Sweet syndrome: Neutrophilic Dermatitis, A Marker of Systemic Disease. Lisa Johnson, D.O. PGY II & Christopher Colbert, D.O. Department of Emergency Medicine, Franciscan St. James Health, Olympia Fields, IL. Abstract. Figures. Discussion. Historical. Past Medical History: Patient denies
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Sweet syndrome: Neutrophilic Dermatitis, A Marker of Systemic Disease
Lisa Johnson, D.O. PGY II & Christopher Colbert, D.O.
Department of Emergency Medicine, Franciscan St. James Health, Olympia Fields, IL
Past Medical History: Patient denies
Past Surgical History: Patient denies
Family History: No known skin disease, cancer nor autoimmune disorders
Social History: Patient is employed as a barber and admits to alcohol and tobacco use. Denies illicit drug use.
Allergies: No known allergies
Immunizations: Up to date
ROS Pertinent Negatives: No fevers or chills. Denies morning stiffness, Raynaud's phenomenon, oral ulcers, alopecia, photosensitivity.
A common complaint addressed in the emergency department is the “skin rash”. Identifying etiology and definitive treatment remains a constant challenge for the emergency medicine physician. The following case highlights a unique presentation of Sweet syndrome, commonly appreciated after tattoo placement, and often misdiagnosed in the emergency department.
A 21 year old African American male presented to the ED with the complaint of a rash on the dorsal aspect of both hands. The character of the rash was described as raised, non-pruritic, and erythematous. The patient was seen at an outside ED 1 month prior after the rash appeared following tattoo placement. There was concern for infectious exposure as the lesions mirrored tattoo placement. At that time, the patient was treated for cellulitis and discharged. After persistence of the lesions, the patient presented to a different emergency room for a “second opinion”. The patient had multiple body tattoos denying any history of prior rash outbreak. The patient denied any contributing medical history. Social history was positive for alcohol and tobacco and the patient is employed as a barber. The remainder of the review of systems was negative. Vital signs were within normal limits with a weight of 81.89 kg. Physical exam was remarkable for warm, dry, pink, erythematous, umbilicated lesions on the bilateral dorsal hands in area of recent tattoo placement, without tenderness, discharge, or warmth. Initially, the patient was discharged with prophylactic treatment including Aldara 5% cream, cephalexin, and Triple antibiotic ointment. The patient again returned to a separate ED 1 month later with no resolution in the appearance of the rash.
Vitals: T 98.2 ºF BP 116/72 HR 60 RR 18 O2 Sat 99% on room air. Wt 81.89 kg
General: Alert, no acute distress
Skin: Warm, dry, normal for ethnicity. Bilateral dorsal hands with erythematous, umbilicated lesions on dorsal hands in area of tattoo placement. No tenderness, discharge, or warmth
HEENT: NC/AT. PERRL, EOMI, normal conjunctiva. TMs clear. Nares patent. Oral mucosa moist. No pharyngeal erythema or exudates
Cardiovascular: Regular rate and rhythm, no murmurs. Normal peripheral perfusion. No edema
Respiratory: Clear to auscultation bilaterally, Non-labored respirations
Abdominal: Soft, nontender and nondistended. Bowel sounds normal
Musculoskeletal: Strength 5/5 upper and lower extremities bilaterally
Neurological: A&Ox3, CN II-XII intact, no focal deficits. Normal sensory observed.
Lymphatics: No lymphadenopathy
Diagnosis of Left dorsal hand punch biopsy:
Acral skin showing neutrophilic dermatitis with focal abscess formation in the papillary dermis associated with a neutrophilic scale crust within the stratum corneum. Special stains of PAS, GMS and AFB for fungus and acid fast bacilli negative.
Laboratory & Diagnostic Studies
Gram stain: No WBC No organisms seen
Wound culture: No growth
Fungal culture: No fungal elements seen
AFB smear: No acid-fast bacilli seen
HIV ½ Ab screen: Nonreactive
Hepatitis A Total Ab: Nonreactive
Hepatitis B surface Ag: NonreactiveHepatitis B surface Ab: 96
Hepatitis B core Total Ab: Nonreactive
Hepatitis C Ab: Nonreactive
Syphilis screen by EIA: Nonreactive
From the second ED visit, the patient was provided a dermatologic follow up appointment. The dermatologist described the rash as hyperkeratotic papules, with coalescing plaques overlying the tattoo. Differential diagnoses included deep fungal, atypical mycobacterium, koebnerization related psoriasis or sarcoidosis. Upon reviewing the biopsy results, dermatology determined that the most likely diagnosis is Sweet Syndrome. The patient is scheduled to follow up and will receive steroid treatment followed by laser therapy if necessary.