Case Report
Neutrophilic dermatosis of the dorsal hands related to cocaine abuse
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(A), Placa violácea crostosa; (B), grande bolha com base eritematosa na região radial da mão direita; (C), lesão com exsudato purulento sobre a articulação interfalangeana da mão esquerda.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marcial Álvarez‐Salafranca, Mar García‐García, Begoña de Escalante Yangüela" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Marcial" "apellidos" => "Álvarez‐Salafranca" ] 1 => array:2 [ "nombre" => "Mar" "apellidos" => "García‐García" ] 2 => array:2 [ "nombre" => "Begoña de Escalante" "apellidos" => "Yangüela" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0365059621001690" "doi" => "10.1016/j.abd.2020.07.023" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => 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"etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Begoña" "apellidos" => "de Escalante Yangüela" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Dermatology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pathology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Internal Medicine, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 573 "Ancho" => 905 "Tamanyo" => 166013 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A high-magnification image showing a heavy dermal infiltrate of neutrophils (Hematoxylin & eosin, ×20).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Neutrophilic dermatoses are a group of heterogeneous cutaneous disorders characterized by dense epidermal, dermal, or hypodermal infiltration of neutrophils. Neutrophilic Dermatosis of the Dorsal Hands (NDDH), first described by Strutton et al., is considered a localized variant of Sweet Syndrome (SS). In the first description, the presence of leukocytoclastic vasculitis in skin biopsies led the authors to name it “pustular vasculitis of the hands”.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, current evidence suggests that vasculitis may represent an epiphenomenon similar to that observed in some cases of SS.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Cocaine abuse has been related to a wide range of mucocutaneous manifestations.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Here, the authors report a patient with a stereotypical clinical picture of NDDH, in which cocaine abuse seemed to be the trigger.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 46-year-old man with a previous history of type 1 diabetes mellitus, atrial fibrillation, dyslipidemia, and Graves-Basedow disease presented with a 5-days history of cutaneous lesions on the dorsal aspect of his hands, associated with thoracic pain, mild cough, and expectoration that had appeared simultaneously. The patient did not present fever nor other acute symptoms. He had not started taking new medications but recognized frequent use of cocaine for 8 months.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Chest radiography revealed right costophrenic angle blunting related to pleural effusion. In this sense, a diagnosis of atypical pneumonia was made and therefore treatment with amoxicillin-clavulanate and subsequently with azithromycin was indicated. Nevertheless, the patient showed no improvement. Thoracoabdominal Computed Tomography (TC) verified a diffuse bilateral infiltrate suggestive of small airway inflammatory disease and a discrete pleural effusion.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Serum biochemistry showed glycemic decompensation (299 mg/dL and HbA1C = 10.6%) and elevated acute phase reactants (Erythrocyte Sedimentation Rate – ESR = 58 mm; C-Reactive Protein – CRP = 4.55 mg/dL). Complete blood count revealed leukocytosis (14 mil/mm<span class="elsevierStyleSup">3</span>) and neutrophilia (10.4 mil/mm<span class="elsevierStyleSup">3</span>). Tumor markers and serum blood electrophoresis were within normal limits. Autoimmunity tests (including Antinuclear Antibodies [ANAs] and Extractable Nuclear antigen Antibodies [ENAs]), serological tests for human immunodeficiency virus, hepatitis B and C virus and respiratory tract infections (including <span class="elsevierStyleItalic">Chlamydia</span><span class="elsevierStyleItalic">pneumoniae</span>, Legionella, <span class="elsevierStyleItalic">Mycoplasma</span><span class="elsevierStyleItalic">pneumoniae</span>, Coxiella, and Respiratory Syncytial Virus) were negative.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Dermatological examination revealed bilateral erythematous-violaceous edematous plaques, partially ulcerated, and pustules coalescing in hemorrhagic bullous lesions on the dorsal aspect of his hands (<a class="elsevierStyleCrossRefs" href="#fig0005">Fig. 1 and 2</a>). Histopathological examination showed acanthosis with subcorneal neutrophilic blister formation and a dense dermal interstitial inflammatory infiltrate predominantly composed of neutrophils (<a class="elsevierStyleCrossRefs" href="#fig0015">Fig. 3 and 4</a>). In addition, karyorrhexis, erythrocyte extravasation, and subepidermal edema were present. A swab culture from skin bullae did not identify pathogenic microorganisms.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was treated with oral prednisone 30 mg daily in a slow-tapering regimen for 8 weeks, along with topical betamethasone/gentamicin cream. Steroid therapy induced a dramatic response of both cutaneous lesions and thoracic pain. Moreover, the patient achieved to stop using cocaine since hospitalization to this day. During 1-year follow-up, no recurrence of the cutaneous lesions was observed, and the patient remained completely asymptomatic.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">NDDH is currently considered an uncommon, localized variant of SS.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Clinically, NDDH is characterized by erythematous-violaceous plaques and nodules, frequently ulcerated, predominantly involving the dorsal hands.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This disorder has a predilection for the radial aspect of the hands and is generally bilateral.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The localized distribution, clinical features and neutrophilic infiltration often lead to the initial diagnosis of cutaneous infection. However, the lesions do not respond to antibiotics and cultures are negative.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Blood analysis usually reveals leukocytosis, neutrophilia and elevated ESR. Nevertheless, these findings are less common than in classical SS.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Most cases of classic SS are idiopathic. Nevertheless, as in classical SS, there is a significant association between NDDH and systemic disease. In this sense, hematological disorders (mainly myelodysplastic syndrome and plasma cell dyscrasias), solid organ tumors, inflammatory bowel disease, and recent infections have been reported as triggers.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> For this reason, it is of paramount importance to perform a thorough physical examination and request complementary tests to rule out underlying systemic disease.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Pulmonary involvement in classic SS is rare. Skin lesions and pulmonary involvement are generally concomitant, being the most common symptoms of dyspnea and cough. Radiologic findings range from unilateral or bilateral interstitial infiltrates to lung opacities, with or without pleural effusion.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> When performed, cytological examination or biopsy can reveal a high proportion of neutrophils with negative cultures. In the present study’s case, these investigations were not performed because of the mild symptoms and its rapid improvement with steroids. To the authors’ best knowledge, there are no previous reports of suspected pulmonary involvement in NDDH.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Histologically, NDDH is characterized by a dense dermal neutrophilic infiltrate with associated dermal edema.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However, findings of leukocytoclastic vasculitis are more frequent than in classic SS. These findings are probably secondary to endothelial damage and are not necessary to make the diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5,7</span></a> Direct immunofluorescence is typically negative.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although the spontaneous resolution has been rarely described, patients with NDDH usually receive active treatment. Although systemic corticosteroids are the mainstay of treatment, many patients benefit from the use of a steroid-sparing systemic agent in order to prevent recurrences, mainly dapsone. Other alternative drugs are colchicine, tetracycline or potassium iodide.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Mucocutaneous manifestations of cocaine abuse have been recently reviewed.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Cocaine-induced vasculopathy is a well-described phenomenon that manifests as purpuric plaques predominantly involving the ears, nose and other facial regions. This purpuric eruption is related to microvascular thrombosis with or without leukocytoclastic vasculitis. Levamisole, a cocaine adulterant, has been identified as a trigger for the autoimmune response linked to this phenomenon.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Regarding neutrophilic dermatoses, Pyoderma Gangrenosum (PG) secondary to chronic cocaine use is well documented and tends to present with multiple lesions.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> Indeed, the strongest evidence for drug-induced PG concerns cocaine.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The histologic examination may show vasculitic changes as a distinctive but no constant finding. It is not well known whether levamisole can be the pathogenic culprit behind cocaine-related PG.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> Jeong et al. propose that levamisole is possibly implicated in the pathogenesis of cocaine-induced PG because of the similarity in the serologic profile of both entities. In this sense, p-ANCA (perinuclear antineutrophil cytoplasmic antibody) and antiphospholipid antibodies are frequently elevated in both vasculopathic levamisole toxicity and PG.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Considering that neutrophilic dermatoses are frequently considered a continuum and there is a significant overlap between these disorders, it is reasonable to hypothesize that levamisole-adultered cocaine could be involved in the genesis of other neutrophilic cutaneous diseases.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, the authors report a patient with NDDH, in which cocaine abuse was identified as a possible trigger. Cocaine use withdrawal along with appropriate acute phase treatment led to a prolonged time without recurrences and need for maintenance therapy. As far as the authors know, the relationship between cocaine and NDDH has not been previously reported.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors’ contributions</span><p id="par0075" class="elsevierStylePara elsevierViewall">Marcial Álvarez-Salafranca: Approval of the final version of the manuscript; composition of the manuscript; collection, analysis, and interpretation of data; participation in the design of the study; critical review of the literature; critical review of the manuscript.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Mar García-García: Approval of the final version of the manuscript; composition of the manuscript; collection, analysis, and interpretation of data; participation in the design of the study; critical review of the literature; critical review of the manuscript.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Begoña de Escalante Yangüela: Approval of the final version of the manuscript; composition of the manuscript; collection, analysis, and interpretation of data; participation in the design of the study; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1581933" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1423926" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Financial support" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Authors’ contributions" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-07-04" "fechaAceptado" => "2020-07-31" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1423926" "palabras" => array:5 [ 0 => "Acute febrile" 1 => "Cocaine-related disorders" 2 => "Neutrophilic dermatosis" 3 => "Prednisone" 4 => "Sweet’s syndrome" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Neutrophilic dermatoses encompass a wide spectrum of diseases characterized by a dense infiltration mainly composed of neutrophils. Neutrophilic dermatosis of the dorsal hands is currently considered a localized variant of Sweet syndrome. Cocaine abuse has been related to a wide range of mucocutaneous manifestations, including neutrophilic dermatoses such as pyoderma gangrenosum. The authors of this study present a patient with neutrophilic dermatosis of the dorsal hands, in which cocaine abuse was identified as a probable trigger.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Álvarez-Salafranca M, García-García M, de Escalante Yangüela B. Neutrophilic dermatosis of the dorsal hands related to cocaine abuse. An Bras Dermatol. 2021;96:574–7.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 605 "Ancho" => 905 "Tamanyo" => 60010 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation. Eythematous-violaceous plaques, pustules, and bullous lesions on the dorsal hands.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 797 "Ancho" => 3175 "Tamanyo" => 162270 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Detail of individual lesions of neutrophilic dermatosis of the dorsal hands (A), Crusted violaceous plaque (B), Large blister with an erythematous base on the radial aspect of the right hand (C), A lesion with purulent discharge over interphalangeal joint of the left hand.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 965 "Ancho" => 1508 "Tamanyo" => 280078 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">At low power, epidermis is acanthotic and there is subcorneal purulent material. A dense neutrophilic infiltrate is present in the upper dermis (Hematoxylin & eosin, ×8).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 573 "Ancho" => 905 "Tamanyo" => 166013 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A high-magnification image showing a heavy dermal infiltrate of neutrophils (Hematoxylin & eosin, ×20).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pustular vasculitis of the hands" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. 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