Cutaneous Leukocytoclastic Vasculitis Associated With A Fast Food Diet

摘要

Leukocytoclastic vasculitis (LCV) is the inflammation and necrosis of the wall of small blood vessels exhibited by endothelial swelling, perivascular polymorphonuclear cellular infiltrate, neutrophil fragmentation and nuclear debris and is typically localized to the skin. Many medications, diseases and infections have been implicated in the development of leukocytoclastic vasculitis. A review of available literature reveals case reports of leukocytoclastic vasculitis induced by medications such as infliximab, rituximab, etanercept, cocaine and numerous others and infections such as HIV and Streptococcal pneumonia as well as malignancies and chronic inflammatory conditions such as ulcerative colitis and collagen vascular diseases. Leukocytoclastic vasculitis induced by food has also been reported. Here, we report an interesting case of cutaneous leukocytoclastic vasculitis that developed in a patient after months of consuming a fast food diet for breakfast, lunch and dinner, which would improve only after abstaining from such a diet. The proper diagnosis and management of leukocytoclastic vasculitis remains a challenge for many clinicians and this report serves to give a brief overview of this condition, its causes, epidemiology, diagnosis and management. Introduction Leukocytoclastic vasculitis is characterized by necrotizing inflammation around blood vessels in the dermis which is composed mainly of neutrophils and their debris. It has been associated with numerous conditions such as autoimmune diseases, infections, malignancies, allergic or adverse reactions to medications or food, although it may also be idiopathic. Cutaneous lesions may vary from purpura, macules, papules, urticarial, vesicles, ulcers, livedo reticularis to necrosis. Systemic manifestations may include pulmonary, gastrointestinal, renal or central nervous system involvement. We describe an unusual case in which isolated cutaneous leukocytoclastic vasculitis was induced after months of consuming a fast food diet associated with the development of hyperlipidemia and hypertriglyceridemia. Case The patient is a 59 year old male with remote history of intravenous drug abuse (IVDA), psoriasis, nephrolithiasis, who reported to his physician that he was consuming a fast food diet for the last 2-3 months and was feeling unwell and developed a rash. On examination were areas of reticular erythema surrounding a pale central area consistent with livedo reticularis on his upper extremities. On the lower extremities were multiple scattered maculopapular erythematous lesions, some blanchable, and some ulcerative nodular lesions at different stages of healing. (Figure 1) The patient was then evaluated by a dermatologist whose clinical impression was consistent with erythema nodosum. A punch biopsy at the time showed a perivascular infiltrate of lymphocytes in the dermis, becoming denser in the deeper part of the reticular dermis with hints of an infiltrate in the subcutaneous fat at the base of the biopsy. The diagnosis by the pathologist was probable panniculitis which ‘could be the surface of erythema nodosum. It was discovered that the patient’s cholesterol level was greater than 900 and he was started on statin therapy. After becoming compliant with a balanced diet, these lesions disappeared though the livedo reticularis persisted.Three years later, when the patient became non-compliant with his diet, the painful nodules recurred would later ulcerate, heal and ultimately disappeared after 6 weeks once he stopped eating at fast food restaurants. In August 2010, he resumed poor eating habits once again with recurrence of a rash, nodules, and ulcers after 2 months. A punch biopsy of an ulcer on his right leg was consistent with leukocytoclastic vasculitis as it had scattered perivascular infiltrates composed of neutrophils with leukocytoclastic debris within the superficial and deep dermis. Several vessels also had neutrophils within their walls and were occluded by fibr