A 42-year-old man comes to the physician with painful skin lesions. The lesions developed on his neck, chest, and arms 1 week ago. He also complains of fever, headache, malaise, and arthralgias. Three weeks ago, he had an upper respiratory infection that resolved with over-the-counter medications. The patient has no other medical problems and takes no medications. He does not use tobacco or illicit drugs and drinks alcohol on social occasions. He works as a cab driver.
His temperature is 38.2° C (100.8° F), blood pressure is 120/70 mm Hg, pulse is 88/min, and respirations are 14/min. Physical examination is otherwise unremarkable.
Skin findings are shown in the photograph.

Laboratory studies show a leukocyte count of 14,000 cells/µL with 87% neutrophils. He is started on oral clindamycin and sent home.
The patient returns for follow-up 3 days later with no improvement. Blood cultures obtained on the initial visit show no growth. Biopsy of the lesion shows a dense neutrophilic infiltrate in the dermis without vasculitis. Gram and fungal stains are negative.
Which of the following is the most appropriate next step in management?

Question

A 42-year-old man comes to the physician with painful skin lesions.  The lesions developed on his neck, chest, and arms 1 week ago.  He also complains of fever, headache, malaise, and arthralgias.  Three weeks ago, he had an upper respiratory infection that resolved with over-the-counter medications.  The patient has no other medical problems and takes no medications.  He does not use tobacco or illicit drugs and drinks alcohol on social occasions.  He works as a cab driver.
His temperature is 38.2° C (100.8° F), blood pressure is 120/70 mm Hg, pulse is 88/min, and respirations are 14/min.  Physical examination is otherwise unremarkable.
Skin findings are shown in the photograph.

Laboratory studies show a leukocyte count of 14,000 cells/µL with 87% neutrophils.  He is started on oral clindamycin and sent home.
The patient returns for follow-up 3 days later with no improvement.  Blood cultures obtained on the initial visit show no growth.  Biopsy of the lesion shows a dense neutrophilic infiltrate in the dermis without vasculitis.  Gram and fungal stains are negative.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_9783_b027_853d_ab33e2564dc5_MD0002_00 This patient's clinical presentation suggests Sweet syndrome (acute febrile neutrophilic dermatosis). Classic Sweet syndrome (most common) is associated with infections (usually 1-3 weeks after upper respiratory tract or gastrointestinal infections), inflammatory bowel disease, and pregnancy. Malignancy-associated Sweet syndrome occurs most commonly with hematologic malignancies but can also occur with solid tumors. Drug-induced Sweet syndrome is most commonly due to granulocyte colony-stimulating factor but can occur with other drugs. Patients typically present with abrupt onset of painful edematous papules, plaques, or nodules. These erythematous or violaceous lesions can be associated with pustules or central yellowish discoloration similar to target lesions. The lesions are located asymmetrically on the head, neck, and upper extremities. Pathergy (lesion development at cutaneous injury sites) can occur, even with minor trauma. Other findings include burning or tenderness without pruritus, fever > 38° C, and possible systemic symptoms (eg, arthralgias, myalgias, malaise, headache). Complete blood count typically shows neutrophilic leukocytosis. Skin biopsy shows dense neutrophilic infiltrate without leukocytoclastic vasculitis. Patients without preexisting malignancy or other associations (eg, inflammatory bowel disease, drug-related, prior infection) should undergo age-appropriate cancer screening. Mild Sweet syndrome (< 5% of body surface area involvement) usually responds to topical corticosteroids; extensive disease requires systemic glucocorticoids. (Choices B and D) This patient has no signs or symptoms of systemic infection or endocarditis such as bacteremia, new heart murmur, or heart failure. Echocardiogram or switching antibiotics is therefore not recommended. (Choice C) The classic butterfly rash of systemic lupus erythematosus appears as erythema and scaling over the cheeks and bridge of the nose with sparing of the nasolabial folds. Some patients develop discoid lesions. Discoid lupus erythematosus typically presents with photosensitive patches of various sizes that are erythematous and well-defined (Image). The lesions tend to heal with hair loss, skin atrophy, deep scarring, and peripheral hyperpigmentation. systemic lupus erythematosus (Image) peripheral hyperpigmentation (Choice E) Essential mixed cryoglobulinemia is associated with hepatitis C virus infection and presents with palpable purpura, arthralgias, renal disease (membranoproliferative glomerulonephritis), low serum complement, and neuropathy. Purpuric skin lesions usually occur in the lower extremities and may progress to necrosis and gangrene. Essential mixed cryoglobulinemia Educational objective: Sweet syndrome is an inflammatory disorder with abrupt onset of painful cutaneous papules, fever, neutrophilic leukocytosis, and dense neutrophilic infiltration on skin biopsy without signs of vasculitis. It may be associated with infections, inflammatory bowel disease, pregnancy, malignancy, or drugs. Treatment involves topical corticosteroids for mild disease and systemic glucocorticoids for more extensive disease. __________ References: Sweet's syndrome: retrospective study of clinical and histologic features of 44 cases from a tertiary care center. (http://www.ncbi.nlm.nih.gov/pubmed/21038541) Sweet's syndrome - a comprehensive review of an acute febrile neutrophilic dermatosis. (http://www.ncbi.nlm.nih.gov/pubmed/17655751)

A 42-Year-Old Man Comes to the Physician with Painful Skin