2018 Research Forum

Erythema Sweetobullosum: A rare presentation of coccidioidomycosis Presenter & Principal Investigator: Hisham Abukamleh MD Faculty Sponsor: Arash Heidari MD Greti Petersen MD 1 , Royce Johnson MD 2 , Arash Heidari MD 3 , Hisham Abukamleh MD 4 Natalie Karapetians MS 5 1 Internal Medicine Faculty; Health Sciences Associate Clinical Professor, David Geffen School of Medicine UCLA 2 Chief, Division of Infectious Disease; Adjunct Professor, David Geffen School of Medicine UCLA 3 Division of Infectious Disease; Health Sciences Associate Clinical Professor, David Geffen School of Medicine UCLA INTRODUCTION Erythema Nodosum (EN) and Erythema Multiforme (EM) are known reactive cutaneous manifestations of acute infection with coccidioidomycosis. In endemic area these findings could be diagnostic in the presence of proper clinical presentation. In our experience we have observed unique form of cutaneous manifestation of acute coccidioidiomycosis with blisters. This form of skin eruption was given different names such as toxic erythema in 1940 and recently sweet syndrome in 2005. The term Erythema Sweetobullosum (ESB) was suggested first by David J. Elbaum in 1998 in San Joaquin Valley California in a 9 case series. This study showed in contrast to sweet syndrome in ESB histology appears to change based on when the patient is seen. Early on ESB shows lymphocytic dominance, later will be neutrophil rich and eventually histiocytic phase and even granulomatous. PURPOSE Introduce an atypical presentation of acute coccidioidomycosis METHOD Retrospective chart review RESULTS 6 cases are identified. Upon presentation they were between 27 to 47 years old half male and half female. In all cases ESB lesions were present as multiple tense erythematous plaques base with central crusting and surrounding cluster of vesicular formation. ESB lesions were located on bilateral upper and lower arms in all cases. IgM Immunodiffusion serology was positive in all cases. Chest x-ray was positive for infiltration or nodule or cavity in 5 cases. Eosinophilia was present in 4 cases (800-1600). All cases had EM and 2 cases had EN present. Histopathology in one case described as subepidermal vesicular dermatitis with lymphocytes and histocytes. No evidence of dissemination was found in all 6 cases. One case lost follow up but rest had significant clinical, radiological and serological response to fluconazole therapy with complete resolution of all skin manifestations. DISCUSSION The various reactive manifestations of Coccidioides are Erythema Nodosum, Erythema Multiforme and Erythema Sweetobullosum. Erythema Sweetobullosum is a distinct manifestation that occur in the acute phase of the infection and is associated with good prognosis. All lesions resolved within weeks in our patients. It is very important to recognize these lesions in the proper clinical setting as it is a clear indication of an underlying Coccidioidomycosis infection. Even though the bullous lesions were extensive they regressed within few weeks and there is no known role for corticosteroids to reduce the 4 Resident Physician R3 5 Medical Student MS3

inflammation. CONCLUSION

We are describing 6 cases of acute pulmonary coccidioidomycosis with unique reactive skin manifestation described as Erythema Sweetobullosum. The acknowledgment of skin findings assists in prompt clinical differentiation to make the diagnosis and initiate treatment.

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