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Leukocytoclastic sparing a with halo effect

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Citation Chen, Chen (Amy), Anar Mikailov, Beverly Faulkner-Jones, and Peggy A. Wu. 2015. “Leukocytoclastic vasculitis sparing a tattoo with halo effect.” JAAD Case Reports 1 (5): 269-271. doi:10.1016/ j.jdcr.2015.06.002. http://dx.doi.org/10.1016/j.jdcr.2015.06.002.

Published Version doi:10.1016/j.jdcr.2015.06.002

Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:26859999

Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA CASE SERIES

Leukocytoclastic vasculitis sparing a tattoo with halo effect

Chen (Amy) Chen, BA,a Anar Mikailov, MD,b Beverly Faulkner-Jones, MD, PhD,c and Peggy A. Wu, MD, MPHb Boston, Massachusetts

Key words: leukocytoclastic vasculitis; palpable purpura; reverse Koebner phenomenon; sparing phenom- enon; Wolf’s isotopic nonresponse.

INTRODUCTION Abbreviation used: The phenomenon of cutaneous diseases sparing sites of previous trauma has been described, al- LCV: leukocytoclastic vasculitis though there are few case reports that illustrate this rare phenomenon. We report an unusual case of leukocytoclastic vasculitis (LCV) that completely clinically normal around his (Fig 2, A spared tattooed skin with an additional halo effect and B). Laboratory data showed a hepatitis C viral around the tattoo. load of 323,000 IU/mL. Cryoglobulins, antinuclear antibody, anti-neutrophil cytoplasmic antibodies, CASE REPORT anti-mitochondrial antibody, and antiesmooth mus- A man in his 40s with recent intravenous drug use cle antibody test results were all normal. A skin and hepatitis C was admitted to the medical intensive biopsy found a superficial perivascular neutrophilic care unit with progressive respiratory failure in infiltrate with sparse leukocytoclasis, red the setting of multifocal pneumonia, an epidural extravasation, and reactive vascular changes with , tricuspid valve endocarditis, oxacillin- complement C3 deposition, consistent with LCV sensitive Staphylococcus aureus bacteremia, and (Fig 3). The etiology was presumed to be secondary acute hepatorenal failure. Laboratory values on to nafcillin, given the known association between admission were notable for a white blood cell count penicillins and LCV1 and the appearance of the of 20 K/L, a hemoglobin level of 11.3 g/dL, in- rash 5 days after nafcillin was initiated. As a result, ternational normalized ratio of 1.7, platelets of his nafcillin was discontinued and vancomycin 30 K/L, creatinine level of 6 mg/dL, and total started instead. By day 14 postadmission, the vascu- bilirubin of 17.2 mg/dL. During his hospital stay, he litis was almost fully resolved without any further received multiple antibiotics (levofloxacin, ceftriax- interventions. one, piperacillin-tazobactam, and nafcillin) and additional new (octreotide, pantopra- DISCUSSION zole, albumin, furosemide, lactulose). The patient LCV is an acute neutrophilic small vessel vasculitis had no known history of drug . On day resulting from vascular deposition of circulating 5 postadmission, nonretiform, palpable purpura immune complexes and subsequent activation of (Fig 1) developed consisting of well-defined, non- the complement cascade. This activation results in blanching, coalescing, 2- to 3-mm bright red to neutrophil chemotaxis and microvascular .2 purple macules and papules primarily involving Clinically, LCV is characterized by palpable purpura, the legs. No splinter hemorrhages, stellate lesions, although less common findings can include urticarial ulcerations, or were noted. No additional plaques, vesicles, bullae, and pustules. LCV can be symptoms were elicited, as the patient was intu- secondary to a variety of agents including medica- bated. Interestingly, the eruption exhibited a tions, chemicals, infections, or underlying systemic ‘‘sparing phenomenon,’’ with a 2- to 3-cm halo of disease; however, up to 60% of cases are idiopathic.2

From Harvard Medical Schoola and the Departments of Dermato- JAAD Case Reports 2015;1:269-71. logyb and Pathology,c Beth Israel Deaconess Medical Center. 2352-5126 Funding sources: None. Ó 2015 by the American Academy of Dermatology, Inc. Published Conflicts of interest: None declared. by Elsevier, Inc. This is an open access article under the CC Correspondence to: Peggy A. Wu, MD, MPH, Beth Israel Deaconess BY-NC-ND license (http://creativecommons.org/licenses/by-nc- Medical Center, Department of Dermatology, 330 Brookline nd/4.0/). Avenue, Shapiro 2nd Floor, Boston, MA 02215-5400. E-mail: http://dx.doi.org/10.1016/j.jdcr.2015.06.002 [email protected].

269 270 Chen et al JAAD CASE REPORTS SEPTEMBER 2015

Fig 1. Extensive nonretiform palpable purpura on bilat- eral lower extremities.

Here we report, to our knowledge, an unusual case of LCV with sparing of tattooed skin to produce a ‘‘halo.’’ The phenomenon of one skin disease sparing the site of a previous has been recognized since 1981, when Cochran and Wilkin3 reported a case of a drug rash failing to appear in a previously irradiated site on a 12-year-old girl. Since then, various related terms have been used to describe this phenomenon, including the reverse Koebner phenomenon (nonappearance or disap- pearance of skin lesions at sites of trauma)4 and Wolf’s isotopic nonresponse (absence of a cutaneous eruption at the site of another unrelated and already healed skin disease).5 Although the exact mecha- nisms and pathophysiology behind these sparing phenomena are unknown, current hypotheses sug- gest that alterations in the local structure or immu- nologic microenvironment at these sites may play a Fig 2. Palpable purpura exhibiting a ‘‘sparing phenome- role.6 non’’ with a 2- to 3-cm halo around a tattoo on the (A) right To date, few articles report on sparing phenom- anterior thigh and (B) right anterior leg. enon in association with LCV. In 2011, Yadav et al7 reported a case of reverse Koebner phenomenon in a demarcated by the tattoo. The authors proposed bandage-covered area in a patient with cutaneous several etiologic explanations for the sparing phe- small vessel immune complex vasculitis. The authors nomenon over tattooed skin. These included the suggested that the sparing phenomenon may have use of Hamamelis virginiana, a component of tattoo been a result of diminished blood flow to the ink with known antietumor necrosis factor and secondary to mechanical pressure from the bandage antiereactive oxygen species properties that may and consequent failure of immune complex deposi- have had an inhibitory effect on the development of tion. In 2014, Pinal-Fernandez and Solans-Laque8 vasculitis, the potential of the tattoo dye to act as a reported a case of relative sparing of a purpuric photoprotective factor against light penetration into rash over tattooed skin, although the purpuric rash the dermis, and microvascular changes caused by still extended several centimeters into the area tattooing. JAAD CASE REPORTS Chen et al 271 VOLUME 1, NUMBER 5

the introduction of fluoride into the dermis through may account for some degree of the observed halo effect. Distortion or destruction of postcapillary venules as a consequence of tattooing may also have a contributory effect. Further studies are required to elucidate the pathogenesis behind this novel phenomenon of LCV sparing a tattoo with halo effect. Fig 3. High-power image of a routine section. There is a superficial dermal and predominantly neutrophilic peri- REFERENCES vascular infiltrate with sparse leukocytoclasis and red 1. Wolkenstein P, Revuz J. Drug-induced severe skin reactions. blood cell extravasation, consistent with a leukocytoclastic Incidence, management and prevention. Drug Saf. 1995;13: vasculitis. (Hematoxylin and eosin stain; original magnifi- 56-68. cation: 3290.) 2. Lotti T, Ghersetich I, Comacchi C, Jorizzo JL. Cutaneous small-vessel vasculitis. J Am Acad Dermatol. 1998;39:667-687; quiz 688-690. 3. Cochran RJ, Wilkin JK. Failure of drug rash to appear in a In this case, purpura not only spared the multiple previously irradiated site. Arch Dermatol. 1981;117:810-811. tattoos but exhibited a unique halo effect of 2 to 3 cm 4. Malakar S, Dhar S. Spontaneous repigmentation of of clinically normal skin surrounding the tattoos. The patches distant from the autologous skin graft sites: a remote term halo is extrapolated from its use in the halo reverse Koebner’s phenomenon? Dermatology. 1998;197:274. 5. Wolf R, Brenner S, Ruocco V, Filioli FG. Isotopic response. Int J where local immunologic changes account for Dermatol. 1995;34:341-348. perinevoid vitiligo. In the case of LCV, the halo effect 6. Pakran J. Sparing phenomena in dermatology. Indian J could reflect local immunologic changes of the Dermatol Venereol Leprol. 2013;79:545-550. dermis caused by tattooing that inhibit neutrophil 7. Yadav S, De D, Kanwar AJ. Reverse koebner phenomenon in migration and subsequent cytokine cascade. The leukocytoclastic vasculitis. Indian J Dermatol. 2011;56:598-599. 8. Pinal-Fernandez I, Solans-Laque R. The ‘sparing phenomenon’ patient’s tattoos were self-administered 20 years pre- of purpuric rash over tattooed skin. Dermatology. 2014;228: viously using ink made from burned plastic ashes, 27-30. Colgate toothpaste, and Alberto VO5 . 9. Bober J, Kucharsk E, Zawierta J, Machoy Z, Chlubek D, Fluoride in animal and human studies has been Ciechanowski K. The influence of fluoride ions in the viability, found to affect immune function through observed reduction of NBT, cytolysis, degranulation, and phagocytosis 9,10 of human and rabbit neutrophils. Fluoride. 2000;33:108-114. effects on T regulatory cells and neutrophils. 10. Hernandez-Castro B, Vigna-Perez M, Doniz-Padilla L, et al. Given the important role of neutrophil migration in Effect of fluoride exposure on different immune parameters in effecting an immune response, we hypothesize that humans. Immunopharmacol Immunotoxicol. 2011;33:169-177.