Jarisch‐Herxheimer reaction among syphilis patients in China

Background/aim The Jarisch‐Herxheimer reaction (JHR) is an acute systemic event that can occur during the treatment of spirochetal infections, especially Treponema pallidum in patients with syphilis. JHR has clinical characteristics of an inflammatory reaction to antibiotic treatment and can occur with many medications as long as the antitreponemal concentrations are sufficiently high. Methods The incidence of and risk factors for JHR were investigated retrospectively among 1125 patients with syphilis. A total of 357 patients (32%) had secondary syphilis, 129 (12%) primary, 178 (16%) early latent, 174 (15%) late latent and 285 (25%) latent unknown duration; two patients had tertiary syphilis. Results Sixteen patients (1.4%) developed JHR. All JHRs occurred in patients with secondary and latent syphilis treated with penicillin. Conclusions JHR occurred much less frequently than in previously reported studies. It is important that dermatologists recognize the clinical characteristics of JHR so that it is not misinterpreted as an allergic reaction to treatment.     

梅毒吉海反应研究现状

梅毒患者在首次给予抗菌素治疗数小时后可发生发热、头痛、原发皮疹加重和一系列生理学变化为特征的吉海反应。本文对其临床表现、发生机制及预防和治疗的研究现状进行综述。     

P20 Red tattoo reactions

Tattoos are becoming increasingly popular, although reactions to tattoos remain relatively uncommon. We describe 4 patients with a variety of red tattoo reactions, one responding well to intralesional steroid therapy. Case 1: A 50‐year‐old man presented with a florid, inflammatory reaction confined to the red area of his forearm tattoo. Biopsy showed a dense lymphocytic and focal macrophage response to tattoo pigment. Mass spectrometry of biopsy tissue revealed high concentrations of titanium and iron. Patch testing was negative. Intralesional steroid injection has produced a marked improvement. Case 2: A 42‐year‐old man presented with an inflammatory reaction affecting the red area of his leg tattoo. Biopsy revealed a florid lymphoid reaction. Case 3: A 30‐year‐old man presented with an eczematous reaction within the red/brown pigmented areas of his tattoos, which was exacerbated by sun exposure. Patch testing showed a (+) positive reaction to cadmium after 96 hours. Photo patch testing was negative. The reaction settled spontaneously within 12 months. Case 4: A 37‐year‐old woman presented with a florid, indurated inflammatory reaction involving the red area of a shoulder tattoo. Patch testing revealed a (++) and (+) positive reaction to nickel and cobalt respectively with a doubtful (?+) reaction to mercury 0.5% in petrolatum after 96 hours. Tattoo reactions, especially red tattoo reactions can present with a spectrum of histological changes, including lichenoid, granulomatous, hypersensitivity, nodular, pseudolymphomatous or sarcoidal reactions. One of our cases responded well to intralesional steroid injection and one case resolved spontaneously.     

Pyoderma gangrenosum‐like lesions provocated by botulinum injections

Botulinum toxin (BoNT) is a valuable therapeutic tool with several medical indications and the most popular of all cosmetic procedures worldwide. This is the reason for the growing number of unregistered products that may be the reason for adverse reactions. We present a case of a 51‐year‐old woman, who developed a pyoderma gangrenosum‐like reaction at injection sites after the administration of an unregistered BoNT product by a beautician. The clinical course, the morphology of the lesions, the result of histopathological biopsy, and the response to the treatment meets the criteria for diagnosis of pyoderma gangrenosum. The case presented by us is the first adverse reaction of this type after BoNT administration.     

Late‐onset anaphylactic reactions following i.v. cyclophosphamide pulse in a patient with systemic sclerosis and systemic lupus erythematosus overlap syndrome

Late‐onset anaphylactic reaction is a rare adverse effect of i.v. cyclophosphamide pulse (IVCY), which is caused by cyclophosphamide metabolites. We herein report a case of scleroderma and lupus overlap syndrome who developed anaphylactic reactions 3 h to 4 days after IVCY. Long time lapses between IVCY and appearance of symptoms are compatible with type I hypersensitivity to cyclophosphamide metabolites, appearing as late‐onset anaphylactic reaction. Albeit unusual, this is an important anaphylactic reaction to be aware of following IVCY.     

Immediate and delayed hypersensitivity to corticosteroids

Corticosteroids are therapeutic agents used in cases of allergy and intolerance. Due to the antiinflammatory effects of the corticosteroids, hypersensitivity reactions often are considered to be a paradox. However, delayed‐type reaction to corticosteroids is a frequent phenomenon in the daily routine. Non‐responding eczema, development of subacute contact eczema, systemic contact dermatitis or maculopapular exanthemas can be a clinical symptom of a delayed‐type hypersensitivity reaction to corticosteroids. Immediate‐type hypersensitivity reactions to corticosteroids remain uncommon. Nevertheless, they can take a severe clinical course. Patients react with anaphylaxis after systemic administration or with aggravation of an allergic reaction under therapy with corticosteroids. Allergologic testing is necessary for diagnosis and providing alternative corticosteroids in case of an emergency.     

Granuloma annulare‐like reaction to the bacillus Calmette‐Guerin vaccination

We report the case of a 6‐month‐old girl with a granuloma annulare (GA)‐like reaction to the bacillus Calmette‐Guerin (BCG) vaccination. The eruption developed at the vaccination site 1 month after vaccination and the lesion gradually disseminated over the body within 2 months. A biopsy specimen of the skin lesion showed degenerated collagen bundles surrounded by imperfect palisading histiocytes, lymphocytes and epithelioid cells in the dermis, which led to a diagnosis of GA‐like reaction as a secondary reaction to BCG inoculation. The eruption at the vaccination site and the scattered GA reaction resolved after 1 month of treatment with prednisolone valerate acetate ointment, leaving only pigmentation.     

The risk for cross-reactions after a cutaneous delayed-type hypersensitivity reaction to heparin preparations is independent of their molecular weight: a systematic review

Background. Heparins are a widely used class of drugs known to cause delayed‐type hypersensitivity (DTH) reactions. Recent publications indicate that the incidence of these may be higher than previously thought. To date, patient‐related but no drug‐related risk factors for the development of DTH reactions to heparins have been identified, although molecular weight is discussed as a potentially relevant parameter. Objectives. To address this, a systematic review was conducted on the frequency of cross‐reactions after DTH reactions to heparin preparations. Methods. We electronically searched MEDLINE and EMBASE, hand‐searched selected journals and references, and contacted experts for unpublished data. Results. Sixty‐six publications and unpublished data of 14 patients resulted in 198 patients with 1084 tests for cross‐reactivity. The primary causative agents were mostly unfractionated heparin (50%) and low molecular weight heparins (49.5%). Cross‐reactions were more likely after an initial DTH reaction to unfractionated heparin than after an initial DTH reaction to low molecular weight heparin. Our findings also indicate that molecular weight does not correlate with the risk for cross‐reactivity, which is in line with recent observations, indicating that different heparins have to be individually considered. Conclusions. The available data demonstrated the lowest overall risk for cross‐reactions for pentosan polysulfate (36.4%) and fondaparinux (10.4%). In the clinical context, fondaparinux is recommended as the current best alternative when a DTH reaction occurs.     

Drug‐induced hypersensitivity syndrome due to carbapenem antibiotics

Drug‐induced hypersensitivity syndrome (DIHS) is characterized by a serious adverse systemic reaction that usually appears after a 3–6‐week exposure to certain drugs, for example, anticonvulsants. Many different precipitating factors have been reported, but the pathophysiology of DIHS remains unknown. However, reactivation of members of the human herpesvirus (HHV) family, and of HHV‐6 in particular, has been reported in patients with DIHS. We report the case of a 64‐year‐old man who developed a generalized erythematous rash, fever, hepatic failure, lymphadenopathy and an increased number of atypical lymphocytes. In addition, reactivation of HHV‐6 and cytomegalovirus (CMV) was demonstrated by real‐time quantitative amplification by polymerase chain reaction. The patient was given a diagnosis of DIHS due to carbapenem antibiotics based on his clinical course, laboratory data, and results of lymphocyte‐stimulation tests with various drugs. This is the first report, to our knowledge, of DIHS induced by carbapenem antibiotics.     

Granulomatous slack skin mycosis fungoides developing simultaneously with sarcoid‐like lesions in a patient with repeated anabolic injections in the past?

We present a 32‐year‐old man with successful treatment and remission of mycosis fungoides of both axillae in 2016 after PUVA therapy and systemic and local administration of corticosteroids. Subsequently, in 2017, the patient also achieved remission of a T‐cell CD 30 positive, ALK‐1 negative large‐cell lymphoma of a retroperitoneal and inguinal lymph node after chemotherapy and radiotherapy. One year later, in 2018, the patient presented to our clinic with progression of skin lesions in both axillary areas and the appearance of а tumor in the right gluteal region.Dermatological examination showed livid‐to‐erythematous, partly sclerotic plaques in the right inguinal area, cutis laxa‐like plaque formations in the right axillary region with similar but less‐developed changes in the left axillary fold, a solitary subcutaneous tumor formation affecting the entire right gluteal region, and enlarged, palpable lymph nodes in the right para‐axillary area. Biopsies were obtained from an axillary lesion and the surgically removed axillary lymph nodes, and histological examination revealed changes of granulomatous slack skin in the axilla and reactive inflammatory changes in the lymph nodes. Histology of gluteal tissue showed a “foreign body” type of reaction with sarcoid‐like features, where the patient in the past have been injected with anabolic and steroidal drugs. Herein we describe a patient with simultaneous occurrence of granulomatous slack skin type mycosis fungoides and a sarcoid‐like reaction. The question remains open whether this represents the so‐called sarcoidosis‐lymphoma syndrome or, more likely, granulomatous slack skin MF associated with a sarcoid‐like reaction of “foreign body” type. The possibility that disturbance of tissue homeostasis by incorporation of certain adjuvants within injections (for example) in the past might have been an inducer of cutaneous T cell lymphoma and sarcoidosis/sarcoid like lesions seems reasonable but also speculative.     

Allergy to 3-nitro-p-hydroxyethylaminophenol and 4-amino-3-nitrophenol in a hair dye

Contact allergy to 3‐nitro‐p‐hydroxyethylaminophenol in a hair dye is described for the first time. p‐Phenylenediamine is the most common screening allergen when allergic contact dermatitis is suspected, but sometimes the allergen is not sufficient for diagnosing allergic contact dermatitis to hair dyes. A 50‐year‐old woman developed a severe scalp dermatitis and developed vesicular hand eczema for the first time in her life. Patch testing was performed with the European Standard Series. The patch testing was supplemented with a local series of cosmetic allergens and the hairdresser's series. At the initial patch testing, there was a + reaction to nickel and a +? to PPD at days 3 and 7. Further, she reacted with a +? to her own hair collected at day 3 after the hair dying which elicited the dermatitis reaction. Open exposure to the product, which had initiated the dermatitis, was negative both before and after the allergic reaction to the product. None of the screening chemicals in the hairdresser's series gave a definite positive reaction. Only by patch testing with the individual hair dye product ingredients, the patient's reactions were explained. The patient gave a positive patch test to 4‐amino‐3‐nitrophenol and 3‐nitro‐p‐hydroxyethylaminophenol at days 3–4 reading.     

Radiation Recall Dermatitis Secondary to Dactinomycin

Radiation recall dermatitis (RRD) is an uncommon reaction typically triggered by the use of chemotherapeutic agents in the months after treatment with radiation therapy. It usually presents as dermatitis in the irradiated field with prominent intertriginous involvement, and because internal involvement occurs in up to one‐third of cases, early recognition is important. RRD has rarely been reported in the pediatric literature. We report the case of a 15‐month‐old boy with RRD to dactinomycin.     

HSV‐associated erythema multiforme in a patient after hematopoietic stem cell transplantation

Herpes simplex virus (HSV)–associated erythema multiforme (HAEM) is an acute and self‐limiting mucocutaneous hypersensitivity reaction triggered by herpes virus infections. We reported a patient with HAEM after hematopoietic stem cell transplantation (HSCT). A 55‐year‐old man received HSCT 7 months ago. He suffered from chronic graft versus host disease 4 months after HSCT and was treated with prednisone and tacrolimus. One week ago, he developed generalized macules with leukopenia. Dermatological examination revealed multiple iris‐like erythemas on his trunk and extremities. The skin lesions and leukopenia resolved upon anti‐HSV treatment.     

Case of vitiligo universalis as a sequela of drug‐induced hypersensitivity syndrome

Drug‐induced hypersensitivity syndrome (DIHS) is a type of severe drug adverse reaction with high morbidity and mortality. DIHS patients have been reported to subsequently develop autoimmune disease, which may be followed by end‐organ decompensation. We report a 47‐year‐old woman who presented with fever, generalized maculopapular eruption, facial edema and eosinophilia with liver function impairment after taking celecoxib and sulfasalazine for 1 month. The patient was diagnosed with definite DIHS. The patient was treated with immunosuppressants including systemic corticosteroid for approximately 1.5 years due to recurrent episodes. Reactivation of human herpesvirus 6 and possible reactivation of cytomegalovirus were detected. Generalized hypopigmentation of the skin and leukotrichia were noted 4 months after the onset of DIHS. Histopathological examination confirmed the diagnosis of vitiligo. Some spontaneous repigmentation was noted 4 years after DIHS without specific treatment. Further immunoserology study showed elevated plasma C‐X‐C motif chemokine 10 level, which is related to vitiligo activity, in our patient. The occurrence of widespread vitiligo after DIHS is an extremely rare condition. This case provides an important reminder for physicians to monitor such severe complications after DIHS.     

Patch testing with hydroxyethyl-p-phenylenediamine sulfate - cross-reactivity with p-phenylenediamine

Background. Adverse reactions to permanent hair dyes are frequent, and primarily result from sensitization to p‐phenylenediamine (PPD). Objectives. To investigate the degree of cross‐reactivity to a chemically similar dye, hydroxyethyl‐p‐phenylenediamine sulfate (HPPS), and whether this might be a dyeing alternative for patients who are sensitive to PPD. Method. HPPS was patch tested in two concentrations in a total of 216 patients suspected of having contact dermatitis caused by hair dyes and/or hair cosmetics. A regular use test with a hair dye containing HPPS was suggested to every patient who had had an adverse reaction to a PPD hair dye in the past. Results. Forty of 216 (19.9%) patients reacted to 1% PPD, whereas only 2/216 (0.9%) showed a positive reaction to 1% HPPS. Reactivity to 2% HPPS was only slightly higher (5/216, 2.3%). On the basis of the 43 PPD‐positive patients, the reactivity to 2% HPPS amounted to 12%; the corresponding figure for toluene‐2,5‐diamine was 15% (5/33). In a use test on two PPD‐positive patients with a hair dye containing HPPS, no adverse reaction was seen, even after several years of regular dyeing. Conclusions. HPPS may be an alternative hair dye for individuals not tolerating PPD‐containing dyes. However, cross‐reactivity with PPD and other aromatic amines may occur. HPPS is also a known sensitizer, and the risk of de novo sensitization can only be assessed by a controlled study on a large panel and under regular use conditions.     

Verlaufsparameter zur Hyposensibilisierung bei Hymenopterengiftallergie

Summary: Course criteria were evaluated in 50 patients receiving Hymenoptera venom immunotherapy (11 times honeybee and 42 times wasp) ≥ 3 years. Co‐morbidity included hypertension in 24 % of patients and non‐immunological thyroid dysfunction in 14 %. In one patient therapy had to be discontinuated because of a type‐III reaction to immunotherapy. Another 10 % of patients developed mild anaphylactic reactions after venom injections. Continuation of immunotherapy was possible under premedication with antihistamines. During immunotherapy 22 % of the patients had at least one re‐sting of the allergy inducing Hymeonoptera. Of these 6 % developed again an anaphylactic reaction grade I, in consequence the injection dose of venom was elevated for further immunotherapy. IgE values increased insignificantly at the beginning of immunotherapy and decreased significantly after 2 years of immunotherapy. A significant decrease of reactivity to skin prick and intracutaneous tests was already demonstrated after 1 year of immunotherapy.     

Extensive orf infection in a toddler with associated id reaction

Orf is a zoonotic parapoxvirus typically transmitted to humans by a bite from goats or sheep. We present an unusual case of multiple orf lesions on the fingers of a 13‐month‐old child who was bitten by a goat and subsequently developed progressive swelling, blistering, and necrotic papulonodules of the hand followed by an additional diffuse, pruritic, papular rash. A primary diagnosis of orf infection was confirmed using real‐time polymerase chain reaction, and the diffuse eruption was clinically consistent with an id reaction. Extensive necrosis and papular id reaction associated with orf rarely have been described.     

Ritodrine-induced erythematous papular eruption in 14 pregnant women

Background Ritodrine hydrochloride, a β2‐adrenergic agonist, has been used for the treatment of pre‐term labor as a relatively safe agent, although tolerable side‐effects have been occasionally reported. Objective The purpose of this study was to assess our clinical experience of skin eruptions caused by ritodrine. Methods Fourteen pregnant women with pruritic skin eruptions associated with the administration of ritodrine for pre‐term labor were examined in Saitama Medical Center Hospital between 2005 and 2008. Results Patients included both primigravidas and multigravidas. Their mean age was 33.7 years (range: 27–41 years). Almost all subjects were in the third trimester of pregnancy. Skin eruptions occurred 7–27 days (mean: 14.9 days) after the start of intravenous or oral ritodrine. In eight patients, the eruption occurred after an increase in the dose of the drug. The reaction was characterized by a pruritic, erythematous, papular eruption, mainly distributed on the abdomen and upper extremities. Lymphocyte transformation tests for ritodrine were positive in five of the eight patients. Conclusions Ritodrine‐induced, erythematous, papular eruption probably occurs more frequently than has been previously estimated. An immunologic mechanism may play a role in the development of this eruption caused by ritodrine, although the reaction is somewhat dependent on the dose.     

Granulomatous tattoo reaction and erythema nodosum in a young woman: common cause or coincidence?

Tattooing has become quite popular in Western countries. With the increasing prevalence, there is also an increased risk of adverse effects. We describe a 17‐year‐old female patient with a black and red–colored tattoo, who developed immediately after red tattooing general malaise with fever, nausea, and vomiting. A bullous reaction was temporarily seen within the red part of her tattoo. The reaction later shifted to a subacute dermatitis with bacterial superinfection. Two months later, she felt ill again. She developed painful tender nodules on the anterior aspect of both lower legs identified as erythema nodosum without sarcoidosis. Is this is a unique case of adverse reaction to tattoo pigments with a type I and a type IV reaction, or is this a coincidence? The treatment was initiated with systemic and topical corticosteroids and topical antibiotics combined with compression bandages for the legs. After 3 weeks of treatment, the erythema nodosum completely resolved and did not reappear during a 1‐year follow‐up. The treatment of the local reactions, however, was unsatisfactory without complete response. There is an indispensable need for regulation of tattoo pigments and tattooing to improve consumer safety.