Case for Diagnosis
Annular and Polycyclic Lesions on the Lower Limbs
Lesiones anulares y policíclicas en miembros inferiores
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The patient sought care for annular lesions on both lower limbs that had first appeared 4 months earlier. The lesions began as erythematous-edematous papules that spread eccentrically, regressed centrally, and were completely asymptomatic. The cutaneous manifestations were accompanied by mild generalized joint pain, with no other signs of systemic involvement.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed annular and polycyclic erythematous plaques with infiltrated borders, confined to the lower limbs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Incisional biopsy revealed a dense superficial perivascular lymphocytic infiltrate accompanied by abundant eosinophils distributed primarily around superficial and deep vessels (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Higher magnification revealed degranulation of eosinophils and flame figures (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">No interface dermatitis or lesions on the overlying epidermis were observed. Direct immunofluorescence was negative.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0025" class="elsevierStylePara elsevierViewall">A full blood work-up was ordered, including complete blood count, biochemistry, coagulation tests, C-reactive protein, sedimentation rate, rheumatoid factor, thyroid hormones, immunoglobulin E, tumor markers, hepatitis B and hepatitis C serology, antinuclear antibodies, anti-DNA antibodies, extractable nuclear antigen antibodies, antithyroid antibodies, and complement. The only important alterations were mild eosinophilia (7.8%, 600<span class="elsevierStyleHsp" style=""></span>cells/μL) and the already diagnosed HCV infection.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Clinicopathologic correlation supported a diagnosis of eosinophilic annular erythema (EAE).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0040" class="elsevierStylePara elsevierViewall">During 3 years of follow-up, the patient experienced self-resolving flares of EAE lasting 1 to 2 months each. The patient refused systemic treatment.</p><p id="par0045" class="elsevierStylePara elsevierViewall">For his HCV-induced chronic liver disease, the patient underwent a 12-week regimen of combination therapy with the direct antiviral agents sofosbuvir and ledipasvir.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0050" class="elsevierStylePara elsevierViewall">EAE was first described as a childhood disease in 1981 by Peterson and Jarratt, who used the term annular erythema of infancy. Years later, Kahofer et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> reported a case of EAE in a 62-year-old woman, and numerous other cases were later described in adults. This rare skin condition presents as multiple erythematous papules that spread outward, forming annular or polycyclic plaques with central clearing, located mainly on the trunk and limbs.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> The lesions tend to be asymptomatic or mildly pruritic and generally are not accompanied by systemic disease. The lesions tend to heal spontaneously or after treatment without leaving sequelae, although in some cases they may leave residual hyperpigmentation.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Histopathology shows an inflammatory infiltrate composed of lymphocytes, histiocytes, and numerous eosinophils. Direct immunofluorescence is negative.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Diagnosis is based on clinicopathologic correlation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The differential diagnosis includes other figurate erythemas such as erythema annulare centrifugum, disseminated granuloma annulare, subacute cutaneous lupus erythematosus, erythema chronicum migrans, urticarial vasculitis, and bullous pemphigoid in the prebullous phase.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Although controversy persists, the most widely accepted theory is that EAE is a clinicopathologic variant within the spectrum of Wells syndrome.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,4</span></a> Although the classic manifestations of Wells syndrome include degranulation of eosinophils, flame figures, and granulomatous reaction, all of these findings have also been reported in EAE, although less frequently, perhaps depending on the degree of progression at the time of biopsy.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Associated disorders identified by a 10-year prospective study included chronic gastritis associated with <span class="elsevierStyleItalic">Helicobacter pylori</span> infection, diabetes mellitus, HCV infection, and chronic kidney disease.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Despite the chronic nature of this dermatosis, control of associated disorders is associated with longer periods of remission.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Although this entity is considered benign, cases associated with neoplasms such as clear cell renal carcinoma,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> metastatic prostate adenocarcinoma,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> and thymoma<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> have also been reported.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our patient, although we found an association with HCV infection, the clinical course of the dermatosis was not modified by treatment with direct antiviral agents.</p><p id="par0085" class="elsevierStylePara elsevierViewall">As for treatment, although the reported cases have responded well to antimalarials as monotherapy or in combination with steroids,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2,4</span></a> this good response does not tend to last and a high recurrence rate has been reported.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Velasco-Tamariz V, Rodríguez-Peralto JL, Guerra-Tapia A. Lesiones anulares y policíclicas en miembros inferiores. Actas Dermosifiliogr. 2018;109:545–546.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 750 "Ancho" => 1000 "Tamanyo" => 77800 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 750 "Ancho" => 1000 "Tamanyo" => 368224 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×100.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 750 "Ancho" => 1000 "Tamanyo" => 240601 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×250.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of eosinophilic annular erythema with chloroquine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 42 | 14 | 56 |
| 2024 Octubre | 324 | 50 | 374 |
| 2024 Septiembre | 280 | 32 | 312 |
| 2024 Agosto | 252 | 57 | 309 |
| 2024 Julio | 187 | 51 | 238 |
| 2024 Junio | 145 | 25 | 170 |
| 2024 Mayo | 188 | 41 | 229 |
| 2024 Abril | 150 | 19 | 169 |
| 2024 Marzo | 172 | 27 | 199 |
| 2024 Febrero | 186 | 25 | 211 |
| 2024 Enero | 234 | 34 | 268 |
| 2023 Diciembre | 128 | 24 | 152 |
| 2023 Noviembre | 227 | 22 | 249 |
| 2023 Octubre | 175 | 17 | 192 |
| 2023 Septiembre | 138 | 36 | 174 |
| 2023 Agosto | 138 | 13 | 151 |
| 2023 Julio | 116 | 27 | 143 |
| 2023 Junio | 103 | 18 | 121 |
| 2023 Mayo | 162 | 22 | 184 |
| 2023 Abril | 98 | 23 | 121 |
| 2023 Marzo | 171 | 24 | 195 |
| 2023 Febrero | 130 | 30 | 160 |
| 2023 Enero | 120 | 40 | 160 |
| 2022 Diciembre | 84 | 32 | 116 |
| 2022 Noviembre | 44 | 32 | 76 |
| 2022 Octubre | 48 | 25 | 73 |
| 2022 Septiembre | 35 | 35 | 70 |
| 2022 Agosto | 38 | 37 | 75 |
| 2022 Julio | 35 | 39 | 74 |
| 2022 Junio | 34 | 21 | 55 |
| 2022 Mayo | 61 | 28 | 89 |
| 2022 Abril | 75 | 41 | 116 |
| 2022 Marzo | 96 | 38 | 134 |
| 2022 Febrero | 100 | 30 | 130 |
| 2022 Enero | 96 | 47 | 143 |
| 2021 Diciembre | 95 | 54 | 149 |
| 2021 Noviembre | 78 | 43 | 121 |
| 2021 Octubre | 92 | 51 | 143 |
| 2021 Septiembre | 64 | 48 | 112 |
| 2021 Agosto | 87 | 37 | 124 |
| 2021 Julio | 79 | 40 | 119 |
| 2021 Junio | 80 | 39 | 119 |
| 2021 Mayo | 49 | 48 | 97 |
| 2021 Abril | 142 | 120 | 262 |
| 2021 Marzo | 90 | 43 | 133 |
| 2021 Febrero | 75 | 53 | 128 |
| 2021 Enero | 46 | 43 | 89 |
| 2020 Diciembre | 37 | 43 | 80 |
| 2020 Noviembre | 29 | 40 | 69 |
| 2020 Octubre | 22 | 12 | 34 |
| 2020 Septiembre | 40 | 31 | 71 |
| 2020 Agosto | 22 | 30 | 52 |
| 2020 Julio | 28 | 20 | 48 |
| 2020 Junio | 29 | 40 | 69 |
| 2020 Mayo | 21 | 17 | 38 |
| 2020 Abril | 15 | 15 | 30 |
| 2020 Marzo | 25 | 14 | 39 |
| 2020 Febrero | 2 | 1 | 3 |
| 2019 Mayo | 0 | 1 | 1 |
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