J AM ACAD DERMATOL
Letters e17
VOLUME 71, NUMBER 1
Fig 1. Cutaneous lupus erythematosus. Erythematous, scarring discoid lesions on the face before (A and B) and after 6 months of treatment with Fumaderm initial (C and D). Courtesy of the Photographic Laboratory (with thanks to J. Bueckmann and P. Wissel), Department of Dermatology, University of Muenster, Germany. 2. Meissner M, Valesky EM, Kippenberger S, Kaufmann R. Dimethyl fumarate e only an anti-psoriatic medication? J Dtsch Dermatol Ges 2012;10:793-801. 3. Kuhn A, Meuth AM, Bein D, Amler S, Beissert S, Bohm M, et al. Revised Cutaneous Lupus Erythematosus Disease Area and Severity Index (RCLASI): a modified outcome instrument for cutaneous lupus erythematosus. Br J Dermatol 2010;163: 83-92. 4. Balak DM, Thio HB. Treatment of lupus erythematosus with fumaric acid esters: two case-reports. J Transl Med 2011;9:15. 5. Klein A, Coras B, Landthaler M, Babilas P. Off-label use of fumarate therapy for granulomatous and inflammatory skin diseases other than psoriasis vulgaris: a retrospective study. J Eur Acad Dermatol Venereol 2012;26:1400-6. http://dx.doi.org/10.1016/j.jaad.2013.12.004
Miliarial gout: A rare clinical presentation To the Editor: Chronic cutaneous tophaceous gout is a manifestation of untreated gouty arthritis that manifests as monosodium urate crystal deposition intradermally or within the subcutaneous tissues of the skin usually over joints or on the ears. Multiple clinical variants of tophaceous gout have been described.1 Miliarial gout is an extremely rare manifestation of tophaceous gout and refers to ‘‘milia-like’’ widely distributed papules containing white to cream colored material on an erythematous base.1,2 Here we describe a case of miliarial gout in a
Fig 1. Miliarial gout. Erythematous pink to yellow papules over the extensor forearms with a firm 2-cm nodule on the right elbow.
patient with a normal serum uric acid level and no previous medical history of gouty arthritis. A 43-year-old Caucasian man presented with grouped, tender, yellowish-red papules that occurred in crops over the metacarpophalangeal joints of his hands, knees, abdomen, extensor
J AM ACAD DERMATOL
e18 Letters
JULY 2014
Allopurinol alone1 or in combination with colchicine2 have been reported to improve miliarial gout, and our patient was referred to a rheumatologist for management but was lost to follow-up. The prevalence of gout is reported to be between 0.5% and 1%, and the incidence of gout is increasing, possibly due to an aging population.5 This case illustrates the importance of considering atypical manifestations of common rheumatologic diseases. Kenyatta A. Mireku, BS, Jessica R. Burgy, MD, and Loretta S. Davis, MD Georgia Regents University, Augusta, Georgia Funding sources: None. Fig 2. Miliarial gout. Hematoxylin-eosinestained section showing granulomatous dermatitis with amorphous crystalline material within the dermis.
forearms, and thighs over the previous year (Fig 1). He reported that these lesions worsened with warm weather and then gradually dissipated. A flesh-colored nodule was present on the right elbow. He denied having pruritus or joint pain. Medical history was significant for diabetes treated with metformin. Family history was negative for cutaneous disease. Punch biopsy of a typical papule was performed and the specimen placed in formalin. Histologic examination revealed granulomatous dermatitis with amorphous crystalline material consistent with gout (Fig 2). Serum uric acid level was within normal limits at 4.9 mg/dL (normal reference range, 3.5 to 7.2 mg/dL). Only a few cases of miliarial gout have been previously reported. As with gouty arthritis, a normal serum uric acid level does not exclude the diagnosis.3 Similar to typical tophaceous gout, miliarial gout can be the initial manifestation of gout. In fact, both of the referenced cases of miliarial gout occurred in the absence of a known history of gouty arthritis. It is unclear whether these patients are predisposed to the development of gouty arthritis in the future. Because there are so many clinical variants of tophaceous gout, patients may present with more than 1 variant. It is likely that our patient’s longstanding nodule on the elbow represents a more typical manifestation of tophaceous gout. Although our patient’s histopathology was typical of tophaceous gout, to actually fulfill clinical diagnostic criteria, as established by the American College of Rheumatology,4 the biopsy specimen should have been submitted in absolute alcohol to demonstrate monosodium urate crystals by polarized light microscopy.
Conflicts of interest: None declared. Correspondence to: Jessica R. Burgy, MD, 1004 Chafee Avenue, FH-100, Department of Dermatology, Augusta, GA 30912-3190 E-mail: [email protected] REFERENCES 1. Shukla R, Vender RB, Alhabeeb A, Salama S, Murphy F. Miliarial gout (a new entity). J Cutan Med Surg 2007;11:31-4. 2. Aguayo RS, Baradad M, Soria X, Abal L, Sanmartın V, Egido R, et al. Unilateral milia-type intradermal tophi associated with underlying urate subcutaneous deposition: an uncommon cutaneous presentation of gout. Clin Exp Dermatol 2013;38: 622-5. 3. McCarty DJ. Gout without hyperuricemia. JAMA 1994;271: 302-3. 4. Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yu TF. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum 1977;20:895-900. 5. Adams PF, Hendershot GE, Marano MA. Centers for Disease Control and Prevention/National Center for Health Statistics. Current estimates from the National Health Interview Survey, 1996. Vital Health Stat 1999;10:1-203. http://dx.doi.org/10.1016/j.jaad.2014.01.851
A case of dermatitis herpetiformis after a mini-gastric bypass surgery To the Editor: Celiac disease and dermatitis herpetiformis share the same strong HLA association, the presence of circulating IgA antitissue and antiepidermal transglutaminase antibodies, and the same typical histologic features of villous atrophy of the small intestine.1 Both diseases can be triggered by gluten overload and gastric surgery.2 We report a case of dermatitis herpetiformis after mini-gastric bypass surgery with no clinical sign or symptom of celiac disease. Mini-gastric bypass is a modification of the standard Roux-en-Y procedure using a long gastric tube with an antecolic loop gastrojejunostomy. It has become a widely
Letters e17
VOLUME 71, NUMBER 1
Fig 1. Cutaneous lupus erythematosus. Erythematous, scarring discoid lesions on the face before (A and B) and after 6 months of treatment with Fumaderm initial (C and D). Courtesy of the Photographic Laboratory (with thanks to J. Bueckmann and P. Wissel), Department of Dermatology, University of Muenster, Germany. 2. Meissner M, Valesky EM, Kippenberger S, Kaufmann R. Dimethyl fumarate e only an anti-psoriatic medication? J Dtsch Dermatol Ges 2012;10:793-801. 3. Kuhn A, Meuth AM, Bein D, Amler S, Beissert S, Bohm M, et al. Revised Cutaneous Lupus Erythematosus Disease Area and Severity Index (RCLASI): a modified outcome instrument for cutaneous lupus erythematosus. Br J Dermatol 2010;163: 83-92. 4. Balak DM, Thio HB. Treatment of lupus erythematosus with fumaric acid esters: two case-reports. J Transl Med 2011;9:15. 5. Klein A, Coras B, Landthaler M, Babilas P. Off-label use of fumarate therapy for granulomatous and inflammatory skin diseases other than psoriasis vulgaris: a retrospective study. J Eur Acad Dermatol Venereol 2012;26:1400-6. http://dx.doi.org/10.1016/j.jaad.2013.12.004
Miliarial gout: A rare clinical presentation To the Editor: Chronic cutaneous tophaceous gout is a manifestation of untreated gouty arthritis that manifests as monosodium urate crystal deposition intradermally or within the subcutaneous tissues of the skin usually over joints or on the ears. Multiple clinical variants of tophaceous gout have been described.1 Miliarial gout is an extremely rare manifestation of tophaceous gout and refers to ‘‘milia-like’’ widely distributed papules containing white to cream colored material on an erythematous base.1,2 Here we describe a case of miliarial gout in a
Fig 1. Miliarial gout. Erythematous pink to yellow papules over the extensor forearms with a firm 2-cm nodule on the right elbow.
patient with a normal serum uric acid level and no previous medical history of gouty arthritis. A 43-year-old Caucasian man presented with grouped, tender, yellowish-red papules that occurred in crops over the metacarpophalangeal joints of his hands, knees, abdomen, extensor
J AM ACAD DERMATOL
e18 Letters
JULY 2014
Allopurinol alone1 or in combination with colchicine2 have been reported to improve miliarial gout, and our patient was referred to a rheumatologist for management but was lost to follow-up. The prevalence of gout is reported to be between 0.5% and 1%, and the incidence of gout is increasing, possibly due to an aging population.5 This case illustrates the importance of considering atypical manifestations of common rheumatologic diseases. Kenyatta A. Mireku, BS, Jessica R. Burgy, MD, and Loretta S. Davis, MD Georgia Regents University, Augusta, Georgia Funding sources: None. Fig 2. Miliarial gout. Hematoxylin-eosinestained section showing granulomatous dermatitis with amorphous crystalline material within the dermis.
forearms, and thighs over the previous year (Fig 1). He reported that these lesions worsened with warm weather and then gradually dissipated. A flesh-colored nodule was present on the right elbow. He denied having pruritus or joint pain. Medical history was significant for diabetes treated with metformin. Family history was negative for cutaneous disease. Punch biopsy of a typical papule was performed and the specimen placed in formalin. Histologic examination revealed granulomatous dermatitis with amorphous crystalline material consistent with gout (Fig 2). Serum uric acid level was within normal limits at 4.9 mg/dL (normal reference range, 3.5 to 7.2 mg/dL). Only a few cases of miliarial gout have been previously reported. As with gouty arthritis, a normal serum uric acid level does not exclude the diagnosis.3 Similar to typical tophaceous gout, miliarial gout can be the initial manifestation of gout. In fact, both of the referenced cases of miliarial gout occurred in the absence of a known history of gouty arthritis. It is unclear whether these patients are predisposed to the development of gouty arthritis in the future. Because there are so many clinical variants of tophaceous gout, patients may present with more than 1 variant. It is likely that our patient’s longstanding nodule on the elbow represents a more typical manifestation of tophaceous gout. Although our patient’s histopathology was typical of tophaceous gout, to actually fulfill clinical diagnostic criteria, as established by the American College of Rheumatology,4 the biopsy specimen should have been submitted in absolute alcohol to demonstrate monosodium urate crystals by polarized light microscopy.
Conflicts of interest: None declared. Correspondence to: Jessica R. Burgy, MD, 1004 Chafee Avenue, FH-100, Department of Dermatology, Augusta, GA 30912-3190 E-mail: [email protected] REFERENCES 1. Shukla R, Vender RB, Alhabeeb A, Salama S, Murphy F. Miliarial gout (a new entity). J Cutan Med Surg 2007;11:31-4. 2. Aguayo RS, Baradad M, Soria X, Abal L, Sanmartın V, Egido R, et al. Unilateral milia-type intradermal tophi associated with underlying urate subcutaneous deposition: an uncommon cutaneous presentation of gout. Clin Exp Dermatol 2013;38: 622-5. 3. McCarty DJ. Gout without hyperuricemia. JAMA 1994;271: 302-3. 4. Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yu TF. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum 1977;20:895-900. 5. Adams PF, Hendershot GE, Marano MA. Centers for Disease Control and Prevention/National Center for Health Statistics. Current estimates from the National Health Interview Survey, 1996. Vital Health Stat 1999;10:1-203. http://dx.doi.org/10.1016/j.jaad.2014.01.851
A case of dermatitis herpetiformis after a mini-gastric bypass surgery To the Editor: Celiac disease and dermatitis herpetiformis share the same strong HLA association, the presence of circulating IgA antitissue and antiepidermal transglutaminase antibodies, and the same typical histologic features of villous atrophy of the small intestine.1 Both diseases can be triggered by gluten overload and gastric surgery.2 We report a case of dermatitis herpetiformis after mini-gastric bypass surgery with no clinical sign or symptom of celiac disease. Mini-gastric bypass is a modification of the standard Roux-en-Y procedure using a long gastric tube with an antecolic loop gastrojejunostomy. It has become a widely
