Rowell's syndrome: a rare but distinct entity in rheumatology.

Rowell's syndrome is a rare disorder characterised by an association of lupus erythematosus with erythema multiforme (EM)-like skin lesions. EM as the initial clinical presentation of systemic lupus erythematosus is also atypical and even rarer. We report the case of an 18-year-old girl admitted to our hospital with fever and polyarthralgia along with multiple discrete ill-defined target lesions with crust formation over forehead, cheek, external ears, scalp, upper chest and back (predominantly over sun-exposed areas) with ulceration over hard palate. Investigations revealed pancytopaenia, a positive rheumatoid factor, positive antinuclear antibody with a speckled pattern, anti-Smith antibody and strongly positive anti-Ro. Patient was diagnosed with Rowell's syndrome as per clinical and laboratory features. Majority of skin lesions including oral ulcerations subsided gradually after treatment with steroids and hydroxychloroquine.

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.

The effect of levamisole in the treatment of recalcitrant recurrent erythema multiforme major: An observational study.

BACKGROUND: Erythema multiforme major (EMM) is an immune-mediated mucocutaneous eruption mostly triggered by herpes simplex virus (HSV) infection. A vicious circle of recurrence may be developed due to HSV reactivation and prolonged use of systemic corticosteroids to control EMM. Levamisole is an immunomodulator and has been applied to prevent relapses of recurrent HSV infection. OBJECTIVE: To evaluate the clinical efficacy and safety of levamisole in patients with recalcitrant recurrent EMM. METHODS: We enrolled 23 patients with recurrent EMM treated with levamisole and 24 controls, and analyzed the demographics, treatments and outcomes. RESULTS: Patients with recurrent EMM for years (mean 3.99 ± 2.71) showed significantly reduced recurrences after various durations of levamisole treatment (recurrences after and before treatment: 3.98 ± 1.04 vs 6.75 ± 1.45 times per year, p = 1.33x10-8). The recurrences of EMM also significantly reduced after levamisole treatment comparing to that of patients without levamisole treatment (p = 3.77x10-9). No patient was reported to have severe side effects during or after levamisole treatment. CONCLUSIONS: Levamisole was effective in reducing recurrences of recalcitrant recurrent EMM and can thus be considered an alternative or add-on therapy for this disorder.

Adverse Immunologically Mediated Oral Mucosal Reactions to Systemic Medication: Lichenoid Tissue Reaction/Interface Dermatitis-Stomatitis, Autoimmune Vesiculobullous Disease, and IgE-Dependent and Immune Complex Reactions.

Drug-induced hypersensitivity immune reactions are exaggerated immunoinflammatory responses to allergenic components of the medications that occur in genetically susceptible subjects. The type of hypersensitivity immune response generated, whether antibody mediated or T cell mediated, or an immune complex reaction is determined by multiple factors, including the molecular characteristics of the allergen, the route of administration of the medication, the manner of presentation of the allergen by antigen-presenting cells to naïve T cells, the repertoire of the T cell receptors, and the cytokine profile within the microenvironment. This review deals with the clinical and histopathological aspects of adverse immunologically mediated oral mucosal reactions to systemic medication. We elaborate on diseases showing features of lichenoid tissue reaction/interface dermatitis-stomatitis, autoimmune vesiculobullous oral lesions, and immunoglobulin E- (IgE-) and immune complex-mediated oral reactions to drugs.

From HSV infection to erythema multiforme through autoimmune crossreactivity.

Scientific and clinical data indicate that human herpes simplex virus 1 (HSV1) and, at a lesser extent, human herpes simplex virus 2 (HSV2) are factor(s) implicated in the development of erythema multiforme (EM). With a focus on oral EM, the present structured review of proteomic and epitope databases searched for the molecular basis that might link HSV1 and HSV2 infections to EM. It was found that a high number of peptides are shared between the two HSVs and human proteins related to the oral mucosa. Moreover, a great number of the shared peptides are also present in epitopes that have been experimentally validated as immunopositive in the human host. The results suggest the involvement of HSV infections in the induction of oral EM via a mechanism of autoimmune cross-reactivity and, in particular, highlight a potential major role for 180kDa bullous pemphigoid antigen and HSV1 infection in the genesis of crossreactions potentially conducive to EM.

Vesicular Contact Reaction May Progress into Erythema Multiforme.

Dear Editor, Erythema multiforme is considered an acute skin condition, characterized by a self-limiting and sometimes recurrent course. It is regarded as a type IV hypersensitivity reaction associated with certain infections, medications, and other various triggers. Allergic contact dermatitis is in turn a delayed type of induced allergy as a result of cutaneous contact with a specific allergen to which the patient develops specific sensitivity. This type of cutaneous reaction is associated with inflammation manifesting with erythema, edema, and vesicles. A 27-year old female patient presented with a 3-day history of erythematous and vesicular lesions which developed 24 hours after cesarean section. Initially the lesions were localized in the area of surgery (mainly the abdomen and upper thighs) and on the next day progressed to the buttocks and lumbar area. The patient was referred to the Outpatient Clinic and was treated with antihistamines, but her dermatological state deteriorated rapidly. At the day of admission to the Department of Dermatology, numerous erythematous and vesicular lesions were present on the skin of the abdomen, thighs, and back (Figure 1, a), but the skin of the neck, chest, and extremities was also covered with erythematous and edematous patches. On the second day of hospitalization, we observed the evolution of lesions localized within the chest and extremities into an erythema multiforme-like targetoid eruption (Figure 1, b). Initially the patient was treated with intravenous injections of dexamethasone and ceftriaxone and orally with second-generation antihistamines (in four-fold doses), followed by intravenous metyloprednisolone pulse-therapy (total dose of 3 g). As the new vesicobullous lesions started to appear on the face and arms, we introduced cyclosporine A orally 400 mg daily. We could then observe gradual remission, but on the seventh day of hospitalization the patient developed a massive labial herpes simplex infection and had to be treated with acyclovir intravenously. Eight days after admission, we switched from intravenous metyloprednisolone to its oral formula. Diagnostic methods included: laboratory analyses (leukocytosis, neutrophilia, lymphopenia could be observed, and also serum CRP elevation). Pemphigoid gestationis was excluded on the basis of a direct immunofluorescence from perilesional skin and on the basis of indirect immunofluorescence and also serum analysis using ELISA for serum IgG antibodies to BP180-NC16A (courtesy of Prof. Marian Dmochowski). Histopathological examination revealed: massive edema of dermal papillae, leading to the formation of sub-epidermal vesicles; individual cell necrosis was observed in the upper epidermis. Within the dermis, a dense, perivascular inflammatory infiltrate was detected: the clinical picture suggested erythema multiforme. Another histopathological examination was performed at the University Clinic of Dermatology and Venereology in Magdeburg, courtesy of Prof. Dr. Harald Gollnick and Dr. Med. I. Franke; it also suggested the bullous form of erythema multiforme (dermal type). Three months after remission, the patient was hospitalized again to perform allergological diagnostics. Patch tests were performed with the European Baseline Series (Chemotechnique Diagnostics) supplemented with disinfectants and textiles used during surgical procedure. For patch testing, Finn Chambers on Scanpor were used. Results were recorded at 48 and 72 hour time points. According to the ICDRG (International Contact Dermatitis Research Group), reactions evaluated as ++ and +++ pluses were considered as positive and reaction evaluated as + plus was considered as doubtful. Patch testing revealed polyvalent contact allergy (Table I), (Figure 2a). The patient also reacted to Kodan Tinctur forte used as a skin disinfectant (contains brown dye LF 1889 - mixture of quinoline yellow, sunset yellow, brilliant black) (Figure 2b). It has to be emphasized, that patch test reading procedure was difficult due to patient's skin reactivity toward a plaster mounting Finn chambers. Literature data suggests that erythema multiforme may occasionally occur in conjunction with allergic contact dermatitis to various non-related substances including chemicals (epoxy-based compound, fragrances, epichlorydrine, bromofluorene), medications (antibiotics, acetaminophen, triamcinolone, bufexamac), plant-derived allergens (poison ivy, tea tree oil, red cedar essential oil), but also rubber ingredients and nickel. The severity of the reaction varies from mild erythema to generalized erythema multiforme or even toxic epidermal necrolysis (1,2,3,4). Lesions characteristic for erythema multiforme may appear during the episode of acute contact dermatitis or may follow a nearly resolving vesicular eczematous eruption. The pathomechanism Patomechanism of an erythema multiforme-like eruption developing in association with allergic contact dermatitis still remains unclear. Immune complex-mediated and T-cell-mediated reactions have been proposed as the cause. However, T-cell-mediated cellular mechanisms seems to be more likely, since generalized erythema multiforme often follows contact dermatitis, which is a type IV allergic reaction mediated by T cells (5,6). According to Bushkell et al. (7), an allergen penetration through the skin may result in a type III hypersensitivity reaction, with involvement of circulating immune complexes, and to confirm that, IgM, IgA, C3, and fibrin deposits are detected in some cases of targetoid lesions in erythema multiforme. On the other hand, Wiedemeyer et al. (8) suggest that contact allergens (i.e. paraphenylenodiamine) may be transported in peripheral blood mononuclear cells from the area of initial skin contact even to distant sites. According to Shiohara et al. (9) and Gonzalez-Delgado et al. (10), epidermal expression of adhesion molecule - 1 (ICAM-1) and the number of CD4+ T cells is increased within the iris lesions of erythema multiforme. Thus, it is possible that adhesion molecules may facilitate epidermal invasion of lymphocytes in these lesions, which is also the place of the expression of maintained allergen molecules. In conclusion, in the described case the causative factor also remained uncertain. The patient was found to have contact allergy to six haptens included in the European Baseline Series and also to a disinfectant used during cesarean section. Among these, both colophonium and formaldehyde are used in adhesives and glues or surface coatings. However, formaldehyde is mainly associated with this type of the reaction - in fact, hapten description supplied by Chemotechnique Diagnostics includes the information that "formaldehyde may produce erythema multiforme-like eruptions".

Exudative erythema multiforme due to cyclobenzaprine

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From erythema multiforme to toxic epidermal necrolysis. Same spectrum or different diseases?

Erythema multiforme (EM), Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute bullous disorders associated to different prognosis, mainly due to infections and drugs. More in particular EM in more than 90% is caused by infections (especially Herpes virus infection), while, on the other hand SJS and TEN are referable in more than 95% of cases to drugs. Distinction among these three forms is often controversal and still debated. An attempt to distinguish these forms has been possible mainly according to anamnesis, clinical presentation (morphology, involved sites, extension of lesions) and pathogenetic mechanisms, being on the contrary more difficult from an histopathological point of view. Nowadays a clear diagnosis and a distinction from other life-threatening diseases is possible with the integration of all the mentioned aspects. Moreover, this recognition should be as early as possible in order to perform a prognostic evaluation of the case and to start supportive cares and therapies as soon as possible.

[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).

Circulating plakin autoantibodies in a patient with erythema multiforme major: are they pathogenic or a manifestation of epitope spreading?

Erythema multiforme is a well-recognised entity but its pathogenesis remains elusive. Theories hypothesise a cell-mediated immune pathogenesis, however recent case reports have observed autoantibodies to the plakin family of proteins, suggesting a role for the humoral immune system. We present a case of erythema multiforme major with circulating desmoplakin autoantibodies in a 36-year old woman who was previously diagnosed with pemphigoid gestationis. The close correlation between the concentration of these autoantibodies and the severity of clinical disease strongly suggests a pathogenic role in her disease. As previous case reports have proposed, these autoantibodies may be directly pathogenic. Alternatively, the epiphenomenon of epitope spreading must be considered in the subset of patients with erythema multiforme major.

Erythema exsudativum multiforme after a Leishmania skin test.

A 45-year-old otherwise healthy male from an endemic region for Leishmania braziliensis infection in Bahia, Brazil, presented with three erosive hemorrhagic infiltrated plaques on the left shin accompanied with lymphadenopathy in the groin since one month. A Leishmania skin test performed on the left forearm was strongly positive (20 × 18 mm). Two days later, the patient felt sick and feverish. Painful erythematous target lesions developed on the palms and scapula together with conjunctivitis. Histopathology confirmed erythema exsudativum multiforme (EEM). Both EEM and cutaneous leishmaniasis were successfully treated with a 5-day course of prednisone 20 mg, and a 20-day course of intravenous pentavalent antimony, respectively.

[Features of dynamics of sera cytokines in patients with erythema multiforme during immunotherapy].

AIM: Study the features of cytokine profile in patients with exudative erythema multiforme (EME) and dynamics of basal level of pro-inflammatory and anti-inflammatory cytokines during immunotherapy. MATERIALS AND METHODS: 39 adult patients with erythema multiforme were examined. The patients were split into groups based on therapy variant. One group (14 individuals) received Immunovac-VP-4 against the background of basic therapy; the other (12 individuals)--cagocel against the background of basic therapy; comparison group (13 individuals) received only basic therapy; 15 individuals composed a group of healthy individuals. All the patients had the level of pro-, anti-inflammatory and regulatory cytokines determined in blood sera by solid-phase EIA method by using Biosource (Austria) test-systems at the beginning of the study and after the therapy. RESULTS: In patients with exudative erythema multiforme Immunovac-VP-4 therapy facilitated a significant (p < 0.05) increase of serum IFN-gamma level, insignificant (p > 0.05) increase of IL-1beta and decrease of IL-17. Whereas cagocel lead to an increase of IL-4 (p > 0.05), IL-2, IFN-gamma (p < 0.05) and decrease of TGF-beta and IL-12 (p < 0.05). At the same time basic therapy facilitated a significant increase of IL-5 and decrease of IL-6, IL-12, IFN-gamma. CONCLUSION: Immunovac-VP-4 facilitates the increase of secretion of IFN-gamma, IL-1beta against the background of TGF-beta that facilitates normalization of cooperation of cells in immune response including against viral infections, and thereby influencing the trigger factor in EME patients.

Rheumatoid arthritis and erythema multiforme: a possible pathogenetic link for T-cell-mediated autoimmune and reactive skin diseases?

We present a case of a woman with a 14-year history of rheumatoid arthritis, who showed simultaneously and gradually appearing, annular, erythematous, itchy patches and exacerbation of the joint symptoms, of one month duration, after pregnancy. Clinical and histologic features led us to the diagnosis of erythema multiforme. While it is not possible to exclude that the co-occurrence of the two conditions is coincidental, our case suggests the possibility that erythema multiforme is a sign of an ample alteration of the immune system that may occur in patients with systemic immune diseases as a consequence of the action of various triggering factors, such as molecular mimicry between endogenous and exogenous antigens or pregnancy, which is notoriously a period of complex and still largely unexplored alterations in the immune system reactivity.

Peripheral blood eosinophil counts predict the prognosis of drug eruptions.

BACKGROUND: Previous studies indicated that eosinophils infiltrate the skin during drug eruptions and that counts may become elevated in circulation. However, little is known about the role of eosinophils in the prognosis of patients with drug eruption. OBJECTIVE: This study aims to investigate the correlation between circulating eosinophil counts and the prognosis of patients with drug eruption. METHODS: A total of 113 patients were enrolled in this study. Clinical features, peripheral blood eosinophil counts, and liver function were analyzed in patients and controls. RESULTS: Our study indicated that eosinophils changed dynamically in different types of drug eruption and that mean eosinophil counts in patients with erythema multiforme-type drug eruption were significantly higher than in patients with other types of eruption. Most patients with eosinophilia had poor liver function, prolonged corticosteroid use, and extended hospitalization, all of which indicate severe disease. CONCLUSIONS: Our data suggest that circulating eosinophil counts were positively correlated with the severity of the drug eruption. Therefore, corticosteroids may be needed to treat patients with eosinophilia in clinical practice.

Frequent detection of herpes simplex virus antigen in skin and peripheral blood CD34+ mononuclear cells from patients with graft-versus-host disease.

Viruses are implicated in the initiation or flare of graft-versus-host disease (GVHD) by virtue of their ability to activate antigen-presenting dendritic cells (DC). Herpes simplex virus (HSV) infects circulating CD34+ stem cell progenitors, favoring their differentiation into skin homing DC (CD1a+ Langerhans cells) that contribute to the development of an inflammatory skin rash known as HSV-associated erythema multiforme (HAEM). Following on these findings, we conducted a prospective study to examine whether HSV is also associated with GVHD. Skin biopsies and peripheral blood mononuclear cells (PBMC) were collected from 37 consecutive patients on admission before and after allogeneic hematopoietic stem cell transplantation (HSCT) and examined for HSV antigen (Pol) expression and the presence of Pol+CD34+ and Pol+CD1a+ cells. Sixteen patients developed a skin rash that was histopathologically consistent with GVHD (group I), 3 patients had a rash that was not GVHD (group II, EM-like) and 18 patients did not develop any rash after HSCT (group III). Skin biopsies from the group I patients were Pol negative pre-HSCT (baseline) but became Pol+ after the diagnosis of GVHD. The GVHD biopsies also contained Pol+CD34+ and Pol+CD1a+ cells, and these patients had a significant percentage of circulating Pol+CD34+ and Pol+CD1a+ PBMC. By contrast, the group II patients had Pol+ skin cells and Pol+CD34+ circulating PBMC at baseline that decreased post-HSCT. The group III patients had Pol negative skin and very few circulating Pol+CD34+ and Pol+CD1a+ PBMC at baseline that were not significantly changed post-HSCT. The data associate skin GVHD with HSV reactivation during conditioning and its propensity for nonreplicative infection of CD34+ PBMC that induces DC activation. Further studies are needed to better elucidate this association.