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  • 1. Case Presentation-Dermatology Kevin T. Belasco, MSIV Touro Univ. College of Osteopathic Medicine May 24, 2004
  • 2. Case Presentation • 32 y/o Caucasian female presents to community clinic with a chief complaint of fever, rash, malaise, and arthralgia with sudden onset beginning 4 days ago • HPI: Patient returned 6 days ago from a three month-long church mission to Cambodia, where she taught English. She states her diet was composed largely of chicken and rice, with coconut milk and purified bottled water.
  • 3. Case Presentation (Cont.) • HPI (Cont.)Patient states she developed a cough with yellow sputum 3 weeks ago and was treated with a tetracycline antibiotic. She denies any headache, dizzines, chills, night sweats, N/V, diarrhea, or hematuria. She also denies any sick contacts • PMHx/PSHx: Tonsillectomy 1982, Cholecystectomy 1991. PMHx otherwise non-contributory • Allergies: NKDA • Meds: MVI, Tylenol prn muscle aches • SocHx: Denies smoking, EtOH, or illicit drug use. Lives with boyfriend in Los Angeles; schoolteacher
  • 4. Case Presentation (Cont.) • ROS: as per HPI; fever, rash, arthralgia, and malaise • VS: T 100.9, P 95 R 22 BP 133/84 • PE: Systems normal except described below: • Gen: WD/WN, pleasant female, NAD, AAO x 3 • HEENT: NC/AT, EOMI, no conjunctival injection, no pharyngeal erythema or exudate, no oral lesions • Skin: sharply demarcated, painful plaques with erythema and pustules on the upper trunk, neck, and face • Musculoskeletal: Mild erythema and swelling with tenderness to palpation over left elbow joint
  • 5. Case Presentation (Cont.) • Laboratory values: • CBC: 16/14.0/40/343 N74 L20 M3 E1 B0 • BMP: 136/4.1/105/28/16/1.1/112 • ESR: 40 • PPD: negative
  • 6. Differential Diagnosis Erythema multiforme Drug Eruption, Fixed Cellulitis Pyoderma gangrenosum Granuloma annulare/ faciale Erythema nodosum Behçet's disease
  • 7. Differential Diagnosis Sweet’s Syndrome Sjögren’s Syndrome Rheumatoid Arthritis (Cutaneous nodules) Systemic Lupus Erythematosus Cutaneous Tuberculosis (Lupus vulgaris) Erythema induratum Subcorneal pustular dermatosis Erythema elevatum
  • 8. Summary of Findings • Clinical: Painful plaques with pustules with abrupt onset fever and arthralgia; history of recent international travel; recent upper respiratory tract infection • Labs: • Leukocytosis with neutrophilia and lymphopenia • Elevated ESR • Negative Gram stain
  • 9. Sweet’s syndrome • Acute febrile neutrophilic dermatosis • Initially described in 1964 by Robert Sweet • Three types: 1. Classic (Strep., Yersinia, BCG/Pneumococcal vaccine, IBD, pregnancy, idiopathic) 2. Malignancy-associated (AML) 3. Drug- induced (G-CSF, all-trans retinoic acid, minocycline, Bactrim, OCPs, carbamazepine, hydralazine) • female-to-male ratio of 2-3:1 • several hundred cases have been reported in the literature
  • 10. Sweet’s syndrome • Typically, skin lesions are preceded by URI or GI infection, and only occur after a 1-3 week asymptomatic period • Most common in women over 30 • Up to 20% cases associated with malignancy
  • 11. Sweet’s syndrome Tender, well-demarcated erythematous plaques George Wash. Univ. Dermatology Dept
  • 12. Sweet’s syndrome Pseudovesiculation with pustules and soft elevation in the center- mamillated George Wash. Univ. Dermatology Dept
  • 13. Sweet’s syndrome • Painful erythematous plaques with pustulation www.dermis.net
  • 14. Sweet’s syndrome: Histopathology www.dermis.net
  • 15. Sweet’s syndrome: Histopathology • Skin biopsy reveals dermal neutrophilic infiltrate in reticular dermis with leukocytoclasia (fragmentation of neutrophilic nuclei); epidermis is usually spared • Associated clinical phenomena: Koebnerization Pathergy (skin lesions at site of trauma)
  • 16. Sweet’s syndrome: Treatment • Prednisone is rapidly effective, in doses ranging from 40-80 mg/day (initial dose of 0.5-1.5 mg per kg per day) • Topical and intralesional corticosteroids have frequently been used as adjunctive treatment along with systemic modalities • Indomethacin, cyclosporine, dapsone, colchicine, KI, doxycycline, and clofazamine have been reported in the literature as effective alternative treatment modalities
  • 17. References • Habif: Clinical Dermatology, 4th ed., Mosby 2004 • Odom, et al: Andrew’s Diseases of the Skin, 9th ed., Elsevier 2000 • Fitzpatrick, JE: Dermatology Secrets in Color. Hanley & Belfus 2001 • www.emedicine.com (Kimball AB review article) • www.dermis.net • dermatology.cdlib.org (Dermatology Online Journal)