CLINICAL HISTORY:

Signs and symptoms:  None

Previous Treatment:  No resolution or improvement with topical steroids

Other information:  Patient was swithed to tacrolimus ointment twice daily and NbUVb three times weekly without improvement.

Due to the complexity of the lesion, the patient's history was reviewed again.

Review of the Past Medical History revealed extensive coronary artery disease, AAA, Diabetes Mellitus Type II, GERD, HTN, and hypercholesterolemia.
A review of the Past Surgical History revealed cardiac stents placed in 1997, 1998, 2000, 2002, 2004, 2005 and another planned during 2006. There was a history of complex cardiac catheterization in 1998 and that the procedure time over four hours to perform.

The patient recalled that the lesion first appeared a few weeks after the aforementioned difficult catheterization.

PHYSICAL EXAM:

85x55 mm well-demarcated, partially crusted, indurated, hypopigmented area with epidermal atrophy and telangectasias.

Clinical Photo

Close up

LABORATORY TESTS:

None

DERMATOHISTOPATHOLOGY:

Initial report revealed an irregular epidermis, homogenization of the papillary dermis, and Sclerosis throughout the dermis with thickening of the dermis and compression of appendages with a few perivascular leukocytes consistent with morphea.

After reviewing the patient's cardiac history, the case was discussed again with the dermatopathologist. In addition to the dermal sclerosis, telangiectasias and atypical fibroblasts were seen.

Telangiectasias and Dermal Fibrosis

Atypical Fibroblasts

DIFFERENTIAL DIAGNOSIS:

1.   Morphea
2.   Radiation Dermatitis
3.   Necrobiosis Lipoidica
4.  
5.  

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Radiation Dermatitis

DISCUSSION:

Radiographic procedures performed worldwide has increased practically every year (1,2). In the United States alone, there were over 4.21 million interventional fluoroscopic procedures in 2006 versus 700,000 in 1996 (3,4,5). The incidence of radiation dermatitis has increased, however, the number of reported cases appears much smaller than might be expected (1,4). There have been fewer than 100 fluoroscopically-induced cases reported in the literature to date (2,3,6,7,8). This is most likely due to the difficulty in diagnosing this condition. Lesions ranging from simple erythema to transient alopecia, telangectasia, atrophy, hyperpigmentation, hypopigmentation, necrosis, chronic ulceration and squamous cell carcinoma have all been described (1,2,3,4,6,9,10,11,12).
In a recent review of 73 patients, initial diagnoses as disparate as fixed-drug eruption, morphea, contact dermatitis, infection and spider-bite were made (4).
Lesions have appeared anywhere from less than 1 day to 10 years after the causative procedure (3,4,6,7,13,14).
Improved physician education and awareness have led to both higher rates of diagnoses as well as better prevention.
Frazier et al (3) in 2007 most recently summarized the known changes to skin observed with increasing dosages of radiation.



To prevent radiation-induced injury, the radiation dose to affected areas of skin should be monitored real-time and kept below these levels (9,10,12,13,18). Emphasis must be placed on detection.

Taking a detailed history is absolutely essential. Most patients do not offer a prior history of fluoroscopy, either because they assume it irrelevant or have forgotten it completely (2,3,4). Histopathology is of limited utility as specimens are often non-diagnostic without proper clinical correlation. Due to poor wound healing, biopsies are discouraged biopsies in these cases4.

TREATMENT:

Biafene topical emulsion with allowed the biopsied area to heal well.

It is only with a high index of suspicion and specific questioning that many of these mysterious cases with a long latent period can be solved. With improved physician awareness, it will hopefully be solved more frequently.

REFERENCES:

1. Barnea, Y., Amir, A., Shafir, R., Weiss, J., & Gur, E. (2002). Chronic Radiodermatitis Injury After Cardiac Catheterization. Annals of Plastic Surgery, 49(6), 668-672.
2. Sajben, F., Schoelch, S., & Barnette, D. (1999). Fluoroscopic-Induced Radiation Dermatitis. Cutis, 64, 57-59.
3. Frazier, T., Richardson, J., Fabre, V., & Callen, J. (2007). Fluoroscopy-Induced Chronic Radiation Skin Injury. Archives of Dermatology, 143, 637-640.
4. Koenig, T., Wolff, D., Mettler, F., & Wagner, L. (2001). Skin Injuries from Fluoroscopically Guided Procedures: Part 1, Characteristics of Radiation Injury. American Journal of Radiology, 177, 3-11.
5. Market Research Cardiac Catherization Products Overview. Retrieved October 30, 2007, from http://www.imvinfo.com/index.aspx?sec=ccath&sub=def
6. Dehen, L., Vilmer, C., Humiliere, C., Corcos, T., Pentousis, D., Ollivaud, L., Chatelain, D., & Dubertret, L. (1999). Chronic radiodermatitis following cardiac catheterisation: a report of two cases and a brief review of the literature. Heart, 81, 308-312.
7. Schecter, A., Lewis, M., Robinson-Boston, L., & Pan, T. (2003). Cardiac catheterization-induced acute radiation dermatitis presenting as a fixed drug eruption - Case Reports. Journal of Drugs in Dermatology, 2(4), 425-427.
8. Wagner, L., Mcneese, M., Marx, M., & Siegel, E. (1999). Severe Skin Reactions from Fluoroscopy: Case Report and Review of the Literature. Radiology, 213, 773-776.
9. Aerts, A., Decraene, T., Van Den Oord, J., Dens, J., Janssens, S., Guelinckx, P., Flour, M., Degreef, H., & Garmyn, M. 2003. Chronic radiodermatitis following percutaneous coronary interventions: a report of two cases. Journal of the European Academy of Dermatology and Venereology, 17, 340-343.

Additional Comment:

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