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Sekerel BE, Ilgun Gurel D, Sahiner UM, Soyer O, Kocaturk E. The many faces of pediatric urticaria. FRONTIERS IN ALLERGY 2023; 4:1267663. [PMID: 38026129 PMCID: PMC10655015 DOI: 10.3389/falgy.2023.1267663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Urticaria is a common disease that can affect individuals of all age groups, with approximately one-quarter of the population experiencing it at least once in their lifetime. Lesions characterized by erythema and itchy hives can appear anywhere on the body. These can vary in size ranging from millimeters to centimeters, and typically clear within 24 h. About 40% of patients with urticaria have accompanying angioedema, which involves localized deep tissue swelling. Urticaria usually occurs spontaneously and is classified into acute and chronic forms, with the latter referring to a condition that lasts for more than 6 weeks. The prevalence of chronic urticaria in the general population ranges from 0.5% to 5%, and it can either be inducible or spontaneous. The most common form of pediatric urticaria is acute and is usually self-limiting. However, a broad differential diagnosis should be considered in children with urticaria, particularly if they also have accompanying systemic complaints. Differential diagnoses of pediatric urticaria include chronic spontaneous urticaria, chronic inducible urticaria, serum sickness-like reaction, urticarial vasculitis, and mast cell disorders. Conditions that can mimic urticaria, including but not limited to cryopyrinopathies, hyper IgD syndrome, Periodic Fever, Aphthous Stomatitis, Pharyngitis and Adenitis (PFAPA), Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPs), and Schnitzler syndrome should also be considered. The many faces of pediatric urticaria can be both easy and confusing. A pragmatic approach relies on clinical foresight and understanding the various forms of urticaria and their potential mimickers. This approach can pave the way for an accurate and optimized diagnostic approach in children with urticaria.
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Affiliation(s)
- Bulent Enis Sekerel
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Deniz Ilgun Gurel
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Umit Murat Sahiner
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Ozge Soyer
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Emek Kocaturk
- Department of Allergology, Charite University School of Medicine, Berlin, Germany
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2
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Leducq S, Maruani A, Bodemer C, Biscardi S, Boccara O, Chinazzo MF, Mahé E, Plantin P, Fraitag S, Mazereeuw-Hautier J, Chiaverini C, Lemelle I, Bessis D, Bourrat E, Mallet S, Bonniaud B, Grall-Lerosey M, Martin L, Boralevi F, Piram M. Accurate diagnosis of acute hemorrhagic edema of infancy: a French multicenter observational study. Eur J Pediatr 2023; 182:4133-4141. [PMID: 37432503 DOI: 10.1007/s00431-023-05098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 07/12/2023]
Abstract
The purpose of the study is to highlight clinical signs that are either suggestive of or against the diagnosis of AHEI to improve diagnosis and management. The medical records of children under 3 years old diagnosed with AHEI were retrospectively reviewed. Clinical data and photographs were reviewed by three independent experts, and the cases were classified as probable, doubtful, or unclear AHEI. Of the 69 cases of children diagnosed with AHEI included in 22 centers, 40 were classified as probable, 22 as doubtful, and 7 as unclear. The median age of patients with probable AHEI was 11 months [IQR 9-15], and they were in overall good condition (n = 33/40, 82.5%). The morphology of the purpura was targetoid in 75% of cases (n = 30/40) and ecchymotic in 70% of cases (n = 28/40) and affected mostly the legs (n = 39/40, 97%), the arms (n = 34/40, 85%), and the face (n = 33/40, 82.5%). Edema was observed in 95% of cases and affected mostly the hands (n = 36/38, 95%) and feet (n = 28/38, 74%). Pruritus was absent in all patients with probable AHEI and described for 6/21 with doubtful AHEI (29%). AHEI was the original diagnosis in only 24 patients (n = 24/40, 60%). The major differential diagnoses were purpura fulminans and urticaria multiforme. Conclusion: AHEI, which the diagnosis is made on clinical findings, is often misdiagnosed. Purpuric lesions localized on the face/ears, arms/forearms, and thighs/legs with edema of the hands without pruritus in a young child with a good overall condition are highly suggestive of AHEI. What is Known: •Acute hemorrhagic edema of infancy (AHEI) is a cutaneous leukocytoclastic vasculitis affecting children under 3 years old. •Appropriate diagnosis is important to distinguish this benign disease from more serious diseases to avoid investigations and treatments, iatrogenic harm and unnecessary follow-up. What is New: •AHEI is an uncommon disorder often misdiagnosed by pediatricians and dermatologists. •Purpuric lesions localized on the face/ears, arms/forearms, and thighs/legs with edema of the hands without pruritus in an infant with a good overall condition are highly suggestive of AHEI.
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Affiliation(s)
- Sophie Leducq
- Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), Unit of Pediatric Dermatology, CHRU Tours, Tours, France.
- Universities of Tours and Nantes, INSERM 1246-SPHERE, , Tours, France.
| | - Annabel Maruani
- Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), Unit of Pediatric Dermatology, CHRU Tours, Tours, France
- Universities of Tours and Nantes, INSERM 1246-SPHERE, , Tours, France
| | - Christine Bodemer
- Department of Dermatology and Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC), APHP, Paris University, Necker-Enfants Malades Hospital, Paris Centre University, Imagine Institute, Paris, France
| | | | - Olivia Boccara
- Department of Dermatology and Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC), APHP, Paris University, Necker-Enfants Malades Hospital, Paris Centre University, Imagine Institute, Paris, France
| | | | - Emmanuel Mahé
- Department of Dermatology, Hôpital Victor Dupouy, Argenteuil, France
| | | | - Sylvie Fraitag
- Pathology Department, Necker-Enfants Malades Hospital, APHP, Paris, France
| | | | | | - Irene Lemelle
- Paediatric Onco-Haematology, Brabois Hospital, University Hospital of Nancy, Vandoeuvre-Lès-Nancy, France
| | - Didier Bessis
- Department of Dermatology, University Hospital of Montpellier, Montpellier, France
| | - Emmanuelle Bourrat
- Department of General Pediatrics, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Stéphanie Mallet
- Department of Dermatology, Hôpital Timone, Aix-Marseille Université, Marseille, France
| | - Bertille Bonniaud
- Department of Dermatology and Genetics of Developmental Anomalies, UMR Inserm 1231, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079, Dijon, France
| | | | | | - Franck Boralevi
- Pediatric Dermatology Unit, Hôpital Pellegrin-Enfants, CHU de Bordeaux, France
| | - Maryam Piram
- Department of Pediatrics, CHU Sainte Justine Research Centre, Sainte Justine University Hospital, University of Montreal, Montreal, QC, Canada
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Weisnicht AM, Byrne R, Henkel EB, Harding SA, Kostelyna SP, Schady D, Lai J, Stubbs LA. Recurrent Rash in an 11-Year-Old Boy With Pericardial and Pleural Effusions. Pediatrics 2022; 150:189805. [PMID: 36305212 DOI: 10.1542/peds.2021-055524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/06/2022] Open
Abstract
An 11-year-old, previously healthy boy presented to the emergency center (EC) for acute respiratory distress in the setting of 5 months of recurrent and worsening rash with progressive fatigue, shortness of breath, chest pain, and cough. At the onset of his rash, he and his younger brothers were diagnosed with roseola. Although his brothers' symptoms resolved, the patient's rash recurred, prompting his primary care provider to prescribe amoxicillin. The rash subsequently worsened, so amoxicillin was stopped; a prednisone course was prescribed which alleviated the rash. Upon completion of the prednisone course, the rash returned more diffusely with associated symptoms of shortness of breath, chest pain, and cough. Because of these symptoms, his mother brought him to the EC, where his vitals were notable for tachypnea and tachycardia. His initial EC imaging workup was remarkable for an echocardiogram with a mild to moderate circumferential pericardial effusion, chest x-ray (CXR) with a large right pleural effusion, and chest computerized tomography significant for prominent and diffuse mediastinal and hilar lymphadenopathy with numerous enlarged axillary lymph nodes. Laboratory results were notable for elevated liver enzymes, inflammatory markers, d-dimer, and brain natriuretic peptide. Differential diagnosis remained broad, including infectious, oncologic, and rheumatologic etiologies. Our panel of experts reviews the evaluation, hospital course, and treatment of this patient presenting with an unusual rash and serositis.
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Affiliation(s)
| | | | | | | | | | | | - Jamie Lai
- Pediatric Rheumatology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Leigh A Stubbs
- Pediatric Rheumatology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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Urticarial vasculitis: Clinical and laboratory findings with a particular emphasis on differential diagnosis. J Allergy Clin Immunol 2022; 149:1137-1149. [PMID: 35396080 DOI: 10.1016/j.jaci.2022.02.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/02/2022] [Accepted: 02/15/2022] [Indexed: 12/22/2022]
Abstract
Urticarial vasculitis (UV) is a rare cutaneous vasculitis of small vessels characterized by recurrent episodes of wheal-like lesions that tend to last more than 24 hours, healing with a residual ecchymotic postinflammatory hyperpigmentation. The histopathologic pattern of UV is that of leukocytoclastic vasculitis, consisting of fibrinoid necrosis of dermal vessels' walls and neutrophil-rich perivascular inflammatory infiltrates. Although its etiopahogenesis remains still undefined, UV is now regarded as an immune complex-driven disease with activation of the complement cascade, leading to exaggerated production of anaphylatoxins that are responsible for neutrophil recruitment and activation. This condition can be categorized into 2 main entities according to serum complement levels: normocomplementemic UV and hypocomplementemic UV, the latter being associated with circulating anti-C1q autoantibodies and possible extracutaneous manifestations. Systemic multiorgan involvement may be seen particularly in syndromic hypocomplementemic UV, also known as McDuffie syndrome. This review summarizes the clinicopathological and laboratory features as well as the underlying pathophysiological mechanisms of UV. A focus on its main differential diagnoses is provided, that is, chronic spontaneous urticaria, bullous pemphigoid, IgA (Henoch-Schönlein purpura) and IgM/IgG immune complex vasculitis, lupus erythematous tumidus, Wells syndrome, erythema multiforme, cutaneous mastocytosis, cryopyrin-associated periodic syndromes, and coronavirus disease 2019-associated and anti-severe acute respiratory syndrome coronavirus 2-vaccine-associated urticarial eruptions.
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Boyd ME, Yusuf S. Teenage boy with bullous rash. Arch Dis Child Educ Pract Ed 2021; 106:352-353. [PMID: 32576570 DOI: 10.1136/archdischild-2019-317600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 05/22/2020] [Indexed: 11/04/2022]
Abstract
-A 14-year-old boy with recent antibiotic treatment for tonsillitis, presented to the emergency department with 1-week history of worsening rash and haemorrhagic bullae involving the bilateral legs, trunk and hands (figures 1 and 2). Laboratory results were significant for proteinuria (2+protein) and haematuria (1+, 5-10 red blood cells/high power field); 24 hours urinary protein and renal function were within normal limits. The patient had an inconclusive skin biopsy.
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Affiliation(s)
| | - Shabana Yusuf
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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6
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Matsumura H, Ishimori S, Fujii Y, Ashida A. Hemorrhagic Bullous Immunoglobulin A Vasculitis in an Adolescent. J Pediatr 2021; 238:333-334. [PMID: 34293366 DOI: 10.1016/j.jpeds.2021.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 07/12/2021] [Accepted: 07/15/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Hideki Matsumura
- Department of Pediatrics, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Aijinkai Takatsuki General Hospital, Osaka, Japan
| | - Yuko Fujii
- Department of Pediatrics, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Akira Ashida
- Department of Pediatrics, Osaka Medical and Pharmaceutical University, Osaka, Japan
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7
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Namba T, Ebuchi Y, Manabe K, Shimizu J. Infantile leukocytoclastic vasculitis caused by enterotoxin-producing methicillin-sensitive Staphylococcus aureus. Pediatr Dermatol 2021; 38:1288-1291. [PMID: 34263483 DOI: 10.1111/pde.14706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Staphylococcus aureus infections are known to cause leukocytoclastic vasculitis (LCV). Herein, we describe a case of an 18-month-old with LCV caused by enterotoxin-producing methicillin-sensitive Staphylococcus aureus (MSSA) emanating from an unrecognized pharyngeal abscess. It is critical to consider the possibility of extracutaneous sources of MSSA infection when investigating an infant with vasculitis. Prompt diagnosis and appropriate treatment are vital in preventing potentially life-threatening complications.
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Affiliation(s)
- Takahiro Namba
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yuki Ebuchi
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Keiko Manabe
- Department of Dermatology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Junya Shimizu
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan
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Leyens J, Bender TTA, Mücke M, Stieber C, Kravchenko D, Dernbach C, Seidel MF. The combined prevalence of classified rare rheumatic diseases is almost double that of ankylosing spondylitis. Orphanet J Rare Dis 2021; 16:326. [PMID: 34294115 PMCID: PMC8296612 DOI: 10.1186/s13023-021-01945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rare diseases (RDs) affect less than 5/10,000 people in Europe and fewer than 200,000 individuals in the United States. In rheumatology, RDs are heterogeneous and lack systemic classification. Clinical courses involve a variety of diverse symptoms, and patients may be misdiagnosed and not receive appropriate treatment. The objective of this study was to identify and classify some of the most important RDs in rheumatology. We also attempted to determine their combined prevalence to more precisely define this area of rheumatology and increase awareness of RDs in healthcare systems. We conducted a comprehensive literature search and analyzed each disease for the specified criteria, such as clinical symptoms, treatment regimens, prognoses, and point prevalences. If no epidemiological data were available, we estimated the prevalence as 1/1,000,000. The total point prevalence for all RDs in rheumatology was estimated as the sum of the individually determined prevalences. RESULTS A total of 76 syndromes and diseases were identified, including vasculitis/vasculopathy (n = 15), arthritis/arthropathy (n = 11), autoinflammatory syndromes (n = 11), myositis (n = 9), bone disorders (n = 11), connective tissue diseases (n = 8), overgrowth syndromes (n = 3), and others (n = 8). Out of the 76 diseases, 61 (80%) are classified as chronic, with a remitting-relapsing course in 27 cases (35%) upon adequate treatment. Another 34 (45%) diseases were predominantly progressive and difficult to control. Corticosteroids are a therapeutic option in 49 (64%) syndromes. Mortality is variable and could not be determined precisely. Epidemiological studies and prevalence data were available for 33 syndromes and diseases. For an additional eight diseases, only incidence data were accessible. The summed prevalence of all RDs was 28.8/10,000. CONCLUSIONS RDs in rheumatology are frequently chronic, progressive, and present variable symptoms. Treatment options are often restricted to corticosteroids, presumably because of the scarcity of randomized controlled trials. The estimated combined prevalence is significant and almost double that of ankylosing spondylitis (18/10,000). Thus, healthcare systems should assign RDs similar importance as any other common disease in rheumatology.
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Affiliation(s)
- Judith Leyens
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Neonatology and Pediatric Care, Children's University Hospital, Bonn, Germany
| | - Tim Th A Bender
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Institute of Human Genetics, University Hospital, Bonn, Germany
| | - Martin Mücke
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
| | - Christiane Stieber
- Institute of General Practice and Family Medicine, University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Dmitrij Kravchenko
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Radiology, University Hospital, Bonn, Germany
| | - Christian Dernbach
- Division of Medical Psychology and Department of Psychiatry, University Hospital, Bonn, Germany
| | - Matthias F Seidel
- Department of Rheumatology, Spitalzentrum-Centre hospitalier, Biel-Bienne, Switzerland.
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Puhl V, Bonnekoh H, Scheffel J, Hawro T, Weller K, von den Driesch P, Röwert-Huber HJ, Cardoso J, Gonçalo M, Maurer M, Krause K. A novel histopathological scoring system to distinguish urticarial vasculitis from chronic spontaneous urticaria. Clin Transl Allergy 2021; 11:e12031. [PMID: 33949135 PMCID: PMC8099228 DOI: 10.1002/clt2.12031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/23/2021] [Accepted: 04/11/2021] [Indexed: 02/03/2023] Open
Abstract
Background Urticarial vasculitis (UV) is defined by long‐lasting urticarial lesions combined with the histopathologic findings of leukocytoclastic vasculitis. As one of the major unmet needs in UV, diagnostic criteria are rather vague and not standardized. Moreover, there seems to be considerable overlap with chronic spontaneous urticaria (CSU), particularly for the normocomplementemic variant of UV. Therefore, this study aimed to develop a diagnostic scoring system that improves the histopathologic discrimination between UV and CSU. Methods Lesional skin sections of patients with clinical and histopathologic diagnosis of UV (n = 46) and CSU (n = 51) were analyzed (blinded to the diagnosis) for the following pre‐defined criteria: presence of leukocytoclasia, erythrocyte extravasation, fibrin deposits, endothelial cell swelling, ectatic vessels, blurred vessel borders, dermal edema, intravascular neutrophil, and eosinophil numbers and numbers of dermal neutrophils, macrophages and mast cells. Results The greatest differences between UV and CSU samples were observed for leukocytoclasia (present in 76% of UV vs. 3.9% of CSU samples; p < 0.0001), erythrocyte extravasation (present in 41.3% of UV vs. 2.0% of CSU samples; p < 0.0001), and fibrin deposits (present in 27.9% of UV vessels vs. 9.7% of CSU vessels; p < 0.0001). Based on these findings, we developed a diagnostic score, the urticarial vasculitis score (UVS), which correctly assigned 37 of 46 cases of UV and 49 of 51 cases of CSU to the previously established diagnosis. Conclusion Our results suggest that the UVS, a combined quantitative assessment of the three criteria leukocytoclasia, fibrin deposits and extravasated erythrocytes, distinguishes UV from CSU in skin histopathology. The UVS, if validated in larger patient samples, may help to improve the diagnostic approach to UV.
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Affiliation(s)
- Viktoria Puhl
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Hanna Bonnekoh
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jörg Scheffel
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tomasz Hawro
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Karsten Weller
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Hans-Joachim Röwert-Huber
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - José Cardoso
- Department of Dermatology and Venereology, University Hospital and Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Margarida Gonçalo
- Department of Dermatology and Venereology, University Hospital and Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Marcus Maurer
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Karoline Krause
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
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10
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Mohamed MMB, Wickman TJ, Fogo AB, Velez JCQ. De Novo Immunoglobulin A Vasculitis Following Exposure to SARS-CoV-2 Immunization. Ochsner J 2021; 21:395-401. [PMID: 34984055 PMCID: PMC8675622 DOI: 10.31486/toj.21.0083] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Immunizations have been previously described as potential triggering events for the development of certain glomerular diseases. However, glomerular disease occurrences are being reported after exposure to a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. Case Report: A 50-year-old male presented to a nephrology clinic for evaluation of persistent proteinuria. Six weeks prior to evaluation, the patient had reported developing a rash 2 weeks after receiving the first dose of a SARS-CoV-2 vaccine (BNT162b2 mRNA, Pfizer, Inc). His primary care provider treated the rash with corticosteroids, leading to partial improvement of the skin lesions. Three weeks after the first vaccine injection, the patient received his scheduled second vaccine injection. Within 2 days, the rash reappeared. This time, the lesions were more severe in nature. Skin biopsy revealed immunoglobulin A (IgA)-dominant leukocytoclastic vasculitis. After the patient completed 2 weeks of oral corticosteroids, urinalysis revealed proteinuria, and consultation with nephrology was requested. On examination, healing papules were noted on his legs. Serum creatinine 2 weeks after the second dose of vaccine was 0.9 mg/dL. Microscopic examination of the urinary sediment revealed acanthocytes. Urine protein to creatinine ratio 3 weeks after the second dose of vaccine was 1.1 g/day. Serum complements were normal, and all pertinent serology was negative. Kidney biopsy findings were consistent with IgA nephropathy. Conclusion: The clinical presentation and pathologic findings in this case strongly suggest that the Pfizer SARS-CoV-2 vaccine can trigger a clinical syndrome compatible with Henoch-Schönlein purpura. The recurrence of the rash following the second dose argues for a definite causal association by the Naranjo criteria.
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Affiliation(s)
| | | | - Agnes B. Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt Medical Center, Nashville, TN
| | - Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland Faculty of Medicine, Ochsner Clinical School, Brisbane, Queensland, Australia
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11
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Basu P, Russell-Goldman E, Nazarian RM, Das S. Alcohol-Associated Immunoglobulin A Vasculitis: A Case Report and Review of the Literature. Dermatopathology (Basel) 2020; 6:288-293. [PMID: 32596212 PMCID: PMC7315200 DOI: 10.1159/000507307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/17/2020] [Indexed: 11/23/2022] Open
Abstract
Immunoglobulin A (IgA)-mediated leukocytoclastic vasculitis is a cutaneous small-vessel vasculitis characterized by skin findings of palpable purpura. It may occur secondary to infections, neoplasms, drugs, and systemic conditions, although it is most commonly idiopathic. A known, but rare, trigger for IgA vasculitis is alcohol consumption. We present a case of a man with IgA vasculitis associated with alcohol use and review the literature on alcohol-associated vasculitis. Although rarely reported, alcohol-associated IgA vasculitis is an important entity to consider for appropriate diagnosis and management of such patients.
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Affiliation(s)
- Pallavi Basu
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | | | - Rosalynn M Nazarian
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shinjita Das
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
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12
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Gehlhausen JR, Wetter DA, Nelson C, Ramachandran S, McNiff JM, Ko CJ. A detailed analysis of the distribution, morphology, and histopathology of complex purpura in hospitalized patients: A case series of 68 patients. J Am Acad Dermatol 2020; 84:1188-1196. [PMID: 32376433 DOI: 10.1016/j.jaad.2020.04.149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Purpura in inpatients commonly leads to dermatologic consultation. The differential diagnosis is broad and algorithms are intricate. OBJECTIVE We evaluated inpatient consultations for complex purpura to document the most common diagnoses and to validate the true diagnostic utility of histopathology, clinical morphology, and distribution. METHODS We reviewed a case series of 68 inpatients during a 4-year period with a dermatologic consultation for purpura and biopsy findings of vasculitis or microvascular occlusion. RESULTS Key features of complex purpura are nonbranching (round) versus branching (retiform) morphology, dependent versus acral or generalized distribution, and leukocytoclastic vasculitis versus microvascular occlusion (with emphasis on depth of involvement). Dependent nonbranching purpura with only superficial vessels involved by leukocytoclastic vasculitis was most often due to IgA vasculitis or cutaneous single-organ small-vessel vasculitis. In contrast, deeper involvement by leukocytoclastic vasculitis was suggestive of systemic disease (eg, antineutrophil cytoplasmic antibody-associated vasculitis). Branching purpura was concerning, with greater than 90% sensitivity and specificity for microvascular occlusion and associated high mortality (≈50%). The majority of patients who died had acral branching lesions. LIMITATIONS Small sample size, inpatients at a tertiary care center, and retrospective nature are some limitations. CONCLUSION Nonbranching dependent purpura corresponded to leukocytoclastic vasculitis, with the most common diagnoses being IgA vasculitis or skin-limited small-vessel vasculitis; patients with deep involvement often had systemic diseases. In this series, branching purpura was due to microvascular occlusion rather than medium-vessel vasculitis, and had associated high mortality.
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Affiliation(s)
- Jeff R Gehlhausen
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut
| | - David A Wetter
- Mayo Clinic Department of Dermatology, Rochester, Minnesota
| | - Caroline Nelson
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut
| | | | - Jennifer M McNiff
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut; Department of Pathology, New Haven, Connecticut
| | - Christine J Ko
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut; Department of Pathology, New Haven, Connecticut.
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Abstract
Cutaneous adverse drug reactions (ADRs) are commonly seen in the pediatric population in both inpatient and outpatient settings and are important to identify, evaluate, and appropriately manage. Early recognition and proper classification of a cutaneous drug reaction allows the clinician the ability to narrow in on a culprit drug and determine whether the medication is safe to continue. This review discusses the clinical presentation, categorization, and management of cutaneous ADRs in the pediatric population. [Pediatr Ann. 2020;49(3):e132-e139.].
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Kolkhir P, Grakhova M, Bonnekoh H, Krause K, Maurer M. Treatment of urticarial vasculitis: A systematic review. J Allergy Clin Immunol 2019; 143:458-466. [PMID: 30268388 DOI: 10.1016/j.jaci.2018.09.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/03/2018] [Accepted: 09/07/2018] [Indexed: 01/19/2023]
Abstract
Urticarial vasculitis (UV) is a difficult-to-treat condition characterized by long-lasting urticarial rashes and histopathologic findings of leukocytoclastic vasculitis. Treatment is dictated by the severity of skin and systemic involvement and the underlying systemic disease. This is a comprehensive systematic review of the efficacy of current UV treatment options. We searched for relevant studies in 7 databases, including MEDLINE, Scopus, and Web of Science. In total, 261 eligible studies and 789 unique patients with UV were included in the systematic review. Most patients with UV are adult women with chronic (≥6 weeks) and systemic disease. UV is mostly idiopathic but can be associated with drugs, malignancy, autoimmunity, and infections. It usually resolves with their withdrawal or cure. Corticosteroids are effective for the treatment of skin symptoms in more than 80% of patients with UV. However, their long-term administration can lead to potentially serious adverse effects. The addition of immunomodulatory or immunosuppressive agents often allows corticosteroid tapering and improves the efficacy of therapy. Biologicals, including omalizumab, as well as corticosteroids, cyclophosphamide, dapsone, mycophenolate mofetil, plasmapheresis, colchicine, hydroxychloroquine, intravenous immunoglobulin, nonsteroidal anti-inflammatory drugs, and cyclosporine, can be effective for both skin and systemic symptoms in patients with UV. H1-antihistamines, montelukast, danazol, H2-antihistamines, pentoxifylline, doxepin, and tranexamic acid are not effective in most patients with UV. As of yet, no drugs have been approved for UV, and management recommendations are based mostly on case reports and retrospective studies. Prospective studies investigating the effects of treatment on the signs and symptoms of UV are needed.
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Affiliation(s)
- Pavel Kolkhir
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology and Allergy, Allergie-Centrum-Charité, Berlin, Germany; I.M. Sechenov First Moscow State Medical University, Division of Immune-mediated skin diseases, Moscow, Russia
| | | | - Hanna Bonnekoh
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology and Allergy, Allergie-Centrum-Charité, Berlin, Germany
| | - Karoline Krause
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology and Allergy, Allergie-Centrum-Charité, Berlin, Germany
| | - Marcus Maurer
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology and Allergy, Allergie-Centrum-Charité, Berlin, Germany.
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15
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Liu F, Wang C, Wang R, Wang W, Li M. Henoch-schonlein Purpura Nephritis with Renal Interstitial Lesions. Open Med (Wars) 2018; 13:597-604. [PMID: 30519637 PMCID: PMC6272053 DOI: 10.1515/med-2018-0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 10/26/2018] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate the clinical pathology and prognosis & outcome of Henoch-Schonlein purpura nephritis (HSPN) with renal interstitial lesions. Methods All 148 patients were analyzed for clinical, renal pathological, and prognostic features. Patients with no, mild, and moderate- severe renal tubulo-interstitial lesions were included in group A, B and C, respectively. Results The estimated glomerular filtration rate (eGFR) of group B was significantly lower than that of group A. The levels of serum creatinine and blood urea nitrogen in group C were significantly higher than those in groups A and B. Clinical type II was correlated with pathological types II and IIIa; pathological type IV and IIIb were correlated with clinical type VI and IV. There were significant differences in the level of red blood cells in urinary sediment, levels of urine occult blood and in the prognosis among the 3 groups. Conclusion Clinically, Type II is the most common cause; pathologically, Type IIIa is more common. The severity of renal tubulo-interstitial lesions is positively correlated with a decline in renal function and GFR. There is a correlation between the severity of renal tubulo-interstitial lesions and the severity of hematuria. Most patients with HSPN have a good prognosis.
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Affiliation(s)
- Feng Liu
- Institute of Pathology, Basic Medical College of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Chenyu Wang
- Institute of Pathology, Basic Medical College of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Rongzhen Wang
- Department of Nephropathy, The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China
| | - Wenge Wang
- Department of Nephropathy, Lanzhou University Second Hospital, Lanzhou, Gansu Province, China
| | - Min Li
- Institute of Pathology, Basic Medical College of Lanzhou University, Lanzhou 730000, Gansu Province, China
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Riancho-Zarrabeitia L, Santurtún A. Cutaneous vasculitis in children: A nationwide epidemiological study in Spain. F1000Res 2017; 6:1527. [PMID: 30079226 PMCID: PMC6058467 DOI: 10.12688/f1000research.12372.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2017] [Indexed: 11/20/2022] Open
Abstract
Background: Cutaneous vasculitis (CV) are a complex group of conditions in children, of which IgA vasculitis (IgAV) is the most common. The objectives of the current study are to describe the incidence of CV in Spain and to analyze the temporal trend in the last 11 years, as well as it seasonal distribution. Methods: Hospital discharges of patients aged 0-18 years with a diagnosis consistent with CV in Spain from 2005 to 2015 were collected from the Spanish National Institute of Statistics (INE) databases. Results: A total of 7304 patients from January 2005 to December 2015 were included; 6991 patients (95%) had a diagnosis of IgAV. The yearly incidence in the whole group was 7.7 per 100,000. Mean age at diagnoses was 6±3 years and 52% were male. The highest rate of admissions was found in the 5-9 year-old group, followed by those with 0-4 years of age (15.7 and 9.0 admissions per 100.000, respectively). Admissions due to CV followed an annual cyclic pattern, with the highest number of daily admissions during fall and winter months and the lowest number in summer months. There was an overall downwards trend of the number of hospital admissions during the period of study, in both males and females (p=0.01). Conclusions: We have estimated an incidence of a 7.7 cases per 100,000 CV in children in Spain. CV-related hospitalization rates have a marked seasonal pattern, with a peak in fall and winter and a nadir in summer months. Children between 5 and 9 years of age are most frequently affected. There is a decreasing trend in CV-related hospitalization, the causes of which should be further assessed.
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Affiliation(s)
| | - Ana Santurtún
- Department of Physiology and Pharmacology, Legal Medicine Unit, University of Cantabria, Santander, 39011, Spain
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