Severe Acute Systemic Reaction After the First Injections of Ixekizumab

We report the case of a 39-year-old woman who presented with generalized malaise; lymphadenopathy; arthritis; dactylitis; ecchymosis; acute onycholysis; and a red, nonpruritic, nonscaly, mottled rash on the right breast 24 hours after the first injections of ixekizumab for psoriasis and psoriatic arthritis. Ixekizumab is a humanized IgG4 monoclonal antibody that binds to IL-17A. Adverse events of ixeki-zumab include infection, inflammatory bowel disease, candidiasis and tinea infections, severe injection-site reactions, arthralgia, headache, infections, neutropenia, and thrombocytopenia. Other biologics, specifically tumor necrosis factor (TNF) inhibitors, have been reported to cause onycholysis attributed to immune dysregulation. We propose that ixekizumab alters the inflammatory cascade that underlies the induction of acute onycholysis and arthritis.

Disseminated verruciform xanthoma: a case report

Verruciform xanthomas (VXs) are rare mucocutaneous lesions that can appear in isolation or in association with chronic inflammation, systemic diseases, or metabolic abnormalities. We report the case of a patient who presented with disseminated VX with oral, cutaneous, and genital involvement without an obvious underlying cause. Treatments including salicylic acid 40%, high-potency topical corticosteroids, antibiotics, and chlorhexidine failed to improve the lesions; however, the patient was satisfied with the cosmetic results of serial shave excisions. This case highlights a rare entity of unknown etiology. Further studies are needed to determine the cause of this mucocutaneous entity so that more effective treatment modalities can be elucidated.

Systemic amyloidosis: unusual presentation mistaken for a recurrent scabies infection

We report the case of a 63-year-old woman with a history of undifferentiated connective-tissue disease, polyarthritis, and bilateral carpal tunnel syndrome who presented with generalized pruritus and erythematous and excoriated papules on the trunk and extremities. Empiric scabies treatment was unsuccessful. Patch testing and T-cell receptor gene rearrangement studies were unremarkable. The patient was found to have mild interstitial lung disease and hypogammaglobulinemia. Eventually a diagnosis of primary systemic amyloidosis was made after she developed frank lingual hypertrophy despite normal initial serum protein electrophoresis and negative abdominal fat pad aspiration. Diagnosis was confirmed with lingual biopsy. This case demonstrates an unusual presentation of primary systemic amyloidosis consisting of arthritis and intense debilitating pruritus without primary skin lesions for a full year prior to diagnosis of multiple myeloma. The patient responded to treatment with chemotherapy and corticosteroids.

Necrolytic acral erythema: an expanding spectrum

Hepatitis C virus (HCV) infection is the most common chronic blood-borne viral infection in the United States. Well-described cutaneous manifestations of HCV infection include polyarteritis nodosa, porphyria cutanea tarda, type II cryoglobulinemia-associated vasculitis, pruritus, erythema nodosum, urticaria and urticarial vasculitis, lichen planus, and erythema multiforme. First described in 1996, necrolytic acral erythema (NAE) is now recognized as a cutaneous acral eruption uniquely associated with HCV infection. Most patients present with chronic, acral, erythematous, and psoriasiform lesions. Acute presentations of NAE are rare and patients may present with atypical clinical features; in these cases, suspicion for HCV infection may be delayed for weeks to months until more classic chronic lesions develop. In many cases, NAE presents before the patient has been diagnosed with HCV infection, which allows dermatologists the unique opportunity to suspect and diagnose HCV infection based on skin findings alone.

Unilateral volar annular syringomata

We report a case of a 71-year-old woman with an atypical unilateral and focally annular distribution of asymptomatic syringomata on the volar surface of the left forearm. We are unaware of previous reports of isolated unilateral syringomata presenting with an annular pattern on the volar distal extremity.