早期慢性迁移性红斑的皮镜特征。

Yunus Ozcan, Sumeyye Gunes Takir, Ebru Karagun, Belkiz Uyar
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Red purpuric dots and clods were randomly distributed over these backgrounds, gradually increasing towards the periphery (Figure 2). The rash was diagnosed as erythema chronicum migrans (ECM), and the patient was started on doxycycline 100 mg BID. The expansion of the rash was stopped, while the speed of central clearing was increased. Half of the rash had healed by the third day (Figure 1, left inset), and it had completely disappeared by the seventh (Figure 1, right inset). Anti-Borrelia burgdorferi antibodies were initially negative for IgM and positive for IgG, but both tested positive two weeks later. ECM is the hallmark of early-stage lyme disease, but it is not always present. In addition to the classically described bull's eye appearance, ECM may appear as homogenous erythematous patches, interrupted annular patches, or patches with hemorrhagic or purpuric components (1). It can manifest anywhere except in the palmoplantar region, but it is more common around large joints. 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引用次数: 0

摘要

尊敬的编辑们:一名来自莱姆病流行地区的37岁男子在其右小腿出现一周前迅速扩大的皮疹。他没有其他合并症或症状,如发烧、虚弱、食欲不振或关节痛,但他回忆起三周前从同一部位取出一只蜱虫。检查发现一个圆形的、蓝红色的红斑斑块,中间有一个间隙(图1)。患者没有感到不适,但触诊时皮疹是温暖的,很容易消退。皮镜检查显示,中心有颈状白色鳞片环绕着蜱虫叮咬点(图2,左图)。周边有三个不同的背景区:皮肤色、蓝红色和亮红色。这些区域之间的过渡并不能完全分辨出来。在这些背景上随机分布着红色的紫癜点和块,并逐渐向周围增加(图2)。皮疹诊断为慢性迁移性红斑(ECM),患者开始服用强力霉素100 mg BID。皮疹的扩大停止,而中央清理的速度加快。到第三天,一半的皮疹愈合(图1,左图),到第七天,皮疹完全消失(图1,右图)。抗伯氏疏螺旋体抗体最初对IgM呈阴性,对IgG呈阳性,但两周后均检测为阳性。ECM是早期莱姆病的标志,但并不总是存在。除了经典描述的牛眼外观外,ECM还可能表现为均匀的红斑斑块、间断的环状斑块或带有出血或紫癜成分的斑块(1)。它可以出现在除掌跖区以外的任何地方,但在大关节周围更常见。尽管ECM在形态学上存在差异,但其临床表现通常非常清晰,足以让皮肤科医生正确诊断90%以上的患者(1)。当ECM不存在或不典型时,可采用ELISA或Western blot等诊断方法。然而,由于缺乏标准化,伯氏疏螺旋体覆盖范围有限,假阳性和假阴性率显著,其可靠性较低(1)。居住在流行地区的个体因先前无症状感染而呈血清阳性可能导致偶然阳性结果。其他方法,包括从活检样本中分离病原体或PCR检测,也有类似的缺点(1)。组织病理学调查是另一种实用的方法,可以产生支持性的结果。ECM表现为弥漫性血管周围和间质炎症,包括淋巴细胞、嗜酸性粒细胞和浆细胞(2),这与皮肤镜下的背景红斑相对应。随着炎症的发展,新形成的区域是浅表的和亮红色的,但随着时间的推移,表面的炎症会消失,留下蓝色的红斑,这与更深的炎症有关(2,3)。皮肤镜检查在协助诊断非肿瘤性疾病,特别是炎症性皮肤病(炎症镜检查)方面越来越受到重视。外渗的红细胞合并血管周围炎症(2)产生紫色的粉红色点和块。考虑到早期治疗的更大疗效和围绕诊断方法的模糊性,临床结果应被认为足以开始治疗,特别是在流行地区(1)。ECM的皮镜检查为支持诊断提供了一种快速且低成本的替代方法。然而,正如Errichetti所强调的,非肿瘤性疾病的皮镜检查应被视为“两步程序”的第二步,首先通过病史和临床检查来确定鉴别诊断(3)。对早期和晚期、典型和非典型病变进行系统的调查将提高该方法的可靠性和实用性。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Dermatoscopic Features of Early Erythema Chronicum Migrans.

Dear Editors, A 37-year-old man from a Lyme disease-endemic area presented with a one-week old rapidly expanding rash on his right calf. He lacked other comorbidities or symptoms such as fever, weakness, lack of appetite, or joint pain, but recalled removing a tick from the same region three weeks earlier. Inspection revealed a round, bluish-red erythematous patch with a central clearing (Figure 1). The patient experienced no discomfort, but the rash was warm and faded easily when palpated. Dermatoscopic inspection revealed collarette-shaped white scales encircling the punctum of the tick bite in the center (Figure 2, left inset). There were three distinct background zones towards the periphery: skin-colored, bluish-red, and bright red. The transitions between the zones were not fully discernable. Red purpuric dots and clods were randomly distributed over these backgrounds, gradually increasing towards the periphery (Figure 2). The rash was diagnosed as erythema chronicum migrans (ECM), and the patient was started on doxycycline 100 mg BID. The expansion of the rash was stopped, while the speed of central clearing was increased. Half of the rash had healed by the third day (Figure 1, left inset), and it had completely disappeared by the seventh (Figure 1, right inset). Anti-Borrelia burgdorferi antibodies were initially negative for IgM and positive for IgG, but both tested positive two weeks later. ECM is the hallmark of early-stage lyme disease, but it is not always present. In addition to the classically described bull's eye appearance, ECM may appear as homogenous erythematous patches, interrupted annular patches, or patches with hemorrhagic or purpuric components (1). It can manifest anywhere except in the palmoplantar region, but it is more common around large joints. Despite the morphological variations of ECM, the clinical presentation is often clear and distinct enough for dermatologists to correctly diagnose more than 90% of patients (1). Diagnostic procedures such as ELISA or Western blot are employed in cases when the ECM is absent or atypical. However, their reliability is low due to the lack of standardization, limited coverage of Borrelia spp., and significant false-positive and false-negative rates (1). Seropositivity owing to previous asymptomatic infection in individuals residing in endemic areas may result in incidental positive findings. Alternative methods, including isolating the pathogen or PCR testing from biopsy samples have similar drawbacks (1). Histopathological investigations are another practical method that yields supportive findings. ECM exhibits diffuse perivascular and interstitial inflammation, including lymphocytes, eosinophils, and plasma cells (2), which corresponds to background erythema in dermatoscopy. As the inflammation develops, the newly-developed regions are superficial and brilliant red, but the surface inflammation fades over time, leaving bluish erythema, which correlates to deeper inflammation (2,3) dermoscopy is gaining appreciation in assisting the diagnosis of nonneoplastic diseases, especially inflammatory dermatoses (inflammoscopy). Extravasated erythrocytes combined with perivascular inflammation (2) generate purpuric pinkish-red dots and clods. Given the greater efficacy of early treatment and the ambiguity surrounding diagnostic methods, clinical findings should be deemed adequate to commence therapy, particularly in endemic regions (1). Dermatoscopic examination of ECM offers a quick and low-cost alternative approach for supporting the diagnosis. However, as emphasized by Errichetti, dermatoscopic examination in non-neoplastic diseases should be regarded as the second step of a "2-step procedure", with differential diagnoses established first by history and clinical examination (3). A systematic investigation of early and late, typical and atypical lesions would improve the reliability and utility of this method.

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