Successful Treatment of Steroid-Dependent Eosinophilic Cellulitis With Cyclosporine
A healthy 11-year-old girl fell on her knees 9 days before admission. Bruises developed on both tibial tuberosity areas, but soon subsided. One day before admission, she developed erythematous painful swelling lesions on both tibial tuberosity areas accompanied by fever (38℃). She was initially admitted to the orthopedic department with a diagnosis of bacterial cellulitis. There was no history of recent travel or insect bite. Physical examination revealed tender, erythematous plaques on both knees (), her left arm and her right ankle area. There were no signs of ulceration, bullae, skin breakdown, streaking, or lymphadenitis.\nInitial laboratory studies revealed a mildly elevated white blood cell count of 10,760/mm3 (78.8% neutrophils, 4.2% eosinophils), an erythrocyte sedimentation rate (ESR) of 8 mm/hr and a C-reactive protein (CRP) of less than 0.3 mg/dL. Her creatine kinase and myoglobin concentrations were 76 U/L and 25 ng/mL, respectively, both within normal limits. Despite treatment with intravenous cefazolin, her fever and painful erythematous rash continued and her peripheral blood eosinophils increased from 9.1% to 35.5%. She was transferred to the pediatric department on the 5th day after admission. Her total IgE concentration was 1,418.5 IU/mL (normal value: 0-170 IU/mL) and she was positive for specific IgE to house dust mites. Her stool was negative for parasites, and her antinuclear antibody, ANCA (anti-neutrophil cytoplasmic antibody) and anti-double-stranded DNA antibody were all within normal limits. A skin biopsy was taken from an erythematous skin lesion of her left leg, with histologic examination revealing diffuse heavy infiltration of eosinophils in the entire dermis, a finding consistent with EC (). She responded well to oral prednisolone for 3 days and was discharged without medication. Four days later, however, a new erythematous painful plaque appeared on her left foot () and blood hypereosinophilia (28.4%) recurred. Due to the relapse after tapering prednisolone several times, she was continued on oral prednisolone for 11 weeks. Because of her steroid dependency and increased intraocular pressure, she was switched from prednisolone to cyclosporine (5 mg/kg/day) for 2 months. Her skin lesions improved and there was no evidence of relapse after cessation of treatment for 6 months.