Kikuchi-Fujimoto disease preceded by lupus erythematosus panniculitis: do these findings together herald the onset of systemic lupus erythematosus?

Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare disorder that must be distinguished from systemic lupus erythematosus (SLE). Although a minority of patients with KFD develop SLE, most patients have a self-limited disease. Importantly, KFD can have skin manifestations resembling cutaneous lupus. Therefore, the diagnosis of SLE should be predicated on a complete rheumatologic workup and not on the constellation of skin disease and lymphadenitis. Nonetheless, as our exceedingly rare case illustrates, patients who do not initially meet diagnostic criteria for SLE require dermatologic follow-up. We present a young adult woman who had a remote history of KFD and later presented with combined features of discoid lupus and lupus erythematosus panniculitis (LEP). On subsequent rheumatologic workup, she fulfilled criteria for SLE. We discuss the differential diagnosis of both KFD and LEP and emphasize how strong communication among dermatologists and other healthcare providers is essential in the management of patients with KFD.

Sustained Drug Free Remission of Lupus Panniculitis with Methotrexate: A Report From Nepal

Cutaneous manifestations are second most common presenting feature of lupus. Discoid lupus erythematosus is the most common variant amongst all; lupus panniculitis being described in only 2–5% of cases. Most cases of cutaneous lupus are associated with autoantibodies and either precede or follow the systemic manifestations of lupus. There is no proven treatment for cutaneous manifestations of lupus including lupus panniculitis. Available non-randomized studies show efficacy of hydroxychloroquine in most cases, whereas methotrexate and other immunosuppressant are used in relapsing cases.

We describe a case of lupus panniculitis presenting as isolated manifestation of lupus with negative autoantibody titers which responded well to methotrexate. We observed that lesions went into drug free remission in 1 year and did not recur on 1 year follow-up. There was no residual skin atrophy or scarring. Drug free remission in isolated cases of lupus panniculitis variant could be possible with timely intervention in the absence of autoantibodies.

Tumid lupus: An unexpected diagnosis for the otolaryngologist

Tumid lupus is an uncommon variant of lupus erythematosus. Patients present with subcutaneous lesions. Ophthalmic literature reports disease manifestation as orbital inflammation. Autoimmune serology is often negative. Without a high index of suspicion, the diagnosis is easily overlooked delaying treatment. Tumid lupus is not significantly discussed in the Otolaryngologic literature. Here we present a Case Report of a male who initially presented to Ophthalmology with unilateral orbital complaint of eyelid puffiness. Orbital biopsy and subsequent biopsy of his submental skin lesions ultimately led to this unexpected diagnosis. We discuss the method to diagnose tumid lupus including representative histopathologic findings.

The proportion of lymphocytic inflammation with CD123-positive cells in lupus erythematous profundus predict a clinical response to treatment

Lupus erythematosus profundus is a rare inflammatory disorder of subcutaneous fat in patients with lupus ery-thematosus. Previous reports suggested that plasmacytoid dendritic cells, which expressed CD123 and CD303 antigens, play a central proinflammatory role in the patho-genesis of lupus erythematosus. To find the factors that determine the response to treatment, we analysed 23 skin specimens from the patients with lupus erythematosus profundus. The patients with considerable lymphocytic inflammation with high percentages of CD123+ cells in dermis and subcutaneous fat significantly responded to the systemic corticosteroid therapies. On the other hand, the patients with minor lymphocytic inflammation with low percentages of CD123+ cells showed poor response to treatments. The mean percentage of CD123+ cells in patients who showed good response to therapy was significantly higher than those that showed poor response (p = 0.027). These results suggest that the clinical response to treatment of lupus erythematosus profundus could be predicted from the histological features.

Lupus Panniculitis with Combined Features of Dermatomyositis Resulting in Severe Lipoatrophy

An 11-year-old girl presented with a one-year history of multiple, hard, slightly painful subcutaneous nodules on her right cheek, upper arms, and buttock. Histology of a skin biopsy specimen showed a lobular panniculitis. Laboratory studies revealed positive ANA, anti-double strand DNA, and elevated muscle enzymes. She was diagnosed as having lupus panniculitis. During hydroxychloroquine treatment, erythema over knuckle joints developed. These unusual clinical and laboratory findings of panniculitis associated connective tissue diseases made it difficult to make a precise diagnosis. We report this unusual case of lupus panniculitis with combined features of dermatomyositis resulting in severe lipoatrophy.

[Lupus erythematosus panniculitis: clinical and histopathological analysis of 22 cases]

OBJECTIVE

To explore the clinical and histopathological manifestations, therapy and prognosis of lupus erythematosus panniculitis (LEP).

METHOD

We retrospectively reviewed the clinical data and histopathological features of 22 cases of LEP diagnosed at Peking Union Medical College Hospital from January 2008 to February 2010.

RESULTS

The lesions appeared as atrophy, erythema, subcutaneous nodules, infiltrated erythema, and ulceration over the scalp, face, upper limbs, and buttock. Histopathological features were lobular panniculitis in the subcutaneous fat; sometimes septal panniculitis could be seen. Hydroxychloroquine sulfate and corticosteroid were effective treatment; most patients responded well to the treatment, while a few experienced recurrence when the treatment tapped or discontinued.

CONCLUSIONS

LEP is a rare cutaneous variant of lupus erythematosus. The diagnosis of LEP is mainly based on clinical findings and pathological features. Hydroxychloroquine and low- and middle-dose corticosteroid are effective for the treatment of LEP.

[Quinacrine in the treatment of cutaneous lupus erythematosus: practical aspects and a case series]

Hydroxychloroquine and chloroquine are antimalarials used as first-line treatment of cutaneous lupus. Quinacrine is not often employed by Spanish physicians due to a lack of information about its use and the fact that it is not marketed in Spain. It is effective in monotherapy or in combination therapy with other antimalarials. One of the advantages of quinacrine over chloroquine and hydroxychloroquine is that it does not appear to cause retinal toxicity. Quinacrine is used as second-line therapy in patients with pre-existing eye problems that contraindicate treatment with chloroquine or hydroxychloroquine (after evaluation of which drug has the better risk-benefit relationship), and in combination therapy with other antimalarials inpatients with resistance or only a partial response to chloroquine or hydroxychloroquine. We report 8 cases of patients with cutaneous lupus who received treatment with quinacrine in monotherapy or in combination with others antimalarials. Lesions resolved in 5 patients and improved in 3. Therapy had to be withdrawn in 1 patient due to an exacerbation of his psoriasis.

Lupus profond et myélopathie

BACKGROUND

We report a case of myelopathy during the course of lupus profundus that is unique to our knowledge.

CASE-REPORT

A 29-year-old woman had lupus profundus since 1999, initially associated with thrombopenia (28,000 platelets/mm3) treated with corticosteroids for 6 months. Several nodular eruptions occurred from 1999 to 2004. Antinuclear antibodies were positive at 1/320 to 1/640 and complement C4 fraction was low. While being treated with hydroxychloroquine for a recent flare-up of nodular lesions of lupus profundus, she complained of paraesthesia of the abdominal wall and of the upper and lower limbs, suggestive of a medullary lesion. MRI disclosed an image of acute myelitis at the level of the second cervical vertebra. High doses of corticosteroids were promptly administered intravenously (methylprednisolone bolus) followed by oral prednisone and hydroxychloroquine. Six months later the patient was free of neurologic or cutaneous symptoms.

DISCUSSION

In the literature, systemic signs are rarely associated with lupus profundus and myelitis has never been reported. Lupus myelitis is a vascular and/or demyelinating and usually segmental lesion of the spinal cord. Neurologic symptoms are those of acute rather than chronic or recurrent transverse myelitis. The prognosis is poor with frequent and severe functional sequelae. Treatment is mainly based on high-dose systemic corticotherapy alone or combined with cyclophosphamide. Our patient responded favourably to early methylprednisolone bolus followed by oral corticosteroids and antimalarial treatment.

CONCLUSION

Lupus profundus is classically of benign course with only cutaneous involvement, but it may sometimes be a sign of systemic lupus and in rare cases may be associated with severe complications.

The dynamism of cutaneous lupus erythematosus: mild discoid lupus erythematosus evolving into SLE with SCLE and treatment-resistant lupus panniculitis

We present a 47-year-old Caucasian female who initially presented with mild discoid lupus erythematosus that evolved into systemic lupus erythematosus with subacute cutaneous LE and treatment-recalcitrant lupus panniculitis. Conventional therapy with antimalarials, systemic steroids, azathioprine, cyclophosphamide, methotrexate, and pulse doses of methylprednisolone did not control the course of the disease. Cyclosporin-A treatment led to clinical improvement and maintained remission.

Lupus panniculitis involving the breast

Lupus panniculitis is an unusual immunological disease that characteristically affects the subcutaneous fat and occurs in 2% of patients with systemic lupus erythematosus. We report a case of lupus panniculitis involving the breast, which represents a very uncommon location. Mammographically, it presented as a suspicious irregular mass involving the subcutaneous fat pad with skin thickening. High echogenicity constituted the most relevant sonographic finding. To the best of our knowledge, the magnetic resonance (MR) features have not been previously described. High signal intensity was found on both T1- and T2-weighted precontrast MR images. A dynamic contrast-enhanced study revealed a suspicious focal mass with irregular margins and rim enhancement, with a type 3 time-signal intensity curve. Differential diagnosis with carcinoma and fat necrosis and the value of core biopsy are discussed.

Sclerodermic Linear Lupus Panniculitis: Report of Two Cases

Lupus erythematosus panniculitis is a rare disease characterized by deep subcutaneous nodules, most commonly localized on the upper limbs and face. Unique clinical presentations, such as linear configuration or 'overlap' forms between lupus erythematosus panniculitis and localized scleroderma have been reported. We present here the clinical characteristics, course and laboratory findings of 2 patients having linear lupus erythematosus panniculitis with localized scleroderma-like changes. The 2 patients (of the 14 patients with lupus erythematosus panniculitis seen by us since 1990) were females with a young age at the onset of disease (median, 25 years). In 1 case, evolution into systemic lupus erythematosus with severe renal involvement occurred whereas the other patient, who had a spontaneous abortion and exhibited anticardiolipin antibodies, should be followed and screened for the emergence of antiphospholipid syndrome. Thus, the clinical behavior of this variant seems to be more aggressive, as compared with the usual course of lupus erythematosus panniculitis, which is considered to be a benign disease, although some reports have suggested that its prognosis is not always favorable. The linear distribution could be the clinical hallmark of such a unique, 'sclerodermic' subset of lupus erythematosus panniculitis.

Lupus-like panniculitis in a patient with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED)

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive disorder, characterised by a loss of self-tolerance to endocrine tissues, chronic candidiasis and ectodermal disorders. APECED is associated with mutations of a single gene, designated autoimmune regulator (AIRE). We describe a 31-year-old APECED patient with non-traumatic, cutaneous ulcers on both forearms with features of a lupus-like panniculitis. On admission to the ICU in September 2001, the patient suffered from a ketoacidotic, hyperglycemic coma and adrenal crisis due to an Enterobacter-cloacae sepsis, originating from multiple, necrotising deep cutaneous ulcers. These ulcers spontaneously developed on both forearms, some of which were just emerging, full blown or healing with scars. Histological examination showed signs of a scarring panniculitis and vasculitis. Immunohistochemistry and direct immunofluorescence with characterisation of immunoglobulin and complement-factor binding pattern revealed features of a lupus-like panniculitis. Sequence analysis of all 14 exons of the AIRE gene revealed a R257 X mutation in exon 6 resulting in a nonsense mutation at codon 257 confirming the diagnosis of APECED. Oral treatment with 60 mg/day corticosteroids for two weeks led to complete resolution of all ulcers. In conclusion, mutations in the AIRE gene may provide the genetic background against which additional factors can initiate an autoimmune process. Here, autoimmune panniculitis appears to be an associated feature of the APECED syndrome. Our findings support the use of immunosuppressive therapy for autoimmune disease components of the APECED syndrome.

Discoid lupus erythematosus and lupus profundus in childhood: a report of two cases

Discoid lupus erythematosus (DLE) is a rare disorder in childhood, with 22 cases reported in the English-language literature. Less than 2% of patients with DLE have an onset before 10 years of age. We describe two children with DLE and lupus profundus with an onset of the disease at the ages of 11 and 15 years and focus on likely histopathologic differences between DLE in children and in adults. Histopathologic characteristics for childhood DLE might be an intense periadnexal and perivascular infiltrate extending into the interstitium and subcutaneous tissue consisting of lymphocytes, histiocytes, eosinophilic granulocytes, and plasma cells and lacking epidermal atrophy. The diagnosis of DLE in our two patients was established by clinicopathologic correlation based on clinical presentation, histologic and immunofluorescent findings in skin biopsy specimens, and the absence of clinical and laboratory evidence of systemic involvement. Therapy with antimalarials resulted in reduction of the skin lesions, but in one patient severe lipoatrophy occurred.

[Cutaneous lupus profundus]

The objective of this studies is to review clinical and laboratory features of lupus panniculitis. The authors report 3 cases of lupus profundus from a group of 70 lupus erythematosus. In both cases the lupus panniculitis presented as subcutaneous infiltrated and indurated nodules. The diagnosis was confirmed on clinical, histological and therapeutic data. The evolution is slow and is characterised by regression of the inflammatory lesions with treatment by antimalarial drugs. The lupus panniculitis has generally a favorable prognosis.

Lupus panniculitis clinically simulating alopecia areata

A 27-year-old woman with a known history of lupus erythematosus presented with two circumscribed patches of non-scarring alopecia closely resembling alopecia areata. Scalp biopsy showed a predominantly subcutaneous and deep dermal lymphocytic infiltrate that surrounded the deep follicular segments and hair bulbs, as well as the eccrine glands. There was associated hyaline fat sclerosis. The epidermis, infundibular and isthmus segments of follicles were relatively spared and lacked the lichenoid inflammation and fibrosis seen with lupus erythematosus. The biopsy findings illustrate that the deep variant of lupus panniculitis may be concentrated around the hair bulbs and deep temporary segments of hair follicles and spare the permanent stem cell-rich follicular segments. This pattern is capable of producing a temporary hair-loss, clinically simulating alopecia areata. The clinical history, presence of subtle erythema and scalp tenderness on physical examination, as well as the biopsy findings, were important clues in distinguishing our case from a true combination of alopecia areata and lupus erythematosus.

Calcifying lupus panniculitis in a patient with subacute cutaneous lupus erythematosus: response to diltiazem and chloroquine

Lupus panniculitis has been reported to occur with a frequency of 2-3% in patients with lupus erythematosus (LE). It is most often reported in association with lesions of discoid LE. We describe a patient with subacute cutaneous LE who developed calcified nodules that were histopathologically consistent with lupus panniculitis. She was treated with a combination of chloroquine and diltiazem with a good therapeutic response. The addition of diltiazem may be beneficial in patients with calcified nodules of lupus panniculitis.

Lupus erythematosus profundus with unusual skin manifestation: subcutaneous nodules coexisting with eyelid plaques

A 71-year-old Japanese woman presented with erythematous plaques on the eyelids and subcutaneous indurations or nodules with or without overlying erythema on the hands, thigh, and leg. She also had oral ulcers, arthralgia and a low grade fever. Laboratory tests revealed an elevated titer of antinuclear antibody, an increased erythrocyte sedimentation rate and anemia. Skin biopsy specimens from the hand and thigh showed lymphocytic perivascular and periappendageal infiltrates and vacuolar alterations at the basement membrane zone of the skin appendages. Moreover, there was a dense lymphocytic infiltrate deep in the dermis with extension into the subcutaneous fat, which was compatible with the diagnosis of lupus erythematosus profundus. Although the biopsy specimen from the eyelid lesion did not contain the subcutaneous fat, the changes in the dermis were essentially the same as those of the hand and thigh. The eruption as well as the other symptoms promptly responded to oral prednisolone.

Lupus erythematosus panniculitis in a patient with autoimmune hepatitis

Lupus erythematosus panniculitis (profundus), a rare variant of chronic panniculitis, sometimes develops during the course of discoid lupus erythematosus or systemic lupus erythematosus. A 61-year-old woman had suffered from autoimmune hepatitis type I for 5 years. Prednisolone had been administered as maintenance therapy and her hepatitis had been well controlled. However, asymptomatic erythematous indurated nodules developed symmetrically in both pre-auricular regions, and skin biopsy revealed lupus erythematosus panniculitis (profundus). Increase in dosage of prednisolone resolved the skin lesion, leaving depressed atrophic scars. This is the first report of lupus erythematosus panniculitis complicating autoimmune hepatitis.

Maintaining remission of lupus erythematosus profundus (LEP) with cyclosporin A

We report a young female patient with recurrent lupus erythematosus profundus (LEP) who has successfully maintained remission of LEP with cyclosporin A (CsA), although conventional treatments such as systemic corticosteroids (low-dose), dapsone, and other immunosuppressive drugs (azathiopurine, cyclophosphamide) could not maintain remission.

Generalized lupus erythematosus profundus in a patient with genetic partial deficiency of C4

Lupus erythematosus profundus (LEP) is an unusual variant of cutaneous lupus erythematosus (CLE)that is characterized by chronic, recurrent inflammation of the subcutaneous tissue leading to fibrosis. It is found in the settings of both discoid and systemic lupus erythematosus. Generalized forms are extremely rare. We present a case of generalized LEP associated with genetic partial C4-deficiency.

[ANCA-positive lupus erythematodes profundus. Successful therapy with low dosage dapsone]

A 44-year-old male patient with lupus erythematosus profundus (lupus panniculitis) (LEP) of the right cheek/infraorbital region presented as a recurrent swelling. He had only anti-neutrophil-cytoplasmic antibodies (ANCA), which have not been previously described in association with LEP. There was no indication of systemic lupus erythematosus. While chloroquine produced no benefits, the skin lesions promptly cleared with dapsone. Step by step we reduced dapsone to a final dose of 50-75 mg per week. The ANCA titer decreased in parallel to the clinical improvement.

Lupus panniculitis treated by a combination therapy of hydroxychloroquine and quinacrine

Lupus erythematosus panniculitis (LEP) is an unusual clinical variant of lupus erythematosus (LE) in which the cutaneous inflammatory reaction occurs primarily in the deeper corium. The common clinical features of LEP includes asymptomatic, firm, sharply defined nodules. The histologic findings are characterized by nonspecific panniculitis composed of lymphoid cells, plasma cells, and histiocytes with varying degrees of necrobiotic changes with fibrinoid deposits. In our case, a 24-year-old male patient visited our clinic with non-tender, hard, plaque-like lesions and overlying erythema on the left zygomatic, nasal, and submandibular area. Histopathologic and direct immunofluorescent findings of the lesion were compatible with LEP. His skin lesions waxed and waned with systemic steroid or hydroxychloroquine therapy. He has responded well to a combination therapy of hydroxychloroquine and quinacrine.

Cytophagic histiocytic panniculitis in systemic lupus erythematosus

This paper presents a case of cytophagic histiocytic panniculitis in a Japanese woman, who had systemic lupus erythematosus complicated with Hashimoto's thyroiditis and lupus nephritis from the age of 12. The patient had painful multiple purplish subcutaneous nodules on the face, trunk and extremities, high fever and liver dysfunction without coagulopathy. The histological features of the skin nodules were extensive histiocyte and/or macrophage infiltration often with leuko- and/or erythrophagocytosis in the subcutaneous fat tissue.

[Kaposi-Irgang lupus erythematosus profundus. Lupus erythematosus panniculitis]

Lupus panniculitis is a rare variant of cutaneous lupus erythematosus. Two typical cases demonstrate the association of lupus panniculitis with signs of discoid lupus erythematosus and systemic lupus erythematosus. Clinically it is characterised by subcutaneous nodules or plaques, which may ulcerate leaving depressed atrophic scars. Histologically the lesions show lobular panniculitis. A positive immunofluorescent band test with deposition of IgG, IgM and C3 at the dermal-epidermal junction and blood vessel walls helps to confirm the diagnosis. The knowledge of the clinical features and histopathology of the disease is important because lupus panniculitis may precede systemic lupus erythematosus by some years.

Lupus erythematosus profundus with partial C4 deficiency responding to thalidomide

A female patient with disfiguring lupus erythematosus profundus (LEP) from the age of 13 years was found to have an isolated partial C4 deficiency, with reduced levels of both allotypes, C4A and C4B. A genetic basis for the hypocomplementaemia was confirmed by a family study of complement and HLA types which revealed heterozygous null alleles for C4A and C4B in the proband. Marked improvement in her cutaneous lesions occurred with thalidomide.

Lupus erythematosus profundus--report of a case treated with dapsone

A male adult patient with discoid lupus erythematosus (DLE) developed lupus erythematosus profundus. We decided to treat him with oral administration of dapsone, which proved to be very effective.