Acute febrile neutrophilic dermatitis: Clinical mimicry of an infected acid burn

Dr Dylan Prunster1, Dr Peter Meier1, Dr Edward Raby1, Dr Helen Douglas1

1Fiona Stanley Hospital – State Burns Service of Western Australia , Perth, Australia

Abstract:

Background

Sweet’s syndrome is a rare dermatosis that afflicts the skin of the hands, upper limb and face. The clinical significance for surgeons revolves around the condition often mimicking infective wounds with surgical debridement exacerbating the condition (Honigsmann et al., 2003). The authors present a case of sweet’s syndrome in a gentleman referred from a peripheral hospital with what was initially thought to be an infected acid burn.

Case

A 40-year-old male with no significant medical history was referred to the state burns service with what was thought to be bilateral symmetrical infected acid burns of the hands sustained whilst playing with batteries. On examination, the patient had symmetrical eruptive, bullous, purpuric skin erosions in bilateral first web spaces and overlying dorsum of both hands, with no associated lymphadenopathy or ascending lymphangitis. Despite 48 hours of intravenous antibiotics and silver dressings, new lesions appeared on other digits, wounds swabs cultured no bacteria. A dermatology opinion was sought, and biopsy performed confirmed the diagnosis of acute inflammatory infiltrate consistent with neutrophilic dermatitis.

Discussion

Sweet’s syndrome is characterised by dense neutrophilic infiltrates within the affected tissue. The pathognomic skin lesions arise as bullous, purpuric skin erosions and ulcerative lesions involving the epidermis and dermis. Classically the dermatoses may arise in response to an underlying systemic illness, malignancy or in response to a cutaneous pathergy. Pathergy is a skin hypersensitivity condition in which a cutaneous injury triggers new skin lesions, and has been described as a result of thermal injuries such as burns and radiation (Cohen, 2003). Surgical debridement is contraindicated as it exacerbates the condition. The gold standard treatment of sweet’s syndrome is with steroids, and the response varies according to the underlying inciting pathology, with recurrent episodes associated with malignancy and myelodysplastic disorders (Honigsmann et al., 2003).

Conclusion

We present an unusual case of Sweet’s syndrome masquerading as an infected acid burn; this case highlights the importance of a thorough clinical history, examination and the importance of a broad differential diagnosis.


Biography:

Dr Dylan Prunster is an unaccredited surgical registrar working within the West Australian Health Department with a keen interest in Plastic and Reconstructive Surgery. He obtained his primary medical qualification from the University of Western Australia and subsequently undertook an internship and residency at Royal Perth Hospital.

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