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Eosinophilic Cellulitis

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121. External Ear, Inflammatory Diseases

, and bacterial cultures to exclude a superimposed infection. In rare instances, a skin biopsy may be performed to identify the lesion. Histopathologic evaluation reveals a dense lymphocytic infiltration with a few eosinophils and plasma cells in the dermis and subcutaneous tissues and lymphoid follicles with germinal centers. T-cell lymphocytic infiltration, especially around blood vessels, is seen in one variant, known as "lymphomatoid contact dermatitis." Clinically and histologically, this can mimic (...) , and recurrent auricular chondritis can lead to permanent damage. Relapsing polychondritis usually manifests as cellulitis of one or both pinna. Because cartilage is lacking, the earlobes are typically spared. Destruction of external auditory canal cartilage may result in conductive hearing loss, while disruption of inner ear anatomy may result in sensorineural hearing loss, vertigo, or tinnitus. Table 1. Manifestations of Relapsing Polychondritis [ ] Organ System Manifestation Incidence, % Additional

2014 eMedicine Surgery

122. Sinusitis, Chronic, Medical Treatment

. Confounding factors that may contribute to inflammation include the following: Persistent infection (including biofilms and osteitis) [ , ] Allergy and other immunologic disorders Intrinsic factors of the upper airway Superantigens Colonizing fungi that induce and sustain eosinophilic inflammation Metabolic abnormalities such as aspirin sensitivity All of these factors can play a role in disruption of the intrinsic mucociliary transport system. This is because an alteration in sinus ostia patency, ciliary (...) A, Chandra M, Nag TC. Clinical implications of microbial biofilms in chronic rhinosinusitis and orbital cellulitis. BMC Ophthalmol . 2016 Sep 21. 16 (1):165. . Brook I, Foote PA, Hausfeld JN. Increase in the frequency of recovery of meticillin-resistant Staphylococcus aureus in acute and chronic maxillary sinusitis. J Med Microbiol . 2008 Aug. 57:1015-7. . Brook I. Acute and chronic bacterial sinusitis. Infect Dis Clin North Am . 2007 Jun. 21(2):427-48, vii. . Brook I. Bacteriology of chronic maxillary

2014 eMedicine Surgery

123. Dermatologic Manifestations of Hematologic Disease (Follow-up)

with painful, necrotic skin ulcers. Histopathology evaluation reveals medial calcification and intimal hyperplasia of small and medium-sized arteries of dermal and subcutaneous tissues. [ ] The differential diagnosis includes vasculitis, cholesterol embolization syndrome, warfarin-induced skin necrosis, nephrogenic fibrosing dermopathy, ecthyma, cryofibrinogenemia, cellulitis, necrotizing fasciitis, coagulation disorders, and adverse drug effects. Treatment options are limited. [ ] Next: Cutaneous (...) walls and without evidence of vasculitis. Eosinophilic thrombi or fibrin can occlude some capillaries. In patients with small-vessel thrombosis induced by cold agglutinin disease, the differential diagnoses must include (DIC), (TTP), warfarin (Coumadin)–induced skin necrosis, cryofibrinogenemia, and (PNH). The best treatment of cold agglutinin disease is avoidance of cold temperatures. In contrast to the treatment of other hemolytic anemias, steroids and splenectomy have no role in the treatment

2014 eMedicine.com

124. Dermatologic Diseases of the Male Genitalia: Nonmalignant (Follow-up)

are used to reduce inflammation. Additional treatment includes proper hygiene, with washing and drying of the prepuce. Circumcision is usually effective and may be indicated if medical therapy fails. [ ] The outcome in treated patients is favorable, and serious complications are rare. Uncommonly, untreated cases can result in cellulitis and gangrene. Treatment failures should prompt further clinical examination and consideration of other etiologies. Failure of response in the setting of appropriate (...) confocal microscopy. [ ] The histopathologic features show a thinned epidermis or epithelium and a dense, superficial, bandlike, predominantly plasmacytic, inflammatory infiltrate in the dermis. The dermal infiltrate also contains lymphocytes, neutrophils, histiocytes, and eosinophils. Dilated capillaries and associated extravasated red cells and hemosiderin deposition may also develop. Differential diagnoses The clinical presentation of Zoon balanitis can mimic erythroplasia of Queyrat (see ). Biopsy

2014 eMedicine.com

125. Dirofilariasis (Follow-up)

, Neafie RC, Perry HD. Subcutaneous dirofilariasis of the eyelid and ocular adnexa. Report of six cases. Arch Ophthalmol . 1980 Jun. 98(6):1079-82. . Joseph K, Vinayakumar AR, Criton S, Vishnu MS, Pariyaram SE. Periorbital mass with cellulitis caused by dirofilaria. Indian J Med Microbiol . 2011. 29 (4):431-3. . . Mittal M, Sathish KR, Bhatia PG, Chidamber BS. Ocular dirofilariasis in Dubai, UAE. Indian J Ophthalmol . 2008 Jul-Aug. 56(4):325-6. . . Sathyan P, Manikandan P, Bhaskar M, Padma S, Singh G (...) and human exposure to Dirofilaria immitis infected mosquitoes in endemic areas of Italy. Parasit Vectors . 2013 Mar 7. 6:60. . . Kim MK, Kim CH, Yeom BW, Park SH, Choi SY, Choi JS. The first human case of hepatic dirofilariasis. J Korean Med Sci . 2002 Oct. 17(5):686-90. . Dobson C, Welch JS. Dirofilariasis as a cause of eosinophilic meningitis in man diagnosed by immunofluorescence and Arthus hypersensitivity. Trans R Soc Trop Med Hyg . 1974. 68(3):223-8. . Moorhouse DE. Dirofilaria immitis: a cause

2014 eMedicine.com

126. Dermatologic Manifestations of Pulmonary Disease (Follow-up)

effusions. Laboratory findings include striking peripheral eosinophilia, usually more than 1.5 X 10 9 cells/L. Eosinophilia is also common in patients with asthma; however, the magnitude is greater in patients with the Churg-Strauss syndrome. Eosinophils are the dominant cell in pleural or pericardial effusions. Other laboratory findings may include a positive perinuclear ANCA serology and elevated immunoglobulin E levels. Cutaneous findings As many as 70% of patients with Churg-Strauss syndrome have (...) cutaneous manifestations. [ ] A variety of lesions may be seen, the most common of which are palpable purpura, subcutaneous nodules, urticarial rashes, and livedo reticularis. Palpable purpura usually involves the lower extremities and is common but nonspecific. Biopsy of these lesions reveals leukocytoclastic vasculitis. The most distinctive lesions are tender subcutaneous nodules occurring on the limbs and scalp, or, less frequently, on the trunk. Biopsies of these lesions reveal an eosinophilic

2014 eMedicine.com

127. Cutaneous Manifestations of HIV Disease (Follow-up)

. The most common cutaneous infections in children with HIV disease are impetigo and cellulitis caused by Staphylococcus aureus . Other cutaneous manifestations of HIV infection in the pediatric age group are as follows: Recurrent herpetic gingivostomatitis Scabies Severe atopic dermatitis Drug eruptions Leukocytoclastic vasculitis Previous Next: Malignancies (KS) was the first reported malignancy associated with HIV infection and was first documented in 1981 from reports in New York, Los Angeles (...) suggest HIV infection. Bournerias et al reported tinea capitis from Microsporum canis in 2 patients infected with HIV. [ ] Pityriasis versicolor may be persistent and recurrent in patients with HIV infection. Previous Next: Deep Fungal Infections Rarely, cutaneous cryptococcosis may be observed in patients with HIV infection. [ ] Clinical manifestations include the following: Cellulitis Papules Plaques Ulcers Translucent dome-shaped papules with central umbilication, resembling MC Cutaneous

2014 eMedicine.com

128. Angioedema (Follow-up)

angioedema with eosinophilia (Gleich's Syndrome). Immunol Allergy Clin North Am . 2006 Nov. 26(4):769-81. . Ferreli C, Pinna AL, Atzori L, Aste N. Eosinophilic cellulitis (Well's syndrome): a new case description. J Eur Acad Dermatol Venereol . 1999 Jul. 13(1):41-5. . Brown AF, McKinnon D, Chu K. Emergency department anaphylaxis: A review of 142 patients in a single year. J Allergy Clin Immunol . 2001 Nov. 108(5):861-6. . Yang MS, Lee SH, Kim TW, et al. Epidemiologic and clinical features of anaphylaxis

2014 eMedicine.com

129. Angioimmunoblastic Lymphadenopathy With Dysproteinemia (Follow-up)

in an elderly patient who presented with generalized pruritic maculopapular eruption and fever after taking doxycycline. [ ] Renner et al described eosinophilic cellulitis (Wells syndrome) in association with angioimmunoblastic lymphadenopathy. [ ] Physical examination All organ systems can be affected by AILD. Typical findings at presentation include the following: Rash (50% of cases) Pruritus (30%) Edema (40%) Pleural effusion (40%) Arthritis (20%) Ascites (25%) Skin involvement in AILD manifests (...) with angioimmunoblastic T-cell lymphoma and proliferative glomerulonephritis. Ann Hematol . 2004 Jul. 83(7):455-9. . Batinac T, Zamolo G, Jonjic N, Gruber F, Nacinovic A, Seili-Bekafigo I, et al. Angioimmunoblastic lymphadenopathy with dysproteinemia following doxycycline administration. Tumori . 2003 Jan-Feb. 89(1):91-5. . Renner R, Kauer F, Treudler R, Niederwieser D, Simon JC. Eosinophilic cellulitis (Wells' syndrome) in association with angioimmunoblastic lymphadenopathy. Acta Derm Venereol . 2007. 87(6):525-8

2014 eMedicine.com

130. Sinusitis, Chronic (Diagnosis)

. Confounding factors that may contribute to inflammation include the following: Persistent infection (including biofilms and osteitis) [ , ] Allergy and other immunologic disorders Intrinsic factors of the upper airway Superantigens Colonizing fungi that induce and sustain eosinophilic inflammation Metabolic abnormalities such as aspirin sensitivity All of these factors can play a role in disruption of the intrinsic mucociliary transport system. This is because an alteration in sinus ostia patency, ciliary (...) A, Chandra M, Nag TC. Clinical implications of microbial biofilms in chronic rhinosinusitis and orbital cellulitis. BMC Ophthalmol . 2016 Sep 21. 16 (1):165. . Brook I, Foote PA, Hausfeld JN. Increase in the frequency of recovery of meticillin-resistant Staphylococcus aureus in acute and chronic maxillary sinusitis. J Med Microbiol . 2008 Aug. 57:1015-7. . Brook I. Acute and chronic bacterial sinusitis. Infect Dis Clin North Am . 2007 Jun. 21(2):427-48, vii. . Brook I. Bacteriology of chronic maxillary

2014 eMedicine.com

131. Campylobacter Infections (Diagnosis)

. Such adherence would promote gut colonization. PEB 1 is a superficial antigen that appears to be a major adhesin and is conserved among C jejuni strains. Some strains of C jejuni produce a heat-labile, choleralike enterotoxin, which is important in the watery diarrhea observed in infections. Infection with the organism produces diffuse, bloody, edematous, and exudative enteritis. The inflammatory infiltrate consists of neutrophils, mononuclear cells, and eosinophils. Crypt abscesses develop in the epithelial (...) in Campylobacter jejuni. Antimicrob Agents Chemother . 2008 Nov. 52(11):3947-54. . Carbone KM, Heinrich MC, Quinn TC. Thrombophlebitis and cellulitis due to Campylobacter fetus ssp. fetus. Report of four cases and a review of the literature. Medicine (Baltimore) . 1985 Jul. 64(4):244-50. . Crushell E, Harty S, Sharif F, Bourke B. Enteric campylobacter: purging its secrets?. Pediatr Res . 2004 Jan. 55(1):3-12. . Drake AA, Gilchrist MJ, Washington JA 2nd, et al. Diarrhea due to Campylobacter fetus subspecies

2014 eMedicine.com

132. Angioimmunoblastic Lymphadenopathy With Dysproteinemia (Diagnosis)

in an elderly patient who presented with generalized pruritic maculopapular eruption and fever after taking doxycycline. [ ] Renner et al described eosinophilic cellulitis (Wells syndrome) in association with angioimmunoblastic lymphadenopathy. [ ] Physical examination All organ systems can be affected by AILD. Typical findings at presentation include the following: Rash (50% of cases) Pruritus (30%) Edema (40%) Pleural effusion (40%) Arthritis (20%) Ascites (25%) Skin involvement in AILD manifests (...) with angioimmunoblastic T-cell lymphoma and proliferative glomerulonephritis. Ann Hematol . 2004 Jul. 83(7):455-9. . Batinac T, Zamolo G, Jonjic N, Gruber F, Nacinovic A, Seili-Bekafigo I, et al. Angioimmunoblastic lymphadenopathy with dysproteinemia following doxycycline administration. Tumori . 2003 Jan-Feb. 89(1):91-5. . Renner R, Kauer F, Treudler R, Niederwieser D, Simon JC. Eosinophilic cellulitis (Wells' syndrome) in association with angioimmunoblastic lymphadenopathy. Acta Derm Venereol . 2007. 87(6):525-8

2014 eMedicine.com

133. Angioedema (Diagnosis)

also been associated with certain conditions or syndromes, such as the following: Cytokine-associated angioedema syndrome (ie, Gleich syndrome or episodic angioedema with eosinophilia) [ ] Well syndrome or eosinophilic cellulitis (ie, granulomatous dermatitis with eosinophilia) [ ] Hypersensitivity angioedema Hypersensitivity (allergic) angioedema is often associated with urticaria. It is typically observed within 30 minutes to 2 hours after exposure to the allergen. Mast cell–mediated angioedema (...) episodic angioedema with eosinophilia (Gleich's Syndrome). Immunol Allergy Clin North Am . 2006 Nov. 26(4):769-81. . Ferreli C, Pinna AL, Atzori L, Aste N. Eosinophilic cellulitis (Well's syndrome): a new case description. J Eur Acad Dermatol Venereol . 1999 Jul. 13(1):41-5. . Brown AF, McKinnon D, Chu K. Emergency department anaphylaxis: A review of 142 patients in a single year. J Allergy Clin Immunol . 2001 Nov. 108(5):861-6. . Yang MS, Lee SH, Kim TW, et al. Epidemiologic and clinical features

2014 eMedicine.com

134. Dermatologic Manifestations of Pulmonary Disease (Diagnosis)

effusions. Laboratory findings include striking peripheral eosinophilia, usually more than 1.5 X 10 9 cells/L. Eosinophilia is also common in patients with asthma; however, the magnitude is greater in patients with the Churg-Strauss syndrome. Eosinophils are the dominant cell in pleural or pericardial effusions. Other laboratory findings may include a positive perinuclear ANCA serology and elevated immunoglobulin E levels. Cutaneous findings As many as 70% of patients with Churg-Strauss syndrome have (...) cutaneous manifestations. [ ] A variety of lesions may be seen, the most common of which are palpable purpura, subcutaneous nodules, urticarial rashes, and livedo reticularis. Palpable purpura usually involves the lower extremities and is common but nonspecific. Biopsy of these lesions reveals leukocytoclastic vasculitis. The most distinctive lesions are tender subcutaneous nodules occurring on the limbs and scalp, or, less frequently, on the trunk. Biopsies of these lesions reveal an eosinophilic

2014 eMedicine.com

135. Dermatologic Manifestations of Hematologic Disease (Diagnosis)

with painful, necrotic skin ulcers. Histopathology evaluation reveals medial calcification and intimal hyperplasia of small and medium-sized arteries of dermal and subcutaneous tissues. [ ] The differential diagnosis includes vasculitis, cholesterol embolization syndrome, warfarin-induced skin necrosis, nephrogenic fibrosing dermopathy, ecthyma, cryofibrinogenemia, cellulitis, necrotizing fasciitis, coagulation disorders, and adverse drug effects. Treatment options are limited. [ ] Next: Cutaneous (...) walls and without evidence of vasculitis. Eosinophilic thrombi or fibrin can occlude some capillaries. In patients with small-vessel thrombosis induced by cold agglutinin disease, the differential diagnoses must include (DIC), (TTP), warfarin (Coumadin)–induced skin necrosis, cryofibrinogenemia, and (PNH). The best treatment of cold agglutinin disease is avoidance of cold temperatures. In contrast to the treatment of other hemolytic anemias, steroids and splenectomy have no role in the treatment

2014 eMedicine.com

136. Dermatologic Diseases of the Male Genitalia: Nonmalignant (Diagnosis)

are used to reduce inflammation. Additional treatment includes proper hygiene, with washing and drying of the prepuce. Circumcision is usually effective and may be indicated if medical therapy fails. [ ] The outcome in treated patients is favorable, and serious complications are rare. Uncommonly, untreated cases can result in cellulitis and gangrene. Treatment failures should prompt further clinical examination and consideration of other etiologies. Failure of response in the setting of appropriate (...) confocal microscopy. [ ] The histopathologic features show a thinned epidermis or epithelium and a dense, superficial, bandlike, predominantly plasmacytic, inflammatory infiltrate in the dermis. The dermal infiltrate also contains lymphocytes, neutrophils, histiocytes, and eosinophils. Dilated capillaries and associated extravasated red cells and hemosiderin deposition may also develop. Differential diagnoses The clinical presentation of Zoon balanitis can mimic erythroplasia of Queyrat (see ). Biopsy

2014 eMedicine.com

137. Cutaneous Manifestations of HIV Disease (Diagnosis)

. The most common cutaneous infections in children with HIV disease are impetigo and cellulitis caused by Staphylococcus aureus . Other cutaneous manifestations of HIV infection in the pediatric age group are as follows: Recurrent herpetic gingivostomatitis Scabies Severe atopic dermatitis Drug eruptions Leukocytoclastic vasculitis Previous Next: Malignancies (KS) was the first reported malignancy associated with HIV infection and was first documented in 1981 from reports in New York, Los Angeles (...) suggest HIV infection. Bournerias et al reported tinea capitis from Microsporum canis in 2 patients infected with HIV. [ ] Pityriasis versicolor may be persistent and recurrent in patients with HIV infection. Previous Next: Deep Fungal Infections Rarely, cutaneous cryptococcosis may be observed in patients with HIV infection. [ ] Clinical manifestations include the following: Cellulitis Papules Plaques Ulcers Translucent dome-shaped papules with central umbilication, resembling MC Cutaneous

2014 eMedicine.com

138. Bedbug Bites (Diagnosis)

, such as erythema, wheals, vesicles, or hemorrhagic nodules. Repeated bites may sensitize individuals, leading to more pronounced cutaneous manifestations or systemic hypersensitivity reactions. The local trauma from bedbug bites can lead to secondary bacterial infection, causing ecthyma, cellulitis, or lymphangitis. There is some evidence that bedbugs may also be a vector for hepatitis B and Chagas disease. Histologic findings from bite-site biopsy specimens typically show eosinophilic infiltrates, which (...) to arthropod allergens. The site of the bite can also become secondarily infected with bacteria infection and lead to ecthyma, cellulitis, and/or lymphangitis. See the image below. Bedbug bites themselves are typically painless. However, the subsequent allergic reaction that may develop can cause intense pruritus. While feeding, bedbugs may inject one of several pharmacologically active substances, including hyaluronidase, proteases, and kinins. These compounds may induce different skin reactions

2014 eMedicine.com

139. Agranulocytosis (Diagnosis)

, namely neutrophils, eosinophils, and basophils. However, the term granulocytopenia is often used synonymously with neutropenia and, in that sense, is again confined to the neutrophil lineage alone. The risk of serious infection increases as the absolute neutrophil count (ANC) falls to the severely neutropenic range (< 500/µL). The duration and severity of neutropenia directly correlate with the total incidence of all infections and of those infections that are life threatening. Tuberculosis (see (...) ). [ , ] Granulocytopenia is defined as a reduced number of blood granulocytes, namely neutrophils, eosinophils, and basophils. However, the term granulocytopenia is often used synonymously with neutropenia and, in that sense, is again confined to the neutrophil lineage alone. Neutropenia is defined in terms of the absolute neutrophil count (ANC). The ANC is calculated by multiplying the total white blood cell (WBC) count by the percentage of neutrophils (segmented neutrophils or granulocytes) plus the band forms

2014 eMedicine.com

140. Dirofilariasis (Diagnosis)

Thighs Abdominal wall Male genitalia Ophthalmic involvement may be periorbital, [ , ] subconjunctival, [ ] subtenon, [ ] or intraocular. [ ] See for more detail. Diagnosis Studies used in the diagnosis and evaluation of dirofilariasis include the following: Complete blood count (CBC) - Using a CBC, eosinophilia may be detected in up to 20% of cases of HPD Sputum cytology - The presence of eosinophils may support a diagnosis of HPD in patients with a coin lesion observed on radiography, although (...) in endemic areas of northeastern Italy indicated that the mosquito host Culex pipiens fed on dogs 70% of the time and on humans 26% of the time. [ ] D immitis is most often associated with coin lesions of the lung (human pulmonary dirofilariasis, or HPD), but isolated reports exist of D immitis or D immitis –like worms causing cutaneous or conjunctival disease. Extrapulmonary D immitis infections described in the literature include a hepatic nodule, [ ] eosinophilic meningitis, [ ] intraocular infection

2014 eMedicine.com

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