). Such initial presentation of SLE is rarely reported in literature.

Drug-induced lupus: an update on its dermatologic aspects

Drug-induced lupus erythematosus (DILE) is defined as an entity characterized by clinical manifestations and immunopathological serum findings similar to those of idiopathic lupus but which is temporally related to continuous drug exposure and resolves after discontinuation of the offending drug. Similar to idiopathic lupus, DILE can be divided into systemic lupus erythematosus (SLE), subacute cutaneous lupus erythematosus (SCLE) and chronic cutaneous lupus erythematosus (CCLE). Based on the literature review and retrospective analysis of our case series, we focused on the dermatological aspects of DILE. The cutaneous features of drug-induced SLE are protean, including particularly purpura, erythema nodosum and photosensitivity as well as the skin lesions characterizing both urticarial and necrotizing vasculitis. The typical laboratory profile of systemic DILE consists of positive antinuclear antibodies (ANA) and antihistone antibodies, the latter being regarded as the serum marker of this subset. The drugs most frequently implicated in the development of systemic DILE are hydralazine, procainamide, isoniazid and minocycline. Drug-induced SCLE usually presents with annular polycyclic or papulosquamous cutaneous manifestations as in the idiopathic form, but blisters or targetoid lesions mimicking erythema multiforme cannot rarely be associated. The clinical presentation is often generalized, with involvement of the lower legs that are usually spared in idiopathic SCLE. ANA and anti-Ro/SSA antibodies are usually present, whereas antihistone antibodies are uncommonly found. Drugs associated with SCLE include particularly calcium channel blockers, angiotensin-converting enzyme inhibitors, thiazide diuretics, terbinafine and the recently reported tumour necrosis factor (TNF)-α antagonists. Drug-induced CCLE is very rarely described in the literature and usually refers to fluorouracile agents or TNF-α antagonists. The picture is characterized by the occurrence of classic discoid lesions, but aspects of lupus tumidus can occasionally develop. ANA are demonstrated in around two-thirds of the cases. Management of DILE is based on the withdrawal of the offending drug. Topical and/or systemic corticosteroids and other immunosuppressive agents should be reserved for resistant cases.

Leflunomide-induced subacute cutaneous lupus erythematosus with erythema multiforme-like lesions

Leflunomide is an immunosuppressive agent that acts by inhibiting pyrimidine synthesis in lymphocytes and other rapidly proliferating cells, as well as by suppressing tumor necrosis factor-α–induced cellular responses. A number of leflunomide-related adverse events have been reported. Among cutaneous side effects, a few cases of subacute cutaneous lupus erythematosus have been described. We report a previously undocumented reaction to leflunomide, manifesting as subacute cutaneous lupus erythematosus and erythema multiforme-like lesions, in a young woman treated with this drug for ankylosing spondylitis. Withdrawal of leflunomide combined with a short cycle of systemic corticosteroid led to the resolution of the patient’s rash, indicating this drug as being responsible for the development of the disease. We conclude that leflunomide might have triggered the occurrence of both subacute cutaneous lupus erythematosus and erythema multiforme in a patient with pre-existing autoimmune diathesis. The suppressive effect of this drug on tumor necrosis factor-α–related mechanisms might have played a role in the induction of such a unique reaction to leflunomide.

Kutaner Lupus erythematodes

Cutaneous lupus erythematosus (CLE) is a heterogenous disorder with a wide range of skin manifestations. Therefore, it has been difficult to develop a unifying concept for classifying CLE from the dermatologic perspective in the past. In 2004, the classification system was updated and includes now acute CLE (ACLE), subacute CLE (SCLE), chronic CLE (CCLE), and intermittent CLE (ICLE). Additional rarely described variants are not listed as separate entities but are included in the classical forms. Diagnosis of the different subtypes of CLE is made by considering genetic, clinical, histopathologic, and immunoserologic findings, with a systematic analysis of individual criteria. In the past years, the etiology and pathogenesis of CLE has been subject of intensive research and it has been shown by several groups that exogenous factors, such as ultraviolet light and drugs, can induce CLE. The first part of this review will enable the reader to identify the various clinical manifestations of CLE and to employ characteristic criteria to assess differential diagnostic considerations.