ARTÍCULOMEDICAL IMAGINGORIGINAL

Necrotizing acute neutrophilicMANUSCRITO leukocyclastic ACEPTADO acute vasculitis

Rotela Fisch,Verónica1,2,a; Agüero Zaputovich, María de Fátima2,b,e; Di Martino Ortíz, Beatriz2,b,f; Rodríguez-Masi, Mirtha2,c,e; Knofelmacher, Oilda2,d,e; Bolla de Lezcano, Lourdes2,d,e

1. Medical Consultant. Federación Latinoamericana de Sociedades Científicas de Estudiantes de Medicina (FELSOCEM). 2. Chair of Dermatology. Faculty of Medical Sciences. Universidad Nacional de Asunción. a. Resident of Dermatology b. Assistant Professor of Dermatology c. Adjunct Professor of Dermatology d. Full Professor of Dermatology e. Dermatologist f. Dermatopatologist

CIMEL 2017; 22(1): 77-79

INTRODUCTION without improvement. Injuries worsened 48 hours after the application of menthol topical ointment. Consulted in the Vasculitis compose a heterogeneous group of diseases with Emergency Service, here an evaluation by dermatologist is different causes and are clinical-pathological processes cha- carried out. racterized by inflammation and necrosis of the blood vessels, regardless of their size, cause, or affected organs (1,2). Physical exam:

Skin injure is frequent, as the only manifestation or on clini- The presence of dermatosis is established by: Round-shaped cal pictures with systemic involvement. Clinically, they result and other rosette blisters, with serosanguineous content, in palpable purple lesions, that can be painful (2,3). Necro- between 1-4 cm of diameter, some eroded, with a necrotic- tizing vasculitis has in common the fibrinoid necrosis and looking center, covered with hematic and melimeric crusts, inflammatory infiltrate in vascular walls. Among the cau- with serosanguine-like separation in nappa; the presentation ses of necrotizing vasculitis are: Wegener’s granulomatosis, form was partially isolated with a target, other confluents for- Takayasu’s arteritis, collagen diseases such as rheumatoid ming larger blisters, irregular edges, net limits, which settle arthritis, systemic lupus erythematosus, acute bacterial and on the antero-internal part of the legs, glutes, thighs, arms, viral infections, respiratory diseases such as asthma, otitis and forearms. (Figure 1 A and B.) media, Loeffler’s syndrome, drugs such as amphetamines, and neoplasms, among others (4).

CLINICAL CASE

Female patient, 55 years old, from an urban environment, currently unemployed. Hypertensive in regular treatment with Losartan 50 mg / d, and asthmatic in treatment with Prednisone occasionally as needed.

History of the current disease:

Clinical picture with 2 weeks of evolution that began with small clear blisters on the legs, which increase in size and number, pruritic, occasionally painful, that later spread along the body, and became hemorrhagic. She consulted at a me- dical center, where she received treatment with Acyclovir Figure 1. Skin lesions: Rounded and rosette blisters, with necrotic for 7 days, and Trimethoprim-Sulfamethoxazole for 3 days, center in legs (A) and forearms (B)

Please cite this article as: Rotela V et al. Necrotizing acute neutrophilic leukocyclastic acute vasculitis. CIMEL 2017; 22(1): 77-79. DOI: https://doi.org/10.23961/ cimel.v22i1.750

CIMEL 2017, Volumen 22, Number 1 MEDICAL IMAGING

Rounded erythematous-violet papules, approximately bet- re 3. B). Necrotic epidermis with dermo-epidermal detach- ween 0.1-0.5 cm of diameter with regular edges, net limits, ment (Figure 4. A) and sub-epidermal blister formation (Fi- arranged in isolation on the back of fingers, and eroded gure 4. B). erythematous on the face. (Figure 2 A and B) ANATOMO-PATHOLOGICAL DIAGNOSIS PROPOSED DIAGNOSTICS Acute neutrophilic leukocytoclastic vasculitis of small vessels Necrotizing Hemorrhagic Varicella Zoster, Gango-pyoder- of the dermis, with formation of subepidermal blister. In- ma, Cutaneous Vasculitis, Erythema Multiforme. flammatory specificity is not observed, nor infiltrating ma- lignant neoplastic, thrombi are not observed. DIAGNOSTIC ASSISTANTS FINAL DIAGNOSIS Laboratory without positive value data, negative Tzank test. Skin biopsy is performed for histopathology. Necrotizing leukocytoclastic acute neutrophilic vasculitis of small vessels of the dermis. HISTOPATHOLOGY TREATMENT AND EVOLUTION Histologically, the small-caliber vessels of the superficial der- mis show endothelial edema, fibrin extravasation (Figure 3. Corticosteroid treatment of these lesions is performed, Pred- A), and the presence of acute neutrophilic inflammation in nisone 1 mg / kg; with good evolution of cutaneous mani- the vascular walls with very extensive leukocytoclasia (Figu- festations, but rapid change of systemic involvement, with

Figure 2. Skin lesions: Erythematous and purpuric papules on the back of the hands (A) and face (B).

Figure 3. Histopathology: Small caliber vessels with endothelial Figure 4. Histopathology: Necrotic epidermis with dermal-epi- edema (A) and marked leukocytoclasia (B). dermal detachment (A) and sub-epidermal blister (B).

CIMEL 2017, Volumen 22, Number 1 ARTÍCULOMEDICAL IMAGINGORIGINAL death of the patient. MANUSCRITO ACEPTADO CONCLUSION

Acute neutrophilic vasculitis is characterized by inflam- mation and necrosis of blood vessels, they can be primary or secondary to other pathological processes. In this case, the necrosis observed in the cutaneous vessels through histo- pathology is highlighted, which agrees with the extremely widespread signs.

Financial support: Self-financed.

Conflicts of interest: All authors have no conflicts of interest to declare.

REFERENCES

1. Meza-Ayala CM, Dehesa-López E, Ruelas-Perea AG, Peña-Martínez E. Leukocytoclastic vasculitis: a diagnostic challenge for the internist. Med Int Méx 2015; 31: 113-118. 2. Liste Rodríguez, Sonia; Chamizo Cabrera, María Guadalu-pe; Paz Enrique, Luis Ernesto; Hernández Alfonso, Eduardo. Leukocytoclastic vasculitis. Cuban Journal of Comprehensive General Medicine. 2013; 30 (4): 415-420. 3. Pulido-Pérez A, Avilés-Izquierdo JA, Suárez-Fernández R. Cutaneous vas-culitis. Dermosifiliogr. 2012; 103 (3): 179-91. 4. Méndez O; Iglesias, A. Necrotizing vasculitis. Acta Med Co-lomb. 1980; (1) 261-283.

Corresponding author:

Verónica Rotela-Fisch E-mail: [email protected]

Received 02 March 2017 Accepted 24 March 2017

CIMEL 2017, Volumen 22, Number 1