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Kumar NA, Dhanaraj M, Srinivasan S, Narendra RR. Erythema elevatum diutinum with lower limb neuropathy: A rare presentation. J Family Med Prim Care 2023; 12:1713-1715. [PMID: 37767434 PMCID: PMC10521826 DOI: 10.4103/jfmpc.jfmpc_378_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/12/2023] [Accepted: 06/17/2023] [Indexed: 09/29/2023] Open
Abstract
Nodular lesions can be seen in a wide range of conditions such as infections, granulomatous conditions, neutrophilic disorders, vasculitis, benign tumours and malignant conditions. These numerous aetiologies behind the occurrence of nodular lesions signify the importance of thorough work-up of the patient to diagnose the underlying reason behind the clinical condition. Erythema elevatum diutinum (EED) is a rare vasculitis with variable clinical presentation, the diagnosis of which can be challenging. Extracutaneous signs such as arthralgias, oral and penile ulcers, involvement of the eye and neuropathy have all been linked to it. Various systemic illnesses, infectious diseases, autoimmune diseases, haematological abnormalities and plasma cell dyscrasias are also associated with EED. Such extracutaneous signs in EED patients indicate that the condition may involve several organ systems. Patients with EED should be assessed for systemic manifestations to ensure focused care, since extracutaneous forms of EED may comprise deposition of circulating immune complexes.
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Affiliation(s)
- N. Ashok Kumar
- Department of D.V.L, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Manoharan Dhanaraj
- Department of D.V.L, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Shreya Srinivasan
- Department of D.V.L, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Raksha Raja Narendra
- Department of D.V.L, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
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Agaimy A, Förster S, Kalla J, Stacher-Priehse E, Titze U, Vieth M. Paravertebral fibrous pseudotumor: Four cases of a distinctive tumefactive lesion overlapping with eosinophilic angiocentric fibrosis and tumoral erythema elevatum diutinum. Ann Diagn Pathol 2023; 62:152073. [PMID: 36502765 DOI: 10.1016/j.anndiagpath.2022.152073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
Eosinophilic angiocentric fibrosis (EAF) is a rare tumefactive fibroinflammatory disease with predilection for the upper respiratory tract, characterized by concentric (onionskin) fibrosis around small arterioles with variable intervening storiform fibrosis admixed with chronic inflammatory infiltrates rich in eosinophils. Erythema elevatum diutinum (EED), another autoimmunological disorder that mainly affects acral sites and extensor surfaces, is characterized by neutrophilic leukocytoclastic vasculitis. Rarely, older EED lesions may present as tumefactive nodular (pseudotumoral) fibrous masses closely mimicking EAF. We herein describe four patients (all males) aged 66-70 years who presented with large (median, 7 cm) tumor-like fibrous lesions in the paravertebral region not associated with a known clinical autoimmune disease. All cases were resected surgically with the suspicion of a neoplasm. They displayed a strikingly similar histological appearance with combined features of EAF and nodular fibrous EED. None had evidence of obliterative phlebitis or increased IgG4: IgG ratio. The etiology of this distinctive lesion and its predilection for the paravertebral area of males remains obscure. A distinctive tumefactive localized reaction to trauma caused by degenerative disease of adjacent vertebrae might be a possible explanation.
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Affiliation(s)
- Abbas Agaimy
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nürnberg, University Hospital Erlangen, Germany.
| | - Stefan Förster
- Klinik und Institut für Nuklearmedizin, Klinikum Bayreuth GmbH, Bayreuth, Germany
| | - Jörg Kalla
- Institut für Pathologie, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | | | - Ulf Titze
- Institut für Pathologie des Klinikum Lippe, Detmold, Germany
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nürnberg, University Hospital Erlangen, Germany; Institut für Pathologie, Klinikum Bayreuth GmbH, Bayreuth, Germany
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Awan BE, Noda Y, Yabuno Y, Hokazono Y, Ansai S, Ogawa R. A Case of Erythema Elevatum Diutinum (EED) Exhibiting A Keloid-Like Appearance. Dermatol Ther (Heidelb) 2021; 11:2235-2240. [PMID: 34778936 PMCID: PMC8611145 DOI: 10.1007/s13555-021-00639-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/30/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Most severe-appearing keloids tend to occur around joints because of the increased extensional stimulation of the scar in those areas. However, erythema elevatum diutinum (EED) appears more commonly on friction sites including extensor surfaces of the extremities and dorsal surfaces of joints. EEDs also presents as red-brown and elevated lesions. Case Presentation In this report, we describe a 42-year-old female who presented with firm, sporadic, brown-colored raised nodules on her bilateral lower extremities. As the appearance of these nodules resembled keloids, resection of the affected area with subsequent radiation therapy was initiated. However, histopathologic examination performed after treatment revealed tuberous lesions in the dermis, increased wired collagen fibers, neutrophilic infiltrate with nuclear dust, and edematous endothelial cells in the small vessels. Consequently, the patient was later diagnosed with EED. Post-surgery, no recurrence or abnormal scars appeared. Discussion Whereas clinical findings of EED are similar to that of keloids, the mechanisms of the two conditions differ considerably, leading to varying management strategies. EEDs can be misdiagnosed as keloids on several grounds; they can both appear morphologically similar, exhibit as stiff lesions, demonstrate chronic inflammation of the reticular dermis, and appear anywhere on the body. The only definitive method of differentiating between the two is through histopathologic examination. Conclusion EED should be considered as one of the differential diagnoses for any patients presenting with keloid-like lesions on friction sites and biopsy should be performed prior to resection and radiotherapy.
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Affiliation(s)
- Bint-E Awan
- Department of Plastic, Aesthetic and Reconstructive Surgery, Nippon Medical School, Tokyo, Japan. .,George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Yoshihiro Noda
- Department of Plastic, Aesthetic and Reconstructive Surgery, Nippon Medical School, Tokyo, Japan
| | - Yuto Yabuno
- Department of Plastic, Aesthetic and Reconstructive Surgery, Nippon Medical School, Tokyo, Japan
| | - Yu Hokazono
- Department of Plastic, Aesthetic and Reconstructive Surgery, Nippon Medical School, Tokyo, Japan
| | - Shinichi Ansai
- Department of Dermatology, Nippon Medical School, Tokyo, Japan
| | - Rei Ogawa
- Department of Plastic, Aesthetic and Reconstructive Surgery, Nippon Medical School, Tokyo, Japan
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Wollina U, Krönert C, Koch A, Schönlebe J, Vojvodic A, Lotti T. Erythema Elevatum Diutinum - Two Case Reports, Two Different Clinical Presentations, and a Short Literature Review. Open Access Maced J Med Sci 2019; 7:3039-3042. [PMID: 31850118 PMCID: PMC6910801 DOI: 10.3889/oamjms.2019.765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Erythema elevatum diutinum (EED) belongs to the spectrum of cutaneous leukocytoclastic vasculitides. EED is a very rare dermatosis presenting with reddish to browning papules and plaques. EED may be associated with infections, hematologic and autoimmune disorders. CASE REPORTS: We present two patients with EED, a 50-year-old woman and a 42-year-old man. While the woman shows an association with colitis ulcerosa, the man had an anti-thrombin deficiency. Treatment was started with oral corticosteroid and dapsone, respectively. In both cases, there was a partial and temporary response. CONCLUSIONS: EED is a rare vasculitis with an unusual clinical presentation and a chronic course. Response to treatment is unsatisfactory and in the long-term run sometimes frustrating.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany
| | - Claudia Krönert
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany
| | - André Koch
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany
| | - Jacqueline Schönlebe
- Institute of Pathology "Georg Schmorl", Städtisches Klinikum Dresden, Academic Teaching Hospital, Dresden, Germany
| | | | - Torello Lotti
- Department of Dermatology, University of Rome "G. Marconi", Rome, Italy
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Ahmad S, Delarosa M, Kleinman W, Ahmad R. Primary Surgical Treatment of Erythema Elevatum Diutinum. J Hand Surg Am 2019; 44:522.e1-522.e5. [PMID: 30241974 DOI: 10.1016/j.jhsa.2018.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/28/2018] [Accepted: 07/24/2018] [Indexed: 02/02/2023]
Abstract
Erythema elevatum diutinum (EED) is a rare skin disease caused an Arthrus-type immunological reaction to antigen with immune complex deposition in the cutaneous microvasculature, which leads to tissue damage secondary to the effects of complement and leukocytes. It presents as brown or red cutaneous nodules, papules, or plaques, often on the extensor surfaces of the hands, knees, or elbows. Onset usually occurs in the fourth to sixth decades but possibly younger in patients with human immunodeficiency virus. Medical treatment is usually successful; however, surgical treatment can be used when chemotherapy fails. We present a case of a 29-year-old man with EED treated with excision and skin grafting.
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Affiliation(s)
- Shannon Ahmad
- Department of Orthopaedics, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Matthew Delarosa
- Department of Orthopaedics, Louisiana State University Health Sciences Center, New Orleans, LA.
| | | | - Rasheed Ahmad
- Department of Orthopaedics, Louisiana State University Health Sciences Center, New Orleans, LA
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Affiliation(s)
- Charlotte Paugam
- Dermatology Department, Hôtel-Dieu University Hospital, Nantes, France
| | - Othman Laghmari
- Histopathology Laboratory, 55 Rue Amiral du Chaffault, Nantes, France
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Abstract
Humoral immunity is the cause of multiple diseases related to antibodies (IgA, IgG, IgM) produced by the patient. Two groups of diseases are identified. The first group is related to circulating antigen-antibody complexes. The antigens are various. They are often unknown. These immune complexes cause a vascular inflammation due to the complement fixation. Consequently, this group is dominated by inflammatory vasculitis. In the second group, the pathology is due to the fixation in situ of antibodies to a target antigen of the skin that is no more recognized by the patient. This group is represented by the auto-immune bullous dermatoses.
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Affiliation(s)
- Janine Wechsler
- Département de pathologie, service d'anatomie et de cytologie pathologiques, hôpital Henri-Mondor, AP-HP, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France.
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Keyal U, Bhatta AK, Liu Y. Erythema elevatum diutinum involving palms and soles: a case report and literature review. Am J Transl Res 2017; 9:1956-1959. [PMID: 28469800 PMCID: PMC5411943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 03/22/2017] [Indexed: 06/07/2023]
Abstract
Erythema elevatum diutinum (EED) is a rare chronic inflammatory dermatosis and a part of the spectrum of cutaneous leukocytoclasticvasculitis. The most common site of involvement is extensor surface of the extremities, with a predilection for the skin overlying joints, particularly hands, feet, elbows and knees, as well as buttocks and Achilles tendons. Here we report a case of EED with atypical presentation involving palms and soles. The patient showed dramatic response to the treatment with prednisolone combined with Tripterygium wilfordii glycoside (TWP). The lesions improved significantly after three months of therapy. We will also review the atypical cases of EED that were previously published in English literature.
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Affiliation(s)
- Uma Keyal
- Department of Dermatopathology, Shanghai Skin Disease Hospital, School of Medicine, Tongji UniversityShanghai, China
| | - Anil Kumar Bhatta
- Department of Dermatopathology, Shanghai Skin Disease Hospital, School of Medicine, Tongji UniversityShanghai, China
| | - Yeqiang Liu
- Department of Dermatopathology, Shanghai Skin Disease Hospital, School of Medicine, Tongji UniversityShanghai, China
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Patnala GP, Sunandini AP, Rayavarapu R, Yandapalli PS. Erythema elevatum diutinum in association with IgA monoclonal gammopathy: A rare case report. Indian Dermatol Online J 2016; 7:300-3. [PMID: 27559509 PMCID: PMC4976413 DOI: 10.4103/2229-5178.185472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Erythema elevatum diutinum (EED) is a rare form of vasculitis characterized clinically by red-violet brown papules, plaques, and nodules mainly involving the extensor surfaces; histologically by leukocytoclastic vasculitis in early lesions, and fibrosis and cholesterolosis in late lesions. EED has been associated with many systemic disorders including infections, autoimmune disorders, and both benign and malignant hematological disorders. As it is a rare form of vasculitis and only 250 cases reported till date, we report a case of EED in association with IgA monoclonal gammopathy with partial response to dapsone treatment.
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Affiliation(s)
- Guru Prasad Patnala
- Deparment of Dermatology Venereology and Leprosy, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
| | - Anila P Sunandini
- Deparment of Dermatology Venereology and Leprosy, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
| | - Rama Rayavarapu
- Deparment of Dermatology Venereology and Leprosy, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
| | - Padmasri Somala Yandapalli
- Deparment of Dermatology Venereology and Leprosy, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
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Kavand S, Lehman JS, Gibson LE. Granuloma Faciale and Erythema Elevatum Diutinum in Relation to Immunoglobulin G4-Related Disease: An Appraisal of 32 Cases. Am J Clin Pathol 2016; 145:401-6. [PMID: 27124923 DOI: 10.1093/ajcp/aqw004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Sima Kavand
- From the Department of Medicine, Presence Saint Francis Hospital, University of Illinois, Evanston
| | - Julia S Lehman
- Departments of Dermatology, Pathology and Laboratory Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Lawrence E Gibson
- Departments of Dermatology, Pathology and Laboratory Medicine, Mayo Clinic College of Medicine, Rochester, MN.
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Rao GR, Joshi R, Phaneendra Prasad AK, Amareswar A, Sandhya S, Sridevi M. Nodular Erythema Elevatum Diutinum Mimicking Kaposi's Sarcoma in a Human Immunodeficiency Virus Infected Patient. Indian J Dermatol 2014; 59:592-4. [PMID: 25484391 PMCID: PMC4248498 DOI: 10.4103/0019-5154.143527] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Erythema elevatum diutinum (EED) has been emerging as a specific Human Immunodeficiency Virus (HIV) associated dermatosis in recent times. It is an extremely rare chronic disease of unknown origin and part of the spectrum of leukocytoclastic vasculitis. We describe a case of EED simulating Kaposi's sarcoma in a 52-year-old HIV infected female patient with no previous opportunistic infections and CD4+ count of 164/mm(3). Therapy with oral dapsone (100 mg/day) for two weeks resulted in resolution of some lesions.
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Affiliation(s)
- G Raghurama Rao
- Department of DVL, GSL Medical College, Rajahmundry, Andhra Pradesh, India
| | - Rajiv Joshi
- Department of Dermatopathology, Hinduja Hospitals, Mumbai, Maharashtra, India
| | | | - A Amareswar
- Surya Skin Care and Research Center, Visakhapatnam, Andhra Pradesh, India
| | - S Sandhya
- Surya Skin Care and Research Center, Visakhapatnam, Andhra Pradesh, India
| | - M Sridevi
- Surya Skin Care and Research Center, Visakhapatnam, Andhra Pradesh, India
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Kim GW, Park HJ, Kim HS, Kim SH, Ko HC, Kim BS, Kim MB. Dapsone Hypersensitivity Syndrome That Occurred during Treatment of Pediatric Patient with Erythema Elevatum Diutinum. Ann Dermatol 2011; 23:S290-5. [PMID: 22346260 PMCID: PMC3276779 DOI: 10.5021/ad.2011.23.s3.s290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 11/15/2010] [Accepted: 11/15/2010] [Indexed: 11/08/2022] Open
Abstract
Herein, we report a case of an 8-year-old girl with dapsone hypersensitivity syndrome (DHS) that occurred during the treatment of erythema elevatum diutinum. She had fever, gross hematuria, and malaise for three weeks after initiation of dapsone therapy. Five days after stopping dapsone treatment, she returned to the emergency clinic because of high fever, emesis, diarrhea, upper respiratory symptoms, and worsening of exanthematous eruptions. A diagnosis of DHS was made, and it improved with oral prednisone. We recommend that pediatric patients who are treated with dapsone need to be observed carefully for the development of DHS.
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Affiliation(s)
- Gun-Wook Kim
- Department of Dermatology, Pusan National University School of Medicine, and Biomedical Research Institutue, Pusan National University Hospital, Busan, Korea
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Abstract
Erythema elevatum diutinum is a rare, chronic cutaneous vasculitis that presents with plaques or nodules on the extensor surfaces of extremities. Although the exact pathogenesis is unknown, patients usually have an underlying systemic medical problem such as malignancy, autoimmune disease or HIV. Management of the cutaneous manifestations is aimed at controlling the underlying disease process, in addition to medical therapy directed at suppressing the lesions. The difficult case of a 60-year-old man, who was not a candidate for medical therapy but has undergone successful surgical therapy of this rare disease for 10 years, is presented.
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