Blackwell Publishing Journal Backfiles 1879-2005
A 69-year-old woman was admitted to the Surgery Department of our hospital in November 1993 because of persistent erythematous skin lesions suspected clinically to be infectious cellulitis- Two months before admission she had noticed a red itchy pruriginous plaque, neasuring 10 × 5 cm, on her left buttock that had become larger in spite of treatment with oral antimicrobials. One month before entry, two more lesions flared up on her right buttock and left groin that soon became infiltrated. She did not notice any systemic symptoms. Past history of urticaria, atopy, tinea infection, or insect bites was not recalled. Two months before the first skin lesion erupted, the second dose of a tetanus vaccine had been given to the patient.The patient's temperature was 36.5°C on admission. On physical examination the patient appeared well and there were no systemic abnormalities. Examination of the skin revealed a red indurated plaque covering her left buttock and another one measuring 4 × 5 cm on the right buttock. A red nodular lesion, 3 × 2 cm in size, on her left groin was also noticed (Fig. 1).Laboratory investigation revealed a total white count of 9.7 × l03mm3, with 68% neutrophils and 22% lymphocytes. Erythrocyte sedimentation rate was 110/h. Her erythrocyte count was 3.33 × 106mm3. Blood glucose, kidney and liver function tests, and complement were all normal, and a polyclonal hypergammaglobulinemia of 23 g/L was seen on immunoelectrophoresis. Antinuclear antibodies (ANA) and alpha-1-antitrypsin antibodies were negative. Parenteral antibiotic therapy with penicillin and clindamycin was started with no improvement. After surgical debridement, no purulent exudate was found.A skin biopsy specimen of an infiltrated plaque was taken, showing an inflammatory infiltrate of lymphocytes and eosinophils, mostly perivascular, in the superficial and deep dermis, but especially in the deep subcutaneous tissue, with histiocytes and clusters of eosinophilic granules on the collagen fibers. Eosinophilic cellulitis (Wells' syndrome) was diagnosed and therapy with 20 mg/day of prednisone was started immediately. The skin lesions improved in a few days and the dose was tapered 3 weeks after starting therapy with oral steroids. She has not experienced any recurrence.
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