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CASE REPORT
Year : 2012  |  Volume : 57  |  Issue : 6  |  Page : 483-485
Recurrent bilaterally symmetrical bullous sweet's syndrome: A rare and confusing entity


Consultant Dermatologist, Vadodara, India

Date of Web Publication1-Nov-2012

Correspondence Address:
Shyam B Verma
18 Amee Society, Diwalipura, Vadodara 390015
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.103070

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   Abstract 

A rare presentation of Sweet's syndrome (SS) (acute febrile neutrophilic dermatosis) is being reported in a 28-year-old man from India. I report a rare presentation of SS that consisted of bilaterally symmetrical, bullous lesions on both forearms with a seasonal recurrence. A thorough work-up for the usual conditions predisposing to or leading to SS did not throw any light on the etiology. After failing treatment with prednisolone alone we added indomethacin, and he responded to the combination in a matter of days with complete clearance of lesions.


Keywords: Bullous lesions, neutrophilic dermatoses, recurrent Sweet′s syndrome


How to cite this article:
Verma SB. Recurrent bilaterally symmetrical bullous sweet's syndrome: A rare and confusing entity. Indian J Dermatol 2012;57:483-5

How to cite this URL:
Verma SB. Recurrent bilaterally symmetrical bullous sweet's syndrome: A rare and confusing entity. Indian J Dermatol [serial online] 2012 [cited 2020 Nov 24];57:483-5. Available from: https://www.e-ijd.org/text.asp?2012/57/6/483/103070

What was known? Sweet's syndrome (SS) also known as acute febrile neutrophilic dermatosis, is characterized by tender erythematous lesions on the skin, fever with leukocytosis showing a predominance of neutrophils, a raised erythrocyte sedimentation rate and a biopsy showing mature neutrophils in the upper and mid dermis, and, generally, absence of vasculitis.It has been described mainly under three headings. Idiopathic or classical SS, SS associated with a malignancy and SS associated with drug intake



   Introduction Top


Localised Sweet's syndrome (SS) with recurrent, bilaterally symmetrical bullous lesions is rare and can be a confusing clinical entity. A case is being described where no specific cause was identified. He also did not have fever, leukocytosis or neutrophilia in the beginning of the disease, but developed them later on. He was treated with prednisolone and then a combination of prednisolone with indomethacin, which led to complete resolution.


   Case Report Top


A 28-year-old man presented in this clinic with a blistering eruption on the ventrolateral aspect of his mid forearms, which he noticed about 10 days back. A similar eruption appeared every monsoon during the rainy season, and resolved in about 1 month or so, but this time it was more severe and very painful. On examination, the man was of thin built, had advanced androgenetic alopecia and looked ill. He was not febrile, but was in pain. There were bilaterally symmetrically located lesions on the ventral aspect of the mid forearms comprising well-circumscribed, painful erythematous plaques studded with crusts and bullae [Figure 1]. There was nothing to suggest contact dermatitis or a history of drug intake. Relevant investigations revealed nothing abnormal except a borderline total leukocyte count and neutrophil count. A pharmacist by profession, he had taken Cefadroxil, azithromycin and ciprofloxacin along with 10 mg prednisolone randomly without any benefit. He was given a full course of 625 mg of clavulinate-potentiated amoxicillin twice daily with paracetamol 500 mg three times a day and 30 mg prednisolone once a day for 5 days, but did not show improvement. When he came on the fifth day, he had developed fever, had severe pain and was unwell. Hb was 13 gm, total count was 12000 with 88% polymorphs, ESR was 15 mm, kidney and liver functions were normal and his urine was normal. A punch biopsy revealed spongiotic epidermis with a mild dermal edema. There were large aggregates of neutrophils in the upper and mid dermis showing nuclear dust [Figure 2]. Blood vessels were not affected and there was no sign of vasculitis [Figure 3]. Based on all this, a diagnosis of recurrent localized bullous SS presenting as bilaterally symmetrical erythematous plaques studded with bullae mimicking contact dermatitis or fixed drug eruption was made. Hematologic and solid organ malignancies were ruled out keeping in mind financial constraints. This was done owing to the association of the vesicobullous variant of SS with such underlying malignancies. Prednisolone was continued and indomethacin tablets were started at the dose of 150 mg per day with food, to which he responded within 5 days with complete resolution of lesions, no fever and normal hematologic parameters [Figure 4].
Figure 1: Bilaterally symmetrical erythematous plaques with ulcerated bullae

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Figure 2: Hematoxylin and eosin, 10×, scanner view showing diffuse infiltrate in the upper and mid dermis

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Figure 3: Hematoxylin and eosin, 100×, high power view showing spongiosis, dermal edema, neutrophils and absence of vasculitis

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Figure 4: Complete resolution of lesions in 2 weeks

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   Discussion Top


Sweet's syndrome also known as acute febrile neutrophilic dermatosis, is characterized by tender erythematous lesions on the skin, fever with leukocytosis showing a predominance of neutrophils, a raised erythrocyte sedimentation rate and a biopsy showing mature neutrophils in the upper and mid dermis, and, generally, absence of vasculitis. [1],[2],[3],[4],[5] It has been described mainly under three headings. Idiopathic or classical SS, SS associated with a malignancy and SS associated with drug intake. [2],[3] Localized SS is a rare variant and there has been a special interest in describing its occurrence on the hands as "neutrophilic dermatosis of dorsal hands (NDDH)." [6],[7],[8] It would be interesting to see whether the bilaterally symmetrical lesions localized to the forearms are a distributional variant of NDDH.

This seems to be a rare and interesting case because of its bilaterally symmetrical localized distribution of ulcerated and crusted plaques studded with bullae and a characteristic histology of SS A detailed examination failed to detect infection. It is possible that he may have been suffering from a recurrent viral infection during the monsoon seasons, which would then explain the post-infection occurrence of SS. [2],[3],[9] The classical idiopathic form has a female predilection. Because SS occurs in males as frequently as in females, when associated with cancer, we diligently tried to rule out malignancy. [2],[3],[10] An exhaustive review of about 15 detailed studies of malignancy-associated SS showed that 21% of the patients had a hematologic or solid organ malignancy. [10] A detailed work up with relevant hematologic investigations, X-ray of chest and abdomen and ultrasonography of the abdomen and pelvis did not reveal anything. Carcinoembryonic antigen (CEA) was normal. The most frequently associated hematologic malignancy in association with SS is acute myelogenous leukemia. Solid tumor malignancies most related with SS are those of genitourinary or gastrointestinal tract in males. A detailed history of drug intake was negative. Vesicles as well as bullae are seen in SS and ulcerated bullous lesions mimicking pyoderma gangrenosum have been described in malignancy-associated SS. [10],[11],[12] Recurrence as seen in our patient has been described in approximately 1/3 rd to 2/3 rd of patients. [2],[3] Patients may be visibly ill with fever but there is no uniform pattern. It can precede the eruption, may occur with it or be present throughout the episode. Absence of fever in malignancy-associated SS has also been demonstrated. Our patient was afebrile during the first consultation but developed fever subsequently. The biopsy showed a typical diffuse infiltrate of mature neutrophils and dermal edema without primary vasculitis as is the case in the majority of cases. [2],[4],[5] However, in some cases of SS, perivascular distribution of neutrophils and leukocytoclasia have been demonstrated. [2],[4],[5]

The patient has been explained the importance of a regular follow-up with routine blood examination twice a year as there are reports of hematologic malignancies being detected as long as 11 years after the skin lesions. [3],[10]

SS is known to respond dramatically to oral steroids. Second-line therapies include potassium iodide, colchicine, indomethacin, dapsone, clofazimine, doxycline and metronidazole. This patient did not respond to 30 mg oral prednisolone initially but responded dramatically with complete resolution of lesions in 5 days when 150 mg indomethacin was added.

In conclusion, a recurrent localized bullous variant of SS presenting with lesions not associated with an overt infection, malignancy or drug intake is being reported bilaterally symmetrically on the forearms.

 
   References Top

1.Barham KL, Jorizzo JL, Gratttan B, Cox NH. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Vasculitis and neutrophiolic vascular reactions. Rook's Textbook of Dermatology. 5 th ed., vol. 3. Oxford; 2004. p. 33-6.  Back to cited text no. 1
    
2.Cohen PR, Kurzrock R. Sweet's syndrome revisited: A review of disease concepts. Int J Dermatol 2003;42:761-78.  Back to cited text no. 2
[PUBMED]    
3.Cohen PR. Sweet's syndrome - a comprehensive review of an acute febrile neutrophilic dermatosis. Orphanet J Rare Dis 2007;2:34.  Back to cited text no. 3
[PUBMED]    
4.Jordaan HF. Acute febrile neutrophilic dermatosis. A histopathological study of 37 patients and a review of the literature. Am J Dermatopathol 1989;11:99-111.  Back to cited text no. 4
[PUBMED]    
5.Going JJ, Going SM, Myskow MW, Beveridge GW. Sweet's syndrome: Histological and immunohistochemical study of 15 cases. J Clin Pathol 1987;40:175-9.  Back to cited text no. 5
    
6.Walling HW, Snipes CJ, Gerami P, Piette WW. The relationship between neutrophilic dermatosis of the dorsal hands and sweet syndrome: Report of 9 cases and comparison to atypical pyoderma gangrenosum. Arch Dermatol 2006;142:57-63.  Back to cited text no. 6
[PUBMED]    
7.Larsen HK, Danielsen AG, Krustrup D, Weismann K. Neutrophilic dermatosis of the dorsal hands. J Eur Acad Dermatol Venereol 2005;19:634-7.  Back to cited text no. 7
[PUBMED]    
8.Neoh CY, Tan AW, Ng SK. Sweet's syndrome: A spectrum of unusual clinical presentations and associations. Br J Dermatol 2007;156:480-5.  Back to cited text no. 8
[PUBMED]    
9.Cohen PR, Kurzrock R. Sweet's syndrome: A neutrophilic dermatosis classically associated with acute onset and fever. Clin Dermatol 2000;18:265-82.  Back to cited text no. 9
[PUBMED]    
10.Cohen PR, Kurzrock R. Sweet's syndrome and cancer. Clin Dermatol 1993;11:149-57.  Back to cited text no. 10
[PUBMED]    
11.Bielsa S, Baradad M, Marti RM, Casanova JM. Sweet's syndrome with bullous lesions. Actas Dermosifiliogr 2005;96:315-3.  Back to cited text no. 11
    
12.Voelter-Mahlknecht S, Bauer J, Metzler G, Fierlbeck G, Rassner G. Bullous variant of Sweet's syndrome. Int J Dermatol 2005;44:946-7.  Back to cited text no. 12
[PUBMED]    

What is new? Bilaterally symmetrical bullous crusted Sweet′s syndrome masquerading as a contact dermatitis, photodermatitis or fixed drug reaction can be a diagnostic dilemma. No overt cause like infection, malignancy or drug intake was identified.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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