Background: 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 at Kern Medical similar to our colleagues in Arizona 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.
Methods: Retrospective chart review.
Results: 6 cases are identified. Upon presentation they were between 27 to 47 years old half male and other 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 (fig. 1, 2 and 3). 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.
Figure 1: 45 year old female with Erythema Sweetobullosum
Figure 2: 42 year old male with Erythema Sweetobullosum
Figure 3: 40 year old female with Erythema Sweetobullosum
Conclusion: We are describing 6 cases of acute pulmonary coccidioidomycosis with unique reactive skin manifestation described as Erythema Sweetobullosum. The acknowledgment of skin findings assist in prompt clinical suspicious to make diagnosis and initiate treatment.
G. Petersen, None