|IMAGES IN RHEUMATOLOGY
|Ahead of print publication
Half-filled or half-empty: Conundrum of “Hypopyon Sign” in pustular psoriasis
Kunal Chandwar1, Prasanna Dogga1, Juhi Dixit1, Digvijay Ekbote1, Rasmi Ranjan Sahoo2, Anupam Wakhlu2
1 Department of Clinical Immunology and Rheumatology, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department Clinical Immunology and Rheumatology, Apollomedics Superspeciality Hospitals, Lucknow, Uttar Pradesh, India
|Date of Submission||15-Dec-2021|
|Date of Acceptance||21-Feb-2022|
|Date of Web Publication||19-Apr-2022|
Department Clinical Immunology and Rheumatology, Apollomedics Superspeciality Hospitals, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Keywords: Psoriasis, sub-corneal pustular dermatosis, Deep vein thrombosis
A 30-year-old woman, with a history of recurrent, nonpruritic, nontender, and nonscarring pustular rash involving the shins at onset and progressing to involve both limbs, trunk, and face over the last 2 years, presented with left lower-limb swelling and the above-described lesions. Examination revealed marked pallor, patchy alopecia, and a tender and swollen left lower limb. There were pustules all over the body, with the highest density on the back, with a “hypopyon sign” [Figure 1]; mucus membranes were spared. Investigations revealed a massive venous thrombosis extending from the posterior tibial vein till the left common iliac vein. Lesional pus was sterile and skin biopsy was suggestive of pustular psoriasis with a negative immunofluorescence. She had severe anemia requiring transfusion and thrombocytosis. The anemia was found to be due to a combination of iron deficiency and anemia of chronic disease and managed accordingly. Anti-cardiolipin antibodies were positive in low titers, but repeat titers were negative. (ANA) and antineutrophil cytoplasmic antibodies (ANCA) were negative. There was nothing to suggest an underlying malignancy or paraproteinemia.
|Figure 1: Multiple sterile pustular lesions over the back with a “hypopyon” sign|
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She was previously being managed as subcorneal pustular dermatosis (SCPD) or Sneddon–Wilkinson's disease and had been initiated on low-dose steroids, dapsone, and therapeutic anticoagulation. However, the response to this therapy was poor. Although pustular psoriasis and subcorneal pustular dermatosis can have similar histopathological features, a younger age (SCPD usually presents in the fifth to seventh decade), involvement of face and scalp, coexistent venous thrombosis, and poor response to dapsone favored a diagnosis of pustular psoriasis. Hypopyon sign has also been documented in pemphigus vulgaris, pemphigus foliaceus, and paraneoplastic pemphigus, but a negative immunofluorescence on skin biopsy ruled out these conditions. The patient was started on methotrexate, to which she responded favorably on follow-up.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Watts PJ, Khachemoune A. Subcorneal pustular dermatosis: A review of 30 years of progress. Am J Clin Dermatol 2016;17:653-71.
Ungprasert P, Sanguankeo A, Upala S, Suksaranjit P. Psoriasis and risk of venous thromboembolism: A systematic review and meta-analysis. QJM 2014;107:793-7.
Singh S, Gupta S, Chaudhary R. Hypopyon sign in pemphigus vulgaris and pemphigus foliaceus. Int J Dermatol 2009;48:1100-2.