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Striaelike Epidermal Distension
A Newly Recognized Cutaneous Manifestation in Acute Leg Edema
Naoko Ishiguro, MD;
Makoto Kawashima, MD
Arch Dermatol. 2002;138:641-642.
INTRODUCTION
We previously reported 2 Japanese cases of anorexia nervosa with an
unusual cutaneous manifestation that arose after the administration of nutritional
intravenous infusions; at the time, we thought that that feature might not
have been described before.1 We recently found
a similar skin symptom in a patient with lung cancer and metastases in both
adrenal glands after an intravenous infusion of corticosteroid was administered
to treat the dysfunction of the adrenal glands. Herein, we report the case
and describe the histologic features of this unique skin manifestation.
REPORT OF A CASE
A 65-year-old man with a 3-year history of lung cancer was admitted
to our hospital in October 2000 for treatment of adrenal gland dysfunction
that was caused by metastases. After an intravenous infusion of 2440 mL of
hydrocortisone sodium succinate (200 mg/d), the patient developed severe leg
edema. Five days later, he presented to the dermatology department for treatment
of the lesions on his legs and feet. Physical examination revealed xerosis,
edema, and numerous linear, reddish or brownish, partially elevated lesions,
2 to 3 mm in width (Figure 1). The
lesions coalesced into plaques with erosions and thin crusts on the patient's
ankles and feet.
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Figure 1. Numerous linear, reddish or brownish
lesions are present on the lateral side of the right leg.
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Laboratory tests revealed anemia, hypoproteinemia, hypoalbuminemia,
low serum colloid-osmotic pressure, a high adrenocorticotropic hormone level,
and a low cortisol level. There was no evidence of liver dysfunction or hepatitis
C virus infection.
Histopathologic examination of a lesion from the left leg showed necrosis
in the upper three fouths of the epidermis, with exocytosis of neutrophils
and eosinophilic degeneration of the basal layer, with subepidermal splits
(Figure 2). The underlying dermis
revealed swelling of the endothelial cells in the upper dermis and infiltration
predominantly of lymphocytes, with a few neutrophils and extravasated erythrocytes,
but no degeneration of collagen or elastic fibers on van Gieson staining.
The results of direct immunofluorescence were negative for immunoglobulin,
fibrinogen, and complements.
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Figure 2. Epidermal necrosis, endothelial
swelling with lymphocytic infiltrations, and extravasated erythrocytes are
evident (hematoxylin-eosin, original magnification x25).
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The patient was treated with 20% albumin, furosemide (Lasix), and azuren
(Azunol) ointment. As the edema decreased, almost all the lesions formed thin
crusts and finally resolved, leaving only a residual pigmentation without
scarring or atrophy.
COMMENT
We previously observed similar skin symptoms in 2 young women with anorexia
nervosa who had developed numerous linear, reddish and brownish lesions on
their legs and feet.1 We reported that the
symptoms, which were similar to striae atrophicae, were an unusual skin manifestation
of anorexia nervosa, although they were not observed histopathologically.
In contrast, the patient described herein did not suffer from anorexia nervosa,
although his skin lesions were similar to those in the previous cases. The
common symptom in these 3 cases was acute leg edema caused by intravenous
infusion. The histopathologic findings in the present case revealed epidermal
necrosis, which is different from those of striae atrophicae.
Similar histologic features appear in necrolytic acral erythema, which
belongs to the family of necrolytic erythemas, in which patients usually show
signs of malnutrition.2 Recently, cases of
necrolytic erythema with hepatitis C or liver dysfunction have reported.2-4 In 1966, el Darouti
and Abu el Ela3 used the term necrolytic acral erythema to describe a distinct skin lesion that was
found to affect the feet of 7 patients who had viral hepatitis C. Although
our patient exhibited similar histologic manifestations, the clinical features
and pathogenesis were entirely different.
Our 3 patients initially had xerosis and low colloid-osmotic pressure
due to malnutrition. When intravenous infusions were administered, the patients
developed severe edema for a short period. Then, skin distension occurred
over their entire epidermis, and erythematous lesions appeared on their legs
and feet. We propose the name striaelike epidermal distension for these unusual symptoms.
AUTHOR INFORMATION
Accepted for publication June 16, 2001.
Corresponding author and reprints: Naoko Ishiguro, MD, Department
of Dermatology, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku-ku,
Tokyo 162-8666, Japan (e-mail: kasei{at}derm.twmu.ac.jp).
From the Department of Dermatology, Tokyo Women's Medical University,
Tokyo, Japan.
REFERENCES
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1. Ishiguro N, Hirohara D, Hotta M, Takano K, Kawashima M. Linear erythema craquelé due to acute oedema in anorexia nervosa. Br J Dermatol. 2001;145:357-358.
PUBMED
2. Khanna VJ, Shieh S, Benjamin J, et al. Necrolytic acral erythema associated with hepatitis C. Arch Dermatol. 2000;136:755-757.
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3. el Darouti M, Abu el Ela M. Necrolytic acral erythema: a cutaneous marker of viral hepatitis C. Int J Dermatol. 1996;35:252-256.
PUBMED
4. Marinkovich MP, Botella R, Datloff J, Sangueza OP. Necrolytic migratory erythema without glucagonoma in patients with
liver disease. J Am Acad Dermatol. 1995;32:604-609.
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