Bhushan Kumar MD, Professor, Former Head, Department of Dermatology, PGIMER, Chandigarh, India on May 17, 2010
It is difficult to believe that all lesions spread all over the body could be attributed to Sweet's Syndrome. Many lesions could be due to extravasations due to pancytopenia or non specific hypersensitivity phenomenon due to AML. Some of lesions may be due to intensive drug therapy.
Classical vasculitis in Sweet's Syndrome does not occur or is uncommon. Obviously this is not a straight forward case of Sweet's Syndrome.
Khalid Al Aboud MD, Medical Director and Consultant Dermatologist, King Faisal Hospital, Makkah, Saudi Arabia on May 18, 2010
Interesting case. Similar to Dr Kumar, I have the feeling that it is not Sweet's Syndrome. Simply, it might be a vasculitis.
David Elpern MD, Dermatologist, Williamstown, MA, USA on May 18, 2010
This is an extraordinarily complex case and Ms. Cohen is to be congratulated for presenting it. I think the key thing here is to nail down the hematologic diagnosis which was likely the trigger for the skin lesions. Both leucocytoclastic vasculitis and Sweet's Disease have been associated with myelodysplastic syndrome and AML. So, a comment from a hematologist is in order. Also, it would be of interest for her skin slides to be seen by one of our dermatopathologists. Neutrophilic dermatoses of many types are associated with hematologic malignancies. Ms. Cohen, you've come so far on this - there is still more to learn. This case will stick with you for the rest of your career, and what you learn from this unfortunate patient will help others in the future.
Osler wrote: "Given the sacred hunger and proper preliminary training, the student-practitioner requires at least three things with which to stimulate and maintain his education, a note-book, a library and a quinquennial brain dusting. I wish I had time to speak of the value of note-taking. You can do nothing as a student in practice without it. Carry a small note-book which will fit into your waistcoat pocket, and never ask a new patient a question without note-book and pencil in hand......Begin early to make a three-fold category - clear cases, doubtful cases and mistakes." This is still somewhat of a doubtful case. Any effort you expend at this point will be a great learning opportunity. After you synthesize our comments and perhaps others, please submit a followup note so we all can learn from you.
Abdullah Mancy MD, Al-Ramadi Teaching Hospital, Ramadi, Iraq on May 18, 2010
Usually bullous or necrotic lesions occur in the syndrome caused by underlying malignancy which could be solid or haematopoeitic malignancy. What about oral cavity? Its involvement is more common in malignancy.
But presence of focal leucocytoclastic vasculitis does not exclude the diagnosis of Sweet syndrome.
Robert I.Rudolph, M.D., FACP. Clinical Professor of Dermatology, University of Pennsylvania, Philadelphia, PA, USA on May 19, 2010
This does not look at all like Sweet's to me. It looks like a vasculitis or drug reaction. Both of the latter, of course, have been well reported to occur with underlying malignancy.
J. Andrew Carlson, MD, FRCPC, Professor, Divisions of Dermatopathology and Dermatology, Department of Pathology, Albany Medical College, Albany, NY, USA on May 19, 2010
I would get levels to exclude an adjacent focus of suppurative folliculitis. It's a neutrophilic dominant process and it appears to be a nodular infiltrate with nuclear debris both around vessels (in the center of the infiltrate) and interstitially. The adjacent dermal vessels do not appear to be involved/show findings of vasculitis as would expect if it was LCV.
If you asked me to pick one diagnosis over the other - late, resolving lesion of neutrophilic vasculitis. Other diagnoses to keep in mind pustular drug eruption.
Ronny Zarro MD, Arbil, Iraq on May 20, 2010
If one consider the revised diagnostic criteria of Sweet's syndrome the patient had both major criteria and 3 (although 2 are required) minor criteria which is quite enough to make the diagnosis of Sweet's syndrome. Conjunctivitis occur in 30% of patients with Sweet's syndrome
Adel Aly MD, Dermatologist, Egypt on May 21, 2010
Yes this supports the diagnosis. Vasculitis can occur as a secondary event due to release of proteases from neutrophilic infiltrate but as you mentioned no extravasation or fibrinoid necrosis. One thing is why you neglect the possibility of pulmonary involvement as a result of Sweet's since it can lead to bronchiolitis oblitrans and even respiratory failure. Regarding the clinical appearance do not forget that pustular vasculitis of hands is considered by some as one variant of Sweet's
Khalifa Sharquie MD, PhD. Professor and Chairman of Iraqi Board of Dermatology, Iraq on May 21, 2010
I am not happy at all with diagnosis of Sweets. I am more in favour of suppurative folliculitis where all the features of the disease could be explained like fever, joint pain etc and this could be seen in myeloproliferative disorders.