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now inducing local pain&#44; warmth and sensation of burning&#46; The dimensions of the left foot plaque increased and the dermatosis progressed&#44; involving both hands &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and feet&#44; this time markedly limiting the functional capacity of the patient&#46; At this point the patient underwent laboratory studies searching for autoimmunity&#44; which were negative&#46; Meanwhile the investigation performed in the context of hematology&#44; with bone marrow examination findings compatible with a myeloproliferative neoplasm&#44; allowed the diagnosis of polycythemia vera with positive JAK-2 mutation&#46; Conjugating the clinical and histopathological data available with the polycythemia vera detected&#44; the diagnosis of erythromelalgia secondary to the myeloproliferative disorder was established&#46; In collaboration with hematology&#44; the patient was started on hydroxyurea 500<span class="elsevierStyleHsp" style=""></span>mg&#47;day and acetylsalicylic acid 100<span class="elsevierStyleHsp" style=""></span>mg&#47;day and advised to avoid the precipitating factors and comply with resting periods with raised lower limbs&#46; This approach lead to an evident symptomatic improvement&#58; after 6 months the patient had no more episodes of erythematoviolaceous plaques although reported occasional warmth and discomfort on the left foot&#46; Platelet count and hemoglobin normalized&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Erythromelalgia is a rare clinical syndrome characterized by episodes of erythema&#44; increased temperature and burning pain&#44; primarily involving the extremities&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> with lower limbs being more commonly affected&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Physical exercise&#44; dependency of the affected limbs and heat exposure are potential triggers&#44; while cold&#44; rest and elevation relieve symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> The classification of this condition varies among authors&#44; but essentially there are primary forms&#44; which can be further divided into familial or sporadic of early &#40;juvenile&#41; or late &#40;adult&#41; onset&#44; and secondary forms&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Multiple diseases are associated with this clinical picture&#44; such as myeloproliferative neoplasms&#44; arterial hypertension&#44; venous insufficiency&#44; diabetes mellitus&#44; systemic lupus erythematosus&#44; rheumatoid arthritis&#44; lichen sclerosus&#44; gout&#44; spinal diseases and multiple sclerosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;6</span></a> Associated diseases may precede erythromelalgia&#44; coincide with the beginning of the disease or occur during its evolution&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Ethiopathogenesis of erythromelalgia is not known&#46; Vascular abnormalities&#44; small-fiber neuropathy and arteriovenous shunting are thought to be involved&#44; contributing to the erythema and pain&#44; but is unclear which one is the inciting event or primary abnormality&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> Histology is usually non-specific and some biopsy specimens don&#8217;t show any pathological findings but capillary proliferation&#44; swelling of endotelial cells&#44; perivascular edema and a sparse lymphocytic infiltrate are common&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> There are no established diagnostic criteria&#44; no clinical guidelines of management or large randomised controlled trials of treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;9</span></a> Erythema&#44; burning pain and hyperalgesia are features of many conditions&#46; Posttraumatic reflex dystrophies&#44; including causalgia&#44; reflex sympathetic dystrophy and shoulder-hand syndrome&#44; can closely mimic erythromelalgia&#46; Peripheral neuropathies&#44; peripheral vascular disorders&#44; Fabry disease and bacterial cellulitis should also be included in the differential diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;10</span></a> In the absence of a confirmatory diagnostic test&#44; diagnosis is based on a careful history and supported by physical examination during the episodes and&#44; once a diagnosis is established&#44; potential secondary causes must be excluded&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There is no universally effective treatment for erythromelalgia and the mainstay of therapy is support and avoidance of triggering factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a> Cases of erythromelalgia that are associated with myeloproliferative disorders usually respond to aspirin&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Otherwise&#44; drugs acting in the neuropathy &#40;gabapentin&#44; tricyclic antidepressants&#44; selective inhibitors of serotonina reuptake&#41;&#44; in vasculopathy &#40;acetylsalicylic acid&#44; calcium channel blockers&#44; prostaglandins&#41; and various nerve blocks have been attempted&#44; with variable success&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> In our case the patient presented initially with non-specific clinical and histological pictures&#46; The diagnosis of erythromelalgia was only established after the detection of polycythemia vera and the exacerbation of the symptomatology&#44; with the characteristic triad of erythema&#44; hyperthermia and pain with intense burning&#46; Our patient&#8217;s complaints were successfuly controled with daily low-dose aspirin&#46; In our case&#44; besides erythromelalgia&#44; which can cause ulcers in severe cases&#44; hydroxyurea&#44; used in the treatment of polycythemia vera&#44; can also induce distal cutaneous ulceration&#44; an association to keep in mind in the follow-up of the patient&#46; Erythromelalgia is a rare heterogeneous disorder with a variable spectrum of severity and should be considered in patients with paroxysmal neuropathic pain&#46; It is probably underdiagnosed and its early recognition is crucial to minimize the impact on patients&#8217; quality of life&#46;</p></span>"
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Case and Research Letters
Secondary erythromelalgia – case report
Eritromelalgia secundaria: informe de caso
F. Gila,
Autor para correspondencia
franciscosgil@gmail.com

Corresponding author.
, P. Luísb, M. Duartec, C. Martinsa
a Departamento de Dermatología, Hospital de Santarém EPE, Santarém, Portugal
b Departamento de Anatomía Patológica, Hospital de Santarém EPE, Santarém, Portugal
c Departamento de Hematología, Hospital de Santarém EPE, Santarém, Portugal
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Physical examination revealed only 2 erythematoviolaceous plaques on the outer side of the left foot&#44; with relatively well defined borders &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; An incisional skin biopsy obtained from one of the lesions showed non-specific findings&#58; a capilar proliferation in the dermis&#44; with some ectatic vessels&#44; and a a discrete lymphocytic inflammatory infiltrate&#46; In the following months&#44; thrombocytosis &#40;800<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41; and a borderline erythrocitosis &#40;15&#44;4<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41; were detected in routine analyses and the patient was referred to hematology consultation&#46; Concomitantly there was a clinical worsening of the dermatosis&#44; with an increase in the frequency and severity of the episodes&#44; including nocturnal&#44; now inducing local pain&#44; warmth and sensation of burning&#46; The dimensions of the left foot plaque increased and the dermatosis progressed&#44; involving both hands &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and feet&#44; this time markedly limiting the functional capacity of the patient&#46; At this point the patient underwent laboratory studies searching for autoimmunity&#44; which were negative&#46; Meanwhile the investigation performed in the context of hematology&#44; with bone marrow examination findings compatible with a myeloproliferative neoplasm&#44; allowed the diagnosis of polycythemia vera with positive JAK-2 mutation&#46; Conjugating the clinical and histopathological data available with the polycythemia vera detected&#44; the diagnosis of erythromelalgia secondary to the myeloproliferative disorder was established&#46; In collaboration with hematology&#44; the patient was started on hydroxyurea 500<span class="elsevierStyleHsp" style=""></span>mg&#47;day and acetylsalicylic acid 100<span class="elsevierStyleHsp" style=""></span>mg&#47;day and advised to avoid the precipitating factors and comply with resting periods with raised lower limbs&#46; This approach lead to an evident symptomatic improvement&#58; after 6 months the patient had no more episodes of erythematoviolaceous plaques although reported occasional warmth and discomfort on the left foot&#46; Platelet count and hemoglobin normalized&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Erythromelalgia is a rare clinical syndrome characterized by episodes of erythema&#44; increased temperature and burning pain&#44; primarily involving the extremities&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> with lower limbs being more commonly affected&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Physical exercise&#44; dependency of the affected limbs and heat exposure are potential triggers&#44; while cold&#44; rest and elevation relieve symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> The classification of this condition varies among authors&#44; but essentially there are primary forms&#44; which can be further divided into familial or sporadic of early &#40;juvenile&#41; or late &#40;adult&#41; onset&#44; and secondary forms&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Multiple diseases are associated with this clinical picture&#44; such as myeloproliferative neoplasms&#44; arterial hypertension&#44; venous insufficiency&#44; diabetes mellitus&#44; systemic lupus erythematosus&#44; rheumatoid arthritis&#44; lichen sclerosus&#44; gout&#44; spinal diseases and multiple sclerosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;6</span></a> Associated diseases may precede erythromelalgia&#44; coincide with the beginning of the disease or occur during its evolution&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Ethiopathogenesis of erythromelalgia is not known&#46; Vascular abnormalities&#44; small-fiber neuropathy and arteriovenous shunting are thought to be involved&#44; contributing to the erythema and pain&#44; but is unclear which one is the inciting event or primary abnormality&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> Histology is usually non-specific and some biopsy specimens don&#8217;t show any pathological findings but capillary proliferation&#44; swelling of endotelial cells&#44; perivascular edema and a sparse lymphocytic infiltrate are common&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> There are no established diagnostic criteria&#44; no clinical guidelines of management or large randomised controlled trials of treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;9</span></a> Erythema&#44; burning pain and hyperalgesia are features of many conditions&#46; Posttraumatic reflex dystrophies&#44; including causalgia&#44; reflex sympathetic dystrophy and shoulder-hand syndrome&#44; can closely mimic erythromelalgia&#46; Peripheral neuropathies&#44; peripheral vascular disorders&#44; Fabry disease and bacterial cellulitis should also be included in the differential diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;10</span></a> In the absence of a confirmatory diagnostic test&#44; diagnosis is based on a careful history and supported by physical examination during the episodes and&#44; once a diagnosis is established&#44; potential secondary causes must be excluded&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There is no universally effective treatment for erythromelalgia and the mainstay of therapy is support and avoidance of triggering factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a> Cases of erythromelalgia that are associated with myeloproliferative disorders usually respond to aspirin&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Otherwise&#44; drugs acting in the neuropathy &#40;gabapentin&#44; tricyclic antidepressants&#44; selective inhibitors of serotonina reuptake&#41;&#44; in vasculopathy &#40;acetylsalicylic acid&#44; calcium channel blockers&#44; prostaglandins&#41; and various nerve blocks have been attempted&#44; with variable success&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> In our case the patient presented initially with non-specific clinical and histological pictures&#46; The diagnosis of erythromelalgia was only established after the detection of polycythemia vera and the exacerbation of the symptomatology&#44; with the characteristic triad of erythema&#44; hyperthermia and pain with intense burning&#46; Our patient&#8217;s complaints were successfuly controled with daily low-dose aspirin&#46; In our case&#44; besides erythromelalgia&#44; which can cause ulcers in severe cases&#44; hydroxyurea&#44; used in the treatment of polycythemia vera&#44; can also induce distal cutaneous ulceration&#44; an association to keep in mind in the follow-up of the patient&#46; Erythromelalgia is a rare heterogeneous disorder with a variable spectrum of severity and should be considered in patients with paroxysmal neuropathic pain&#46; It is probably underdiagnosed and its early recognition is crucial to minimize the impact on patients&#8217; quality of life&#46;</p></span>"
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