WAILEA, MAUI — Histology revealed changes consistent with allergic granulomatous vasculitis, or Churg-Strauss syndrome, an eosinophilic condition that has been reported in rare cases in patients who use inhaled fluticasone propionate and other inhaled corticosteroids.
Microscopic changes included epidermal necrosis and an extensive superficial and deep granulomatous dermal infiltrate with numerous eosinophils.
Some evidence for granulomatous vasculitis also was noted.
Occasional granulomas, radially arranged around degenerated collagen bundles and cellular debris, were also present.
Churg-Strauss syndrome is a small-vessel, systemic vasculitis that can result in eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications.
Neuropathy may or may not be present.
Persistent questioning by telephone revealed that this patient used an oral inhaler, Advair Diskus, for pulmonary disease associated with his former occupation as a coal miner in West Virginia, reported Kenneth E. Greer, M.D., professor and chair of dermatology at the University of Virginia in Charlottesville.
The active ingredients in Advair Discus are fluticasone propionate, a corticosteroid, and salmeterol, a long-acting bronchodilator.
The medication was discontinued, and the patient's lesions resolved within 2 weeks, as shown in the picture below.
The patient's prescription for prednisone also was discontinued.
Dr. Greer presented this case at the annual Hawaii dermatology seminar sponsored by the Skin Disease Education Foundation.
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Photos courtesy Dr. Kenneth E. Greer
A 62-year-old retired coal miner was hospitalized in West Virginia for a weeklong history of symmetric necrotic lesions with blisters on the dorsum and palmar aspect of both hands. Herpes zoster was diagnosed. A consultation was sought with the University of Virginia department of dermatology when his condition failed to improve with intravenous acyclovir. A biopsy was taken and the patient was treated with oral prednisone, 40 mg/day for a potential diagnosis of Sweet's syndrome. What's your diagnosis?