[Occurrence of psoriasis in a patient presenting Shulman fasciitis treated with infliximab]. / Survenue d'un psoriasis au cours d'un traitement par infliximab pour fasciite de Shulman.

BACKGROUND: Anti-TNFalpha drugs are used in certain rheumatologic and gastrointestinal inflammatory diseases and are also effective in cutaneous psoriasis. Several case reports have recently been published concerning induction of paradoxical psoriasis during the course of anti-TNF therapy. We report a new case involving infliximab used to treat Shulman fasciitis. CASE REPORT: A 39-year-old woman was treated with infliximab for corticoid-dependent Shulman fasciitis. No personal or familial cutaneous psoriasis was noted in her history. Two months after the third infusion, she developed psoriasis vulgaris and pustular palmoplantar psoriasis which improved under topical corticosteroids. Her psoriatic lesions worsened one month after the first maintenance infusion. Since the Shulman fasciitis was not under control, infliximab was withdrawn and replaced with azathioprine. Six months later, her psoriasis was in remission and the Shulman fasciitis was under control. DISCUSSION: TNFalpha plays an important role in the physiopathology of psoriasis through its action on inflammatory infiltrate, angiogenesis and keratinocyte proliferation. Several studies have reported the efficiency of TNFalpha inhibitors in moderate to severe cutaneous psoriasis. However, fourteen cases of induction or worsening of psoriasis have been reported with these drugs, suggesting a class effect. We report a new case of cutaneous psoriasis induced by infliximab in a patient presenting corticoid-dependent Shulman fasciitis, and we discuss the possible immunological mechanisms responsible for this paradoxical side effect. Other cutaneous lesions have been reported during treatment with TNFalpha inhibitors. The benefits of this treatment on the underlying inflammatory disease must be balanced against the potential cutaneous side effects when deciding whether to continue with anti-TNFalpha treatment.

[Pancreatic panniculitis revealing a pancreaticportal fistula and portal thrombosis]. / Cytostéatonécrose pancréatique révélant une fistule pancréatico-portale et une thrombose portale.

BACKGROUND: Pancreatic panniculitis is a rare condition that usually occurs in association with acute or chronic pancreatitis or pancreatic carcinoma. We report a case of pancreatic panniculitis revealing a pancreaticportal fistula and portal thrombosis. CASE REPORT: A 79-year-old man was admitted for nodular panniculitis of the lower extremities without any digestive symptoms. Laboratory tests revealed very high plasma levels of amylase and lipase. A skin biopsy showed lobular panniculitis with ghost cells characteristic of pancreatic panniculitis. Rare pancreatic calcifications and portal thrombosis were seen on an abdominal CT scan and on endoscopic ultrasound examination of the pancreas. A pancreaticportal fistula was detected by endoscopic retrograde pancreatography. Finally, an endoscopic pancreatic prothesis was inserted in Wirsung's canal after failure of medical treatment (parenteral nutrition and octreotide). Skin lesions resolved and plasma pancreatic enzymes normalized. DISCUSSION: This case report is interesting because of the lack of gastrointestinal symptoms associated with pancreatic panniculitis and the discovery of a chronic pancreatitis of uncertain etiology. This case highlights the need to screen for pancreaticportal fistula and portal thrombosis, which are often associated with pancreatic panniculitis.

A 6-month prospective survey of cutaneous drug reactions in a hospital setting.

BACKGROUND: Few prospective studies are available on the incidence and analysis of the characteristics of adverse cutaneous drug reactions in hospital settings. OBJECTIVES: A 6-month prospective study was managed in our hospital among hospitalized patients to: (i) evaluate the incidence of cutaneous allergic reactions from systemic drugs; (ii) study characteristics of patients with cutaneous drug reactions; (iii) describe the adverse cutaneous reactions; and (iv) evaluate drug reaction imputability and preventability. METHODS: All suspected allergic cutaneous reactions to systemic drugs were collected during a 6-month period (November 2000 to May 2001). Exhaustivity of recording was ensured by regular dissemination of information about this study to the practitioners; a simple method for inclusion by fax was established. Inclusion criteria were suspected cutaneous allergic reactions induced by systemic drugs responsible for hospitalization or developed during hospitalization. A physical examination was done by a dermatologist who completed a standardized questionnaire. Requested information included patient characteristics (associated disorders, severity score), drug intake (list and chronology of the drug intake during the 3 weeks preceding the adverse reaction) and characteristics of the skin reaction (type, course). A group comprising dermatologists and pharmacologists evaluated the drug imputability and preventability. RESULTS: Forty-eight cases were collected. A prevalence of 3.6/1000 among hospitalized patients was estimated. The prevalence rate was higher in patients hospitalized in medical departments (0.5%) than in surgical departments (0.01%) (P < 0.001). The cases were mostly recruited in departments of infectious diseases and dermatology. The most frequent associated disorders were: human immunodeficiency virus (HIV) infection (19%), connective tissue disease (10%) and viral or autoimmune hepatitis (12%). Of these patients, 31% had had a previous immunological drug reaction. Adverse cutaneous drug reactions were principally exanthematous (56%). Reactions were considered severe in 34% of cases because they were responsible for hospitalization (18%), increased the duration of hospitalization (14%) or were life threatening (2%). Principal imputable drugs were antibiotics, mainly penicillins. An imputability score was likely in 56% of cases, but it was only possible to conclude definitively in 44% of patients. In 15% of the cases, the side-effect was considered to be preventable. CONCLUSIONS: This study finds a lower incidence than other studies that reported an incidence of 2% of cutaneous drug reactions in hospitalized patients, but only allergic adverse cutaneous reactions induced by systemic drugs were collected in this study. The previous studies were principally done in selected patients hospitalized only in general internal medicine or medical divisions. Our results confirm some data already known about skin drug reactions: HIV infection as a risk factor (P < 0.0001), high prevalence of adverse cutaneous reactions due to antibiotics, and difficulty in ascertaining the imputability of a drug. A high proportion (34%) of these reactions was severe and 15% were avoidable; these two facts justify the development of an intensive programme of clinical pharmacology.