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CLINICAL REPORT Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV
Annular Eruptive Pseudoangiomatosis and Adenovirus Infection : A Novel Clinical Variant of Paraviral Exanthems and a Novel Virus Association
Antonio CHUH 1 , Rüdiger PANZER 2 , Ann-Christine ROSENTHAL 2 , Ehrhardt PROKSCH 2 , Werner KEMPF 3 , Vijay ZAWAR 4 , Helmuth FICKENSCHER 5 and Regina FÖLSTER-HOLST 2
1
Jockey Club School of Public Health and Primary Care , The Chinese University of Hong Kong and the Prince of Wales Hospital , Shatin , Hong Kong , 2 Dermatologie , Venerologie und Allergologie , and 5 Institut für Infektionsmedizin , Christian-Albrechts-Universität zu Kiel und Universitätsklinikum Schleswig-Holstein , Campus Kiel , Kiel , Germany , 3 Histologische Diagnostik , and Department of Dermatology , University Hospital Zürich , Zürich , Switzerland , and 4 Department of Dermatology , Godavari Foundation Medical College and Research Center , DUPMCJ , Nashik , India
Eruptive pseudoangiomatosis is a distinct exanthem thought to be caused by viruses . The usual rash configu ration is erythematous papules and macules . An association with echovirus infection has been reported . We present here one adult and one child with this exan them , supported by clinical , histopathological , and immunohistochemical findings . Both patients presented with prodromal symptoms , widespread angioma-like macules in annular configuration , blanchable telangiectasia , followed by spontaneous remission in 6 – 8 weeks . Lesional histopathology of the adult patient revealed dilated dermal blood vessels and lymphohistiocytic infiltrates predominated by CD4 + lymphocytes with a 5:1 ratio of CD4 : CD8 lymphocytes . No B cells or CD56 + natural killer cells were found . Serology of both patients revealed evidence of active infections by adenoviruses , and a range of other viruses were excluded . We believe that these 2 patients manifested annular eruptive pseudoangio matosis , a novel variant of the rash with a probable adenovirus association that has not yet been reported .
Key words : annular rash ; cell-medicated immunity ; eruptive hypomelanosis ; Gianotti – Crosti syndrome ; pityriasis rosea ; viral infection .
Accepted Oct 3 , 2016 ; Epub ahead of print Oct 4 , 2016 Acta Derm Venereol 2017 ; 97 : 354 – 357 .
Corr : Antonio Chuh , Shops 5 and 6 , The Imperial Terrace , 356 Queen ’ s Road West , G / F , Hong Kong . E-mail : antonio . chuh @ yahoo . com . hk
Eruptive pseudoangiomatosis ( EP ) was first described by Cherry et al . in 1969 ( 1 ). In 1993 , Prose et al . ( 2 ) described 3 children with angioma-like papules during viral illnesses . As the skin lesions appeared suddenly , “ like an explosion ”, it qualifies as eruptive . As the macroscopic appearance is akin to cherry angiomas , with the histopathological changes not incorporating vascular proliferation , it qualifies as pseudoangiomatosis . EP was thus termed as such by Prose et al . in 1993 ( 2 ), some 24 years after the initial description of this exanthem ( 1 ).
Owing to its clinical course , with spontaneous remission , infectious causes are suspected . EP is one of several loosely categorized skin diseases known as paraviral exanthems , denoting that the disease is suspected to be related to infectious , usually viral , causes , but without an established single microbe-disease aetiology ( 3 , 4 ).
The inclusion of diseases in this category is debated , but is generally taken to be pityriasis rosea , pityriasis lichenoides , Gianotti – Crosti syndrome , asymmetric periflexural exanthem / unilateral laterothoracic exanthem , papular-purpuric gloves and socks syndrome , EP , and eruptive hypomelanosis ( 3 – 5 ).
In this family of diseases , EP is probably one of the least common . We present here reports of one adult and one child with eruptions for which the clinical features and laboratory findings strongly substantiated a diagnosis of EP , and suggest a novel aetiology and a novel morphological variant of this exanthema .
CASE REPORTS
Patient 1 . A 19-year-old male presented with a 2-day history of a mildly pruritic skin rash , characterized by annular erythema with dark-red plaques . Some of the annular lesions were closed , while others were openended ( arcs ). The lesions were identifiable as blanchable telangiectasia on the trunk , arms and face ( Fig . 1a – c ). The patient had diarrhoea , which started one week before onset of the rash .
A lesional skin biopsy was performed for histopathological and immunohistochemical analyses ( Fig . 1d ). Beneath an epidermis with focally increased basal pigmentation , there were slightly ectatic capillary vessels with prominent hobnail-like endothelia , and perivascular lympho-histiocytic infiltrates with admixture of melanophages . Immunohistochemical staining showed predominantly CD4 + lymphocytes with a ratio of CD4 : CD8 lymphocytes of approximately 5:1 . There was no admixture of B cells , CD56 + natural killer cells , or natural killer T cells . In addition , CD123 + plasmacytoid dendritic cells were absent .
Serological investigations on the active serum revealed elevated titres of IgG and IgA against the adenoviruses ( IgG : 33.6 U / ml , reference : < 14 U / ml ; IgA : 29.8 U / doi : 10.2340 / 00015555-2541 Acta Derm Venereol 2017 ; 97 : 354 – 357
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2017 Acta Dermato-Venereologica .