Letters to the Editor
be associated with clinical manifestations; skin thickness of the former is thinner than that of the latter. A thick epidermis may mask early erythematous lesions of BD occurring on the palm.
CONFLICT OF INTEREST:
None.
Shinya KITAMURA, Hiroaki IWATA, Keisuke IMAFUKU, Hiroo HATA, Ken NATSUGA, Satoru AOYAGI, Hiroshi SHIMIZU Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
REFERENCES 1 Harnalikar M, Dongre A, Khopkar U. Bowen’s disease on palm: a rare presentation. Indian J Dermatol 2011; 56: 353–354. 2 Murao K, Tetsutani M, Ishigami T et al. Bowen disease of the palm associated with human papillomavirus 52. Clin Exp Dermatol 2013; 38: 489–491. 3 Cavicchini S, Tourlaki A, Ghislanzoni M et al. Pigmented Bowen disease of the palm: an atypical case diagnosed by dermoscopy. J Am Acad Dermatol 2010; 62: 356–357. € l M, Co € l C, Soran A et al. Arsenic-related Bowen’s disease, palmar 4 Co keratosis, and skin cancer. Environ Health Perspect 1999; 107: 687–689. 5 Kossard S, Rosen R. Cutaneous Bowen’s disease. An analysis of 1001 cases according to age, sex, and site. J Am Acad Dermatol 1992; 27: 406–410.
doi: 10.1111/1346-8138.12745
Immunoglobulin A vasculitis in the oldest old Dear Editor, Immunoglobulin (Ig)A vasculitis, the eponym for Henoch– € nlein purpura, is primarily a pediatric disease that occurs Scho between ages of 3 and 15 years,1 and less common in adults. Here, we report the oldest case of IgA vasculitis according to the English-language and Japanese published work. Our patient had intestinal and renal involvements, which prompted us to treat her with systemic corticosteroid therapy. A 97-year-old Japanese woman who had been in a nursing home visited our hospital because of abdominal pain, diarrhea and general malaise. There was a past history of hypertension,
(a)
(b)
which was treated with antihypertensives. No antecedent infection was noted. Total leukocyte count and C-reactive protein (CRP) level were elevated (11 500/lL and 7.9 mg/dL, respectively). Urinalysis showed a 3+ reaction for occult blood and a 2+ reaction for protein. Gastrointestinal endoscopy revealed diffuse patches of hyperemic and ecchymotic lesions in the affected colon (Fig. 1a). She also presented with a progressive purpuric rash on her four extremities (Fig. 1b), accompanied by arthralgia of her bilateral ankles and knees. A biopsy specimen from her forearm showed a neutrophil infiltrate around the small vessels with erythrocyte extravasation in the upper dermis
(c)
Figure 1. Clinical and histopathological findings. (a) Colonoscopy, showing patches of hyperemic and ecchymotic lesions. (b) Palpable purpura on her lower extremities. (c) Histopathology, showing leukocytoclastic vasculitis in the papillary dermis (hematoxylin– eosin, original magnification 9200).
Correspondence: Koji Kamiya, M.D., Ph.D., Toei Hospital, 5 Miwakamikuri, Toei-chou, Kitashitara-gun, Aichi 449-0293, Japan. Email: [email protected] Funding: None.
226
Ó 2015 Japanese Dermatological Association
Letters to the Editor
(Fig. 1c), indicating leukocytoclastic vasculitis. The serum IgA level was elevated (428 mg/dL; normal, 90–400), but other laboratory tests, including platelet count and serum antineutrophil cytoplasmic antibody, were normal or negative. According to the consensus statement,2 the definitive diagnosis of IgA vasculitis was made. After the initial treatment with 20 mg/day (0.5 mg/kg per day) of prednisolone, abdominal symptoms and skin lesions were alleviated gradually. In parallel, her leukocyte count, CRP level and urinalysis were normalized. Currently, the dose of prednisolone was tapered to 5 mg/day without relapse. Our patient exhibited typical clinical manifestations of IgA vasculitis, including palpable purpura, arthralgia, abdominal pain and hematuria/proteinuria, with its typical histopathological findings. She had remarkable intestinal lesions, similar to cutaneous vasculitis. Endoscopy provided substantial diagnostic utility as previously reported.3 The older patients more frequently have renal involvement, which potentially affects the mortality.4 Patients with microscopic hematuria and/or mild proteinuria should be followed closely to evaluate the progression of renal complications. Although a variety of infections and drugs are recognized as possible triggers for IgA vasculitis, the pathogenesis of IgA vasculitis remains unknown. Given an important role of IgA, the increased level of serum IgA in our case is suggestive of its involvement in the pathogenesis. Our case is unusual in age, because IgA vasculitis is rarely seen particularly in the oldest old. To our best knowledge, our 97-year-old woman is the oldest case in the published work. Despite her extremely old age, she was treated with 0.5 mg/kg per day of prednisolone with successful therapeutic effects on the abdominal and urinary symptoms. A systematic review concluded that corticosteroids may lessen the risk of
recurrence, gastrointestinal complications and renal diseases.5 It is notable that neither abdominal nor renal symptom recurred in our oldest old case, suggesting the effectiveness of corticosteroid therapy even in the elderly.
CONFLICT OF INTEREST:
None.
Koji KAMIYA,1,2 Haruo NIWA,1 Miwako NIWA,1 Yasunari KAMIYA,3 Akitoshi SAITO,1 Tadashi NATSUME,1 Yoshiki TOKURA2 Departments of 1General Medicine, 3Orthopedic Surgery, Toei Hospital, Kitashitara-gun, and 2Department of Dermatology, Hamamatsu University School of Medicine, Hamamatsu, Japan doi: 10.1111/1346-8138.12747
REFERENCES 1 Jennette JC, Falk RJ, Bacon PA et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum 2013; 65: 1–11. 2 Mills JA, Michel BA, Bloch DA et al. The American College of Rheumatology 1990 criteria for the classification of Henoch-Schonlein purpura. Arthritis Rheum 1990; 33: 1114–1121. 3 Chen MJ, Wang TE, Chang WH, Tsai SJ, Liao WS. Endoscopic findings in a patient with Henoch-Schonlein purpura. World J Gastroenterol 2005; 11: 2354–2356. 4 Diehl MP, Harrington T, Olenginski T. Elderly-onset Henoch-Schonlein purpura: a case series and review of the literature. J Am Geriatr Soc 2008; 56: 2157–2159. 5 Weiss PF, Feinstein JA, Luan X, Burnham JM, Feudtner C. Effects of corticosteroid on Henoch-Schonlein purpura: a systematic review. Pediatrics 2007; 120: 1079–1087.
Mycosis fungoides with psoriasiform lesions Dear Editor, A 54-year-old Japanese man presented with erythematous lesions all over his body. He had been treated by topical steroids without any benefit. A biopsy had been performed and the diagnosis of psoriasis vulgaris had been made by a previous doctor at the age of 53 years. Then, cyclosporin was administrated but the eruption did not respond. We examined the cutaneous condition carefully and found two types of lesions. The lesions of the face and right side of the abdomen were irregularly shaped erythema with pityroid scales (Fig. 1a,b) and the left side of the upper abdomen was indurated, welldemarcated erythema with thick scales (Fig. 1c). The hair was partially lost and nails showed pitting (Fig. 1d). We took a biopsy specimen from both types of lesions. The former revealed a partially acanthotic epidermis with microabscesses
containing atypical lymphocytes which also infiltrated along the basal layer and hair follicles (Fig. 1e–g). Immunohistochemical staining showed that the atypical lymphocytes were positive for CD3 and CD4, but not for CD8 (Fig. 1h–m). The latter showed hyperkeratosis, parakeratosis and neutrophilic microabscesses in the horny cell layer. The epidermis showed acanthosis with regularly extending rete ridges. There was a perivascular infiltration of lymphocytes in the papillary dermis (Fig. 1n). The lymphocytes infiltrating into the epidermis were composed mainly of CD4+ cells (Fig. 1o–q). The former lesions were diagnosed as mycosis fungoides (MF) of erythematous stage. The latter lesions were considered to be psoriasis vulgaris. Thus, we suspected that he had both MF and psoriasis vulgaris. Complete blood count, biochemical tests and whole-body computed tomography revealed no abnormal findings. Cyclosporin
Correspondence: Naoko Jinno, M.D., Department of Dermatology, Tokyo Women’s Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo 162-8666, Japan. Email: [email protected]
Ó 2015 Japanese Dermatological Association
227
be associated with clinical manifestations; skin thickness of the former is thinner than that of the latter. A thick epidermis may mask early erythematous lesions of BD occurring on the palm.
CONFLICT OF INTEREST:
None.
Shinya KITAMURA, Hiroaki IWATA, Keisuke IMAFUKU, Hiroo HATA, Ken NATSUGA, Satoru AOYAGI, Hiroshi SHIMIZU Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
REFERENCES 1 Harnalikar M, Dongre A, Khopkar U. Bowen’s disease on palm: a rare presentation. Indian J Dermatol 2011; 56: 353–354. 2 Murao K, Tetsutani M, Ishigami T et al. Bowen disease of the palm associated with human papillomavirus 52. Clin Exp Dermatol 2013; 38: 489–491. 3 Cavicchini S, Tourlaki A, Ghislanzoni M et al. Pigmented Bowen disease of the palm: an atypical case diagnosed by dermoscopy. J Am Acad Dermatol 2010; 62: 356–357. € l M, Co € l C, Soran A et al. Arsenic-related Bowen’s disease, palmar 4 Co keratosis, and skin cancer. Environ Health Perspect 1999; 107: 687–689. 5 Kossard S, Rosen R. Cutaneous Bowen’s disease. An analysis of 1001 cases according to age, sex, and site. J Am Acad Dermatol 1992; 27: 406–410.
doi: 10.1111/1346-8138.12745
Immunoglobulin A vasculitis in the oldest old Dear Editor, Immunoglobulin (Ig)A vasculitis, the eponym for Henoch– € nlein purpura, is primarily a pediatric disease that occurs Scho between ages of 3 and 15 years,1 and less common in adults. Here, we report the oldest case of IgA vasculitis according to the English-language and Japanese published work. Our patient had intestinal and renal involvements, which prompted us to treat her with systemic corticosteroid therapy. A 97-year-old Japanese woman who had been in a nursing home visited our hospital because of abdominal pain, diarrhea and general malaise. There was a past history of hypertension,
(a)
(b)
which was treated with antihypertensives. No antecedent infection was noted. Total leukocyte count and C-reactive protein (CRP) level were elevated (11 500/lL and 7.9 mg/dL, respectively). Urinalysis showed a 3+ reaction for occult blood and a 2+ reaction for protein. Gastrointestinal endoscopy revealed diffuse patches of hyperemic and ecchymotic lesions in the affected colon (Fig. 1a). She also presented with a progressive purpuric rash on her four extremities (Fig. 1b), accompanied by arthralgia of her bilateral ankles and knees. A biopsy specimen from her forearm showed a neutrophil infiltrate around the small vessels with erythrocyte extravasation in the upper dermis
(c)
Figure 1. Clinical and histopathological findings. (a) Colonoscopy, showing patches of hyperemic and ecchymotic lesions. (b) Palpable purpura on her lower extremities. (c) Histopathology, showing leukocytoclastic vasculitis in the papillary dermis (hematoxylin– eosin, original magnification 9200).
Correspondence: Koji Kamiya, M.D., Ph.D., Toei Hospital, 5 Miwakamikuri, Toei-chou, Kitashitara-gun, Aichi 449-0293, Japan. Email: [email protected] Funding: None.
226
Ó 2015 Japanese Dermatological Association
Letters to the Editor
(Fig. 1c), indicating leukocytoclastic vasculitis. The serum IgA level was elevated (428 mg/dL; normal, 90–400), but other laboratory tests, including platelet count and serum antineutrophil cytoplasmic antibody, were normal or negative. According to the consensus statement,2 the definitive diagnosis of IgA vasculitis was made. After the initial treatment with 20 mg/day (0.5 mg/kg per day) of prednisolone, abdominal symptoms and skin lesions were alleviated gradually. In parallel, her leukocyte count, CRP level and urinalysis were normalized. Currently, the dose of prednisolone was tapered to 5 mg/day without relapse. Our patient exhibited typical clinical manifestations of IgA vasculitis, including palpable purpura, arthralgia, abdominal pain and hematuria/proteinuria, with its typical histopathological findings. She had remarkable intestinal lesions, similar to cutaneous vasculitis. Endoscopy provided substantial diagnostic utility as previously reported.3 The older patients more frequently have renal involvement, which potentially affects the mortality.4 Patients with microscopic hematuria and/or mild proteinuria should be followed closely to evaluate the progression of renal complications. Although a variety of infections and drugs are recognized as possible triggers for IgA vasculitis, the pathogenesis of IgA vasculitis remains unknown. Given an important role of IgA, the increased level of serum IgA in our case is suggestive of its involvement in the pathogenesis. Our case is unusual in age, because IgA vasculitis is rarely seen particularly in the oldest old. To our best knowledge, our 97-year-old woman is the oldest case in the published work. Despite her extremely old age, she was treated with 0.5 mg/kg per day of prednisolone with successful therapeutic effects on the abdominal and urinary symptoms. A systematic review concluded that corticosteroids may lessen the risk of
recurrence, gastrointestinal complications and renal diseases.5 It is notable that neither abdominal nor renal symptom recurred in our oldest old case, suggesting the effectiveness of corticosteroid therapy even in the elderly.
CONFLICT OF INTEREST:
None.
Koji KAMIYA,1,2 Haruo NIWA,1 Miwako NIWA,1 Yasunari KAMIYA,3 Akitoshi SAITO,1 Tadashi NATSUME,1 Yoshiki TOKURA2 Departments of 1General Medicine, 3Orthopedic Surgery, Toei Hospital, Kitashitara-gun, and 2Department of Dermatology, Hamamatsu University School of Medicine, Hamamatsu, Japan doi: 10.1111/1346-8138.12747
REFERENCES 1 Jennette JC, Falk RJ, Bacon PA et al. 2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum 2013; 65: 1–11. 2 Mills JA, Michel BA, Bloch DA et al. The American College of Rheumatology 1990 criteria for the classification of Henoch-Schonlein purpura. Arthritis Rheum 1990; 33: 1114–1121. 3 Chen MJ, Wang TE, Chang WH, Tsai SJ, Liao WS. Endoscopic findings in a patient with Henoch-Schonlein purpura. World J Gastroenterol 2005; 11: 2354–2356. 4 Diehl MP, Harrington T, Olenginski T. Elderly-onset Henoch-Schonlein purpura: a case series and review of the literature. J Am Geriatr Soc 2008; 56: 2157–2159. 5 Weiss PF, Feinstein JA, Luan X, Burnham JM, Feudtner C. Effects of corticosteroid on Henoch-Schonlein purpura: a systematic review. Pediatrics 2007; 120: 1079–1087.
Mycosis fungoides with psoriasiform lesions Dear Editor, A 54-year-old Japanese man presented with erythematous lesions all over his body. He had been treated by topical steroids without any benefit. A biopsy had been performed and the diagnosis of psoriasis vulgaris had been made by a previous doctor at the age of 53 years. Then, cyclosporin was administrated but the eruption did not respond. We examined the cutaneous condition carefully and found two types of lesions. The lesions of the face and right side of the abdomen were irregularly shaped erythema with pityroid scales (Fig. 1a,b) and the left side of the upper abdomen was indurated, welldemarcated erythema with thick scales (Fig. 1c). The hair was partially lost and nails showed pitting (Fig. 1d). We took a biopsy specimen from both types of lesions. The former revealed a partially acanthotic epidermis with microabscesses
containing atypical lymphocytes which also infiltrated along the basal layer and hair follicles (Fig. 1e–g). Immunohistochemical staining showed that the atypical lymphocytes were positive for CD3 and CD4, but not for CD8 (Fig. 1h–m). The latter showed hyperkeratosis, parakeratosis and neutrophilic microabscesses in the horny cell layer. The epidermis showed acanthosis with regularly extending rete ridges. There was a perivascular infiltration of lymphocytes in the papillary dermis (Fig. 1n). The lymphocytes infiltrating into the epidermis were composed mainly of CD4+ cells (Fig. 1o–q). The former lesions were diagnosed as mycosis fungoides (MF) of erythematous stage. The latter lesions were considered to be psoriasis vulgaris. Thus, we suspected that he had both MF and psoriasis vulgaris. Complete blood count, biochemical tests and whole-body computed tomography revealed no abnormal findings. Cyclosporin
Correspondence: Naoko Jinno, M.D., Department of Dermatology, Tokyo Women’s Medical University, 8-1 Kawadacho, Shinjuku-ku, Tokyo 162-8666, Japan. Email: [email protected]
Ó 2015 Japanese Dermatological Association
227
