Finger nodules with a papulovesicular hands and feet eruption: a complicated human Orf virus infection.

BACKGROUND: Orf virus (ORFV) is the pathogen responsible for Orf, a zoonotic viral infection that can be spread to humans from sheep and goats. Here, we present a case of human Orf complicated by an immune-related reaction, to raise awareness of this under-recognized disease avoiding unnecessary investigations and overtreatment. CASE REPORT: A 51-year-old woman with no previous medical history presented with a one-week history of three asymptomatic swelling nodules with a grey necrotic center and red outer halo on her index finger. At physical examination there was also a pruritic papulovesicular eruption on her hands and feet. She reported a recent contact with a goat which had a similar nodular lesion in its mouth. A biopsy of the lesions was performed and a diagnosis of Orf complicated by widespread erythema multiforme was made based on the clinical and histopathological features. The lesions spontaneously resolved within the next 2 weeks. CONCLUSIONS: Orf is not very prevalent in our region, so we performed a biopsy of the lesion to guide us toward a diagnosis. However, we should remember that the diagnosis of ecthyma relies on clinical evaluation and epidemiological criteria.

Cutaneous Toxicities Associated with Immune Checkpoint Inhibitors: An Observational, Pharmacovigilance Study.

Cutaneous immune-related adverse events (cirAEs) are the most prevalent complication to arise from immunotherapy and cause significant morbidity. We aimed to determine the spectrum, timing, clinical features, and outcomes of cirAEs by conducting an observational pharmacovigilance study using VigiBase, the World Health Organization's global database of individual case safety reports from over 130 member countries (ClinicalTrials.gov, number NCT04898751). We compared adverse event reporting in patients who received immune checkpoint inhibitors (91,323 adverse events) with those of the full reporting database (18,919,358 adverse events). There were 10,933 cases of cirAEs within 51 distinct dermatologic types, with 27 specific eruptions with disproportionate signal represented (information component [IC]025 > 0). Of these 27 eruptions, there were eight cirAEs with n > 100 reports, including vitiligo (IC025 = 4.87), bullous pemphigoid (IC025 = 4.08), lichenoid dermatitis (IC025 = 3.69), erythema multiforme (IC025 = 1.03), toxic epidermal necrolysis (IC025 = 0.95), Stevens‒Johnson syndrome (IC025 = 0.41), drug eruption (IC025 = 0.11), and eczematous dermatitis (IC025 = 0.11). There were differences in time to onset after immune checkpoint inhibitor initiation, with a median of approximately 1 month (erythema multiforme, Stevens‒Johnson syndrome, and toxic epidermal necrolysis), 2 months (drug eruption and eczematous dermatitis), 4 months (lichenoid dermatitis), and 5‒6 months (bullous pemphigoid and vitiligo). CirAEs are diverse, dependent on cancer type, and have distinct and different onset times that are linked to the cirAE subtype.

Mycoplasma pneumoniae-induced rash and mucositis: A new entity.

Mycoplasma pneumoniae is a well-known cause of community-acquired pneumonia, mostly associated with dermatological manifestations especially with mucosal involvement and targetoid cutaneous lesions. For many years, it was considered among the spectrum of erythema multiforme. Recently, some authors have recommended the creation of a new syndrome called "mycoplasma-induced rash and mucositis." This new syndrome has distinct epidemiological, clinical and histological features making it different from drug-induced Stevens-Johnson syndrome, toxic epidermal necrosis and erythema multiforme. Herein, we report two patients with acute Mycoplasma pneumoniae respiratory tract infection presenting severe mucocutaneous lesions in accordance with this new syndrome.

A case of Good's syndrome complicated by erythema multiforme.

Good's syndrome (GS) is a rare, adult-onset combined B cell and T cell immunodeficiency with an associated thymoma. These patients have an increased risk of bacterial, fungal, viral and opportunistic infections. This report describes a 75-year-old female patient who presented with a full body rash and an anterior mediastinal mass. She underwent a biopsy of her rash and mass, which revealed erythema multiforme and WHO Type A thymoma, respectively. During her hospitalisation, she was also found to have oropharyngeal candidiasis, methicillin-susceptible Staphylococcus aureus bacteraemia and herpes simplex virus type 2 (HSV-2) skin lesions. Based on the number of infections and severity of her rash, an immunocompromised state was suspected. Immunological testing revealed a B cell and T cell deficiency as well as low serum immunoglobulins. This combination of hypogammaglobulinaemia and thymoma led to a diagnosis of GS. While there have been many case reports of GS, this is the first report of the immunodeficiency presenting with erythema multiforme.

Orofacial granulomatosis and erythema multiforme in an adolescent with Crohn's disease.

The cutaneous manifestations of Crohn's disease are myriad. A 15-year-old girl presented with recurrent lip swelling and eventual development of diarrhea and targetoid macules on the palms, feet, and back. She was finally diagnosed with Crohn's disease in the setting of a clinical presentation and histopathology consistent with orofacial granulomatosis and erythema multiforme. We review the literature and summarize reported occurrences of these cutaneous diseases in children with Crohn's disease.

Erythema multiforme triggered by Treponema pallidum infection in an HIV-infected patient.

We are currently facing a worldwide epidemic of syphilis. Clinical manifestations that are rarely seen have been encountered, leading the dermatologist to confront unusual clinical conditions in daily practice. Erythema multiforme triggered by syphilis is very rare and is also seldom reported in the literature. We report a case of secondary syphilis in an HIV-positive patient, whose clinical, pathologic and serologic features were consistent with the diagnosis of erythema multiforme triggered by syphilis.

Acral manifestations of systemic diseases: Drug-induced and infectious diseases.

Drug reactions and systemic diseases often involve the skin. In particular, most drug-induced reactions and many infectious diseases present with dermatologic manifestations localized acrally, that is on distal portions of limbs (hand, foot) and head (ears, nose). A detailed review of all acral dermatologic signs of drug reactions and systemic diseases is beyond the scope of this paper, although some of these disorders will be discussed specifically here.

[Effect of proteflazid on TLRs expression by mononuclear leukocytes of peripheral blood and epithelial cells of mucous membranes and skin in patients with herpes-associated erythema multiforme and erythema annulare centrifugum].

The article reports survey data on 23 patients with erythemas, including 19 patients with herpes-associated erythema multiforme (HAEM) and 4 patients with Darier's erythema annulare centrifugum (DEAC). Patients in the initial state (baseline) and after two weeks of therapy with proteflazid were characterized by measuring the levels of Toll-like receptor (TLR) expression in peripheral blood mononuclear cells (PBMC) and in epithelial cells of the throat and the skin. The TLR expression in PBMC and skin was assessed by flow cytometry with monoclonal antibodies (ICA) (Caltag Laboratories, USA; Hycult Biotech, Netherlands) against relevant antigens. In addition, patients were also characterized by the content of subpopulations of lymphocytes expressing surface markers CD3, CD4, CD8, CD16, CD21, CD23, CD72, CD25, and HLA-DR in the peripheral blood, which was measured by flow cytometry. The therapy with proteflazid in patients with both HAEM and DEAC led to normalization of the level of both T-cell and B-cell immunity, which was manifested by an increase in the total number of lymphocytes, CD3+, CD4+, CD21+, and CD72+. Measurements of the dynamics of TLR expression in the course of immunotherapy showed an increase in the number of TLR 2, 3, 4, 7, 8, and 9 in PBMC (which was especially pronounced for TLR2) and in epithelium of the pharyngeal mucosa and skin (increased expression of TLR3, 7, and 9).

[Lip synechiae after erythema multiforme]. / Synéchies de la muqueuse labiale dans les suites d'un érythème polymorphe.

BACKGROUND: Mucosal erosions in bullous diseases and leading to mucosal sequelae are widely described in toxic epidermal necrolysis (TEN). These complications cause disfigurement and functional impairment. They are more rarely reported in erythema multiforme (EM). We report a case of lip adhesion following EM induced by Mycoplasma pneumoniae. PATIENT AND METHODS: A 12-year-old boy was hospitalized in a paediatric intensive care unit. He had a prominent target skin rash on the palms and soles. Mucosal injury was associated with conjunctivitis, balanitis without dysuria and hyperalgesic stomatitis. M. pneumoniae serology was positive with immunoglobulin M. We made a diagnosis of EM secondary to M. pneumoniae infection. Two months later, the skin lesions had completely disappeared but the patient's mouth opening was limited to 25 mm and he presented bilateral adhesions between the upper and lower lips of 5mm on the right and 8mm on the left resulting in aesthetic and functional damage. DISCUSSION: Mucosal damage and its sequelae have been widely described in TEN. Ophthalmic sequelae are more frequent. A case of labial synechiae secondary to TEN has been reported. In EM, mucosal lesions occur in 100% of cases with a further mucosal problem being present in 50% of patients. Mucosal damage has been reported during EM flares but there are no studies of side-effects after the acute episode. Oral mucosal adhesions can cause cosmetic sequelae, but above all they hinder functional prognosis. These complications must be prevented by making gutters of vestibular deepening and lip movements with maximum mouth opening several times a day, starting as soon as possible. Appropriate pain management should be undertaken to ensure patient comfort and avoid the need for analgesics and restriction of movement. CONCLUSION: Mucosal sequelae exist in EM. Whatever their cause, complications involving the mucosa must be prevented through early, tailored and multidisciplinary treatment. Adequate pain management must not be overlooked.

Erythema multiforme major due to occupational exposure to the herbicides alachlor and butachlor.

Alachlor and butachlor are commonly used chloroacetanilide herbicides. They are cytotoxic, but there have been rare reported cases of alachlor or butachlor induced erythema multiforme major. We report the case of a 38-year-old farmer with erythema multiforme major due to the occupational exposure to alachlor/butachlor. The patient presented to the ED because of itching. Confluent erythematous to violaceous maculopatches with bullae and erosions were seen on the trunk, both upper extremities and both lower extremities. He had no relevant past or family history of a similar skin disease. He had used alachlor/butachlor for 3 days before he developed the itch. We performed a skin incisional biopsy and found diffuse hydropic degeneration with many necrotic keratinocytes in the epidermis and mild to moderate superficial perivascular lymphocytic infiltrate admixed with neutrophils and eosinophils in the upper dermis. These results confirmed the diagnosis of erythema multiforme major. The patient was admitted and received systemic and topical steroids. After 18 days, most lesions had healed, and he was discharged.

Drug-induced Lyell and Stevens-Johnson syndromes.

1) Lyell syndrome is characterised by toxic epidermal necrolysis in which epidermal detachment affects more than 30% of the body surface area. Stevens-Johnson syndrome is a minor form affecting less than 10% of the body surface area; 2) Patients who present with these cutaneous symptoms, along with throat pain, red eyes and a damaged or detached oral mucosa must be hospitalised immediately; 3) Lyell syndrome is exclusively caused by drugs while Stevens-Johnson syndrome can also be caused by bacteria and viruses. Rapid withdrawal of the drug improves prognosis.

Relevance and consequences of erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis in gynecology.

BACKGROUND: Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) can be distinguished by location, morphology and extent of cutaneous and mucosal lesions. EM has minimal effects on pregnancy and the genital tract. SJS and TEN on the other hand are related with premature labor and vaginal scarring that can lead to long-term painful lesions, stenosis, vaginal adenosis and telangiectasia. CASE: A 33-year-old G3P2 with a medical history of SJS has multiple recurrences during pregnancy of what seems to be EM instead of SJS with a favorable outcome. CONCLUSION: Differentiation between EM, SJS and TEN is important in gynecology to predict the effects of the diseases on the genital tract and on pregnancy.

Eritema multiforme / Erythema multiforme

O eritem multiforme é uma síndorme aguda, episódica e autolimitada, que se manifesta por lesões cutâneas características, simetricamente distribuídas, na maioria das vezes recorrentes, e por lesões mucosas. Vinte por cento dos casos ocorrem em crianças. Classifica-se em eritema multiforme menor e maior, conforme o grau de comprometimento do estado geral e da extensão das mucosas acometidas. Os autores apresentam um relato de caso de eritema multiforme atendido em hospital universitário, considerado na admissão como um quadro de meningococcemia.

The erythema multiforme can be defined as an acute, episodic and self-limited syndorme, that is manifested by cutaneous lesions characteristics, symmetrical distributed, and most of the time recurrente, being able to compromise mucosa. It is classified in minor and major erythema multiforme, as the degree of commitment of the general stte and the extension of the attacked mucosa. Twenty percent of the patients are children. The authors present a relate of case from erythema multiforme taken care in a university hospital, considered in admission like meningococcemia.