CLINICAL HISTORY:

Signs and symptoms:  54 year old white female presents for in hospital consultation with erythematous nodules on her forearms bilaterally and her left medial thigh for 2 days duration. The patient reports some associated tenderness and denies any associated pruritis, burning or discharge. She has had no previous occurrence of similar lesions.

Previous Treatment: 

Other information:  Current Medication:
Patient reports having received chemotherapy for recurrent breast carcinoma one week prior to admission. She also reports receiving Neupogen (filgrastim) after chemotherapy.

Other medications include:

Herceptin (trastuzumab)

Taxotere (docetaxel)

Xeloda (capecitabine)

Coumadin

Vioxx

PHYSICAL EXAM:

A well nourished caucasian female in no acute distress. Three erythematous nodulovesicles ranging from .5 to 1.3 cm are noted on the forearms bilaterally and a single similar lesion is found on the left medial thigh. Lesions were tender to palpation. No axillary, epitrochlear or inguinal adenopathy was noted. Oral mucosa is WNL.

LABORATORY TESTS:

WBC 0.9

Hgb 9.0

Hct 26.5

Plt 117,000

ESR 80

DERMATOHISTOPATHOLOGY:

Marked edematous epidermis with subcorneal and intraepidermal blister formation. Reticular and mid dermis show intense inflammatory infiltrate of neutrophils with scattered eosinophils and mast cells. Some leukocytoclasis is present with nuclear dust, but leukocytoclastic vasculitis is not seen.

DIFFERENTIAL DIAGNOSIS:

1.   Pyoderma Gangrenosum
2.   Sweet’s Syndrome
3.   Bullous Drug Eruption
4.   Infectious Pyoderma
5.  

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Sweet’s Syndrome

DISCUSSION:

Classic Sweet’s syndrome is characterized by erythematous papules or nodules that coalesce to form plaques, leukocytosis , and acute onset of fever. A synonym is Acute Febrile Neutrophilic Dermatosis. Arthritis, arthralgias, myalgias, conjunctivitis and oral lesion may also be seen. Sweet’s primarily affects adults with women outnumbering men 3:1. The majority of cases follow upper respiratory infections, however, other infectious associations include yersinia, toxoplasmosis, histoplasmosis, salmonellosis, vulvovaginitis and tuberculosis (Andrews p 156).

Hematologic and solid tumors are associated in 10% of Sweet’s cases. The most common medications associated include granulocyte-colony-stimulating-factor (Neupogen), oral contraceptives, minocycline and trimethoprim/sulfamethoxazole.

Upon biopsy, our patient had a thin transudate without obvious pus extrude through the lesion. Culture results were negative.

TREATMENT:

Initial treatment included 1% hydrocortisone and 1%iodoquinol (Vytone) alternating with mupirocin (Bactroban) ointment. The consulting physician imperically began treatment with Unasyn 3gm IV q 8 hours.

No new lesions were noted during hospitalization, and at the time of discharge the wbc was 8,000. Lesions slowly involuted without scarring over the next 6 weeks and no new lesions presented. The patient continued to receive Neupogen and all of her other medications without incident..

We believe that our patient fulfilled the classic criteria for Sweet’s syndrome. Although, her subsequent leukocytosis may have been multifactorial.

Other Treatment options:

Glucocorticoid therapy was not initiated due to the lack of progression of the lesions and her immunosuppressed status.

REFERENCES:

1. Richard B. Odom, Andrews’ Diseases of the Skin, 9th edition, W. B. Saunders Company, 2000[Medline]

2. Thomas B. Fitzpatrick, Color Atlas and Synopsis of Clinical Dermatology, 3rd edition, McGraw-Hill, 1997

3. David Elder, Synopsis and Atlas of Lever’s Histopathology of the Skin, Lippincott Williams & Wilkins, 1999

Additional Comment:

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